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1.
Nutrients ; 13(8)2021 Aug 11.
Artigo em Inglês | MEDLINE | ID: mdl-34444914

RESUMO

There is little data on the experience of managing pediatric Intestinal Failure (IF) in Latin America. This study aimed to identify and describe the current organization and practices of the IF teams in Latin America and the Caribbean. An online survey was sent to inquire about the existence of IF teams that managed children on home parenteral nutrition (HPN). Our questionnaire was based on a previously published European study with a similar goal. Twenty-four centers with pediatric IF teams in eight countries completed the survey, representing a total number of 316 children on HPN. The median number of children on parenteral nutrition (PN) at home per team was 5.5 (range 1-50). Teams consisted of the following members: pediatric gastroenterologist and a pediatric surgeon in all teams, dietician (95.8%), nurse (91.7%), social worker (79.2%), pharmacist (70.8%), oral therapist (62.5%), psychologist (58.3%), and physiotherapist (45.8%). The majority of the centers followed international standards of care on vascular access, parenteral and enteral nutrition, and IF medical and surgical management, but a significant percentage reported inability to monitor micronutrients, like vitamins A (37.5%), E (41.7%), B1 (66.7%), B2 (62.5%), B6 (62.5%), active B12 (58.3%); and trace elements-including zinc (29.2%), aluminum (75%), copper (37.5%), chromium (58.3%), selenium (58.3%), and manganese (58.3%). Conclusion: There is wide variation in how IF teams are structured in Latin America-while many countries have well-established Intestinal rehabilitation programs, a few do not follow international standards. Many countries did not report having an IF team managing pediatric patients on HPN.


Assuntos
Gastroenterologia/estatística & dados numéricos , Enteropatias/terapia , Equipe de Assistência ao Paciente/estatística & dados numéricos , Pediatria/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Região do Caribe , Criança , Pré-Escolar , Feminino , Gastroenterologia/métodos , Humanos , Lactente , Recém-Nascido , América Latina , Masculino , Nutrição Parenteral no Domicílio/estatística & dados numéricos , Pediatria/métodos , Inquéritos e Questionários
2.
Clin Pediatr (Phila) ; 60(9-10): 418-426, 2021 09.
Artigo em Inglês | MEDLINE | ID: mdl-34342242

RESUMO

Pediatrician Screening, Brief Intervention, and Referral to Treatment (SBIRT) practices vary widely, though little is known about the correlates of SBIRT implementation. Using data from a national sample of US pediatricians who treat adolescents (n = 250), we characterized self-reported utilization rates of SBIRT among US pediatricians and identified provider- and practice-level characteristics and barriers associated with SBIRT utilization. All participants completed an electronic survey querying the demographics, practice patterns, and perceived barriers related to SBIRT practices. Our results showed that 88% of respondents reported screening for substance use annually, but only 26% used structured/validated screening instruments. Furthermore, 40% of respondents provided evidence-based brief interventions, and only 11% implemented all core SBIRT practices. Common barriers (eg, confidentiality and insufficient time) and unique provider- and setting-specific barriers to implementation were identified. These findings indicate that although most pediatricians deliver some SBIRT components in their practice, few implement the full SBIRT model, and barriers persist.


Assuntos
Intervenção na Crise/métodos , Programas de Rastreamento/métodos , Pediatras/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Encaminhamento e Consulta/estatística & dados numéricos , Transtornos Relacionados ao Uso de Substâncias/diagnóstico , Transtornos Relacionados ao Uso de Substâncias/terapia , Adolescente , Comportamento do Adolescente , Confidencialidade , Intervenção na Crise/estatística & dados numéricos , Humanos , Transtornos Relacionados ao Uso de Substâncias/prevenção & controle , Tempo , Estados Unidos
3.
Bone Joint J ; 103-B(7 Supple B): 103-110, 2021 07.
Artigo em Inglês | MEDLINE | ID: mdl-34192916

RESUMO

AIMS: Due to the opioid epidemic in the USA, our service progressively decreased the number of opioid tablets prescribed at discharge after primary hip (THA) and knee (TKA) arthroplasty. The goal of this study was to analyze the effect on total morphine milligram equivalents (MMEs) prescribed and post-discharge opioid repeat prescriptions. METHODS: We retrospectively reviewed 19,428 patients undergoing a primary THA or TKA between 1 February 2016 and 31 December 2019. Two reductions in the number of opioid tablets prescribed at discharge were implemented over this time; as such, we analyzed three periods (P1, P2, and P3) with different routine discharge MME (750, 520, and 320 MMEs, respectively). We investigated 90-day refill rates, refill MMEs, and whether discharge MMEs were associated with represcribing in a multivariate model. RESULTS: A discharge prescription of < 400 MMEs was not a risk factor for opioid represcribing in the entire population (p = 0.772) or in opioid-naïve patients alone (p = 0.272). Procedure type was the most significant risk factor for narcotic represcribing, with unilateral TKA (hazard ratio (HR) = 5.62), bilateral TKA (HR = 6.32), and bilateral unicompartmental knee arthroplasty (UKA) (HR = 5.29) (all p < 0.001) being the highest risk for refills. For these three procedures, there was approximately a 5% to 6% increase in refills from P1 to P3 (p < 0.001); however, there was no significant increase in refill rates after any hip arthroplasty procedures. Total MMEs prescribed were significantly reduced from P1 to P3 (p < 0.001), leading to the equivalent of nearly 500,000 fewer oxycodone 5 mg tablets prescribed. CONCLUSION: Decreasing opioids prescribed at discharge led to a statistically significant reduction in total MMEs prescribed. While the represcribing rate did not increase for any hip arthroplasty procedure, the overall refill rates increased by about 5% for most knee arthroplasty procedures. As such, we are now probably prescribing an appropriate amount of opioids at discharge for knee arthroplasty procedure, but further reductions may be possible for hip arthroplasty procedures. Cite this article: Bone Joint J 2021;103-B(7 Supple B):103-110.


Assuntos
Analgésicos Opioides/administração & dosagem , Artroplastia de Quadril , Artroplastia do Joelho , Dor Pós-Operatória/tratamento farmacológico , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Prescrições de Medicamentos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Morfina/administração & dosagem , Alta do Paciente , Estudos Retrospectivos
4.
Eur J Vasc Endovasc Surg ; 62(3): 432-438, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34217598

RESUMO

OBJECTIVE: Patients with intermittent claudication (IC) are initially treated with supervised exercise therapy (SET), as advised by national and international guidelines. Dutch health insurance companies and the Dutch National Health Care Institute suggested an 87% compliance rate with these guidelines in the Netherlands in 2017 and judged this to be undesirably low. The aim of this study was to evaluate compliance with IC guidelines and to elaborate on the reasons for deviating from them (practice variation) in a large teaching hospital. METHODS: A retrospective single centre cohort study was conducted at a large teaching hospital in the Netherlands. In total, 420 patients with newly diagnosed IC between 1 January 2017 and 31 December 2018 were analysed. Data included risk profiles and prescribed therapies. RESULTS: For all 420 included patients, the compliance rate with the guidelines for SET was 80.5%. The rate of adequately motivated and defensible practice variation was 15.7%; the rate of unjustified practice variation was 3.8%. Meaningful care was seen in 96.2% of cases. CONCLUSION: Deviation from IC guidelines was found in 19.5% of patients. Almost three quarters of this deviation can be explained by the decision to provide personalised, meaningful care.


Assuntos
Terapia por Exercício/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Claudicação Intermitente/terapia , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Terapia por Exercício/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Países Baixos , Guias de Prática Clínica como Assunto , Estudos Retrospectivos
5.
Am J Cardiol ; 153: 43-50, 2021 08 15.
Artigo em Inglês | MEDLINE | ID: mdl-34210501

RESUMO

Lipoprotein (a) [Lp(a)] is associated with increased risk of atherosclerotic cardiovascular disease (ASCVD). As directed therapy for Lp(a) emerges, it is important to understand patterns of Lp(a) testing in routine clinical practice. We set out to characterize Lp(a) testing across a large academic health system. Using electronic health record (EHR) data from 2014 to 2019, we compared patients who underwent Lp(a) testing to date-matched peers who had low density lipoprotein (LDL-C) assessment alone. We analyzed ordering provider characteristics and rates of initiation of new lipid lowering therapy (LLT) within 12 months after testing. Of 1,296 adults with Lp(a) test results, 629 (48.5%) had prior history of ASCVD and 667 (51.4%) did not. Compared with those with LDL-C testing alone, individuals who underwent Lp(a) testing were more like to have a myocardial infarction or ischemic stroke at a young age and multiple prior cardiovascular events. Though the majority of Lp(a) tests were ordered in outpatient encounters, a higher proportion of Lp(a) tests compared with LDL-C tests were performed in the inpatient setting. Neurology and psychiatry were the most common specialty to order Lp(a) tests in our cohort. There was a significantly increased initiation of LLT after Lp(a) testing compared with LDL-C testing across all medication types. Consistent with guidelines, Lp(a) testing is used in those with early onset ASCVD, and among those with multiple cardiovascular events. Lp(a) testing is associated with more aggressive LLT in following year. Further research is needed to characterize Lp(a) testing across larger populations.


Assuntos
Aterosclerose/sangue , Doenças Cardiovasculares/sangue , LDL-Colesterol/sangue , Hiperlipidemias/diagnóstico , Hipolipemiantes/uso terapêutico , Lipoproteína(a)/sangue , Padrões de Prática Médica/estatística & dados numéricos , Centros Médicos Acadêmicos , Idoso , Assistência Ambulatorial/estatística & dados numéricos , Aterosclerose/epidemiologia , Análise Química do Sangue/estatística & dados numéricos , Doenças Cardiovasculares/epidemiologia , Feminino , Fatores de Risco de Doenças Cardíacas , Hospitalização , Humanos , Hiperlipidemias/sangue , Hiperlipidemias/tratamento farmacológico , AVC Isquêmico/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/epidemiologia
6.
Eur J Endocrinol ; 185(4): D11-D20, 2021 Aug 27.
Artigo em Inglês | MEDLINE | ID: mdl-34288884

RESUMO

Non-functioning pituitary adenomas (NFPA) usually present with symptoms of mass effect. Thus, the first-line treatment generally consists of transsphenoidal surgery. Since these tumors are usually large and invasive, post-surgical tumor remnants are common. Active surveillance is the follow-up strategy adopted by most pituitary centers, although the prevalence of residual tumor growth may reach 50% in 5-10 years, often leading to repeat surgery, radiation therapy, or both. NFPA remain the only pituitary tumor type for which no medical therapy has been approved. In this debate, we consider the evidence in favor and against using cabergoline to treat progressing NFPA.


Assuntos
Adenoma/tratamento farmacológico , Cabergolina/uso terapêutico , Neoplasias Hipofisárias/tratamento farmacológico , Adenoma/epidemiologia , Adenoma/patologia , Adenoma/cirurgia , Quimioterapia Adjuvante , Progressão da Doença , Humanos , Recidiva Local de Neoplasia/epidemiologia , Recidiva Local de Neoplasia/prevenção & controle , Neoplasia Residual , Procedimentos Neurocirúrgicos , Seleção de Pacientes , Neoplasias Hipofisárias/epidemiologia , Neoplasias Hipofisárias/patologia , Neoplasias Hipofisárias/cirurgia , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Carga Tumoral/efeitos dos fármacos
7.
N Engl J Med ; 385(4): 342-351, 2021 07 22.
Artigo em Inglês | MEDLINE | ID: mdl-34289277

RESUMO

BACKGROUND: Historically, the receipt of prescription opioids has differed among racial groups in the United States. Research has not sufficiently explored the contribution of individual health systems to these differences by examining within-system prescription opioid receipt according to race. METHODS: We used 2016 and 2017 Medicare claims data from a random 40% national sample of fee-for-service, Black and White beneficiaries 18 to 64 years of age who were attributed to health systems. We identified 310 racially diverse systems (defined as systems with ≥200 person-years each for Black and White patients). To test representativeness, we compared patient characteristics and opioid receipt among the patients in these 310 systems with those in the national sample. Within the 310 systems, regression models were used to explore the difference between Black and White patients in the following annual opioid measures: any prescription filled, short-term receipt of opioids, long-term receipt of opioids (one or more filled opioid prescriptions in all four calendar quarters of a year), and the opioid dose in morphine milligram equivalents (MME); models controlled for patient characteristics, state, and system. RESULTS: The national sample included 2,197,153 person-years, and the sample served by 310 racially diverse systems included 896,807 person-years (representing 47.4% of all patients and 56.1% of Black patients in the national sample). The national sample and 310-systems sample differed meaningfully only in the percent of person-years contributed by Black patients (21.3% vs. 25.9%). In the 310-systems sample, the crude annual prevalence of any opioid receipt differed slightly between Black and White patients (50.2% vs. 52.2%), whereas the mean annual dose was 36% lower among Black patients than among White patients (5190 MME vs. 8082 MME). Within systems, the adjusted race differences in measures paralleled the population trends: the annual prevalence of opioid receipt differed little, but the mean annual dose was higher among White patients than among Black patients in 91% of the systems, and at least 15% higher in 75% of the systems. CONCLUSIONS: Within individual health systems, Black and White patients received markedly different opioid doses. These system-specific findings could facilitate exploration of the causes and consequences of these differences. (Funded by the National Institute on Aging and the Agency for Healthcare Research and Quality.).


Assuntos
Analgésicos Opioides/uso terapêutico , Disparidades em Assistência à Saúde/etnologia , Padrões de Prática Médica/estatística & dados numéricos , Adolescente , Adulto , Afro-Americanos , Pessoas com Deficiência , Grupo com Ancestrais do Continente Europeu , Feminino , Serviços de Saúde , Disparidades em Assistência à Saúde/estatística & dados numéricos , Humanos , Masculino , Medicare , Pessoa de Meia-Idade , Manejo da Dor , Medicamentos sob Prescrição/uso terapêutico , Estados Unidos , Adulto Jovem
8.
Medicine (Baltimore) ; 100(24): e26195, 2021 Jun 18.
Artigo em Inglês | MEDLINE | ID: mdl-34128851

RESUMO

ABSTRACT: To approximate the breakdown of narrow anterior chamber angle conditions, on general ophthalmology clinics, in the predominantly white population of the South East Kent region in the United Kingdom.A review was done of all patients attending a secondary care ophthalmology general clinic over a 3-year period. Patients were assessed with: slitlamp biomicroscopy with indentation gonioscopy; SD optical coherence tomography, Humphrey visual field analyzer, and high frequency ultrasound and categorized into various narrow angle conditions. These were: narrow Van Herrick but open angle; primary narrow angle but nonoccludable; primary angle closure suspect; primary angle closure; chronic narrow angle glaucoma; plateau iris configuration; plateau iris syndrome, and phacomorphic narrow angle.A total of 14,520 patients were referred to the clinic, of those 10,491 attended and were analyzed. Six hundred seventy four (6.4%) of the patients had some form of narrow angle condition in at least 1 eye. The majority of these patients were at relative low risk of pathology such as nonoccludable narrow angles (359/53.3%) and narrow Van Herrick but open angles (93/13.8%). 8.8% of all the narrow angle patients had primary angle closure suspect or primary angle closure. Plateau iris pathology was seen in 68 (10.1%) of patients with 18 (26%) having confirmed plateau iris syndrome after peripheral iridotomy. Phacomorphic pathology was confirmed in 75 (11.1%) patients.Narrow angle patients form a significant proportion (6.4%) of those attending general ophthalmology clinic in the predominantly white population in the South East Kent Region of the United Kingdom. The majority of these (67.1%) are at a relatively low risk of developing acute or chronic angle closure glaucoma. Of the remaining patients 8.8% have primary angle closure suspect or primary angle closure and 2.9% have already progressed to chronic narrow angle closure glaucoma. Plateau iris pathology and phacomorphic glaucoma account for the remainder of the presentations.


Assuntos
Glaucoma de Ângulo Fechado/epidemiologia , Doenças da Íris/epidemiologia , Oftalmologia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Câmara Anterior/patologia , Estudos Transversais , Feminino , Glaucoma de Ângulo Fechado/diagnóstico , Gonioscopia , Humanos , Iris/patologia , Doenças da Íris/diagnóstico , Masculino , Pessoa de Meia-Idade , Prevalência , Tomografia de Coerência Óptica , Ultrassonografia , Reino Unido/epidemiologia , Testes de Campo Visual
9.
J Manipulative Physiol Ther ; 44(4): 280-288, 2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-34090548

RESUMO

OBJECTIVES: The purpose of this study was to assess the status, supply, demographics, and characteristics of chiropractic practice in the continent of Africa. METHODS: A survey consisting of questions on demographics, clinical practice, and patient profile was administered to 608 chiropractors practicing in the different countries of the African continent. Chiropractic association officers of each country were contacted via e-mail for assistance in the distribution of the survey link to chiropractors in their country. The initial questionnaire was pretested with a small group of chiropractors from 2 African countries-4 from Ethiopia and 6 from Botswana-to assess the validity of the questions. The legal status of the chiropractic practice was obtained from online resources. Descriptive statistics were conducted in Microsoft Excel. RESULTS: Of the 54 countries in the continent of Africa, 23 countries were identified to have chiropractors. One hundred twenty-four surveys were returned from 15 countries with an overall response rate of 20.3% by clinicians with varying years in clinical practice. Nearly 84% of the chiropractors were between ages 26 and 50. More than 69% reported being a graduate of 1 of the 2 academic institutions located in Africa. Most chiropractors practice in South Africa. Most chiropractors practice in privately owned clinics, and 38% practice in multidisciplinary clinics. Nearly 92% reported using diversified technique and 27% used McKenzie exercises for treatment. Patients presented with a variety of conditions, predominantly chronic pain (59%). CONCLUSIONS: This study provides a general overview on the status, supply, demographics, and characteristics of chiropractic practice in the continent of Africa. The supply of chiropractors in Africa is scarce and unevenly distributed. Although in the early stages of recognition, chiropractors in Africa are contributing to the care of people with musculoskeletal and spine-related disorders. Considering the high burden of spine pain, there appears to be potential for growth for chiropractic in the continent of Africa.


Assuntos
Atitude do Pessoal de Saúde , Quiroprática/estatística & dados numéricos , Manipulação Quiroprática/estatística & dados numéricos , Doenças Musculoesqueléticas/terapia , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Pessoal de Saúde/normas , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos , África do Sul , Inquéritos e Questionários
10.
West J Emerg Med ; 22(3): 756-762, 2021 Apr 19.
Artigo em Inglês | MEDLINE | ID: mdl-34125057

RESUMO

INTRODUCTION: Our goal was to determine whether implementation of a prescription drug monitoring program (PDMP) altered emergency department (ED) opioid prescription rates overall and in patients of different pain severities. METHODS: We conducted this single-center, retrospective review at an academic ED. The study examined patients discharged from the ED who received opioid prescriptions, before and after the state's implementation of a PDMP (August 25, 2016). The monthly rate was a ratio of the patients given ≥ 1 opioid prescription to the ED patients with a numeric pain rating scale (NPRS) > 0. We performed an interrupted time series analysis on each demographic. RESULTS: The overall ED opioid prescription rate decreased from 51.3% (95% confidence interval [Cl], 50.4%-52.2%) to 47.9% (95% Cl, 47.0%-48.7%). For males, this decreased from 51.1% to 46.7% (P < 0.0001), while in females it did not significantly change (51.6% to 49.7% [P = 0.0529]). For those with mild pain, the rate increased from 27.5% to 34.3% (P < 0.0001), while for those with moderate pain, it did not significantly change (42.8% to 43.5% [P = 0.5924]). For those with severe pain, the rate decreased from 66.1% to 59.6% (P < 0.0001). CONCLUSION: We found that PDMP implementation was associated with an overall decrease in opioid prescription rates, and that patients with mild pain were prescribed opioids more often while severe pain patients were prescribed opioids less often.


Assuntos
Analgésicos Opioides/uso terapêutico , Serviço Hospitalar de Emergência/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Programas de Monitoramento de Prescrição de Medicamentos/organização & administração , Adulto , Feminino , Humanos , Análise de Séries Temporais Interrompida , Masculino , Pessoa de Meia-Idade , Manejo da Dor/métodos , Estudos Retrospectivos
11.
CMAJ Open ; 9(2): E659-E666, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34131029

RESUMO

BACKGROUND: Ten randomized controlled trials over the last 2 decades support treating low-risk pediatric distal radius fractures with removable immobilization and without physician follow-up. We aimed to determine the proportion of these fractures being treated without physician follow-up and to determine whether different hospital and physician types are treating these injuries differently. METHODS: We conducted a retrospective population-based cohort study using ICES data. We included children aged 2-14 years (2-12 yr for girls and 2-14 yr for boys) with distal radius fractures having had no reduction or operation within a 6-week period, and who received treatment in Ontario emergency departments from 2003 to 2015. Proportions of patients receiving orthopedic, primary care and no follow-up were determined. Multivariable log-binomial regression was used to quantify associations between hospital and physician type and management. RESULTS: We analyzed 70 801 fractures. A total of 20.8% (n = 14 742) fractures were treated without physician follow-up, with the proportion of physician follow-up consistent across all years of the study. Treatment in a small hospital emergency department (risk ratio [RR] 1.86, 95% confidence interval [CI] 1.72-2.01), treatment by a pediatrician (RR 1.22, 95% CI 1.11-1.34) or treatment by a subspecialty pediatric emergency medicine-trained physician (RR 1.73, 95% CI 1.56-1.92) were most likely to result in no follow-up. INTERPRETATION: While small hospital emergency departments, pediatricians and pediatric emergency medicine specialists were most likely to manage low-risk distal radius fractures without follow-up, the majority of these fractures in Ontario were not managed according to the latest research evidence. Canadian guidelines are required to improve care of these fractures and to reduce the substantial overutilization of physician resources we observed.


Assuntos
Assistência ao Convalescente , Serviços de Saúde da Criança/estatística & dados numéricos , Tratamento Conservador , Ortopedia/métodos , Padrões de Prática Médica/estatística & dados numéricos , Fraturas do Rádio , Assistência ao Convalescente/métodos , Assistência ao Convalescente/estatística & dados numéricos , Criança , Tratamento Conservador/métodos , Tratamento Conservador/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Sobremedicalização/prevenção & controle , Ontário/epidemiologia , Medicina de Emergência Pediátrica/normas , Melhoria de Qualidade/organização & administração , Fraturas do Rádio/epidemiologia , Fraturas do Rádio/terapia
12.
Br J Surg ; 108(6): 717-726, 2021 06 22.
Artigo em Inglês | MEDLINE | ID: mdl-34157090

RESUMO

BACKGROUND: Surgical strategies are being adapted to face the COVID-19 pandemic. Recommendations on the management of acute appendicitis have been based on expert opinion, but very little evidence is available. This study addressed that dearth with a snapshot of worldwide approaches to appendicitis. METHODS: The Association of Italian Surgeons in Europe designed an online survey to assess the current attitude of surgeons globally regarding the management of patients with acute appendicitis during the pandemic. Questions were divided into baseline information, hospital organization and screening, personal protective equipment, management and surgical approach, and patient presentation before versus during the pandemic. RESULTS: Of 744 answers, 709 (from 66 countries) were complete and were included in the analysis. Most hospitals were treating both patients with and those without COVID. There was variation in screening indications and modality used, with chest X-ray plus molecular testing (PCR) being the commonest (19·8 per cent). Conservative management of complicated and uncomplicated appendicitis was used by 6·6 and 2·4 per cent respectively before, but 23·7 and 5·3 per cent, during the pandemic (both P < 0·001). One-third changed their approach from laparoscopic to open surgery owing to the popular (but evidence-lacking) advice from expert groups during the initial phase of the pandemic. No agreement on how to filter surgical smoke plume during laparoscopy was identified. There was an overall reduction in the number of patients admitted with appendicitis and one-third felt that patients who did present had more severe appendicitis than they usually observe. CONCLUSION: Conservative management of mild appendicitis has been possible during the pandemic. The fact that some surgeons switched to open appendicectomy may reflect the poor guidelines that emanated in the early phase of SARS-CoV-2.


Assuntos
Apendicite/terapia , Atitude do Pessoal de Saúde , COVID-19 , Padrões de Prática Médica/estatística & dados numéricos , Cirurgiões , Antibacterianos/uso terapêutico , Apendicectomia/métodos , Apendicectomia/estatística & dados numéricos , Teste para COVID-19/estatística & dados numéricos , Administração Hospitalar , Humanos , Pandemias , Equipamento de Proteção Individual/estatística & dados numéricos , Inquéritos e Questionários
15.
Eur J Endocrinol ; 185(2): 265-278, 2021 Jul 01.
Artigo em Inglês | MEDLINE | ID: mdl-34061767

RESUMO

Objective: Metabolic syndrome is a cluster of cardio-metabolic risk factors associated with an increased risk of cardiovascular disease and type 2 diabetes. In the last two decades, several definitions of metabolic syndrome have been proposed for the pediatric population; all of them agree on the defining components but differ in the suggested criteria for diagnosis. This review aims to analyze the current diagnostic criteria of metabolic syndrome in pediatrics with reference to their feasibility and reliability in clinical practice. Methods: The systematic research was conducted from January 2003 to June 2020 through MEDLINE via PubMed, Cochrane Library and EMBASE databases. Results: After the selection phase, a total of 15 studies (182 screened) met the inclusion criteria and are reported in the present review. Twelve studies were cross-sectional, two were longitudinal and one was a consensus report. The sample population consisted of multiethnic group or single ethnic group, including Turkish, European, Asian and Hispanic subjects. Conclusions: To date, there is not a univocal, internationally accepted pediatric definition of metabolic syndrome, which guarantees a high sensitivity and stability of the diagnosis. The definition proposed by IDF results the most straightforward and easy to use in clinical practice, having the unquestionable advantage of requiring measurements quickly accessible in clinical practice, without the adoption of multiple reference tables. Further research is needed to validate a new version of such definition which includes the diagnostic cut-off points recently suggested by published guidelines.


Assuntos
Técnicas de Diagnóstico Endócrino , Síndrome Metabólica/diagnóstico , Pediatria , Adolescente , Idade de Início , Criança , Pré-Escolar , Técnicas de Diagnóstico Endócrino/normas , Técnicas de Diagnóstico Endócrino/estatística & dados numéricos , Estudos de Viabilidade , Feminino , Humanos , Masculino , Síndrome Metabólica/epidemiologia , Pediatria/métodos , Pediatria/normas , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Reprodutibilidade dos Testes
16.
J Surg Oncol ; 124(4): 521-528, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34061359

RESUMO

BACKGROUND: Racial disparities currently exist for the utilization rate of esophagectomy for Black patients with operable esophageal carcinoma. METHODS: A total of 37 271 cases with the American Joint Committee on Cancer clinical stage I, II, and III esophageal carcinoma that were reported to the National Cancer Database were analyzed between 2004 and 2016. A multivariable-adjusted logistic regression model was used to evaluate differences in the odds ratio of esophagectomy not being recommended based on race. Kaplan-Meier curves and log-rank tests were used to evaluate differences in overall survival. Propensity score methodology with inverse probability of treatment weighting (IPTW) was used to balance baseline differences in patient demographics. RESULTS: After IPTW adjustment, we identified 30 552 White patients and 3529 Black patients with clinical stage I-III esophageal carcinoma. Black patients had three times greater odds of not being recommended for esophagectomy (odds ratio: 3.03, 95% confidence interval: 2.67-3.43, p < 0.0001) compared to White patients. Black patients demonstrated significantly worse 3- and 5-year overall survival rates compared to White patients (log-rank p < 0.0001). CONCLUSION: Black patients with clinical stage I-III esophageal cancer were significantly less likely to be recommended for esophagectomy even after adjusting for baseline demographic covariates compared to White patients.


Assuntos
Afro-Americanos/estatística & dados numéricos , Neoplasias Esofágicas/cirurgia , Esofagectomia/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Pessoal de Saúde/psicologia , Disparidades em Assistência à Saúde , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Neoplasias Esofágicas/etnologia , Neoplasias Esofágicas/patologia , Esofagectomia/tendências , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Taxa de Sobrevida , Adulto Jovem
18.
CMAJ Open ; 9(2): E613-E622, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34088732

RESUMO

BACKGROUND: For many patients, health care needs increase toward the end of life, but little is known about the extent of outpatient physician care during that time. The objective of this study was to describe the volume and mix of outpatient physician care over the last 12 months of life among patients dying with different end-of-life trajectories. METHODS: We conducted a retrospective descriptive study involving adults (aged ≥ 18 yr) who died in Ontario between 2013 and 2017, using linked provincial health administrative databases. Decedents were grouped into 5 mutually exclusive end-of-life trajectories (terminal illness, organ failure, frailty, sudden death and other). Over the last 12 months and 3 months of life, we examined the number of physician encounters, the number of unique physician specialties involved per patient and specialty of physician, the number of unique physicians involved per patient, the 5 most frequent types of specialties involved and the number of encounters that took place in the home; these patterns were examined by trajectory. RESULTS: Decedents (n = 359 559) had a median age of 78 (interquartile range 66-86) years. The mean number of outpatient physician encounters over the last year of life was 16.8 (standard deviation [SD] 13.7), of which 9.0 (SD 9.2) encounters were with family physicians. The mean number of encounters ranged from 11.6 (SD 10.4) in the frailty trajectory to 24.2 (SD 15.0) in the terminal illness trajectory across 3.1 (SD 2.0) to 4.9 (SD 2.1) unique specialties, respectively. In the last 3 months of life, the mean number of physician encounters was 6.8 (SD 6.4); a mean of 4.1 (SD 5.4) of these were with family physicians. INTERPRETATION: Multiple physicians are involved in outpatient care in the last 12 months of life for all end-of-life trajectories, with family physicians as the predominant specialty. Those who plan health care models of the end of life should consider support for family physicians as coordinators of patient care.


Assuntos
Assistência Ambulatorial , Morte Súbita/epidemiologia , Morte , Fragilidade , Médicos de Família , Assistência Terminal , Idoso , Assistência Ambulatorial/métodos , Assistência Ambulatorial/estatística & dados numéricos , Causas de Morte , Feminino , Fragilidade/mortalidade , Fragilidade/terapia , Humanos , Masculino , Ontário/epidemiologia , Pacientes Ambulatoriais/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Estudos Retrospectivos , Assistência Terminal/métodos , Assistência Terminal/estatística & dados numéricos
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