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1.
BMJ ; 367: l5205, 2019 Oct 02.
Artigo em Inglês | MEDLINE | ID: mdl-31578187

RESUMO

OBJECTIVES: To determine how clinicians vary in their response to new guidance on existing or new interventions, by measuring the timing and magnitude of change at healthcare institutions. DESIGN: Automated change detection in longitudinal prescribing data. SETTING: Prescribing data in English primary care. PARTICIPANTS: English general practices. MAIN OUTCOME MEASURES: In each practice the following were measured: the timing of the largest changes, steepness of the change slope (change in proportion per month), and magnitude of the change for two example time series (expiry of the Cerazette patent in 2012, leading to cheaper generic desogestrel alternatives becoming available; and a change in antibiotic prescribing guidelines after 2014, favouring nitrofurantoin over trimethoprim for uncomplicated urinary tract infection (UTI)). RESULTS: Substantial heterogeneity was found between institutions in both timing and steepness of change. The range of time delay before a change was implemented was large (interquartile range 2-14 months (median 8) for Cerazette, and 5-29 months (18) for UTI). Substantial heterogeneity was also seen in slope following a detected change (interquartile range 2-28% absolute reduction per month (median 9%) for Cerazette, and 1-8% (2%) for UTI). When changes were implemented, the magnitude of change showed substantially less heterogeneity (interquartile range 44-85% (median 66%) for Cerazette and 28-47% (38%) for UTI). CONCLUSIONS: Substantial variation was observed in the speed with which individual NHS general practices responded to warranted changes in clinical practice. Changes in prescribing behaviour were detected automatically and robustly. Detection of structural breaks using indicator saturation methods opens up new opportunities to improve patient care through audit and feedback by moving away from cross sectional analyses, and automatically identifying institutions that respond rapidly, or slowly, to warranted changes in clinical practice.


Assuntos
Prescrições de Medicamentos/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Avaliação de Processos (Cuidados de Saúde)/métodos , Indicadores de Qualidade em Assistência à Saúde/estatística & dados numéricos , Medicina Estatal/estatística & dados numéricos , Anti-Infecciosos/uso terapêutico , Conjuntos de Dados como Assunto , Substituição de Medicamentos/estatística & dados numéricos , Medicamentos Genéricos/uso terapêutico , Inglaterra , Medicina Geral/organização & administração , Medicina Geral/normas , Medicina Geral/estatística & dados numéricos , Humanos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Avaliação de Processos (Cuidados de Saúde)/estatística & dados numéricos , Medicina Estatal/normas , Fatores de Tempo , Infecções Urinárias/tratamento farmacológico
2.
BMC Infect Dis ; 19(1): 770, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31481020

RESUMO

BACKGROUND: We sought to assess reporting in China's Pneumonia of Unknown Etiology (PUE) passive surveillance system for emerging respiratory infections and to identify ways to improve the PUE surveillance system's detection of respiratory infections of public health significance. METHODS: From February 29-May 29, 2016, we actively identified and enrolled patients in two hospitals with acute respiratory infections (ARI) that met all PUE case criteria. We reviewed medical records for documented exposure history associated with respiratory infectious diseases, collected throat samples that were tested for seasonal and avian influenza, and interviewed clinicians regarding reasons for reporting or not reporting PUE cases. We described and analyzed the proportion of PUE cases reported and clinician awareness of and practices related to the PUE system. RESULTS: Of 2619 ARI admissions in two hospitals, 335(13%) met the PUE case definition; none were reported. Of 311 specimens tested, 18(6%) were seasonal influenza virus-positive; none were avian influenza-positive. < 10% PUE case medical records documented whether or not there were exposures to animals or others with respiratory illness. Most commonly cited reasons for not reporting cases were no awareness of the PUE system (76%) and not understanding the case definition (53%). CONCLUSIONS: Most clinicians have limited awareness of and are not reporting to the PUE system. Exposures related to respiratory infections are rarely documented in medical records. Increasing clinicians' awareness of the PUE system and including relevant exposure items in standard medical records may increase reporting.


Assuntos
Notificação de Doenças , Necessidades e Demandas de Serviços de Saúde , Pneumonia/epidemiologia , Pneumonia/etiologia , Vigilância da População , Adulto , China/epidemiologia , Doenças Transmissíveis Emergentes/diagnóstico , Doenças Transmissíveis Emergentes/epidemiologia , Diagnóstico Diferencial , Notificação de Doenças/métodos , Notificação de Doenças/normas , Feminino , Necessidades e Demandas de Serviços de Saúde/organização & administração , Necessidades e Demandas de Serviços de Saúde/normas , Hospitalização , Humanos , Influenza Humana/epidemiologia , Masculino , Notificação de Abuso , Testes Obrigatórios/normas , Pessoa de Meia-Idade , Projetos Piloto , Pneumonia/diagnóstico , Vigilância da População/métodos , Padrões de Prática Médica/organização & administração , Padrões de Prática Médica/normas , Avaliação de Programas e Projetos de Saúde , Infecções Respiratórias/diagnóstico , Infecções Respiratórias/epidemiologia , Infecções Respiratórias/etiologia , Engajamento no Trabalho
3.
Schmerz ; 33(5): 466-470, 2019 Oct.
Artigo em Alemão | MEDLINE | ID: mdl-31478143

RESUMO

Since the adoption of the law of March 6, 2017, any German physician can prescribe medical cannabis flowers and cannabis-based magistral and finished medicinal products. No specific indications for prescriptions are provided in the law. The statutory health insurance companies bear the costs once an application for cost coverage has been approved by the Medical Service of the Health Funds. The German associations of psychiatry (child, adolescents, and adults), neurology, palliative care, addictology, and pain medicine are watching these developments in the media, politics, and medical world with concern due to: the option to prescribe cannabis flowers despite the lack of sound evidence and against the recommendations of the German Medical Association; the lack of distinction between medical cannabis flowers and cannabis-based magistral and finished medical products; the indiscriminately positive reports on the efficacy of cannabis-based medicines for chronic pain and mental disorders; the attempts by the cannabis industry to influence physicians; the increase in potential indications by leaders of medical opinion paid by manufacturers of cannabis-based medicines. The medical associations make the following appeal to journalists: To report on the medical benefits and risks of cannabis-based medicines in a balanced manner. To physicians: to prescribe cannabis-based medicines with caution; to prefer magistral and finished medicinal products over cannabis flowers. To politicians: to consider data according to the standards of evidence-based medicine when making decisions and provide financial support for medical research into cannabis-based medicines.


Assuntos
Cannabis , Dor Crônica , Seguro Saúde , Jornalismo , Maconha Medicinal , Política , Padrões de Prática Médica , Dor Crônica/tratamento farmacológico , Alemanha , Humanos , Seguro Saúde/ética , Seguro Saúde/normas , Maconha Medicinal/uso terapêutico , Médicos/ética , Médicos/normas , Padrões de Prática Médica/ética , Padrões de Prática Médica/normas
4.
Expert Opin Drug Saf ; 18(11): 1091-1098, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31524003

RESUMO

Objectives: Inappropriate prescription is a problem related to aging and deprescription could be a possible strategy. The aim of this study was to adapt the available evidence on deprescribing to the medication management of older people living in long-term care facilities. Methods: The authors carried out a bibliographic search based on the most prevalent drugs in our context to develop a specific deprescribing intervention. A committee of experts reviewed this intervention which was later validated through an interobserver variability study. Finally, the authors evaluated it in a sample of patients through a controlled before-after study. Results: The authors included 119 subjects living in a public elderly long-term care center and 122 controls living in a center with similar clinical characteristics. The authors evaluated 852 medications, identifying a total of 175 (20.5%) potentially inappropriate medications and 162 (92.5%) drugs were deprescribed (1.4 per patient). The application of the intervention meant an annual saving of 9.525.25 €. Conclusion: The implementation of a deprescribing intervention aimed at the most prevalent drugs prescribed in a particular setting improves the appropriateness of pharmacotherapy in the patients.


Assuntos
Desprescrições , Prescrição Inadequada/prevenção & controle , Conduta do Tratamento Medicamentoso/organização & administração , Lista de Medicamentos Potencialmente Inapropriados , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Custos de Medicamentos , Feminino , Instituição de Longa Permanência para Idosos , Humanos , Prescrição Inadequada/economia , Assistência de Longa Duração/normas , Masculino , Casas de Saúde , Padrões de Prática Médica/normas
5.
Presse Med ; 48(7-8 Pt 1): e209-e215, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31421945

RESUMO

AIM: Identified Palliative Care Beds (Lits Identifiés Soins Palliatifs - LISPs) is a French specificity. Primarily created to integrate palliative care culture into conventional hospital units, the relevance of this measure became a controversial issue. Nowadays, hospital teams continue to frequently encounter complex situations regarding medical care for palliative patients. To the best of our knowledge, there is only one study, a quantitative one, bridging the gap about that subject. It showed failure in practicing palliative care work around LISP. Our study is based on a qualitative method that complements the quantitative study. It aimed to describe difficulties that limit palliative care practices in managing adult patients in LISP. METHOD: This qualitative exploratory survey was conducted with a sample of health service professionals (n=20), from senior physicians to caregivers. Each semi-structured interview included open questions regarding their experiences, feelings and difficulties with palliative care practices on LISP. It also included closed questions concerning interviewee's demographics and career course. The data for this research were submitted to a two-stage analysis: first, a global review of each interview was performed to identify trends. Then, a detailed breakdown, question by question, was implemented. RESULTS: From a quantitative perspective, the interviews revealed 305 difficulties, indicating the gaps and barriers limiting the implementation of a palliative approach in these services. From a qualitative perspective, five topics raised our attention by their recurrence in discourses: (1) partial knowledge about palliative care definition and legislation mostly due to a lack of training; (2) need for time; (3) need for human resources; (4) need for communication; (5) hard time in transitioning from curative to palliative care. PERSPECTIVE: This survey gives the opportunity to understand health service professionals' difficulties in practicing palliative care in conventional medical services. It raises the central issue of the pricing reform on the health institutes activity. It also provides angles of inquiry to improve LISP effectiveness. This qualitative and descriptive study was designed to explore difficulties in practicing palliative care around LISP. Nevertheless, according to the size of the sample, results will need to be confirmed by a more extensive qualitative survey.


Assuntos
Continuidade da Assistência ao Paciente , Unidades Hospitalares/organização & administração , Cuidados Paliativos/organização & administração , Equipe de Assistência ao Paciente/organização & administração , Padrões de Prática Médica , Qualidade da Assistência à Saúde/organização & administração , Adulto , Atitude do Pessoal de Saúde , Cuidadores/organização & administração , Cuidadores/normas , Barreiras de Comunicação , Continuidade da Assistência ao Paciente/organização & administração , Continuidade da Assistência ao Paciente/normas , Assistência à Saúde/métodos , Assistência à Saúde/organização & administração , Assistência à Saúde/normas , Arquitetura de Instituições de Saúde/normas , França , Conhecimentos, Atitudes e Prática em Saúde , Número de Leitos em Hospital , Unidades Hospitalares/normas , Humanos , Entrevistas como Assunto , Satisfação no Emprego , Cuidados Paliativos/psicologia , Cuidados Paliativos/normas , Equipe de Assistência ao Paciente/normas , Padrões de Prática Médica/organização & administração , Padrões de Prática Médica/normas , Pesquisa Qualitativa , Qualidade da Assistência à Saúde/normas , Estudos Retrospectivos , Inquéritos e Questionários
7.
Crit Rev Oncol Hematol ; 141: 112-124, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31276964

RESUMO

Protein kinase inhibitors (PKI) are a growing class of anticancer agents. They are prescribed with flat doses, and their oral administration is associated with interindividual variability in exposure. Patients can be over- or underexposed, due to numerous factors. We reviewed key pharmacokinetic concepts and mechanisms by which PKIs prescription could be altered. Challenging situations that could lead to increased toxicity or to therapeutic failure are described and recommendation for clinicians are proposed. Finally, the interest of therapeutic drug monitoring and indications for its use in daily practice is discussed.


Assuntos
Padrões de Prática Médica/normas , Inibidores de Proteínas Quinases/farmacocinética , Inibidores de Proteínas Quinases/uso terapêutico , Área Sob a Curva , Biomarcadores Farmacológicos/análise , Relação Dose-Resposta a Droga , Interações de Medicamentos , Monitoramento de Medicamentos/métodos , Humanos , Inativação Metabólica/fisiologia , Farmacologia Clínica , Padrões de Prática Médica/estatística & dados numéricos , Inibidores de Proteínas Quinases/farmacologia , Distribuição Tecidual
8.
J Stroke Cerebrovasc Dis ; 28(9): 2434-2441, 2019 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-31301984

RESUMO

BACKGROUND AND AIM: In recent years, interest in the quality of medical care has rapidly increased worldwide. However, quality indicators that contribute to establishing standard treatment in stroke medicine, especially rehabilitation, are not well-developed in Japan. Japan has established Kaifukuki (convalescent) rehabilitation wards, and the development of quality indicators for stroke rehabilitation in the convalescent phase is an urgent issue. METHODS: We first reviewed the literature regarding quality indicators for stroke rehabilitation. Next, we extracted candidate indicators from identified reports and guidelines and surveyed educational hospitals certified by the Japanese Association of Rehabilitation Medicine. On the basis of the survey results, we reevaluated the suitability of the proposed indicators in discussions with an expert panel. RESULTS: The questionnaire survey highlighted several important items that revealed there is room for improvement in adherence. For stroke rehabilitation in the convalescent phase, we adopted 15 indicators that were feasible as indicators to be used for comparisons between facilities, based on scoring by and opinions of the expert panel. These indicators measured structure (2 indicators), process (5 indicators), and outcome (8 indicators). CONCLUSION: This is the first study to establish quality indicators to standardize stroke rehabilitation in Japan. We developed this set of 15 indicators using an evidence-based approach. However, many tasks remain for continuous quality improvement.


Assuntos
Fidelidade a Diretrizes/normas , Avaliação de Processos e Resultados (Cuidados de Saúde)/normas , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Reabilitação do Acidente Vascular Cerebral/normas , Acidente Vascular Cerebral/terapia , Avaliação da Deficiência , Pesquisas sobre Serviços de Saúde , Nível de Saúde , Humanos , Japão/epidemiologia , Recuperação de Função Fisiológica , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
9.
N Engl J Med ; 381(2): 111-120, 2019 07 11.
Artigo em Inglês | MEDLINE | ID: mdl-31291514

RESUMO

BACKGROUND: Point-of-care testing of C-reactive protein (CRP) may be a way to reduce unnecessary use of antibiotics without harming patients who have acute exacerbations of chronic obstructive pulmonary disease (COPD). METHODS: We performed a multicenter, open-label, randomized, controlled trial involving patients with a diagnosis of COPD in their primary care clinical record who consulted a clinician at 1 of 86 general medical practices in England and Wales for an acute exacerbation of COPD. The patients were assigned to receive usual care guided by CRP point-of-care testing (CRP-guided group) or usual care alone (usual-care group). The primary outcomes were patient-reported use of antibiotics for acute exacerbations of COPD within 4 weeks after randomization (to show superiority) and COPD-related health status at 2 weeks after randomization, as measured by the Clinical COPD Questionnaire, a 10-item scale with scores ranging from 0 (very good COPD health status) to 6 (extremely poor COPD health status) (to show noninferiority). RESULTS: A total of 653 patients underwent randomization. Fewer patients in the CRP-guided group reported antibiotic use than in the usual-care group (57.0% vs. 77.4%; adjusted odds ratio, 0.31; 95% confidence interval [CI], 0.20 to 0.47). The adjusted mean difference in the total score on the Clinical COPD Questionnaire at 2 weeks was -0.19 points (two-sided 90% CI, -0.33 to -0.05) in favor of the CRP-guided group. The antibiotic prescribing decisions made by clinicians at the initial consultation were ascertained for all but 1 patient, and antibiotic prescriptions issued over the first 4 weeks of follow-up were ascertained for 96.9% of the patients. A lower percentage of patients in the CRP-guided group than in the usual-care group received an antibiotic prescription at the initial consultation (47.7% vs. 69.7%, for a difference of 22.0 percentage points; adjusted odds ratio, 0.31; 95% CI, 0.21 to 0.45) and during the first 4 weeks of follow-up (59.1% vs. 79.7%, for a difference of 20.6 percentage points; adjusted odds ratio, 0.30; 95% CI, 0.20 to 0.46). Two patients in the usual-care group died within 4 weeks after randomization from causes considered by the investigators to be unrelated to trial participation. CONCLUSIONS: CRP-guided prescribing of antibiotics for exacerbations of COPD in primary care clinics resulted in a lower percentage of patients who reported antibiotic use and who received antibiotic prescriptions from clinicians, with no evidence of harm. (Funded by the National Institute for Health Research Health Technology Assessment Program; PACE Current Controlled Trials number, ISRCTN24346473.).


Assuntos
Antibacterianos/uso terapêutico , Proteína C-Reativa/análise , Prescrição Inadequada/prevenção & controle , Testes Imediatos , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Idoso , Biomarcadores/sangue , Feminino , Nível de Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Doença Pulmonar Obstrutiva Crônica/sangue
11.
Presse Med ; 48(7-8 Pt 1): 767-779, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31303371

RESUMO

OBJECTIVES: In France, too few general practitioners (GP) follow the training about suicide prevention and risk. This study aimed at reviewing international publications regarding GP's training on suicide risk, in order to inform us about the training practices in the world and potentially discover new methodologies. METHODS: We performed bibliographic databases searches on GPs training about suicide prevention and risk, for practicing GPs, excluding studies about particular population groups, following the PRISMA statement guidelines. Training duration, educational program, content, time of assessment, tools, and information about train the trainers or kirkpatrick's level were identified for each selected study. RESULTS: This review revealed that there is no consensus on the training program or on the assessment tools in GP's training about suicide prevention and risk. Nevertheless, it reveals a similar framework including a theoretical part, with a fundamental knowledge content, and an interactive part. CONCLUSION: If reaching standardized training practices seems difficult to achieve, standardizing assessment tools might be a relevant purpose. Indeed, using the same tools would allow proper training comparison. Practically speaking, this review inspired us in the implementation of in situ training and convincing us to undertake a French translation of an assessment scale.


Assuntos
Medicina Geral/educação , Clínicos Gerais/educação , Suicídio/prevenção & controle , Estudos de Casos e Controles , Educação Médica Continuada/métodos , Educação Médica Continuada/normas , Educação Médica Continuada/estatística & dados numéricos , Avaliação Educacional , França/epidemiologia , Medicina Geral/métodos , Medicina Geral/normas , Medicina Geral/estatística & dados numéricos , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Aprendizagem Baseada em Problemas/métodos , Aprendizagem Baseada em Problemas/normas , Suicídio/estatística & dados numéricos , Tentativa de Suicídio/prevenção & controle , Tentativa de Suicídio/estatística & dados numéricos
12.
Expert Rev Clin Pharmacol ; 12(7): 643-659, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31155978

RESUMO

Introduction: Combined antiretroviral therapy has transformed HIV infection into a chronic disease thus people living with HIV (PLWH) live longer. As a result, the management of HIV infection is becoming more challenging as elderly experience age-related comorbidities leading to complex polypharmacy and a higher risk for drug-drug or drug-disease interactions. Furthermore, age-related physiological changes affect pharmacokinetics and pharmacodynamics thereby predisposing elderly PLWH to incorrect dosing or inappropriate prescribing and consequently to adverse drug reactions and the subsequent risk of starting a prescribing cascade. Areas covered: This review discusses the demographics of the aging HIV population, physiological changes and their impact on drug response as well as comorbidities. Particular emphasis is placed on common prescribing issues in elderly PLWH including drug-drug interactions with antiretroviral drugs. A PubMed search was used to compile relevant publications until February 2019. Expert opinion: Prescribing issues are highly prevalent in elderly PLWH thus highlighting the need for education on geriatric prescribing principles. Adverse health outcomes potentially associated with polypharmacy and inappropriate prescribing should promote interventions to prevent harm including medication reconciliation, medication review, and medication prioritization according to the risks/benefits for a given patient. A multidisciplinary team approach is recommended for the care of elderly PLWH.


Assuntos
Fármacos Anti-HIV/administração & dosagem , Infecções por HIV/tratamento farmacológico , Padrões de Prática Médica/normas , Fatores Etários , Idoso , Envelhecimento , Fármacos Anti-HIV/efeitos adversos , Interações de Medicamentos , Humanos , Prescrição Inadequada/prevenção & controle , Reconciliação de Medicamentos/métodos , Equipe de Assistência ao Paciente/organização & administração , Polimedicação
13.
Expert Rev Clin Pharmacol ; 12(8): 749-755, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31232610

RESUMO

Introduction: With the majority of elderly persons consuming multiple drugs, inappropriate drug use is a major issue in geriatric medicine. Areas covered: We reviewed PubMed, Embase, and Cochrane from inception to 1 May 2019 for potentially inappropriate use of medications, polypharmacy, and age-dependent changes in pharmacokinetics and pharmacodynamics. We selected to highlight new aspects that have emerged in recent years: appropriate monitoring of drug adherence and the introduction of Big Data analysis in advancing geriatric pharmacology. Expert opinion: There are major gaps in the pharmacological treatment of the elderly. Most drugs were designed and tested in adults, with no pharmacokinetic and pharmacodynamic data on changes in old age. This void must be corrected through systematic and well-designed research programs. Potentially inappropriate use of medications (PIM) in the elderly is a serious issue in advanced age. Analysis of PIM shows relatively low predictive value in real life medicine. Most physicians continue to prescribe to the elderly medicines which should not be given at all, or not combined. Polypharmacy is a complex issue in old age, and in many cases treating physicians are not conducting critical assessment of the need for numerous medications.


Assuntos
Prescrição Inadequada/estatística & dados numéricos , Lista de Medicamentos Potencialmente Inapropriados/estatística & dados numéricos , Padrões de Prática Médica/normas , Adulto , Fatores Etários , Idoso , Humanos , Adesão à Medicação , Polimedicação , Projetos de Pesquisa , Fatores de Risco
14.
Int Braz J Urol ; 45(4): 732-738, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31184455

RESUMO

Minimally invasive urologic surgery has been developing in Brazil and now is a routine part of care in many regions and patients with different conditions benefit from it. Training in laparoscopic and robotic surgery has evolved and concerns exist both over the quality of surgical training and the practical effect on results of the urological training. This is an unprecedented study which undertook a census to determinate the current state of laparoscopic and robotic urological practice and to know the mains barriers to adequate practice in Brazil. In august 2017, surveys, consisting of an anonymous questionnaire with 15 questions, were sent via internet to the mailing list of the Brazilian Society of Urology (SBU). With these data, activities related to laparoscopy and robotic surgery of our urologists and the mains difficulties and barriers to practice laparoscopy and robotic surgery were evaluated. In our survey, 413 questionnaires were completed. Majority of the responders were currently working in the southeast region of Brazil (52.1%) and 75.5% of the surgeons performed laparoscopic surgery while, only 12.8%, robotic surgery. The lack of experience on the technique and the lack of equipment were the mains barriers and difficulties for not executing laparoscopic and robotic surgeries, respectively. Proper longitudinal training and access to good equipment in minimally invasive surgery are still barriers for urologists in our country.


Assuntos
Laparoscopia/normas , Padrões de Prática Médica/normas , Procedimentos Cirúrgicos Robóticos/normas , Procedimentos Cirúrgicos Urológicos/normas , Urologistas/normas , Brasil , Humanos , Laparoscopia/métodos , Laparoscopia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Procedimentos Cirúrgicos Robóticos/métodos , Procedimentos Cirúrgicos Robóticos/estatística & dados numéricos , Inquéritos e Questionários , Procedimentos Cirúrgicos Urológicos/métodos , Procedimentos Cirúrgicos Urológicos/estatística & dados numéricos , Urologistas/estatística & dados numéricos , Urologia/normas
15.
BMC Health Serv Res ; 19(1): 272, 2019 Apr 30.
Artigo em Inglês | MEDLINE | ID: mdl-31039784

RESUMO

BACKGROUND: The appropriateness of psychotropic prescriptions in the elderly is a major quality-of-care challenge at hospital. Quality indicators have been developed to prevent inappropriate psychotropic prescriptions. We aimed to select and automatically calculate such indicators, from the Bordeaux University Hospital information system, and to analyze the appropriateness of psychotropic prescription practices, in an observational study. METHODS: Experts selected indicators of the appropriateness of psychotropic prescriptions in hospitalized elderly patients, according to guidelines from the French High Authority for Health. The indicators were reformulated to focus on psychotropic administrations. The automated calculation of indicators was analyzed by comparing their measure to data collected from a clinical audit. In elderly patients hospitalized between 2014 and 2015, we then analyzed the evolution of the appropriateness of psychotropic prescription practices during hospital stay, using methods of visualization, and described practices by considering patients' characteristics. RESULTS: Two indicators were automated to detect overuse and misuse of psychotropic drugs. Indicators identified frequent inappropriate drug administrations, but practices tended to become more appropriate after quality-of-care improvement actions. In the majority of patients (85%), there was no inappropriate administration of psychotropic drugs during hospital stay; for the remaining 15% with at least one inappropriate administration, physicians tended to limit overuse or misuse during hospital stay. Inappropriate administrations were more frequent in patients suffering from psychiatric disorders, dependence and associated complications or morbidities. CONCLUSIONS: The automated indicators are structuring tools for the development of a drug prescription monitoring system. Inappropriate psychotropic administrations were limited by physicians during hospital stay; some inappropriate prescriptions might be explained by clinical characteristics of patients.


Assuntos
Prescrição Inadequada/prevenção & controle , Transtornos Mentais/tratamento farmacológico , Padrões de Prática Médica/normas , Psicotrópicos/uso terapêutico , Idoso , Idoso de 80 Anos ou mais , Auditoria Clínica , Prescrições de Medicamentos/estatística & dados numéricos , Feminino , Sistemas de Informação Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Padrões de Prática Médica/estatística & dados numéricos
16.
Genet Epidemiol ; 43(6): 609-616, 2019 09.
Artigo em Inglês | MEDLINE | ID: mdl-31045282

RESUMO

With the advent of very large scale genome-wide association studies (GWASs), the promise of Mendelian randomization (MR) has begun to be fulfilled. However, whilst GWASs have provided essential information on the single nucleotide polymorphisms (SNPs) associated with modifiable risk factors needed for MR, the availability of large numbers of SNP instruments raises issues of how best to use this information and how to deal with potential problems such as pleiotropy. Here we provide commentary on some of the recent advances in the MR analysis, including an overview of the different genetic architectures that are being uncovered for a variety of modifiable risk factors and how users ought to take that into consideration when designing MR studies.


Assuntos
Doença/genética , Pleiotropia Genética/genética , Estudo de Associação Genômica Ampla , Implementação de Plano de Saúde , Análise da Randomização Mendeliana , Polimorfismo de Nucleotídeo Único , Padrões de Prática Médica/normas , Clínicos Gerais/normas , Humanos , Fatores de Risco
17.
Ann Vasc Surg ; 59: 248-258, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31132446

RESUMO

BACKGROUND: Ambulatory hospitalization for endovascular repair of lower extremity peripheral arterial disease (PAD) could be a real opportunity to respond to the burden of PAD, to reduce costs, and to improve patients' empowerment. The French Society of Vascular and Endovascular Surgery (SCVE) established guidelines to facilitate the development of ambulatory hospitalization in France. METHODS: In 2017, we used the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and MEDLINE database to conduct a systematic review of available literature. A total of 448 relevant articles were found. Twelve articles, all published after the year 2000, were included and reviewed by two independent investigators. The SCVE mandated a scientific committee to collectively establish these guidelines. RESULTS: Eligibility for ambulatory management shall be based on the assessment of the triad: (1) patient, (2) procedure, and (3) structure. Comprehensive information and a detailed procedural pathway should be provided for the patient. No age limit is recommended. American Society of Anesthesiologists I, II, and III stable patients are eligible for ambulatory intervention. Specific comorbidities such as severe obesity, sleep apnea, and/or chronic kidney failure should be assessed preoperatively. Critical limb ischemia and complex lesions have not been considered as exclusion criteria. Antiplatelet drug use (aspirin and/or clopidogrel) has not been considered as a contraindication. Femoral ultrasound-guided puncture is recommended. Manual compression or closure devices have been recommended for 7F sheath or less. A minimum of 4 hours of monitoring after percutaneous femoral access is required before discharge. CONCLUSIONS: The SCVE guidelines aim to frame the practice of ambulatory endovascular procedures for lower extremity peripheral artery disease and to give vascular interventionalists help in their routine practice.


Assuntos
Procedimentos Cirúrgicos Ambulatórios/normas , Procedimentos Endovasculares/normas , Extremidade Inferior/irrigação sanguínea , Doença Arterial Periférica/cirurgia , Padrões de Prática Médica/normas , Procedimentos Cirúrgicos Ambulatórios/efeitos adversos , Tomada de Decisão Clínica , Consenso , Procedimentos Endovasculares/efeitos adversos , França , Fidelidade a Diretrizes/normas , Humanos , Resultado do Tratamento
18.
J Stroke Cerebrovasc Dis ; 28(8): 2155-2158, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31103551

RESUMO

OBJECTIVE: To determine adherence to nimodipine administration in patients admitted with aneurysmal subarachnoid hemorrhage (aSAH). BACKGROUND: Oral nimodipine (60 mg every 4 hours for 21 days) is recommended by the national guidelines for aSAH. A Cochrane systematic review has determined that nimodipine reduces the risk of cerebral ischemia and is currently the only effective drug for the prevention of vasospasm in aSAH patients. DESIGN/METHODS: We retrospectively analyzed 109 patients with aSAH admitted to the Neurosciences Intensive Care Unit (NICU) at a tertiary care medical center between 2010 and 2013. Nimodipine-prescribing patterns, days of therapy completed, and adverse effects were tabulated. Patients not initiated on nimodipine and reasons for prematurely stopping therapy were noted. RESULTS: One hundred two (93%) patients with aSAH were started on oral nimodipine upon admission to the NICU. Early death (3%) and hypotension (1%) were reasons why patients were not started on nimodipine. Only 36 (33%) patients received nimodipine, 60 mg orally every 4 hours for 21 days. In 26 patients (39%), the dose of nimodipine was reduced because of excessive drops in blood pressure. Transient discontinuation occurred in 2 (2%) patients. Thirty one (47%) patients were discharged from the hospital before 21 days and nimodipine was not ordered to continue at home. CONCLUSION: We found that the majority of patients with aSAH in our practice did not complete 21 days of nimodipine. Hypotension was mostly responsible for dosing change or discontinuation.


Assuntos
Pressão Sanguínea/efeitos dos fármacos , Bloqueadores dos Canais de Cálcio/administração & dosagem , Nimodipina/administração & dosagem , Padrões de Prática Médica , Hemorragia Subaracnóidea/tratamento farmacológico , Vasodilatadores/administração & dosagem , Administração Oral , Adulto , Idoso , Bloqueadores dos Canais de Cálcio/efeitos adversos , Esquema de Medicação , Feminino , Fidelidade a Diretrizes , Humanos , Hipotensão/induzido quimicamente , Hipotensão/fisiopatologia , Masculino , Pessoa de Meia-Idade , Nimodipina/efeitos adversos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Padrões de Prática Médica/tendências , Estudos Retrospectivos , Fatores de Risco , Hemorragia Subaracnóidea/diagnóstico , Hemorragia Subaracnóidea/fisiopatologia , Fatores de Tempo , Resultado do Tratamento , Vasodilatadores/efeitos adversos
19.
Gac Med Mex ; 155(2): 202-203, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31056602

RESUMO

Doctors require flexibility for prescription. However, some limits are laid down both by current knowledge and by restrictions imposed by access and rules and regulations. The Committee for Ethics and Transparency in the Physician-Industry Relationship (CETREMI) of the National Academy of Medicine proposes several suggestions to help patients, which include the selection of the best alternatives for each case, formalization of prescription standards variations (doses, drug indications, etc.) written down in the medical records, and avoidance of fashions, untested novelties, argumentations solely based on advertising or commercial promotion and conflicts of interest.


Assuntos
Ética Médica , Médicos/organização & administração , Padrões de Prática Médica/normas , Comitês Consultivos , Humanos , México , Médicos/ética , Padrões de Prática Médica/ética
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