Your browser doesn't support javascript.
loading
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 67.696
Filtrar
1.
Curr Oncol ; 28(3): 2007-2013, 2021 05 26.
Artigo em Inglês | MEDLINE | ID: mdl-34073214

RESUMO

The COVID-19 situation is a worldwide health emergency with strong implications in clinical oncology. In this viewpoint, we address two crucial dilemmas from the ethical dimension: (1) Is it ethical to postpone or suspend cancer treatments which offer a statistically significant benefit in quality of life and survival in cancer patients during this time of pandemic?; (2) Should we vaccinate cancer patients against COVID-19 if scientific studies have not included this subgroup of patients? Regarding the first question, the best available evidence applied to the ethical principles of Beauchamp and Childress shows that treatments (such as chemotherapy) with clinical benefit are fair and beneficial. Indeed, the suspension or delay of such treatments should be considered malefic. Regarding the second question, applying the doctrine of double-effect, we show that the potential beneficial effect of vaccines in the population with cancer (or those one that has had cancer) is much higher than the potential adverse effects of these vaccines. In addition, there is no better and less harmful known solution.


Assuntos
COVID-19/prevenção & controle , Tomada de Decisão Clínica/ética , Neoplasias/tratamento farmacológico , Seleção de Pacientes/ética , Tempo para o Tratamento/ética , Antineoplásicos/administração & dosagem , COVID-19/epidemiologia , COVID-19/imunologia , COVID-19/virologia , Vacinas contra COVID-19/administração & dosagem , Vacinas contra COVID-19/efeitos adversos , Humanos , Oncologia/ética , Neoplasias/imunologia , Neoplasias/mortalidade , Neoplasias/psicologia , Pandemias/prevenção & controle , Qualidade de Vida , Fatores de Risco , SARS-CoV-2/imunologia , Fatores de Tempo , Vacinação/efeitos adversos , Vacinação/ética
3.
BMJ Open ; 11(6): e043906, 2021 06 16.
Artigo em Inglês | MEDLINE | ID: mdl-34135032

RESUMO

RATIONALE: Clinical trials are the gold standard for testing interventions. COVID-19 has further raised their public profile and emphasised the need to deliver better, faster, more efficient trials for patient benefit. Considerable overlap exists between data required for trials and data already collected routinely in electronic healthcare records (EHRs). Opportunities exist to use these in innovative ways to decrease duplication of effort and speed trial recruitment, conduct and follow-up. APPROACH: The National Institute of Health Research (NIHR), Health Data Research UK and Clinical Practice Research Datalink co-organised a national workshop to accelerate the agenda for 'data-enabled clinical trials'. Showcasing successful examples and imagining future possibilities, the plenary talks, panel discussions, group discussions and case studies covered: design/feasibility; recruitment; conduct/follow-up; collecting benefits/harms; and analysis/interpretation. REFLECTION: Some notable studies have successfully accessed and used EHR to identify potential recruits, support randomised trials, deliver interventions and supplement/replace trial-specific follow-up. Some outcome measures are already reliably collected; others, like safety, need detailed work to meet regulatory reporting requirements. There is a clear need for system interoperability and a 'route map' to identify and access the necessary datasets. Researchers running regulatory-facing trials must carefully consider how data quality and integrity would be assessed. An experience-sharing forum could stimulate wider adoption of EHR-based methods in trial design and execution. DISCUSSION: EHR offer opportunities to better plan clinical trials, assess patients and capture data more efficiently, reducing research waste and increasing focus on each trial's specific challenges. The short-term emphasis should be on facilitating patient recruitment and for postmarketing authorisation trials where research-relevant outcome measures are readily collectable. Sharing of case studies is encouraged. The workshop directly informed NIHR's funding call for ambitious data-enabled trials at scale. There is the opportunity for the UK to build upon existing data science capabilities to identify, recruit and monitor patients in trials at scale.


Assuntos
COVID-19 , Humanos , Seleção de Pacientes , SARS-CoV-2 , Reino Unido
4.
BMC Infect Dis ; 21(1): 519, 2021 Jun 02.
Artigo em Inglês | MEDLINE | ID: mdl-34078315

RESUMO

BACKGROUND: Late presentation remains a key barrier towards controlling the HIV epidemic. Indicator conditions (ICs) are those that are AIDS-defining, associated with a prevalence of undiagnosed HIV > 0.1%, or whose clinical management would be impeded if an HIV infection were undiagnosed. IC-guided HIV testing is an effective strategy in identifying undiagnosed HIV, but opportunities for earlier HIV diagnosis through IC-guided testing are being missed. We present a protocol for an interventional study to improve awareness of IC-guided testing and increase HIV testing in patients presenting with ICs in a hospital setting. METHODS: We designed a multicentre interventional study to be implemented at five hospitals in the region of Amsterdam, the Netherlands. Seven ICs were selected for which HIV test ratios (proportion of patients with an IC tested for HIV) will be measured: tuberculosis, cervical/vulvar cancer or high-grade cervical/vulvar dysplasia, malignant lymphoma, hepatitis B and C, and peripheral neuropathy. Prior to the intervention, a baseline assessment of HIV test ratios across ICs will be performed in eligible patients (IC diagnosed January 2015 through May 2020, ≥18 years, not known HIV positive) and an assessment of barriers and facilitators for HIV testing amongst relevant specialties will be conducted using qualitative (interviews) and quantitative methods (questionnaires). The intervention phase will consist of an educational intervention, including presentation of baseline results as competitive graphical audit and feedback combined with discussion on implementation and opportunities for improvement. The effect of the intervention will be assessed by comparing HIV test ratios of the pre-intervention and post-intervention periods. The primary endpoint is the HIV test ratio within ±3 months of IC diagnosis. Secondary endpoints are the HIV test ratio within ±6 months of diagnosis, ratio ever tested for HIV, HIV positivity percentage, proportion of late presenters and proportion with known HIV status prior to initiating treatment for their IC. DISCUSSION: This protocol presents a strategy aimed at increasing awareness of the benefits of IC-guided testing and increasing HIV testing in patients presenting with ICs in hospital settings to identify undiagnosed HIV in Amsterdam, the Netherlands. TRIAL REGISTRATION: Dutch trial registry: NL7521 . Registered 14 February 2019.


Assuntos
Infecções por HIV/diagnóstico , Programas de Rastreamento/métodos , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Teste de HIV , Hospitais , Humanos , Países Baixos/epidemiologia , Seleção de Pacientes , Prevalência
5.
Urologe A ; 60(6): 732-739, 2021 Jun.
Artigo em Alemão | MEDLINE | ID: mdl-34061221

RESUMO

In implant surgery for erectile dysfunction and urinary incontinence, adequate patient selection is essential for postoperative therapy success. Several scientific studies report patient satisfaction rates for penile implants and artificial urinary sphincter implantation of over 90%. Nevertheless, studies also report, that between 5 and 30% of the patients are not satisfied with the result of their operation. Sufficient patient information and consent prior surgical procedure in urological prosthetics are a key determinant for later patient satisfaction and therapy success. Diligent assessment of realistic expectations, possible complications, and risks must be made. Unrealistic and exaggerated expectations need to be met and discussed with the patient. Therefore adequate physician-patient communication is essential. Especially in the case of surgical revision or for patients with risk factors, the probability of complications is higher and may significantly increase later dissatisfaction. Also, the involvement of the partner plays a major role in later patient satisfaction in urological implant surgery. Finally, there is a group of patients for which the risk of later dissatisfaction is particularly high. These are patients with compulsive/obsessive behavior, unrealistic expectations, patients after revision surgery, self-entitled patients, as well as those patients who deny the extent of their illness, visit multiple surgeons (surgeon hopping) or have psychiatric illnesses. These patients are referred to with the acronym "CURSED" patients.


Assuntos
Disfunção Erétil , Implante Peniano , Prótese de Pênis , Urologia , Comunicação , Disfunção Erétil/cirurgia , Humanos , Consentimento Livre e Esclarecido , Masculino , Satisfação do Paciente , Seleção de Pacientes
7.
BMJ Open ; 11(6): e047786, 2021 06 04.
Artigo em Inglês | MEDLINE | ID: mdl-34088709

RESUMO

OBJECTIVES: Twenty per cent of people with alcohol use disorders develop advanced fibrosis and warrant referral to secondary care. Improving outcomes in alcohol-related liver disease (ArLD) relies on its earlier detection in primary care with non-invasive tests (NIT). We aimed to determine the proportion of alcohol-related referrals who were diagnosed with advanced fibrosis in secondary care, the prevalence of both alcohol and fatty liver disease ('BAFLD') and the potential impact of NIT on referral stratification. DESIGN/SETTING: Retrospective analysis of all general practitioner-referrals with suspected ArLD/non-alcoholic fatty liver disease (NAFLD) to a UK hepatology-centre between January 2015 and January 2018. PARTICIPANTS: Of 2944 new referrals, 762 (mean age 55.5±13.53 years) met inclusion criteria: 531 NAFLD and 231 ArLD, of which 147 (64%) could be reclassified as 'BAFLD'. PRIMARY OUTCOME MEASURE: Proportion of referrals with suspected ArLD/NAFLD with advanced fibrosis as assessed by tertiary centre hepatologists using combinations of FibroScan, imaging, examination and blood tests and liver histology, where indicated. SECONDARY OUTCOME MEASURES: Included impact of body mass index/alcohol consumption on the odds of a diagnosis of advanced fibrosis, and performance of NIT in predicting advanced fibrosis in planned post-hoc analysis of referrals. RESULTS: Among ArLD referrals 147/229 (64.2%) had no evidence of advanced fibrosis and were judged 'unnecessary'. Advanced fibrosis was observed in men drinking ≥50 units per week (U/w) (OR 2.74, 95% CI 1.51 to 5, p=0.001) and ≥35 U/w in women (OR 5.11, 95% CI 1.31 to 20.03, p=0.019). Drinking >14 U/w doubled the likelihood of advanced fibrosis in overweight/obesity (OR 2.11; 95% CI 1.44 to 3.09; p<0.001). Use of fibrosis 4 score could halve unnecessary referrals (OR 0.50; 95% CI 0.32 to 0.79, p=0.003) with false-negative rate of 22%, but was rarely used. CONCLUSIONS: The majority of referrals with suspected ArLD were deemed unnecessary. NIT could improve identification of liver damage in ArLD, BAFLD and NAFLD in primary care. Anecdotal thresholds for harmful drinking (35 U/w in women and 50 U/w in men) were validated. The impact of alcohol on NAFLD highlights the importance of multi-causality in chronic liver disease.


Assuntos
Alcoolismo , Hepatopatia Gordurosa não Alcoólica , Adulto , Idoso , Feminino , Testes Hematológicos , Humanos , Cirrose Hepática/diagnóstico , Cirrose Hepática/epidemiologia , Masculino , Pessoa de Meia-Idade , Hepatopatia Gordurosa não Alcoólica/diagnóstico , Hepatopatia Gordurosa não Alcoólica/epidemiologia , Seleção de Pacientes , Atenção Primária à Saúde , Encaminhamento e Consulta , Estudos Retrospectivos , Atenção Secundária à Saúde , Reino Unido/epidemiologia
14.
Surg Clin North Am ; 101(3): 467-482, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34048766

RESUMO

Salvage esophagectomy is an option for patients with recurrent or persistent esophageal cancer after definitive chemoradiation therapy or those who undergo active surveillance after induction chemoradiation therapy. Salvage resection is associated with higher rates of morbidity compared with planned esophagectomy but offers patients with locally advanced disease a chance at improved long-term survival. Salvage resection should be preferentially performed in a multidisciplinary setting by high-volume and experienced surgeons. Technical considerations, such as prior radiation dosage, radiation field, and choice of conduit, should be taken into account.


Assuntos
Adenocarcinoma/cirurgia , Carcinoma de Células Escamosas/cirurgia , Neoplasias Esofágicas/cirurgia , Esofagectomia/métodos , Terapia de Salvação/métodos , Adenocarcinoma/terapia , Carcinoma de Células Escamosas/terapia , Quimiorradioterapia , Neoplasias Esofágicas/terapia , Humanos , Terapia Neoadjuvante , Seleção de Pacientes , Fatores de Tempo , Resultado do Tratamento
16.
BMC Surg ; 21(1): 255, 2021 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-34022853

RESUMO

BACKGROUND: The area which located at the medial pedicle, posterior vertebral body and ventral hemilamina is defined as the hidden zone. Surgical management of hidden zone lumbar disc herniation (HZLDH) is technically challenging due to its difficult surgical exposure. The conventional interlaminar approach harbors the potential risk of post-surgical instability, while other approaches consist of complicated procedures with a steep learning curve and prolonged operation time. OBJECTIVE: To introduce microscopic extra-laminar sequestrectomy (MELS) technique for treatment of hidden zone lumbar disc herniation and present clinical outcomes. METHODS: Between Jan 2016 to Jan 2018, twenty one patients (13 males) with HZLDH were enrolled in this study. All patients underwent MELS (19 patients underwent sequestrectomy only, 2 patients underwent an additional inferior discectomy). The nerve root and fragment were visually exposed using MELS. The operation duration, blood loss, intra- and postoperative complications, and recurrences were recorded. The Visual Analog Scale (VAS), Oswestry Disability Index (ODI), and the modified MacNab criteria were used to evaluate clinical outcomes. Postoperative stability was evaluated both radiologically and clinically. RESULTS: The mean follow-up period was 20.95 ± 2.09 (18-24) months. The mean operation time was 32.43 ± 7.19 min and the mean blood loss was 25.52 ± 5.37 ml. All patients showed complete neurological symptom relief after surgery. The VAS and ODI score were significantly improved at the final follow-up compared to those before operation (7.88 ± 0.70 vs 0.10 ± 0.30, 59.24 ± 10.83 vs 11.29 ± 3.59, respectively, p < 0.05). Seventeen patients (81%) obtained an "excellent" outcome and the remaining four (19%) patients obtained a "good" outcome based the MacNab criteria. One patient suffered reherniation at the same level one year after the initial surgery and underwent a transforaminal endoscopic discectomy. No major complications and postoperative instability were observed. CONCLUSIONS: Our observation suggest that MELS is safe and effective in the management of HZLDH. Due to its relative simplicity, it comprises a flat surgical learning curve and shorter operation duration, and overall results in reduced disturbance to lumbar stability.


Assuntos
Discotomia Percutânea , Deslocamento do Disco Intervertebral , Discotomia , Endoscopia , Humanos , Deslocamento do Disco Intervertebral/diagnóstico por imagem , Deslocamento do Disco Intervertebral/cirurgia , Vértebras Lombares/cirurgia , Masculino , Seleção de Pacientes , Estudos Retrospectivos , Resultado do Tratamento
18.
BMC Gastroenterol ; 21(1): 219, 2021 May 13.
Artigo em Inglês | MEDLINE | ID: mdl-33985430

RESUMO

BACKGROUND: Schistosoma mansoni related hepatic fibrosis is usually associated with hemodynamic alteration with increased mortality due to bleeding varices. The diagnosis of varices before bleeding imposes a big challenge in resource-limited countries using endoscopy. Published evidence on the utility of non-invasive clinical tools in predicting the presence of varices among patients with S. mansoni related periportal fibrosis is still inadequate including Aspartate to platelet ratio index (APRI) and Platelet to splenic diameter ratio (PSDR) levels. This study describes the determinants of portal varices and assesses the potential utility of the APRI and PSDR level in the discrimination of portal varices among patients with S. mansoni related periportal fibrosis (PPF). METHODS: A case-control study using cross-sectional data was done among patients with Schistosoma mansoni related periportal fibrosis at Bugando Medical Centre, in Mwanza Tanzania. The derivation cohort included patients enrolled between 2015 and 2019 and the validation cohort included patients enrolled from 2019 till March 2021. Socio-demographic, laboratory, ultrasound, and upper digestive endoscopic information were analyzed using STATA 13. The prevalence and determinants of varices were determined by logistic regression. The sensitivity and specificity of independent factors were determined to assess their utility in discriminating the presence of portal varices in patients with PPF. RESULTS: In total, 250 patients were included in the derivation cohort, 109 (43.6%; 95% CI 37.3-49.9) of them had varices. The odds of having varices were independently increased among patients with higher APRI levels than 1.51, (AOR: 5.8; 95% CI 3.1-11.1; p < 0.001) and PSDR levels that were lower than 5700 (AOR: 5.9; 95% CI 3.2-11.2; p < 0.001). Both APRI and PSDR levels had significantly high sensitivity and specificity in predicting the presence of esophageal varices. However, the combined values of APRI and PSDR had higher specificity than any of the two markers. Of the 200 patients in the validation cohort 94 (47.0%; 95% CI 40.0-54.2) had varices, the discriminative power of the final model and the predictive ability of both APRI, PSDR, and APRI-PSDR combined levels were highly maintained. CONCLUSIONS: This study indicates that varices are a common encounter among patients with S. mansoni related periportal fibrosis and it is independently associated with higher APRI and lower PSDR levels suggesting that these tools are potential discriminators of varices in this subgroup of patients. The reproducibility of these results should further be assessed longitudinally as potential non-invasive tools in selecting patients at high risk of having esophageal varices who could benefit from the targeted endoscopic intervention in a resource-limited setting like ours.


Assuntos
Varizes Esofágicas e Gástricas , Schistosoma mansoni , Animais , Ácido Aspártico , Estudos de Casos e Controles , Estudos Transversais , Endoscopia , Varizes Esofágicas e Gástricas/etiologia , Humanos , Cirrose Hepática/complicações , Seleção de Pacientes , Reprodutibilidade dos Testes , Tanzânia
19.
Maturitas ; 148: 14-17, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34024346

RESUMO

The objective of this project is to create eligibility criteria for the use of menopausal hormone therapy (MHT) similar to those established for contraceptive methods. A consortium of scientific societies coordinated by the Spanish Menopause Society met to formulate recommendations for the use of MHT by patients with medical conditions based on the best available evidence. The project protocol, which was registered in the Open Science Framework platform (DOI 10.17605/OSF.IO/J6WBC), will be conducted in two phases. As a first step we will conduct a series of systematic reviews on the safety of MHT, addressing eight clinical questions. The findings of these systematic reviews will help to inform a structured process in which a panel of experts will define the eligibility criteria according to a specific framework, which will facilitate the discussion and development process. For the first time, a set of eligibility criteria, based on clinical evidence and developed according to the most rigorous methodological tools, will be defined. This will provide health professionals with a powerful decision-making tool that can be used in the management of menopausal symptoms.


Assuntos
Terapia de Reposição Hormonal/métodos , Terapia de Reposição Hormonal/normas , Menopausa/efeitos dos fármacos , Seleção de Pacientes , Projetos de Pesquisa , Sociedades Científicas/organização & administração , Feminino , Humanos , Revisões Sistemáticas como Assunto
20.
Medicine (Baltimore) ; 100(20): e25994, 2021 May 21.
Artigo em Inglês | MEDLINE | ID: mdl-34011092

RESUMO

ABSTRACT: In precision oncology, immune check point blockade therapy has quickly emerged as novel strategy by its efficacy, where programmed death ligand 1 (PD-L1) expression is used as a clinically validated predictive biomarker of response for the therapy. Automating pathological image analysis and accelerating pathology evaluation is becoming an unmet need. Artificial Intelligence and deep learning tools in digital pathology have been studied in order to evaluate PD-L1 expression in PD-L1 immunohistochemistry image. We proposed a Dual-scale Categorization (DSC)-based deep learning method that employed 2 VGG16 neural networks, 1 network for 1 scale, to critically evaluate PD-L1 expression. The DSC-based deep learning method was tested in a cohort of 110 patients diagnosed as non-small cell lung cancer. This method showed a concordance of 88% with pathologist, which was higher than concordance of 83% of 1-scale categorization-based method. Our results show that the DSCbased method can empower the deep learning application in digital pathology and facilitate computer-aided diagnosis.


Assuntos
Antígeno B7-H1/análise , Biomarcadores Tumorais/análise , Carcinoma Pulmonar de Células não Pequenas/diagnóstico , Diagnóstico por Computador/métodos , Neoplasias Pulmonares/diagnóstico , Antígeno B7-H1/antagonistas & inibidores , Antígeno B7-H1/genética , Biomarcadores Tumorais/antagonistas & inibidores , Biomarcadores Tumorais/genética , Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Carcinoma Pulmonar de Células não Pequenas/genética , Carcinoma Pulmonar de Células não Pequenas/patologia , Aprendizado Profundo , Regulação Neoplásica da Expressão Gênica , Humanos , Inibidores de Checkpoint Imunológico/farmacologia , Inibidores de Checkpoint Imunológico/uso terapêutico , Imuno-Histoquímica , Pulmão/imunologia , Pulmão/patologia , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/genética , Neoplasias Pulmonares/patologia , Seleção de Pacientes , Medicina de Precisão/métodos
SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA
...