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4.
BMJ ; 368: l6831, 2020 01 15.
Artigo em Inglês | MEDLINE | ID: mdl-31941686

RESUMO

OBJECTIVES: To determine whether patients discharged after hospital admissions for conditions covered by national readmission programs who received care in emergency departments or observation units but were not readmitted within 30 days had an increased risk of death and to evaluate temporal trends in post-discharge acute care utilization in inpatient units, emergency departments, and observation units for these patients. DESIGN: Retrospective cohort study. SETTING: Medicare claims data for 2008-16 in the United States. PARTICIPANTS: Patients aged 65 or older admitted to hospital with heart failure, acute myocardial infarction, or pneumonia-conditions included in the US Hospital Readmissions Reduction Program. MAIN OUTCOME MEASURES: Post-discharge 30 day mortality according to patients' 30 day acute care utilization; acute care utilization in inpatient and observation units and the emergency department during the 30 day and 31-90 day post-discharge period. RESULTS: 3 772 924 hospital admissions for heart failure, 1 570 113 for acute myocardial infarction, and 3 131 162 for pneumonia occurred. The overall post-discharge 30 day mortality was 8.7% for heart failure, 7.3% for acute myocardial infarction, and 8.4% for pneumonia. Risk adjusted mortality increased annually by 0.05% (95% confidence interval 0.02% to 0.08%) for heart failure, decreased by 0.06% (-0.09% to -0.04%) for acute myocardial infarction, and did not significantly change for pneumonia. Specifically, mortality increased for patients with heart failure who did not utilize any post-discharge acute care, increasing at a rate of 0.08% (0.05% to 0.12%) per year, exceeding the overall absolute annual increase in post-discharge mortality in heart failure, without an increase in mortality in observation units or the emergency department. Concurrent with a reduction in 30 day readmission rates, stays for observation and visits to the emergency department increased across all three conditions during and beyond the 30 day post-discharge period. Overall 30 day post-acute care utilization did not change significantly. CONCLUSIONS: The only condition with increasing mortality through the study period was heart failure; the increase preceded the policy and was not present among patients who received emergency department or observation unit care without admission to hospital. During this period, the overall acute care utilization in the 30 days after discharge significantly decreased for heart failure and pneumonia, but not for acute myocardial infarction.


Assuntos
Unidades de Observação Clínica/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Insuficiência Cardíaca , Infarto do Miocárdio , Pneumonia , Cuidados Semi-Intensivos , Idoso , Idoso de 80 Anos ou mais , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Revisão da Utilização de Seguros , Masculino , Sobremedicalização/prevenção & controle , Medicare/estatística & dados numéricos , Mortalidade , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/terapia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/mortalidade , Pneumonia/terapia , Estudos Retrospectivos , Cuidados Semi-Intensivos/métodos , Cuidados Semi-Intensivos/organização & administração , Cuidados Semi-Intensivos/tendências , Estados Unidos/epidemiologia
5.
N Engl J Med ; 382(6): 503-513, 2020 02 06.
Artigo em Inglês | MEDLINE | ID: mdl-31995683

RESUMO

BACKGROUND: There are limited data from randomized trials regarding whether volume-based, low-dose computed tomographic (CT) screening can reduce lung-cancer mortality among male former and current smokers. METHODS: A total of 13,195 men (primary analysis) and 2594 women (subgroup analyses) between the ages of 50 and 74 were randomly assigned to undergo CT screening at T0 (baseline), year 1, year 3, and year 5.5 or no screening. We obtained data on cancer diagnosis and the date and cause of death through linkages with national registries in the Netherlands and Belgium, and a review committee confirmed lung cancer as the cause of death when possible. A minimum follow-up of 10 years until December 31, 2015, was completed for all participants. RESULTS: Among men, the average adherence to CT screening was 90.0%. On average, 9.2% of the screened participants underwent at least one additional CT scan (initially indeterminate). The overall referral rate for suspicious nodules was 2.1%. At 10 years of follow-up, the incidence of lung cancer was 5.58 cases per 1000 person-years in the screening group and 4.91 cases per 1000 person-years in the control group; lung-cancer mortality was 2.50 deaths per 1000 person-years and 3.30 deaths per 1000 person-years, respectively. The cumulative rate ratio for death from lung cancer at 10 years was 0.76 (95% confidence interval [CI], 0.61 to 0.94; P = 0.01) in the screening group as compared with the control group, similar to the values at years 8 and 9. Among women, the rate ratio was 0.67 (95% CI, 0.38 to 1.14) at 10 years of follow-up, with values of 0.41 to 0.52 in years 7 through 9. CONCLUSIONS: In this trial involving high-risk persons, lung-cancer mortality was significantly lower among those who underwent volume CT screening than among those who underwent no screening. There were low rates of follow-up procedures for results suggestive of lung cancer. (Funded by the Netherlands Organization of Health Research and Development and others; NELSON Netherlands Trial Register number, NL580.).


Assuntos
Tomografia Computadorizada de Feixe Cônico , Detecção Precoce de Câncer/métodos , Neoplasias Pulmonares/diagnóstico por imagem , Neoplasias Pulmonares/mortalidade , Idoso , Bélgica/epidemiologia , Reações Falso-Positivas , Feminino , Humanos , Incidência , Neoplasias Pulmonares/epidemiologia , Masculino , Sobremedicalização , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Sistema de Registros , Fatores Sexuais , Fumar/epidemiologia
7.
Radiol Med ; 125(3): 272-279, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-31784927

RESUMO

OBJECTIVE: The purpose of this study is to investigate the role of cervical radiography in the study of patients with vertigo and dizziness. PATIENTS: This is a retrospective single-institution case series study of 493 patients suffering from vertigo and dizziness who were referred (from January 2011 to December 2012) to the hospital to study those symptoms. METHODS: We studied cervical radiographies, CT and MRI of the cervical spine made in the sample and the radiological findings. We analyzed demographic characteristics, presence of psychiatric pathology and emergency assistance due to vertigo in patients who have undergone cervical study. RESULTS: A total of 57% of patients had cervical radiography made; this was more frequent in women, Spanish people, with psychiatric pathology and who have gone to the emergency department for vertigo (p < 0.05). Degenerative changes were found in 74.1% of the patients with radiography made, more frequently at an older age, osteophytes in 49.5% and abnormal cervical lordosis in 37.1%. CONCLUSIONS: There are sociodemographic factors that influence in the request for cervical radiographs in patients with vertigo and dizziness. Given the suspicion of cervical vertigo, we do not consider that the findings in the radiographs help in the diagnosis. In our opinion, an excessive use of cervical radiography is made in patients with vertigo and dizziness.


Assuntos
Vértebras Cervicais/diagnóstico por imagem , Tontura , Imagem por Ressonância Magnética/estatística & dados numéricos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Vertigem , Análise de Variância , Distribuição de Qui-Quadrado , Tontura/epidemiologia , Emergências , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Sobremedicalização/estatística & dados numéricos , Pessoa de Meia-Idade , Estudos Retrospectivos , Distribuição por Sexo , Espanha/epidemiologia , Vertigem/epidemiologia
8.
Gut ; 69(1): 112-121, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-30981990

RESUMO

BACKGROUND AND AIMS: Serrated polyposis syndrome (SPS) is associated with an increased risk of colorectal cancer (CRC). International guidelines recommend surveillance intervals of 1-2 years. However, yearly surveillance likely leads to overtreatment for many. We prospectively assessed a surveillance protocol aiming to safely reduce the burden of colonoscopies. METHODS: Between 2013 and 2018, we enrolled SPS patients from nine Dutch and Spanish hospitals. Patients were surveilled using a protocol appointing either a 1-year or 2-year interval after each surveillance colonoscopy, based on polyp burden. Primary endpoint was the 5-year cumulative incidence of CRC and advanced neoplasia (AN) during surveillance. RESULTS: We followed 271 SPS patients for a median of 3.6 years. During surveillance, two patients developed CRC (cumulative 5-year incidence 1.3%[95% CI 0% to 3.2%]). The 5-year AN incidence was 44% (95% CI 37% to 52%), and was lower for patients with SPS type III (26%) than for patients diagnosed with type I (53%) or type I and III (59%, p<0.001). Most patients were recommended a 2-year interval, and those recommended a 2-year interval were not at increased risk of AN: AN incidence after a 2-year recommendation was 15.6% compared with 24.4% after a 1-year recommendation (OR 0.57, p=0.08). CONCLUSION: Risk stratification substantially reduced colonoscopy burden while achieving CRC incidence similar to previous studies. AN incidence is considerable in SPS patients, but extension of surveillance intervals was not associated with increased AN in those identified as low-risk by the protocol. We identified SPS type III patients as low-risk group that might benefit from even less frequent surveillance. TRIAL REGISTRATION NUMBER: The study was registered on http://www.trialregister.nl; trial-ID NTR4609.


Assuntos
Polipose Adenomatosa do Colo/diagnóstico , Neoplasias Colorretais/diagnóstico , Polipose Adenomatosa do Colo/epidemiologia , Polipose Adenomatosa do Colo/cirurgia , Idoso , Estudos de Coortes , Colonoscopia/métodos , Colonoscopia/estatística & dados numéricos , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/cirurgia , Feminino , Seguimentos , Humanos , Incidência , Masculino , Sobremedicalização/prevenção & controle , Sobremedicalização/estatística & dados numéricos , Pessoa de Meia-Idade , Países Baixos/epidemiologia , Vigilância da População/métodos , Prevalência , Estudos Prospectivos , Fatores de Risco , Espanha/epidemiologia
9.
Eur Radiol ; 30(1): 514-522, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-31375867

RESUMO

OBJECTIVES: To analyze the utility of metabolic imaging, and specifically of dedicated breast positron emission tomography (dbPET) to differentiate between indolent and potentially aggressive ductal carcinoma in situ (DCIS). METHODS: After institutional review board approval, we retrospectively reviewed the cases of pure DCIS who underwent dbPET before biopsy and surgery in Lucus Augusti Universitary Hospital (Lugo, Spain) and in Fudan Cancer Institute (Shanghai, China) between January 2016 and May 2018. Grade 1 and "non-comedo" grade 2 DCIS were considered low-risk disease, while intermediate-grade with necrosis or grade 3 cases were included in the high-risk group. DbPET sensitivity and specificity to differentiate between indolent and potentially aggressive DCIS were determined along with their respective 95% confidence intervals. RESULTS: We enrolled 139 surgery-confirmed pure DCIS cases. Fifty were high-risk neoplasms and 89 low-risk DCIS. Only seven low-risk lesions were positive at dbPET and five of potentially aggressive neoplasms did not show FDG uptake, all included into the field of view (FOV). Sensitivity and specificity of dbPET to differentiate between indolent and potentially aggressive DCIS were 90% (95% CI, 77-96%) and 92% (95% CI, 84-97%), respectively. CONCLUSION: Metabolic imaging could help to identify the subgroup of indolent lesions from those potentially aggressive ones that may be managed by active surveillance. KEY POINTS: • Low- and high-grade DCIS likely arise from two distinct evolutionary paths and when low-grade lesions progress to invasive cancer, the tumor is frequently low grade and well differentiated. • Ongoing clinical trials evaluate whether patients with low-risk DCIS could be safely managed by an active surveillance approach, with avoidance of unnecessary treatments and without impact on ipsilateral invasive breast cancer free survival time. • Dedicated breast PET may differentiate harmless from potentially hazardous DCIS, supporting active surveillance for the management of those women with low-grade DCIS, decreasing the rate of the upgrade to invasive carcinoma at surgical excision.


Assuntos
Neoplasias da Mama/diagnóstico por imagem , Carcinoma Intraductal não Infiltrante/diagnóstico por imagem , Sobremedicalização/prevenção & controle , Tomografia por Emissão de Pósitrons/métodos , Adulto , Idoso , Idoso de 80 Anos ou mais , Mama/diagnóstico por imagem , Mama/patologia , Neoplasias da Mama/patologia , Carcinoma Intraductal não Infiltrante/patologia , China , Diagnóstico Diferencial , Feminino , Humanos , Pessoa de Meia-Idade , Estudos Retrospectivos , Sensibilidade e Especificidade , Espanha
11.
BMJ ; 367: l6978, 2019 12 18.
Artigo em Inglês | MEDLINE | ID: mdl-31852679
12.
N Z Med J ; 132(1488): 11-20, 2019 01 18.
Artigo em Inglês | MEDLINE | ID: mdl-31851657

RESUMO

AIM: Unnecessary treatment of asymptomatic bacteriuria is a concern. Hutt Valley District Health Board sought to reduce clinically inappropriate urine culture requests through removal of urine dipsticks from wards and education of staff using Choosing Wisely principles. The purpose of this research is to quantitatively evaluate the success of these initiatives. METHODS: The numbers and results of urine cultures performed for Hutt Valley DHB were analysed, for the period from January 2015 to October 2017. Urinalyses were compared between those designated as 'inpatient' and those as 'outpatient', with the latter being the control of this study. The numbers of primary and secondary coded discharge diagnoses of UTIs were used as a measure of the negative impact of the interventions. RESULTS: There was a 28% reduction in monthly urine culture requests for inpatients, after staff education and removal of urine dipsticks, with no change in those for outpatients (the negative control). After the intervention, a higher proportion of urine cultures were positive for urinary pathogens (25.2% compared to 23.0%) and the average number of diagnoses of UTI in hospital discharges decreased 17% (from 161 to 134). CONCLUSION: The removal of urine dipsticks from wards and the education of staff significantly reduced the number of urine culture requests and is a useful strategy to reduce the overuse of antibiotics for asymptomatic bacteriuria without an increase in the number of UTIs. These simple interventions could be used at other hospitals as part of measures to reduce unnecessary care and overdiagnosis.


Assuntos
Sobremedicalização/prevenção & controle , Procedimentos Desnecessários/estatística & dados numéricos , Urinálise/estatística & dados numéricos , Adulto , Educação em Saúde , Humanos , Sobremedicalização/economia , Sobremedicalização/estatística & dados numéricos , Nova Zelândia , Procedimentos Desnecessários/economia , Urinálise/economia , Urinálise/métodos , Infecções Urinárias/diagnóstico , Infecções Urinárias/microbiologia
14.
BMC Health Serv Res ; 19(1): 880, 2019 Nov 21.
Artigo em Inglês | MEDLINE | ID: mdl-31752835

RESUMO

BACKGROUND: Proton pump inhibitors (PPIs) are one of the most frequently prescribed classes of drug in the world and there is a growing number of publications on correct versus incorrect use of PPIs worldwide. The knowledge of PPIs among the medical staff is essential for improving the rationality of PPI application. The present study aimed to investigate awareness, attitude and behavior toward PPI use among medical staff in the Southwest of China. METHODS: The present descriptive-analytical study was conducted on 900 medical staff from three professional groups (300 doctors, 300 nurses and 300 pharmacists) in China. The study data were collected through a self-designed questionnaire which included demographics, awareness, attitude and behavior toward PPI use. The study was carried out in 22 hospitals in Luzhou between February and June 2018. RESULTS: Of 900 surveys issued, 851valid questionnaires (295doctors, 268 nurses and 288 pharmacists) were returned. Of all respondents, 33.25% were men and 66.75% were women. The score related to PPI awareness score of medical staff was low (59.47 ± 15.75). The level of awareness of pharmacist was significantly higher than that of doctors and nurses (P < 0.01), which was related to gender, age, occupation, educational level, professional title, hospital nature and hospital grade. Similarly, on the attitude towards PPI use, the pharmacists scored also significantly higher than doctors and the nurses (P < 0.01). Three hundred eighty-one of 851 medical staff had used PPI in the past 1 year, of which omeprazole was the most widely used. Among doctors, nurses and pharmacists, the usage rate of PPI was 50.85, 42.16, 40.97%, respectively. The use frequency was related to occupation and professional title. The score about the behavior toward PPIs of the nurses was also significantly lower than that of doctors and pharmacists (P < 0.01). CONCLUSIONS: The study indicated that the medical staff lack of awareness concerning rational use of PPI in China, especially nurse. Thus, it is necessary to call for action on the improvement of PPI awareness and medication-taking behaviors to reduce PPI overuse and to promote the rationality of PPI application.


Assuntos
Conhecimentos, Atitudes e Prática em Saúde , Inibidores da Bomba de Prótons/uso terapêutico , Adulto , Atitude do Pessoal de Saúde , China , Competência Clínica , Estudos Transversais , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Masculino , Sobremedicalização/estatística & dados numéricos , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Omeprazol/uso terapêutico , Farmacêuticos , Médicos , Padrões de Prática Médica/estatística & dados numéricos , Inquéritos e Questionários , Adulto Jovem
15.
J Med Microbiol ; 68(12): 1766-1770, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31746725

RESUMO

Introduction. Evidence for the clinical utility of bronchoalveolar lavage (BAL) galactomannan in the management of fungal disease outside of haemato-oncology patients is limited.Aim. To determine how the introduction of BAL galactomannan testing impacted on the diagnosis and management of invasive aspergillosis and other fungal diseases in non-haemato-oncology patients.Methodology. Retrospective review of all adult patients (age ≥16 years) without a diagnosis of haematological malignancy who had a positive BAL galactomannan from 1 November 2014 to 30 April 2018. Using electronic patient records we obtained demographic data, clinical details, laboratory investigations, relevant radiology and antimicrobial history for each case.Results. In total, 121 episodes with a galactomannan OD index of ≥0.500 were included in the study; 29 cases (24 %) were felt to reflect fungal disease. Antifungal therapy was commenced as a direct consequence of a positive BAL galactomannan result in 13 patients where the ultimate diagnosis was subsequently considered to be non-mycological: associated medication-related side-effects in this group included deranged liver function tests (n=3), rash (n=1) and fever (n=1), related to amphotericin B (n=1) and voriconazole (n=4).Conclusion. We show that vigilance is required when interpreting galactomannan results in non-haematology patients to avoid potentially harmful overtreatment.


Assuntos
Antifúngicos/uso terapêutico , Líquido da Lavagem Broncoalveolar/química , Mananas/análise , Sobremedicalização , Micoses/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Antifúngicos/efeitos adversos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Micoses/tratamento farmacológico , Estudos Retrospectivos , Adulto Jovem
17.
Pathologe ; 40(Suppl 3): 342-346, 2019 Dec.
Artigo em Alemão | MEDLINE | ID: mdl-31705233

RESUMO

BACKGROUND: Advances in diagnostic methods have led to an early detection of thyroid nodules with debatable malignant potential in numerous cases. This can result in a potential overtreatment of thyroid lesions with very good prognosis. OBJECTIVES: To avoid surgical overtreatment, an individualized, risk-adapted management is required that respects the different tumor biology of the underlying histological entities. METHODS: The current guidelines of the leading professional societies, the American Thyroid Association (ATA) and the German Association of Endocrine Surgeons (CAEK), were compared and critically studied, to describe risk-adapted, more conservative treatment options for certain types of thyroid neoplasms according to the 2017 WHO definition. RESULTS: The German CAEK recommends thyroidectomy as a routine operation in the case of thyroid carcinoma. Exceptions are papillary thyroid microcarcinoma and minimally invasive follicular thyroid carcinoma, which can be treated by lobectomy. The ATA proposes an "active surveillance" for papillary thyroid microcarcinoma and lobectomy in cases of differentiated thyroid carcinoma <4 cm in diameter in the absence of clearly predefined risk factors. CONCLUSIONS: The pre- or intraoperative pathological diagnosis of the underlying tumor entity is the key point, which allows for an adaption of the resection strategy for thyroid malignancy. Depending on the type of carcinoma, the current guidelines of international expert societies allow for parenchyma-sparing operations and, according to the ATA, even an "active surveillance."


Assuntos
Neoplasias da Glândula Tireoide , Nódulo da Glândula Tireoide , Carcinoma , Diagnóstico Diferencial , Humanos , Sobremedicalização , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/terapia , Nódulo da Glândula Tireoide/diagnóstico , Nódulo da Glândula Tireoide/patologia , Nódulo da Glândula Tireoide/terapia , Tireoidectomia
18.
Am Surg ; 85(10): 1113-1117, 2019 Oct 01.
Artigo em Inglês | MEDLINE | ID: mdl-31657305

RESUMO

Although recommendations help guide surgeons' mesh choice in abdominal wall reconstruction (AWR), financial and institutional pressures may play a bigger role. Standardization of an AWR algorithm may help reduce costs and change mesh preferences. We performed a retrospective review of high- and low-risk patients who underwent inpatient AWR between 2014 and 2016. High risk was defined as immunosuppression and/or history of infection/contamination. Patients were stratified by the type of mesh as biologic/biosynthetic or synthetic. These cohorts were analyzed for outcome, complications, and cost. One hundred twelve patients underwent complex AWR. The recurrence rate at two years was not statistically different between high- and low-risk cohorts. No significant difference was found in the recurrence rate between biologic and synthetic meshes when comparing both high- and low-risk cohorts. The average cost of biologic mesh was $9,414.80 versus $524.60 for synthetic. The estimated cost saved when using synthetic mesh for low-risk patients was $295,391.20. In conclusion, recurrence rates for complex AWR seem to be unrelated to mesh selection. There seems to be an excess use of biologic mesh in low-risk patients, adding significant cost. Implementing a critical process to evaluate indications for biologic mesh use could decrease costs without impacting the quality of care, thus improving the overall value of AWR.


Assuntos
Parede Abdominal/cirurgia , Materiais Biocompatíveis/economia , Redução de Custos , Sobremedicalização/economia , Telas Cirúrgicas/economia , Algoritmos , Materiais Biocompatíveis/efeitos adversos , Estudos de Coortes , Humanos , Hospedeiro Imunocomprometido , Sobremedicalização/estatística & dados numéricos , Pessoa de Meia-Idade , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias , Recidiva , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Telas Cirúrgicas/efeitos adversos , Telas Cirúrgicas/estatística & dados numéricos
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