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3.
J Urol ; 202(5): 936-943, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31112106

RESUMO

PURPOSE: Shared patient-physician decision making regarding the treatment of prostate cancer detected by prostate specific antigen screening involves a complex calculus weighing cancer risk and patient life expectancy. We sought to quantify these competing risks using the probability that the cancer was over diagnosed, ie would not have been clinically diagnosed (diagnosed without screening) during the remaining lifetime of the patient. MATERIALS AND METHODS: Using an established model of prostate cancer screening and clinical diagnosis we simulated screen detected cases and determined whether a modeled clinical diagnosis would occur before noncancer death. Time of noncancer death was based on comorbidity adjusted population lifetables. Logistic regression models were fitted to the simulated data and used to estimate over diagnosis probabilities given patient age, prostate specific antigen level, Gleason sum and comorbidity category. An online calculator was developed to communicate over diagnosis estimates. Face validity and ease of use were assessed by surveying 32 clinical experts. RESULTS: Estimated probabilities of over diagnosis ranged from 4% to 78% across clinicopathological variables and comorbidity status. When ignoring comorbidity, the estimated probability of over diagnosis in a 70-year-old man with prostate specific antigen 9.4 ng/ml and Gleason 6 was 34%. With severe comorbidities the estimate increased to 51%. Such a personalization may help inform the choice between active surveillance and definitive treatment. Based on responses from 20 of 32 experts we modified the explanation of over diagnosis for the online calculator and the input method for comorbid conditions. CONCLUSIONS: The probability of over diagnosis is strongly influenced by comorbidity status in addition to age. Personalized estimates incorporating comorbidity may contribute to shared decision making between patients and providers regarding personalized treatment selection.


Assuntos
Detecção Precoce de Câncer , Programas de Rastreamento/métodos , Sobremedicalização/tendências , Antígeno Prostático Específico/sangue , Próstata/patologia , Neoplasias da Próstata/diagnóstico , Idoso , Biomarcadores Tumorais/sangue , Biópsia , Causas de Morte/tendências , Comorbidade , Humanos , Expectativa de Vida , Masculino , Pessoa de Meia-Idade , Gradação de Tumores , Neoplasias da Próstata/sangue , Neoplasias da Próstata/epidemiologia , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
4.
Eur J Endocrinol ; 180(6): 407-416, 2019 Jun 01.
Artigo em Inglês | MEDLINE | ID: mdl-31035256

RESUMO

Objective To investigate the association between hypothyroidism and cardiovascular disease (CVD) in both treated and untreated hypothyroid patients, and the consequences of over- and under-treatment with respect to cardiovascular risk. Design A registry-based case-control study nested within a population-based cohort of 275 467 individuals with at least one serum thyroid stimulating hormone (TSH) measurement in the period of 1995-2011. Methods Incident cases of CVD were matched with controls according to gender, age and year of birth. Conditional logistic regression analyses were performed to calculate CVD risks associated with exposure to hypothyroidism, with adjustment for 19 pre-existing comorbidities, including cardiovascular disease and diabetes, using the Charlson Comorbidity Index. Results Overall, 20 487 individuals experienced CVD (9.4%, incidence rate 13.1 per 1000 person-years, 95% confidence interval (CI), 13.0-13.3). Risk of CVD was increased in untreated hypothyroidism compared to euthyroidism (odds ratio (OR): 1.83 (95% CI: 1.43-2.35; P < 0.001)). Cardiovascular risk was increased in both treated and untreated hypothyroid individuals per half year of elevated TSH (OR: 1.11 (95% CI: 1.06-1.16; P < 0.001) and OR: 1.15 (95% CI: 1.09-1.23; P = 0.001), respectively). In patients treated with levothyroxine, OR for CVD was 1.12 (95% CI: 1.06-1.18; P < 0.001) for each 6 months of decreased TSH. Conclusion Cardiovascular risk is increased in untreated, but not in treated hypothyroid patients. Among those with treated hypothyroidism, duration of decreased TSH (overtreatment) had a similar impact on cardiovascular risk as duration of elevated TSH (under-treatment), highlighting the importance of initiating treatment and maintaining biochemical euthyroidism in hypothyroid patients in order to reduce the risk of CVD and death.


Assuntos
Doenças Cardiovasculares/epidemiologia , Doenças Cardiovasculares/terapia , Hipotireoidismo/epidemiologia , Hipotireoidismo/terapia , Sobremedicalização/tendências , Adulto , Idoso , Doenças Cardiovasculares/diagnóstico , Estudos de Casos e Controles , Estudos de Coortes , Feminino , Mau Uso de Serviços de Saúde/tendências , Humanos , Hipotireoidismo/diagnóstico , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , Fatores de Tempo
5.
BMC Pregnancy Childbirth ; 19(1): 132, 2019 Apr 16.
Artigo em Inglês | MEDLINE | ID: mdl-30991975

RESUMO

BACKGROUND: Cesarean section (CS) is an important intervention in complicated births when the safety of the mother or baby is compromised. Despite worldwide concerns about the overutilization of CS in recent years, many African women and their newborns still die because of limited or no access to CS services. We evaluated temporal and spatial trends in CS births in Uganda and modeled future trends to inform programming. METHODS: We performed secondary analysis of total births data from the Uganda National Health Management Information System (HMIS) reports during 2012-2016. We reviewed data from 3461 health facilities providing basic, essential obstetric and emergency obstetric care services in all 112 districts. We defined facility-based CS rate as the proportion of cesarean deliveries among total live births in facilities, and estimated the population-based CS rate using the total number of cesarean deliveries as a proportion of annual expected births (including facility-based and non-facility-based) for each district. We predicted CS rates for 2021 using Generalised Linear Models with Poisson family, Log link and Unbiased Sandwich Standard errors. We used cesarean deliveries as the dependent variable and calendar year as the independent variable. RESULTS: Cesarean delivery rates increased both at facility and population levels in Uganda. Overall, the CS rate for live births at facilities was 9.9%, increasing from 8.5% in 2012 to 11% in 2016. The overall population-based CS rate was 4.7%, and increased from 3.2 to 5.9% over the same period. Health Centre IV level facilities had the largest annual rate of increase in CS rate between 2012 and 2016. Among all 112 districts, 80 (72%) had a population CS rate below 5%, while 38 (34%) had a CS rate below 1% over the study period. Overall, Uganda's facility-based CS rate is projected to increase by 36% (PRR 1.36, 95% CI 1.35-1.36) in 2021 while the population-based CS rate is estimated to have doubled (PRR 2.12, 95% CI 2.11-2.12) from the baseline in 2016. CONCLUSION: Cesarean deliveries are increasing in Uganda. Health center IVs saw the largest increases in CS, and while there was regional heterogeneity in changes in CS rates, utilization of CS services is inadequate in most districts. We recommend expansion of CS services to improve availability.


Assuntos
Cesárea/tendências , Instalações de Saúde/estatística & dados numéricos , Acesso aos Serviços de Saúde/estatística & dados numéricos , Serviços de Saúde Materna/tendências , Sobremedicalização/tendências , Adulto , Feminino , Humanos , Recém-Nascido , Gravidez , Análise Espaço-Temporal , Uganda , Adulto Jovem
6.
Int J Radiat Oncol Biol Phys ; 104(5): 1012-1016, 2019 08 01.
Artigo em Inglês | MEDLINE | ID: mdl-30981834

RESUMO

PURPOSE: To evaluate the adoption of the Royal Australian and New Zealand College of Radiologists Choosing Wisely (CW) radiation oncology recommendations before and after the release of the recommendations. METHODS AND MATERIALS: The Victorian Radiotherapy Minimum Data Set captures details of radiation therapy delivered in the state of Victoria, Australia. This study included the following 3 groups of patients relevant to 3 of the 5 CW recommendations: women who received a diagnosis of early-stage breast cancer at age ≥50 years who had breast radiation therapy (excluding nodal irradiation), patients with cancer who had palliative bone radiation therapy (excluding those with primary bone malignancies), and patients with cancer who had stereotactic radiation therapy to the brain (excluding those with primary malignancies of the central nervous system). The outcomes of interest were use of hypofractionated breast radiation therapy (<25 fractions), use of long-course palliative bone radiation therapy (>10 fractions), and use of adjuvant whole brain radiation therapy within 1 month of stereotactic radiation therapy. The Cochrane-Armitage test was used to evaluate changes in practice over time. RESULTS: Among the 8204 patients who had breast radiation therapy, there was an increase in hypofractionation use from 42% in 2013 to 82% in 2017 (P < .001). The progressive increase in hypofractionation use was observed across institutions. Of the 15,634 courses of palliative bone radiation therapy delivered, only 1279 (8%) were >10 fractions, and this decreased from 10% in 2013 to 5% in 2017 (P < .001). Of the 1049 patients who received stereotactic radiation therapy for brain metastases, only 2% had adjuvant whole brain radiation therapy, and this decreased from 4% in 2013 to 0.7% in 2017 (P = .02). CONCLUSIONS: There was a significant change in radiation oncology practice in Australia between 2013 and 2017, in line with the CW recommendations. However, some of the recommendations need to be revised to reflect the rapidly evolving evidence in radiation oncology.


Assuntos
Neoplasias Ósseas/radioterapia , Neoplasias Encefálicas/radioterapia , Neoplasias da Mama/radioterapia , Hipofracionamento da Dose de Radiação , Radioterapia (Especialidade)/normas , Radiocirurgia/estatística & dados numéricos , Fatores Etários , Neoplasias Ósseas/secundário , Neoplasias Encefálicas/secundário , Neoplasias da Mama/patologia , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Hospitais Privados/estatística & dados numéricos , Hospitais Públicos/estatística & dados numéricos , Humanos , Sobremedicalização/prevenção & controle , Sobremedicalização/estatística & dados numéricos , Sobremedicalização/tendências , Pessoa de Meia-Idade , Cuidados Paliativos/estatística & dados numéricos , Cuidados Paliativos/tendências , Guias de Prática Clínica como Assunto , Radioterapia (Especialidade)/tendências , Radiocirurgia/tendências , Radioterapia Adjuvante/normas , Radioterapia Adjuvante/estatística & dados numéricos , Radioterapia Adjuvante/tendências , Vitória
8.
Artigo em Inglês | MEDLINE | ID: mdl-30880944

RESUMO

Purpose: GOLD guidelines classify COPD patients into A-D groups based on health status as assessed by COPD Assessment Test (CAT) or mMRC tools and exacerbations and recommend single or dual long-acting bronchodilators as maintenance therapy, with additional inhaled corticosteroids (ICS) if the disease remains uncontrolled. We aimed to classify primary care COPD patients into A-D groups, assess usual treatment and adherence to guidelines, potential mismatches between CAT-and mMRC-based classification and described symptoms within groups. Patients and methods: A total of 257 primary care COPD patients were enrolled between 2015 and 2016 in Greece. Physicians used structured interviews to collect cross-sectional data including demographics, symptoms, CAT, mMRC scores, and medications. Patients were classified into A-D groups based on CAT and mMRC, and prevalence of symptoms and medication was estimated within A-D groups. Interviews with physicians were also performed to explore additional issues about treatment and adherence to guidelines. Results: Mean (SD) age was 65 (12.3) years with 79% males. The majority of patients reported uncontrolled symptoms (91% and 61% with ≥10 CAT or ≥2 mMRC scores, respectively). Thirty-seven percentage had $2 exacerbations in the past year. Group B was the largest followed by Groups D, A, and C. Patients were classified as more severe by CAT than by mMRC. In all groups, the majority were treated with combined long-acting beta agonist/ICS (> 50%). When patients were asked to report their main symptoms, dyspnea and cough were the most important symptoms mentioned, and there was a great variation between the A-D groups. However, Groups A-C reported mainly morning symptoms, whereas Group D suffered symptoms all day. Physicians reported a significant number of barriers to implementing guidelines, eg, frequent lack of guideline updates, access to diagnostic procedures, and prescription-reimbursement issues. Conclusion: Our study confirms poor adherence to guidelines regarding treatment with an overuse of ICS and important barriers to implementation. A mismatch in classification occurs depending on the tool used, which can mislead clinicians in their choice of treatment.


Assuntos
Broncodilatadores/administração & dosagem , Fidelidade a Diretrizes/tendências , Pulmão/efeitos dos fármacos , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/tendências , Atenção Primária à Saúde/tendências , Doença Pulmonar Obstrutiva Crônica/tratamento farmacológico , Corticosteroides/administração & dosagem , Agonistas de Receptores Adrenérgicos beta 2/administração & dosagem , Idoso , Broncodilatadores/efeitos adversos , Estudos Transversais , Progressão da Doença , Combinação de Medicamentos , Feminino , Grécia/epidemiologia , Pesquisas sobre Serviços de Saúde , Nível de Saúde , Humanos , Pulmão/fisiopatologia , Masculino , Sobremedicalização/tendências , Pessoa de Meia-Idade , Antagonistas Muscarínicos/administração & dosagem , Prevalência , Doença Pulmonar Obstrutiva Crônica/diagnóstico , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Doença Pulmonar Obstrutiva Crônica/fisiopatologia , Fatores de Tempo , Resultado do Tratamento
9.
Anticancer Res ; 39(3): 1397-1401, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30842174

RESUMO

BACKGROUND/AIM: To evaluate the diagnosis and management of prostate cancer (PCa) across twenty years of clinical practice. MATERIALS AND METHODS: From January 2000 to January 2019, 7,000 patients underwent transperineal prostate biopsy and 990 went through radical prostatectomy, respectively. The clinical and pathological stage in the presence of prostate cancer (PCa) are reported here. RESULTS: The overall number of biopsies increased over time from 1,500 (years 2000-2005) to 2,150 (years 2015-2019). PCa was found in 2,500/7,000 (37.7%) patients while the diagnosis of very low risk PCa increased from 3.2% to 13.6% and diagnosis of metastatic PCa decreased from 12% to 4%. A greater number of men with locally advanced/oligometastatic PCa underwent surgery over time with increasing numbers of nodal involvement and positive surgical margins from 5.4% and 27.2% to 10.8% and 35.6%, respectively. CONCLUSION: Overtreatment of PCa has been reduced over time by establishing Active Surveillance protocols. Additionally, the multidisciplinar approach has improved the management of locally advanced/oligometastatic PCa.


Assuntos
Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/terapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Humanos , Masculino , Sobremedicalização/tendências , Pessoa de Meia-Idade , Resultado do Tratamento
10.
BMC Musculoskelet Disord ; 20(1): 50, 2019 Feb 02.
Artigo em Inglês | MEDLINE | ID: mdl-30711002

RESUMO

BACKGROUND: At any one time, one in every five Canadians has low back pain (LBP), and LBP is one of the most common health problems in primary care. Guidelines recommend that imaging not be routinely performed in patients presenting with LBP without signs or symptoms indicating a potential pathological cause. Yet imaging rates remain high for many patients who present without such indications. Inappropriate imaging can lead to inappropriate treatments, results in worse health outcomes and causes harm from unnecessary radiation. There is a need to understand the extent of, and factors contributing to, inappropriate imaging for LBP, and to develop effective strategies that target modifiable barriers and facilitators. The primary study objectives are to determine: 1) The rate of, and factors associated with, inappropriate lumbar spine imaging (x-ray, CT scan and MRI) for people with non-specific LBP presenting to primary care clinicians in Ontario; 2) The barriers and facilitators to reduce inappropriate imaging for LBP in primary care settings. METHODS: The project will comprise an inception cohort study and a concurrent qualitative study. For the cohort study, we will recruit 175 primary care clinicians (50 each from physiotherapy and chiropractic; 75 from family medicine), and 3750 patients with a new episode of LBP who present to these clinicians. Clinicians will collect data in the clinic, and each participant will be tracked for 12 months using Ontario health administrative and self-reported data to measure diagnostic imaging use and other health outcomes. We will assess characteristics of the clinicians, patients and encounters to identify variables associated with inappropriate imaging. In the qualitative study we will conduct in-depth interviews with primary care clinicians and patients. DISCUSSION: This will be the first Canadian study to accurately document the extent of the overuse of imaging for LBP, and the first worldwide to include data from the main healthcare professions offering primary care for people with LBP. This study will provide robust information about rates of inappropriate imaging for LBP, along with factors associated with, and an understanding of, potential reasons for inappropriate imaging.


Assuntos
Dor Lombar/diagnóstico por imagem , Vértebras Lombares/diagnóstico por imagem , Imagem por Ressonância Magnética/tendências , Padrões de Prática Médica/tendências , Atenção Primária à Saúde/tendências , Projetos de Pesquisa , Tomografia Computadorizada por Raios X/tendências , Quiroprática/tendências , Tomada de Decisão Clínica , Pesquisa sobre Serviços de Saúde , Humanos , Sobremedicalização/prevenção & controle , Sobremedicalização/tendências , Ontário , Fisioterapeutas/tendências , Médicos de Família/tendências , Valor Preditivo dos Testes , Pesquisa Qualitativa
12.
World J Gastroenterol ; 25(2): 178-189, 2019 Jan 14.
Artigo em Inglês | MEDLINE | ID: mdl-30670908

RESUMO

Many upper gastrointestinal (GI) endoscopies worldwide are performed for inappropriate indications. This overuse of healthcare negatively affects healthcare quality and puts pressure on endoscopy services. Dyspepsia is one of the most common inappropriate indications for upper GI endoscopy as diagnostic yield is low. Reasons for untimely referral are: unfamiliarity with dyspepsia guidelines, uncertainty about etiology of symptoms, and therapy failure. Unfiltered open-access referrals feed upper GI endoscopy overuse. This review highlights strategies applied to diminish use of upper GI endoscopies for dyspepsia. First, we describe the impact of active guideline implementation. We found improved guideline adherence, but resistance was encountered in the process. Secondly, we show several forms of clinical assessment. While algorithm use reduced upper GI endoscopy volume, effects of referral assessment of individual patients were minor. A third strategy proposed Helicobacter pylori test and treat for all dyspeptic patients. Many upper GI endoscopies can be avoided using this strategy, but outcomes may be prevalence dependent. Lastly, empirical treatment with Proton pump inhibitors achieved symptom relief for dyspepsia and avoided upper GI endoscopies in about two thirds of patients. Changing referral behavior is complex as contributing factors are manifold. A collaboration of multiple strategies is most likely to succeed.


Assuntos
Dispepsia/diagnóstico , Endoscopia Gastrointestinal/estatística & dados numéricos , Infecções por Helicobacter/diagnóstico , Helicobacter pylori/isolamento & purificação , Sobremedicalização/estatística & dados numéricos , Dispepsia/epidemiologia , Dispepsia/microbiologia , Endoscopia Gastrointestinal/normas , Endoscopia Gastrointestinal/tendências , Fidelidade a Diretrizes/normas , Fidelidade a Diretrizes/estatística & dados numéricos , Fidelidade a Diretrizes/tendências , Infecções por Helicobacter/epidemiologia , Infecções por Helicobacter/microbiologia , Humanos , Colaboração Intersetorial , Sobremedicalização/tendências , Guias de Prática Clínica como Assunto , Prevalência , Encaminhamento e Consulta/normas , Encaminhamento e Consulta/estatística & dados numéricos , Encaminhamento e Consulta/tendências
13.
An. pediatr. (2003. Ed. impr.) ; 90(1): 26-31, ene. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-177173

RESUMO

Objetivo: La hiperfrecuentación es un problema relevante en las consultas pediátricas de atención primaria, por lo que el objetivo de nuestro estudio ha sido analizar el nivel de frecuentación en dichas consultas y su relación con determinados aspectos psicosociales de las familias asignadas a las mismas. Pacientes y métodos: Estudio descriptivo observacional realizado mediante cuestionarios recogidos durante un periodo de 6 meses y registrando la frecuentación de los 6meses previos. Se han completado 346 encuestas de niños entre 6 meses y 13 años de edad pertenecientes a dos consultas urbanas de atención primaria de Madrid. Se analizaron datos crudos, comparaciones entre grupos y análisis multivariante. Resultados: El promedio de consultas en los últimos 6meses, del total de incluidos en el estudio, fue de 3,06 en el centro de salud y de 0,77 consultas en urgencias. Se consideró hiperfrecuentadores a los que habían acudido 6 o más veces al centro de salud en este periodo (> p90), que fueron 33 niños (9,53%). En el análisis multivariante, las variables relacionadas con ser hiperfrecuentador en las consultas del centro de salud fueron la presencia de elevado nivel de ansiedad en los padres (OR = 5,50; IC 95%: 2,49-12,17; p < 0,0001) y la edad de los niños (OR = 0,73; IC95%: 0,58-0,91; p = 0,005). El modelo presentó un área bajo la curva de 0,761 (IC 95%: 0,678-0,945; p < 0,0001). Conclusiones: La frecuentación en las consultas pediátricas de atención primaria está directamente relacionada con el nivel elevado de ansiedad de los padres e inversamente con la edad de los niños. Sería recomendable detectar y a ser posible intervenir en los casos de elevada ansiedad parental para así intentar reducir la hiperfrecuentación asistencial


Objective: Hyper-attendance is a significant problem in paediatric Primary Care clinics. The aim of our study was to analyse the level of attendance in these clinics and its relationship with certain psychosocial aspects of the families attending them. Patients and methods: Observational descriptive study was conducted using questionnaires collected during a period of 6 months, as well as recording the frequency of attendance in the previous 6months. A total of 346 questionnaires of children between 6months and 13 years of age belonging to 2 urban Primary Care clinics in Madrid were completed. The raw data was analysed, and comparisons between groups and multivariate analysis were performed. Results: The mean number of consultations in the last 6 months, of the total included in the study, was 3.06 in the Primary Care centre, and 0.77 in the emergency services. It was considered over-frequent for those who had attended the Primary Care health centre 6 or more times in this period (> p90), of which there were 33 children (9.53%). In the multivariate analysis, the variables related to being frequent users of Primary Care clinics were: the presence of high level of anxiety in the parents (OR = 5.50; 95% CI: 2.49-12.17, P < .0001), and the age of the children (OR = 0.73; 95% CI: 0.58-0.91, P = .005). The model presented an area under the curve of 0.761 (95% CI: 0.678-0.945, P < .0001). Conclusions: The frequency of visits in paediatric Primary Care clinics is directly related to the high level of anxiety of the parents, and inversely to the age of the children. It would be advisable to detect and, if possible, intervene in cases of high parental anxiety in order to try to reduce the over-frequency in the paediatric primary health care


Assuntos
Humanos , Lactente , Pré-Escolar , Criança , Adolescente , Impacto Psicossocial , Encaminhamento e Consulta/estatística & dados numéricos , Atenção Primária à Saúde , Depressão/epidemiologia , Sobremedicalização/tendências , Estudo Observacional , Inquéritos e Questionários , Análise Multivariada , Estatísticas não Paramétricas , Modelos Logísticos , Sobremedicalização/estatística & dados numéricos
14.
J Clin Endocrinol Metab ; 104(3): 785-792, 2019 03 01.
Artigo em Inglês | MEDLINE | ID: mdl-30329071

RESUMO

Context: Thyroid cancer incidence increased with the greatest change in adults aged ≥65 years. Objective: To determine the relationship between area-level use of imaging and thyroid cancer incidence over time. Design, Setting and Participants: Longitudinal imaging patterns in Medicare patients aged ≥65 years residing in Surveillance, Epidemiology, and End Results (SEER) regions were assessed in relationship to differentiated thyroid cancer diagnosis in patients aged ≥65 years included in SEER-Medicare. Linear mixed-effects modeling was used to determine factors associated with thyroid cancer incidence over time. Multivariable logistic regression was used to determine patient characteristics associated with receipt of thyroid ultrasound as initial imaging. Main Outcome Measure: Thyroid cancer incidence. Results: Between 2002 and 2013, thyroid ultrasound use as initial imaging increased (P < 0.001). Controlling for time and demographics, use of thyroid ultrasound was associated with thyroid cancer incidence (P < 0.001). Findings persisted when cohort was restricted to papillary thyroid cancer (P < 0.001), localized papillary thyroid cancer (P = 0.004), and localized papillary thyroid cancer with tumor size ≤1 cm (P = 0.01). Based on our model, from 2003 to 2013, at least 6594 patients aged ≥65 years were diagnosed with thyroid cancer in the United States due to increased use of thyroid ultrasound. Thyroid ultrasound as initial imaging was associated with female sex and comorbidities. Conclusion: Greater thyroid ultrasound use led to increased diagnosis of low-risk thyroid cancer, emphasizing the need to reduce harms through reduction in inappropriate ultrasound use and adoption of nodule risk stratification tools.


Assuntos
Adenocarcinoma Folicular/epidemiologia , Adenoma Oxífilo/epidemiologia , Sobremedicalização/estatística & dados numéricos , Câncer Papilífero da Tireoide/epidemiologia , Neoplasias da Glândula Tireoide/epidemiologia , Adenocarcinoma Folicular/diagnóstico por imagem , Adenoma Oxífilo/diagnóstico por imagem , Fatores Etários , Idoso , Feminino , Humanos , Incidência , Masculino , Sobremedicalização/tendências , Medicare/estatística & dados numéricos , Medição de Risco/métodos , Medição de Risco/estatística & dados numéricos , Programa de SEER/estatística & dados numéricos , Câncer Papilífero da Tireoide/diagnóstico por imagem , Glândula Tireoide/diagnóstico por imagem , Neoplasias da Glândula Tireoide/diagnóstico por imagem , Ultrassonografia/estatística & dados numéricos , Estados Unidos/epidemiologia
15.
Proc Natl Acad Sci U S A ; 115(51): 12887-12895, 2018 12 18.
Artigo em Inglês | MEDLINE | ID: mdl-30559181

RESUMO

Bacterial infections have been traditionally controlled by antibiotics and vaccines, and these approaches have greatly improved health and longevity. However, multiple stakeholders are declaring that the lack of new interventions is putting our ability to prevent and treat bacterial infections at risk. Vaccine and antibiotic approaches still have the potential to address this threat. Innovative vaccine technologies, such as reverse vaccinology, novel adjuvants, and rationally designed bacterial outer membrane vesicles, together with progress in polysaccharide conjugation and antigen design, have the potential to boost the development of vaccines targeting several classes of multidrug-resistant bacteria. Furthermore, new approaches to deliver small-molecule antibacterials into bacteria, such as hijacking active uptake pathways and potentiator approaches, along with a focus on alternative modalities, such as targeting host factors, blocking bacterial virulence factors, monoclonal antibodies, and microbiome interventions, all have potential. Both vaccines and antibacterial approaches are needed to tackle the global challenge of antimicrobial resistance (AMR), and both areas have the underpinning science to address this need. However, a concerted research agenda and rethinking of the value society puts on interventions that save lives, by preventing or treating life-threatening bacterial infections, are needed to bring these ideas to fruition.


Assuntos
Antibacterianos/uso terapêutico , Infecções Bacterianas/tratamento farmacológico , Vacinas Bacterianas/uso terapêutico , Farmacorresistência Bacteriana , Bactérias/efeitos dos fármacos , Bactérias/imunologia , Sistemas de Liberação de Medicamentos/tendências , Humanos , Sobremedicalização/tendências
16.
J Opioid Manag ; 14(5): 309-316, 2018.
Artigo em Inglês | MEDLINE | ID: mdl-30387854

RESUMO

OBJECTIVE: Little is known regarding clinician prescribing of opioid medications and of patient use of prescribed opioid medications in pediatrics. The authors sought to learn more about pediatric clinician opioid prescribing practices and patient utilization and disposal of prescribed opioids. DESIGN: Cross-sectional, observational study. SETTING: Tertiary care pediatric healthcare center. PARTICIPANTS: Pediatric clinicians who prescribe opioid medications and parents of children prescribed an opioid medication. MAIN OUTCOME MEASURES: Clinicians were surveyed about opioid prescribing practices for acute pain management in children, and parents were asked about utilization and disposal of prescribed opioids. RESULTS: Most clinician respondents (64 percent) reported prescribing opioid medications to manage acute pain. The typical length of opioid prescriptions was limited to 7 days (93 percent). Parents reported a high prevalence of leftover opioid medications (86 percent). Most (59 percent) did not dispose of the remaining medication. CONCLUSIONS: Targets for intervention to reduce unnecessary opioid exposure in youth are identified.


Assuntos
Dor Aguda/tratamento farmacológico , Analgésicos Opioides/administração & dosagem , Pediatras/tendências , Padrões de Prática Médica/tendências , Dor Aguda/diagnóstico , Adolescente , Fatores Etários , Analgésicos Opioides/provisão & distribução , Criança , Estudos Transversais , Esquema de Medicação , Prescrições de Medicamentos , Pesquisas sobre Serviços de Saúde , Humanos , Sobremedicalização/tendências , Eliminação de Resíduos de Serviços de Saúde
17.
Sci Rep ; 8(1): 14663, 2018 10 02.
Artigo em Inglês | MEDLINE | ID: mdl-30279510

RESUMO

The incidence of cancer in the United Kingdom has increased significantly over the last four decades. The aim of this study was to examine trends in UK cancer incidence and mortality by cancer site and assess the potential for overdiagnosis. Using Cancer Research UK incidence and mortality data for the period (1971-2014) we estimated percentage change in incidence and mortality rates and the incidence-mortality ratio (IMR) for cancers in which incidence had increased >50%. Incidence and mortality trend plots were used to assess the potential for overdiagnosis. Incidence rates increased from 67% (uterine) to 375% (melanoma). Change in mortality rates ranged from -69% (cervical) to +239% (liver). The greatest divergences occurred in uterine (IMR = 132), prostate (IMR = 9.6), oral (IMR = 9.8) and thyroid cancer (IMR = 5.3). Only in liver cancer did mortality track incidence (IMR = 1.1). For four cancer sites; uterine, prostate, oral and thyroid, incidence and mortality trends are suggestive of overdiagnosis. Trends in melanoma and kidney cancer suggest potential overdiagnosis and an underlying increase in true risk, whereas for cervical and breast cancer, trends may also reflect improvements in treatments or earlier diagnosis. A more detailed analysis is required to fully understand these patterns.


Assuntos
Sobremedicalização/tendências , Neoplasias/epidemiologia , Neoplasias/mortalidade , Estudos de Coortes , Feminino , Humanos , Incidência , Masculino , Mortalidade/tendências , Reino Unido/epidemiologia
18.
Rev Bras Enferm ; 71(5): 2440-2446, 2018.
Artigo em Inglês, Português | MEDLINE | ID: mdl-30304174

RESUMO

OBJECTIVE: To identify polypharmacy and potentially inappropriate medications (PIM) for elder people with chronic health situations and its implications for gerontological nursing. METHOD: Descriptive and transversal study, conducted from March to September 2016 by pharmaceutical residents in the clinic of Endocrinology of a hospital in Mid-West region of Brazil. RESULTS: 44 elder people with an average age of 69.5 (± 6.79) years old had their assessed prescriptions. We identified 65 medications prescribed 253 times, in which 10 PIM (15.4%) were prescribed 51 times. 33 seniors (72.7%) had at least one PIM, of those, 66.7% were polymedicated. Of the total, 22 elder people (50%) were subjected to polypharmacy and made use of at least one PIM. CONCLUSION: The results showed high incidence of PIM and polypharmacy, as well as their physiological impacts to the elder population. The study provokes discussions about that the trained nurse in human aging has skills and competencies able to enhance interventions related to pharmacotherapy.


Assuntos
Enfermagem Geriátrica/métodos , Sobremedicalização/tendências , Polimedicação , Idoso , Brasil , Estudos Transversais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Processo de Enfermagem , Fatores de Risco
20.
Pediatr. aten. prim ; 20(79): 291-295, jul.-sept. 2018.
Artigo em Espanhol | IBECS | ID: ibc-180958

RESUMO

En los últimos años, varias sociedades e instituciones científicas, nacionales e internacionales, han emitido recomendaciones sobre "no hacer" (do not do) determinadas intervenciones médicas por no estar suficientemente basadas en pruebas científicas, con el objetivo principal de mejorar la calidad y sostenibilidad de la atención sanitaria y la seguridad en el paciente. Presentamos una recopilación y síntesis de las recomendaciones elaboradas por diferentes organizaciones sanitarias dirigidas a los pediatras de Atención Primaria y orientadas a disminuir pruebas y consultas innecesarias


In recent years, several national and international scientific societies and healthcare organizations have created "do not do" recommendations. They are trying to reduce healthcare interventions that are not based on scientific evidence, to improve the quality and sustainability of the health system and to promote patient safety. We present a compilation and synthesis of the recommendations published by different health organizations aiming to reduce unnecessary tests and consultations to Pediatric Primary Health Care practitioners


Assuntos
Humanos , Criança , Atenção Primária à Saúde/organização & administração , Prática Clínica Baseada em Evidências/organização & administração , Procedimentos Desnecessários/tendências , Sobremedicalização/tendências , Padrões de Prática Médica/normas , Gestão da Segurança/organização & administração , Cuidado da Criança/normas , Medicina de Emergência Pediátrica/organização & administração , Encaminhamento e Consulta/tendências
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