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2.
Zhonghua Wei Chang Wai Ke Za Zhi ; 22(11): 1012-1015, 2019 Nov 25.
Artigo em Chinês | MEDLINE | ID: mdl-31770830

RESUMO

De-escalation strategy is the gradual transition of various complex, expensive, high-risk but effective treatments for critically ill patients to simple, safe, physiological but still effective ones. Chronic critical illness refers to patients suffering severe disease or surgical hit who later shift into a chronic state of relapse or even aggravation and stay in the intensive care unit for extended period. Risk factors for surgical related chronic critical illness include advanced age, malnutrition, multiple organ dysfunction and multiple hits. During the treatment of critically ill patients, the strategy of de-escalation therapy should always be implemented, including rational use of antibiotics, de-escalation of liquid therapy (i.e. de-resuscitation), timely removal of ventilator, rapid introduction and with drawal of continuous renal replacement measures, parenteral + enteral nutrition support therapy and timely cessation of sedation.


Assuntos
Tratamento Conservador/métodos , Cuidados Críticos/métodos , Estado Terminal/terapia , Doença Crônica/prevenção & controle , Doença Crônica/terapia , Humanos , Unidades de Terapia Intensiva , Suspensão de Tratamento
3.
Medicine (Baltimore) ; 98(47): e18014, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31764816

RESUMO

RATIONALE: Early initiation of antiretroviral therapy (ART) leads to long-term viral suppression, reduces proviral reservoir size, and prolongs time to rebound. Since human immunodeficiency virus (HIV) is a lifelong disease, diagnostic monitoring after confirmed infection is typically not performed; therefore, little is known about the impact of early initiation and long-term ART on the sensitivity of assays that detect HIV antibodies and viral nucleic acid in children and adolescents. PATIENT CONCERNS: Here we report 1 case of diagnosed and confirmed perinatal HIV-1C infection with longstanding viral suppression, who subsequently had a negative HIV-1 deoxyribonucleic acid (DNA) test, undetectable antibodies to HIV-1, and high CD4+ T cell count after 14 years of ART. DIAGNOSIS: The patient was diagnosed with HIV in 2002 at 1 and 2 months of age using DNA polymerase chain reaction. At 8 months old, his viral load was 1210 HIV ribonucleic acid (RNA) copies/mL and CD4 T cell count was 3768 cells/mm. INTERVENTION: At the age of 9 months, highly active antiretroviral therapy comprising of zidovudine, nevirapine, and lamivudine was initiated. The patient remained on this treatment for 14 years 11 months and was virally suppressed. OUTCOMES: At the age of 14 years 4 months, the participant decided to visit a local voluntary HIV testing center, where a rapid HIV test came out negative and the viral load was undetectable (<400 HIV-1 RNA copies/mL). These results led to termination of ART which led to viral rebound within 9 months. LESSONS: As more people with early HIV infection initiate early ART in the context of "Test and Treat all" recommendations, aspects of this report may become more commonplace, with both clinical and public health implications. If the possibility of functional cure (or false-positive diagnosis) is being considered, decisions to terminate ART should be made cautiously and with expert guidance, and may benefit from highly sensitive quantification of the proviral reservoir.


Assuntos
Terapia Antirretroviral de Alta Atividade , DNA Viral/sangue , Infecções por HIV/tratamento farmacológico , HIV-1/fisiologia , Provírus/genética , Ativação Viral , Adolescente , Seguimentos , Humanos , Recém-Nascido , Masculino , Fatores de Tempo , Suspensão de Tratamento
4.
J Law Med ; 27(1): 164-177, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31682348

RESUMO

A doctor may make a unilateral decision to withdraw or withhold life-sustaining treatment from a patient. Recent cases involving critically ill children in Australia, England and Wales have demonstrated how doctors may determine a child's life is not worth maintaining despite parental demands for treatment. The breadth of a doctor's discretion to not provide treatment is ambiguous though, and the extent to which a doctor may make unilateral quality of life judgments is not clear. The ambiguity arises because of different framing of a doctor's obligations, a lack of clear role delineation between relevant decision-makers and differences in opinion about the appropriate scope of inquiry when applying concepts like "futility" and "best interests". This ambiguity is likely to cause confusion in practice and may be the difference between a child receiving life-sustaining treatment.


Assuntos
Qualidade de Vida , Suspensão de Tratamento , Austrália , Criança , Tomada de Decisões , Inglaterra , Humanos , País de Gales
5.
J Law Med ; 27(1): 192-210, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31682350

RESUMO

Courts in England and Wales, Australia, and New Zealand have insisted the question of when it is acceptable to withdraw or withhold life-sustaining medical treatment from a child must be considered on a case-by-case basis. Over the last 40 years a number of cases have considered whether treatment is objectively in the child's best interests. This article seeks to identify whether there are factors identified and weighed in a consistent manner across cases. Thirty cases involving decisions about the provision of life-sustaining medical treatment to children three years old or younger were identified. Judges regularly refer to the need to weigh benefits and burdens and these factors were identified and assigned scores. Eight key factors were identified, and a scoring range was assigned to each. The factors focus on the condition and position of the child and the burdens of invasive medical treatment. The review demonstrates there are factors consistently identified and despite criticisms of the indeterminacy of the best interests test, there may be a broadly consistent approach to decision-making. Cognitive capacity and unavoidably imminent death appear to be the two most influential factors in determining whether life-sustaining treatment should be provided.


Assuntos
Tomada de Decisões , Suspensão de Tratamento , Austrália , Criança , Pré-Escolar , Inglaterra , Humanos , Nova Zelândia , País de Gales
7.
Vasc Health Risk Manag ; 15: 399-408, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31571891

RESUMO

Stroke prevention with oral anticoagulants in patients with atrial fibrillation predisposes for bleeding. As a result, in select patient groups anticoagulation is withheld because of a perceived unfavorable risk-benefit ratio. Reasons for withholding anticoagulation can vary greatly between clinicians, often leading to discussion in daily clinical practice on the best approach. To guide clinical decision-making, we have reviewed available evidence on the most frequently reported reasons for withholding anticoagulation: previous bleeding, frailty and age, and an overall high bleeding risk.


Assuntos
Anticoagulantes/efeitos adversos , Fibrilação Atrial/tratamento farmacológico , Hemorragia/induzido quimicamente , Acidente Vascular Cerebral/prevenção & controle , Suspensão de Tratamento , Administração Oral , Fatores Etários , Anticoagulantes/administração & dosagem , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/epidemiologia , Tomada de Decisão Clínica , Fragilidade/epidemiologia , Nível de Saúde , Hemorragia/epidemiologia , Humanos , Seleção de Pacientes , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia
8.
Rev Assoc Med Bras (1992) ; 65(9): 1168-1173, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31618332

RESUMO

OBJECTIVE: Treatment limitation, as well as do-not-resuscitate (DNR) directives, are difficult but important to improve patients' quality of life and minimize dysthanasia. We aimed to study the approach to withholding, withdrawal, and DNR decisions, patients' characteristics, and process documentation in a general Intensive Care Unit (ICU) in Portugal. METHODS: A retrospective analysis of data regarding the limitation of treatment decisions collected from previously-designed forms and complemented by medical record consultation. RESULTS: A total of 1602 patients were admitted to the ICU between 2011 and 2016. DNR decisions were documented in 127 cases (7.9%). Patients with treatment limitations were older and had higher Simplified Acute Physiology Score II. The most frequent diagnosis preceding these decisions was sepsis (52.0%, n = 66); the most common main reason for limiting treatment was a poor prognosis of acute illness. Of the patients to whom a DNR was implemented, 117 (92.1%) died in the ICU (40.1% of the total number of ICU deaths), and hospital mortality was 100%. Participants in these decisions, as well as types of treatment withdrawn and their respective timings, were not registered in medical records. CONCLUSION: Treatment limitation and DNR decisions were relatively common, in line with other Southern European studies, but behind Northern European and North American centers. Patients with these limitations were older and more severely ill than patients without such decisions. Documentation of these processes should be clear and detailed, either in specific forms or computerized clinical records; there is room for improvement in this area.


Assuntos
Unidades de Terapia Intensiva/organização & administração , Registros Médicos , Ordens quanto à Conduta (Ética Médica) , Suspensão de Tratamento/normas , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisões , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Portugal , Qualidade de Vida , Estudos Retrospectivos , Sepse/mortalidade
13.
17.
J R Soc Med ; 112(11): 472-475, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31526209

RESUMO

A significant loss of bone mineral density and the appearance of multiple vertebral fractures after discontinuation of denosumab treatment have been described. To date, no hip fractures have been reported. We present three cases of patients who suffered femoral fractures after denosumab suppression.


Assuntos
Densidade Óssea/efeitos dos fármacos , Denosumab/farmacologia , Fraturas do Quadril/etiologia , Osteoporose Pós-Menopausa/tratamento farmacológico , Suspensão de Tratamento , Absorciometria de Fóton , Idoso , Idoso de 80 Anos ou mais , Conservadores da Densidade Óssea/farmacologia , Feminino , Fraturas do Quadril/diagnóstico , Humanos , Pessoa de Meia-Idade
18.
Clin Interv Aging ; 14: 1445-1450, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31496671

RESUMO

Discontinuation of denosumab during osteoporosis treatment leads to rapid loss of bone mineral density and induces a bone turnover rebound effect. Previous studies have reported analysis based on dual-energy X-ray absorptiometry scanning (DXA). Here, we report the first case involving analysis of three-dimensional bone mineral density and bone strength, measured by quantitative computed tomography (QCT) after discontinuation of denosumab. An 82-year-old woman who discontinued denosumab because of patient's wish was administered the fifth dose after a gap of 14 months. Her bone mineral density evaluated by DXA and QCT, bone strength, and bone turnover marker levels showed significant rebound phenomenon. The levels of the cortical parameters of the hip were also decreased indicating an increased risk of femoral fractures after denosumab interruption. Our case highlights the increased risk of fractures after discontinuation of denosumab. Therefore, denosumab must be used judiciously without interruption in the dosage schedule.


Assuntos
Conservadores da Densidade Óssea/uso terapêutico , Denosumab/uso terapêutico , Osteoporose Pós-Menopausa/tratamento farmacológico , Suspensão de Tratamento , Absorciometria de Fóton , Idoso de 80 Anos ou mais , Fenômenos Biomecânicos/efeitos dos fármacos , Densidade Óssea/efeitos dos fármacos , Esquema de Medicação , Feminino , Humanos , Tomografia Computadorizada por Raios X
19.
BMC Public Health ; 19(1): 1214, 2019 Sep 03.
Artigo em Inglês | MEDLINE | ID: mdl-31481046

RESUMO

BACKGROUND: Treatment of latent tuberculosis infection (LTBI) in high-risk groups is an effective strategy for TB control and elimination in low incidence settings. A nine-month course of daily isoniazid (INH) has been the longest prescribed therapy; however, completion rates are suboptimal. We need data to guide TB program outreach efforts to optimize LTBI treatment completion rates. METHODS: We pooled seven (2009-2015) years of LTBI treatment outcome data. We computed the probability of INH treatment disruption over time by patient demographic and clinical risk factors. We used log-rank tests and Cox proportional hazards models to assess the risk factors for treatment disruption. RESULTS: We analyzed data from 12,495 persons with complete data on INH treatment initiation. Pediatric cases (0-17 years), recent contacts of active TB patients, and non-U.S.-born adults living in the United States ≤5 years represented 25.2, 13.0, and 59.2% of the study population, respectively. Overall, 48.4% failed to complete therapy. The median treatment duration was 306 days (95% CI: 297, 315). A significant drop in adherence could be observed around day 30 of treatment initiation. Indeed, by day 30 of treatment, 17.0% (95% CI: 16.4, 17.7) of patients had defaulted on therapy. Pediatric patients (HR = 0.83, 95% CI: 0.78, 0.89), recent contacts (HR = 0.74, 95% CI: 0.68, 0.81), patients with diabetes (HR = 0.77, 95% CI: 0.60, 0.98), and patients with HIV (HR = 0.39, 95% CI: 0.30, 0.51) had a lower risk of treatment default. However, black patients (HR = 1.57, 95% CI: 1.44, 1.70), Hispanic patients (HR = 1.54, 95% CI: 1.43, 1.66), and non-U.S.-born persons living in the United States ≤5 years (HR = 1.25, 95% CI: 1.18, 1.32) were significantly more likely to default on therapy. CONCLUSIONS: In this analysis of INH treatment outcome, we see high levels of treatment discontinuation. On average, patients defaulted on their prescribed nine-month daily INH therapy within 30 days of initiating treatment, and those at increased risk of progression to active disease were most likely to do so. We highlight the need to introduce patient-centered programs to increase treatment adherence in this population.


Assuntos
Antituberculosos/uso terapêutico , Isoniazida/uso terapêutico , Tuberculose Latente/tratamento farmacológico , Suspensão de Tratamento/estatística & dados numéricos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Recém-Nascido , Masculino , Fatores de Tempo , Resultado do Tratamento , Estados Unidos
20.
World Neurosurg ; 131: e508-e513, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31398522

RESUMO

BACKGROUND: Poor-grade subarachnoid hemorrhage (SAH) has been associated with a high case fatality, either in the acute phase or in the later stages. The exact causes of death in these patients are unknown. METHODS: We performed a retrospective study of all consecutive patients with SAH with World Federation of Neurosurgical Societies grade IV or V on admission from 2009 to 2013 at 2 tertiary referral centers in Amsterdam, the Netherlands, and Toronto, Ontario, Canada, who had died during their hospital stay. RESULTS: Of 357 patients, 152 (43%) had died. Of these 152 patients, 87 (24%) had not undergone aneurysm treatment. The median interval to death was 3 days (interquartile range, 1-12 days) after initial hemorrhage. The major cause of death in both centers was withdrawal of life support (107 patients [71%]; 74 of 94 [79%] in Amsterdam and 33 of 58 [58%] in Toronto; P < 0.01), followed by brain death in 23 (15%; 16 of 58 [28%] in Amsterdam vs. 7 of 94 [7%] in Toronto; P < 0.01). The remaining causes of death represented <15%. CONCLUSIONS: The decision to withdraw life support was the major reason for death of patients with poor-grade SAH for an overwhelming majority of the patients. The exact reasons for withdrawal of life support, other than cultural and referral differences, were undetermined. Insight into the reasons of death should be prospectively studied to improve the care and clinical outcomes of patients with poor-grade SAH.


Assuntos
Morte Encefálica , Eutanásia Passiva , Cuidados para Prolongar a Vida , Hemorragia Subaracnóidea/mortalidade , Causas de Morte , Feminino , Parada Cardíaca/mortalidade , Humanos , Hipertensão Intracraniana/mortalidade , Masculino , Isquemia Mesentérica/mortalidade , Pessoa de Meia-Idade , Neoplasias/mortalidade , Países Baixos , Ontário , Pneumonia/mortalidade , Recidiva , Estudos Retrospectivos , Índice de Gravidade de Doença , Choque Séptico/mortalidade , Hemorragia Subaracnóidea/terapia , Suspensão de Tratamento
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