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1.
Otolaryngol Head Neck Surg ; 162(4): 554-558, 2020 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-31959051

RESUMO

OBJECTIVE: Congenital ear anomalies are associated with congenital cardiac and renal defects. Renal ultrasounds, electrocardiogram, and echocardiogram can be utilized for diagnosis of these concurrent defects. No standard of care exists for the workup of patients with microtia. The goals of this study were to describe the utilization of diagnostic testing for cardiac and renal anomalies and to identify their prevalence in patients with microtia. STUDY DESIGN: Case series with chart review. SETTING: Children's Hospital of Pittsburgh of the University of Pittsburgh Medical Center. SUBJECTS AND METHODS: This study is an Institutional Review Board-approved retrospective review of consecutive patients born between 2002 and 2016 who were diagnosed with microtia and seen in the otolaryngology clinic at a tertiary care children's hospital. Demographics, sidedness and grade of microtia, comorbid diagnoses, and details of renal and cardiovascular evaluations were recorded. Factors associated with retroperitoneal ultrasound and cardiac testing were assessed with logistic regression. RESULTS: Microtia was present in 102 patients, and 98 patients were included as they received follow-up. Microtia was associated with craniofacial syndrome in 34.7% of patients. Renal ultrasound was performed in 64.3% of patients, and 12.9% of patients with ultrasounds had renal aplasia. Cardiac workup (electrocardiogram or echocardiogram) was completed in 60.2% of patients, and of this subset, 54.2% had a congenital heart defect. CONCLUSION: Diagnostic testing revealed renal anomalies and cardiac defects in patients with isolated microtia at a higher rate than in the general population. This suggests the need for further evaluation of the role of routine screening in patients with microtia.


Assuntos
Anormalidades Múltiplas/diagnóstico , Microtia Congênita/complicações , Cardiopatias Congênitas/complicações , Cardiopatias Congênitas/diagnóstico , Rim/anormalidades , Anormalidades Múltiplas/epidemiologia , Adolescente , Criança , Pré-Escolar , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Feminino , Cardiopatias Congênitas/epidemiologia , Humanos , Lactente , Recém-Nascido , Masculino , Prevalência , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Estudos Retrospectivos
2.
Rev Med Interne ; 41(3): 192-195, 2020 Mar.
Artigo em Francês | MEDLINE | ID: mdl-31987671

RESUMO

Clinical reasoning is at the heart of physicians' competence, as it allows them to make diagnoses. However, diagnostic errors are common, due to the existence of reasoning biases. Artificial intelligence is undergoing unprecedented development in this context. It is increasingly seen as a solution to improve the diagnostic performance of physicians, or even to perform this task for them, in a totally autonomous and more efficient way. In order to understand the challenges associated with the development of artificial intelligence, it is important to understand how the machine works to make diagnoses, what are the similarities and differences with the physician's diagnostic reasoning, and what are the consequences for medical training and practice.


Assuntos
Inteligência Artificial , Diagnóstico por Computador , Técnicas e Procedimentos Diagnósticos , Médicos/psicologia , Tomada de Decisões/fisiologia , Diagnóstico por Computador/psicologia , Diagnóstico por Computador/normas , Diagnóstico por Computador/estatística & dados numéricos , Erros de Diagnóstico/psicologia , Erros de Diagnóstico/estatística & dados numéricos , Técnicas e Procedimentos Diagnósticos/psicologia , Técnicas e Procedimentos Diagnósticos/normas , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Humanos , Intuição/fisiologia , Médicos/estatística & dados numéricos , Padrões de Prática Médica/normas , Padrões de Prática Médica/estatística & dados numéricos , Preconceito/psicologia
3.
BMC Emerg Med ; 19(1): 62, 2019 10 30.
Artigo em Inglês | MEDLINE | ID: mdl-31666023

RESUMO

BACKGROUND: Emergency Department (ED) overcrowding adversely affects patients' health, accessibility, and quality of healthcare systems for communities. Several studies have addressed this issue. This study aimed to conduct a systematic review study concerning challenges, lessons and way outs of clinical emergencies at hospitals. METHODS: Original research articles on crowding of emergencies at hospitals published from 1st January 2007, and 1st August 2018 were utilized. Relevant studies from the PubMed and EMBASE databases were assessed using suitable keywords. Two reviewers independently screened the titles, abstracts and the methodological validity of the records using data extraction format before their inclusion in the final review. Discussions with the senior faculty member were used to resolve any disagreements among the reviewers during the assessment phase. RESULTS: Out of the total 117 articles in the final record, we excluded 11 of them because of poor quality. Thus, this systematic review synthesized the reports of 106 original articles. Overall 14, 55 and 29 of the reviewed refer to causes, effects, and solutions of ED crowding, respectively. The review also included four articles on both causes and effects and another four on causes and solutions. Multiple individual patients and healthcare system related challenges, experiences and responses to crowding and its consequences are comprehensively synthesized. CONCLUSION: ED overcrowding is a multi-facet issue which affects by patient-related factors and emergency service delivery. Crowding of the EDs adversely affected individual patients, healthcare delivery systems and communities. The identified issues concern organizational managers, leadership, and operational level actions to reduce crowding and improve emergency healthcare outcomes efficiently.


Assuntos
Aglomeração , Serviço Hospitalar de Emergência/organização & administração , Fatores Etários , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Acesso aos Serviços de Saúde/organização & administração , Administração Hospitalar , Humanos , Gravidade do Paciente , Fatores Sexuais , Listas de Espera , Fluxo de Trabalho
4.
Rev. esp. cardiol. (Ed. impr.) ; 72(10): 813-819, oct. 2019. tab, graf
Artigo em Espanhol | IBECS | ID: ibc-189319

RESUMO

Introducción y objetivos: En un estudio de base poblacional, se analizaron las posibles diferencias en función del sexo en la atención al dolor torácico o las palpitaciones como motivo de consulta. Métodos: El estudio OFRECE incluyó una muestra aleatoria de la población española de 8.400 participantes de edad ≥ 40 años, de los que 1.132 (13,5%) tenían antecedentes de consulta por dolor en el pecho y 1.267 (15,1%), por palpitaciones y se incluyen en este estudio. Se calculó la odds ratio (OR) de que se practicaran determinadas pruebas y se comunicaran los resultados de las consultas en relación con el hecho de ser mujer, tanto brutas como ajustadas por los factores de riesgo cardiovascular clásicos, antecedentes de enfermedad cardiovascular y diagnóstico de angina estable o fibrilación auricular confirmado en este estudio en cada caso. Resultados: No se observaron diferencias en los antecedentes de consulta por dolor torácico entre mujeres y varones (el 13 y el 14,1%; p=0,159) y sí en las consultas por palpitaciones (el 19,0 y el 10,4% respectivamente; p <0,001). A las mujeres con antecedentes de consulta por dolor torácico, en comparación con los varones, se les realizaron menos ecocardiogramas (el 32,5 y el 45,3%; p <0,001), se las remitió con menor frecuencia al cardiólogo (el 49,1 y el 60,1%; p <0,001), ingresaron menos (el 20,1 y el 39,4%; p <0,001) y se alcanzó un diagnóstico en menor proporción de casos (el 60,9 y el 71,9%; p <0,001). Al ajustar, disminuyen las diferencias y dejan de ser significativas en todos los casos: para ecocardiogramas, OR ajustada=0,81 (IC95%, 0,60-1,09); para remisión al cardiólogo, OR ajustada=0,86 (IC95%, 0,63-1,16), y para ingreso, OR ajustada=0,76 (IC95%, 0,54-1,09). En el caso de las palpitaciones, las diferencias no ajustadas son menores y todas desaparecen al ajustar. Conclusiones: Este trabajo no confirma un sesgo en razón del sexo en la atención a estos síntomas, aunque no es descartable completamente un sesgo de género en el diagnóstico confirmado en el estudio que limite su capacidad para identificar diferencias en la atención a las pacientes


Introduction and objectives: To analyze differences between sexes in the clinical management of patients presenting with symptoms of chest pain and/or palpitations within a population-based study. Methods: The OFRECE study included a random sample of 8400 individuals from the Spanish population aged 40 years and older; 1132 (13.5%) had previously consulted for chest pain and 1267 (15.1%) had consulted for palpitations and were included in the present study. We calculated both the crude and adjusted odds ratios (OR) of undergoing certain tests and the results of consultations by sex. Adjustment was performed by classic cardiovascular risk factors, a personal history of cardiovascular disease, and a diagnosis of stable angina or atrial fibrillation confirmed in the OFRECE study in each case. Results: No differences were observed in history of consultation for chest pain between women and men (13% vs 14.1%; P=.159) but differences were found in palpitations (19% vs 10.4%, respectively; P <.001). Women who had previously consulted for chest pain underwent fewer echocardiograms (32.5% vs 45.3%, respectively; P <.001), were less frequently referred to a cardiologist (49.1% vs 60.1%; P <.001), were less often admitted to hospital (20.1% vs 39.4%; P <.001), and less frequently received a confirmed diagnosis (60.9 vs 71, 9; P <.001). After full adjustment, all differences decreased and become nonsignificant echocardiograms: adjusted OR, 0.81; 95%CI, 0.60-1.09; referral to a cardiologist: adjusted OR, 0.86; 95%CI, 0.63-1.16; hospital admission: adjusted OR, 0.76; 95%CI, 0.54-1.09). For palpitations, crude differences were smaller and all became nonsignificant after adjustment. Conclusions: This study does not confirm the existence of sex-related bias in the management of chest pain and palpitations. However, such bias cannot be completely ruled out in diagnoses confirmed within the OFRECE study, which might limit its ability to detect sex-related differences in health care


Assuntos
Humanos , Masculino , Feminino , Adulto , Pessoa de Meia-Idade , Idoso , Gênero e Saúde/políticas , Determinantes Sociais da Saúde/tendências , Disparidades nos Níveis de Saúde , Disparidades em Assistência à Saúde/tendências , Dor no Peito/epidemiologia , Taquicardia/epidemiologia , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Acesso aos Serviços de Saúde/tendências , Atenção à Saúde , Técnicas de Diagnóstico Cardiovascular/estatística & dados numéricos , Sexismo/estatística & dados numéricos
5.
Gynecol Obstet Invest ; 84(6): 591-598, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31311023

RESUMO

PURPOSE: To perform a systematic review and meta-analysis of studies comparing the diagnostic accuracy of Risk of Ovarian Malignancy Algorithm (ROMA) and risk of malignancy index (RMI) for detecting ovarian cancer. METHODS: A systematic review and meta-analysis was performed according to PRISMA statement. A search for studies evaluating the diagnostic performance of ROMA and RMI-I indices for detecting ovarian malignancy from January 2010 to October 2018 was performed in the PubMed/MEDLINE and Web of Science databases. The quality of the studies was evaluated by the Quality Assessment of Diagnostic Accuracy Studies 2. RESULTS: Sixty-six citations were identified. After exclusions, 8 papers comprising 2,662 women (1,319 premenopausal and 1,343 postmenopausal) were ultimately included. The mean prevalence of ovarian malignancy was 29.0% in premenopausal women and 51.0% in postmenopausal women. High risk of bias for patient selection was observed for most studies. ROMA and RMI-I had a similar diagnostic performance in postmenopausal women (pooled sensitivity [87 vs. 77%] and specificity [75 vs. 85%], respectively. p = 0.29). In premenopausal women, RMI-I showed better specificity than ROMA (89 vs. 78%, p = 0.022) with similar sensitivity (73 vs. 80%, p= 0.27). Significant heterogeneity was found for sensitivity and specificity in comparisons of both groups. CONCLUSIONS: ROMA and RMI-I have similar diagnostic performance for detecting ovarian cancer in women presenting with an adnexal mass. However, RMI-I showed a higher specificity than ROMA in premenopausal women. Notwithstanding, as the risk of bias is high in most studies, our results should be interpreted with caution.


Assuntos
Doenças dos Anexos/diagnóstico , Algoritmos , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Neoplasias Ovarianas/diagnóstico , Adulto , Antígeno Ca-125 , Feminino , Humanos , Pessoa de Meia-Idade , Neoplasias Ovarianas/epidemiologia , Neoplasias Ovarianas/patologia , Medição de Risco , Sensibilidade e Especificidade
6.
Medicina (Kaunas) ; 55(6)2019 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-31212673

RESUMO

Background and objectives: Identification of cancer biomarkers that are differentially expressed (DE) between two biological conditions is an important task in many microarray studies. There exist several methods in the literature in this regards and most of these methods designed especially for unpaired samples, those are not suitable for paired samples. Furthermore, the traditional methods use p-values or fold change (FC) values to detect the DE genes. However, sometimes, p-value based results do not comply with FC based results due to the smaller pooled variance of gene expressions, which occurs when variance of each individual condition becomes smaller. There are some methods that combine both p-values and FC values to solve this problem. But, those methods also show weak performance for small sample cases in the presence of outlying expressions. To overcome this problem, in this paper, an attempt is made to propose a hybrid robust SAM-FC approach by combining rank of FC values and rank of p-values computed by SAM statistic using minimum ß-divergence method, which is designed for paired samples. Materials and Methods: The proposed method introduces a weight function known as ß-weight function. This weight function produces larger weights corresponding to usual and smaller weights for unusual expressions. The ß-weight function plays the significant role on the performance of the proposed method. The proposed method uses ß-weight function as a measure of outlier detection by setting ß = 0.2. We unify both classical and robust estimates using ß-weight function, such that maximum likelihood estimators (MLEs) are used in absence of outliers and minimum ß-divergence estimators are used in presence of outliers to obtain reasonable p-values and FC values in the proposed method. Results: We examined the performance of proposed method in a comparison of some popular methods (t-test, SAM, LIMMA, Wilcoxon, WAD, RP, and FCROS) using both simulated and real gene expression profiles for both small and large sample cases. From the simulation and a real spike in data analysis results, we observed that the proposed method outperforms other methods for small sample cases in the presence of outliers and it keeps almost equal performance with other robust methods (Wilcoxon, RP, and FCROS) otherwise. From the head and neck cancer (HNC) gene expression dataset, the proposed method identified two additional genes (CYP3A4 and NOVA1) that are significantly enriched in linoleic acid metabolism, drug metabolism, steroid hormone biosynthesis and metabolic pathways. The survival analysis through Kaplan-Meier curve revealed that combined effect of these two genes has prognostic capability and they might be promising biomarker of HNC. Moreover, we retrieved the 12 candidate drugs based on gene interaction from glad4u and drug bank literature based gene associations. Conclusions: Using pathway analysis, disease association study, protein-protein interactions and survival analysis we found that our proposed two additional genes might be involved in the critical pathways of cancer. Furthermore, the identified drugs showed statistical significance which indicates that proteins associated with these genes might be therapeutic target in cancer.


Assuntos
Biomarcadores Tumorais/análise , Técnicas e Procedimentos Diagnósticos/normas , Biomarcadores Tumorais/genética , Simulação por Computador , Técnicas e Procedimentos Diagnósticos/instrumentação , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Perfilação da Expressão Gênica/instrumentação , Perfilação da Expressão Gênica/métodos , Humanos , Prognóstico
7.
Acta Trop ; 195: 83-89, 2019 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-31054287

RESUMO

Misdiagnosis of malaria could lead to the overuse of antimalarials resulting in the progression of underlying illness as well as increased risk of mortality. Misdiagnosis is an important consideration as a significant proportion of febrile illnesses in sub-Saharan Africa are attributable to conditions other than malaria. A health facility survey was carried out for a simple random sample of health facilities across 4 provinces of central Zambia in 2014. Twenty-nine facilities with at least 10 outpatients per day were included in the final sample. A modified service provision assessment questionnaire was used for data collection along with several other instruments. Primary outcomes included the quality and accuracy of diagnostic testing for malaria as well as health worker diagnostic and treatment practices. Laboratory technicians displayed 65.5% sensitivity and 86.0% specificity in performing malaria microscopy. Rapid diagnostic test results as reported by health workers were cross-checked by survey staff revealing 99.8% (95% CI: 98.0%-100.0%) concordance. Overall, 69.5% (177/286) (95% CI [58.8%-78.4%]) of patients were reported as febrile of which 37.0% (68/177) (95% CI [21.0%-56.6%]) had a malaria test requested or conducted by their health worker. Appropriate health worker adherence to recommended malaria case management practices (i.e. requesting/conducting malaria tests for febrile patients and providing appropriate antimalarial treatment for test positive cases or forgoing antimalarial treatment for test negative cases) was 30.5% (57/177) (95% CI [17.1%-48.4%]). Presence of fever (aOR = 10.6; 95% CI [3.6-31.2]) and self-reported headache (aOR = 2.2; 95% CI [1.0-4.9]) were significant factors in explaining health worker practices of requesting or performing malaria tests. Routine practice of IQA activities (aOR = 4.8; 95% CI [1.5-15.1]) and self-reported headache (aOR = 3.3; 95% CI [1.1-10.1])) were both significant predictors of antimalarial drug treatment or prescription among malaria untested patients. Prescriber adherence to malaria diagnostic test results in central Zambia is good, but the overall testing rate of febrile patients was low. Additionally, a number of patients observed during this survey were found to have received a clinical diagnosis of malaria without parasitological confirmation and many patients without test results received antimalarial treatment.


Assuntos
Antimaláricos/uso terapêutico , Administração de Caso/estatística & dados numéricos , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Instalações de Saúde/estatística & dados numéricos , Malária/diagnóstico , Malária/tratamento farmacológico , Pacientes Ambulatoriais/estatística & dados numéricos , Estudos Transversais , Humanos , Inquéritos e Questionários , Zâmbia
10.
Neurology ; 92(13): 631-634, 2019 03 26.
Artigo em Inglês | MEDLINE | ID: mdl-30910941

RESUMO

OBJECTIVE: With the long-term goal of improving community health by screening for dementia, we tested the utility of integrating the Six-Item Screener (SIS) into our emergency department neurology consultations. METHODS: In this cross-sectional observational study, we measured SIS performance within 24 hours of hospital arrival in 100 consecutive English-speaking patients aged ≥45 years. Performance was compared to patient age, previously charted cognitive impairment, and proxies for in-hospital complexity: whether or not a patient was admitted to the hospital and the number of medical studies ordered. RESULTS: Those with poor SIS performance were older (p = 0.02) and more likely to have previously charted cognitive impairment (p < 0.01; sensitivity 86%, specificity 77%). Poor performers were more likely to be admitted to the hospital (p = 0.04; odds ratio 3.6) and were subjected to more tests once admitted (p < 0.01), relationships that persisted after accounting for age and history of cognitive impairment. CONCLUSIONS: Poor performance on the SIS was associated with previously charted cognitive impairment, justifying future study of its ability to detect unrecognized dementia cases. Until then, its ability to inexpensively anticipate medically complex hospital admissions motivates broader emergency department use of the SIS.


Assuntos
Disfunção Cognitiva/diagnóstico , Demência/diagnóstico , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Hospitalização/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Disfunção Cognitiva/epidemiologia , Demência/epidemiologia , Serviço Hospitalar de Emergência , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Programas de Rastreamento , Testes de Estado Mental e Demência , Pessoa de Meia-Idade , Encaminhamento e Consulta
11.
Genet Med ; 21(10): 2199-2207, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-30894705

RESUMO

PURPOSE: We evaluated clinical and genetic features enriched in patients with multiple Mendelian conditions to determine which patients are more likely to have multiple potentially relevant genetic findings (MPRF). METHODS: Results of the first 7698 patients who underwent exome sequencing at Ambry Genetics were reviewed. Clinical and genetic features were examined and degree of phenotypic overlap between the genetic diagnoses was evaluated. RESULTS: Among patients referred for exome sequencing, 2% had MPRF. MPRF were more common in patients from consanguineous families and patients with greater clinical complexity. The difference in average number of organ systems affected is small: 4.3 (multiple findings) vs. 3.9 (single finding) and may not be distinguished in clinic. CONCLUSION: Patients with multiple genetic diagnoses had a slightly higher number of organ systems affected than patients with single genetic diagnoses, largely because the comorbid conditions affected overlapping organ systems. Exome testing may be beneficial for all cases with multiple organ systems affected. The identification of multiple relevant genetic findings in 2% of exome patients highlights the utility of a comprehensive molecular workup and updated interpretation of existing genomic data; a single definitive molecular diagnosis from analysis of a limited number of genes may not be the end of a diagnostic odyssey.


Assuntos
Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Testes Genéticos/métodos , Sequenciamento Completo do Exoma/métodos , Diagnóstico Diferencial , Exoma/genética , Feminino , Genômica/métodos , Genótipo , Sequenciamento de Nucleotídeos em Larga Escala/métodos , Humanos , Masculino , Mutação/genética , Fenótipo , Estudos Retrospectivos , Análise de Sequência de DNA/métodos
12.
J Med Syst ; 43(3): 74, 2019 Feb 12.
Artigo em Inglês | MEDLINE | ID: mdl-30756197

RESUMO

Medical treatments change over time for multiple reasons, including introduction of new treatments, availability of new scientific evidence, change in institutional guidelines, and market efforts by pharmaceutical and medical device companies. Monitoring and analyzing these secular trends will also inform the evaluation of evidence based practice as well as outcome research. Using a large national clinical dataset from the United States Veterans Health Administration (VHA), we measured the change in prevalence of all diseases, medications, and procedures by year from 2001 to 2014. To assess statistical significance, we used a generalized linear model. Among the large number of changes that were observed, multiple significant changes were related to diabetes mellitus type II (DM2). Prevalence of DM2 in the VHA increased after 2001 but plateaued by 2008; blood sugar testing by glycosylated hemoglobin increased consistently while glucose testing decreased; and the trend of insulin and metformin use was consistent with the trend in DM2 prevalence, while glyburide and rosiglitazone use dropped sharply.


Assuntos
Classificação Internacional de Doenças/tendências , Padrões de Prática Médica/tendências , United States Department of Veterans Affairs/tendências , Glicemia , Diabetes Mellitus Tipo 2/tratamento farmacológico , Diabetes Mellitus Tipo 2/epidemiologia , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Hemoglobina A Glicada , Humanos , Hipoglicemiantes/uso terapêutico , Guias de Prática Clínica como Assunto , Medicamentos sob Prescrição , Estados Unidos , Vacinação/estatística & dados numéricos
13.
AIDS Behav ; 23(2): 318-335, 2019 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-29971735

RESUMO

This exploratory analysis investigates relationships of place characteristics to HIV testing among people who inject drugs (PWID). We used CDC's 2012 National HIV Behavioral Surveillance (NHBS) data among PWID from 19 US metropolitan statistical areas (MSAs); we restricted the analytic sample to PWID self-reporting being HIV negative (N = 7477). Administrative data were analyzed to describe the 1. Sociodemographic Composition; 2. Economic disadvantage; 3. Healthcare Service/Law enforcement; and 4. HIV burden of the ZIP codes, counties, and MSAs where PWID lived. Multilevel models tested associations of place characteristics with HIV testing. Fifty-eight percent of PWID reported past-year testing. MSA-level per capita correctional expenditures were positively associated with recent HIV testing among black PWID, but not white PWID. Higher MSA-level household income and imbalanced sex ratios (more women than men) in the MSA were associated with higher odds of testing. HIV screening for PWID is suboptimal (58%) and needs improvement. Identifying place characteristics associated with testing among PWID can strengthen service allocation and interventions in areas of need to increase access to HIV testing.


Assuntos
Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Infecções por HIV/diagnóstico , Características de Residência/estatística & dados numéricos , Abuso de Substâncias por Via Intravenosa , Adulto , Afro-Americanos , Cidades/estatística & dados numéricos , Grupo com Ancestrais do Continente Europeu , Feminino , Infecções por HIV/prevenção & controle , Gastos em Saúde , Serviços de Saúde , Acesso aos Serviços de Saúde , Humanos , Renda , Aplicação da Lei , Governo Local , Masculino , Programas de Rastreamento , Pessoa de Meia-Idade , Análise Multinível , Análise Multivariada , Razão de Chances , Distribuição por Sexo , Segregação Social , População Urbana/estatística & dados numéricos , Adulto Jovem
14.
J Clin Epidemiol ; 106: 1-9, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30278213

RESUMO

BACKGROUND AND OBJECTIVE: Meta-analysis may produce estimates that are unrepresentative of a test's performance in practice. Tailored meta-analysis (TMA) circumvents this by deriving an applicable region for the practice and selecting the studies compatible with the region. It requires the test positive rate, r and prevalence, p being estimated for the setting but previous studies have assumed their independence. The aim is to investigate the effects a correlation between r and p has on estimating the applicable region and how this affects TMA. METHODS: Six methods for estimating 99% confidence intervals (CI) for r and p were investigated: Wilson's ± Bonferroni correction, Clopper-Pearson's ± Bonferroni correction, and Hotelling's T2 statistic ± continuity correction. These were analyzed in terms of the coverage probability using simulation trials over different correlations, sample sizes, and values for r and p. The methods were then applied to two published meta-analyses with associated practice data, and the effects on the applicable region, studies selected, and summary estimates were evaluated. RESULTS: Hotelling's T2 statistic with a continuity correction had the highest median coverage (0.9971). This and the Clopper-Pearson method with a Bonferroni correction both had coverage consistently above 0.99. The coverage of Hotelling's CI's varied the least across different correlations. For both meta-analyses, the number of studies selected was largest when Hotelling's T2 statistic was used to derive the applicable region. In one instance, this increased the sensitivity by over 4% compared with TMA estimates using other methods. CONCLUSION: TMA returns estimates that are tailored to practice providing the applicable region is accurately defined. This is most likely when the CI for r and p are estimated using Hotelling's T2 statistic with a continuity correction. Potentially, the applicable region may be obtained using routine electronic health data.


Assuntos
Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Metanálise como Assunto , Modelos Estatísticos , Simulação por Computador , Intervalos de Confiança , Depressão/diagnóstico , Técnicas e Procedimentos Diagnósticos/normas , Medicina Geral , Humanos , Prevalência , Reprodutibilidade dos Testes
15.
BMC Infect Dis ; 18(1): 607, 2018 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-30509278

RESUMO

BACKGROUND: There is no consensus on the most accurate combination of diagnostic criteria to define community acquired pneumonia (CAP). We describe inclusion criteria in randomized controlled trials (RCT) of CAP and assess their performance for the diagnosis of formally identified CAP. METHODS: RCTs related to CAP recorded on ClinicalTrials.gov were analysed. Due to high heterogeneity, we divided close CAP inclusion criteria into patterns (i.e. combinations of inclusion criteria). To assess their diagnostic performances, these CAP definition patterns were applied to a reference population of 319 suspected CAP patients, in whom the CAP diagnosis had been confirmed (n = 163) or excluded (n = 156) by an adjudication committee after a systematic thoracic CT-scan and a 28-day follow-up period. RESULTS: In the 47 RCTs included in the analysis, 42 different CAP inclusion criteria combinations were identified and 8 patterns created. This heterogeneity was not explained either by the trials' methodology or by their objectives. When applied to the reference population, the performance ranges of the 8 definition patterns were 9.8-56.4% for sensitivities, 56.4 97.4% for specificities, 63.6 83.6% for positive predictive values and 50.8-66.7% for negative predictive values. None of the CAP definitions had both sensitivity and specificity superior to 65%. Depending on the CAP definition, the rate of included patients without CAP ("false positives") ranged from 1 to 21%. CONCLUSIONS: CAP diagnostic criteria within RCTs are heterogeneous, which may have far-reaching consequences on validity of RCT results.


Assuntos
Infecções Comunitárias Adquiridas/diagnóstico , Infecções Comunitárias Adquiridas/epidemiologia , Pneumonia Associada a Assistência à Saúde/diagnóstico , Pneumonia Associada a Assistência à Saúde/epidemiologia , Seleção de Pacientes , Ensaios Clínicos Controlados Aleatórios como Assunto , Adulto , Técnicas e Procedimentos Diagnósticos/normas , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia/diagnóstico , Pneumonia/epidemiologia , Ensaios Clínicos Controlados Aleatórios como Assunto/normas , Ensaios Clínicos Controlados Aleatórios como Assunto/estatística & dados numéricos , Reprodutibilidade dos Testes , Projetos de Pesquisa , Sensibilidade e Especificidade
16.
Rev. cuba. cir ; 57(4): e708, oct.-dic. 2018.
Artigo em Espanhol | LILACS | ID: biblio-991055

RESUMO

RESUMEN Introducción: En la actualidad, la diversidad de criterios relacionados con las reintervenciones quirúrgicas constituyen un verdadero problema científico, por cuanto, resulta de gran importancia profundizar en torno a los principales aspectos cognoscitivos relacionados con este tema a fin de elevar la calidad asistencial y, con esa premisa, el índice de supervivencia, sobre todo en la población envejecida como grupo vulnerable. Objetivos: Identificar los factores que permitan reconocer las condiciones modificables que disminuyan las complicaciones y fallecimientos de los enfermos tributarios de un nuevo tratamiento quirúrgico para salir adelante y sobrevivir. Métodos: Revisión digital de publicaciones actualizadas en español e inglés en bases de datos: Google, Redalyc, PubMed, Medline, Lilacs, Elsevier. Resultados: Las complicaciones posquirúrgicas y las que requieren una reintervención en particular son de origen multifactorial. No existe una definición y una clasificación estandarizada de las complicaciones posquirúrgicas para notificarlas. Las más utilizadas son las objetivas de Clavien Dindo y Accordeon, basadas en la estratificación del tratamiento requerido, el riesgo y gravedad. Conclusiones: A pesar de que el gran avance tecnológico actual en los métodos diagnósticos y terapéuticos ha permitido que los pacientes con complicaciones posquirúrgicas sean reintervenidos con mayor seguridad, la morbilidad y la mortalidad a causa de estas continúan elevadas(AU)


ABSTRACT Introduction: Nowadays, the diverse criteria related to surgical reinterventions are a real scientific problem since it is very important to delve into the main cognitive aspects associated to this topic in order to raise the quality of medical assistance and thus the survival index in the old population as a vulnerable group. Objectives: To identify the factors that allow recognizing the modifiable conditions that lead to less complications and deaths of patients undergoing a new surgical treatment. Methods: Search of updated publications in English and Spanish made in Goggle, Redalyc, PubMed, Medline, Lilacs and Elsevier databases. Results: The postsurgical complications and those requiring surgical reintervention in particular are of multifactoral origin. There is neither one single definition nor one standardized classification of the postsurgical complications to notify them. The most used objective classifications are Claven Dindo and Accordeon, based on the stratification of the required treatment, the risk and the severity. Conclusions: In spite of the fact that the great technological advances in the diagnostic and therapeutic methods have allowed the reoperation of complicated patients with higher margin of safety, morbidity and mortality caused by such complications are still high(AU)


Assuntos
Humanos , Complicações Pós-Operatórias/mortalidade , Reoperação/efeitos adversos , Literatura de Revisão como Assunto , Bases de Dados Bibliográficas/estatística & dados numéricos , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos
17.
Arch. Health Sci. (Online) ; 25(3): 41-45, 21/12/2018.
Artigo em Português | LILACS | ID: biblio-1046416

RESUMO

Introdução: Os avanços médicos das últimas décadas contribuíram para aumentar a sobrevida de pacientes críticos e com a resposta imune comprometida. Consequentemente, a população em risco de adquirir infecções de origem fúngica também cresceu. Com altas taxas de morbidade e mortalidade, o difícil diagnóstico deste tipo de infecção, em conjunto com terapias ineficazes, gera elevados custos e sobrecarga ao sistema de saúde. Objetivos: Padronizar um método molecular de detecção fúngica diretamente do sangue e avaliar esta técnica comparativamente com a atualmente considerada padrão-ouro (hemocultura), associando aspectos clínicos, tempo de realização das técnicas e os custos envolvidos. Casuística e Métodos:Neste sentido, 94 pacientes com suspeita de infecção de corrente sanguínea foram submetidos a uma técnica de nestedPCR para detecção de DNA fúngico. Resultados: A técnica molecular foi positiva em 48,9% das amostras, enquanto que a hemocultura foi positiva em apenas 13,0% dos casos. Esses resultados demonstram uma alta sensibilidade do nested PCR e com um valor preditivo negativo de 100% em pacientes com suspeita clínica de infecção fúngica sistêmica e em situações de risco. O tempo de realização do método e os custos associados a ele, em comparação à hemocultura, também demonstraram seu potencial para uso clínico. Conclusões: Em comparação com a hemocultura, o método padronizado de nestedPCR constitui um teste rápido e economicamente viável capaz de descartar uma infecção sistêmica provocada por fungo, podendo facilitar o diagnóstico e evitar terapias ineficientes e caras, diminuir o tempo de internação e os impactos econômicos gerados por esse tipo de infecção.


Introduction: Medical advances in the past decades have contributed to the increase of survival of critically ill patients and the ones with impaired immune response. Consequently, the population at risk of acquiring a fungal infection also has increased. This type of infection generates expensive costs and heavy burden to the Health system. It also brings high morbidity and mortality rates, difficulty in diagnosing, and ineffective therapies. Objectives: Standardize a molecular method of fungal detection directly from blood and compare this technique with the blood culture, which is currently considered the gold standard. It associates clinical aspects, time, and costs involved. Patients and Methods: In this sense, 94 patients with suspected bloodstream infection were submitted to the technique of nested PCR for detection of fungal DNA. Results: The molecular technique was positive in 48.9% of the samples, while the blood culture was positive in only 13% of the cases. These results demonstrate high sensibility of the nested PCR and negative predictive value of 100%. The performing time and the costs associated with the method also demonstrated its value for clinical use. Conclusions: Therefore, the nested PCR is a quick and economically viable test, capable of ruling out a systemic infection caused by fungus, being able to facilitate the diagnosis, avoid inefficient and expensive therapies, and decrease the length of hospital stay, reducing the burden caused by this type of infection.


Assuntos
Humanos , Masculino , Feminino , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Infecções Fúngicas Invasivas/sangue , Biologia Molecular/métodos
19.
Int J Health Care Qual Assur ; 31(8): 1014-1029, 2018 Oct 08.
Artigo em Inglês | MEDLINE | ID: mdl-30415623

RESUMO

PURPOSE: The purpose of this paper is to present a review of health information system (HIS)-induced errors and its management. This paper concludes that the occurrence of errors is inevitable but it can be minimised with preventive measures. The review of classifications can be used to evaluate medical errors related to HISs using a socio-technical approach. The evaluation could provide an understanding of errors as a learning process in managing medical errors. DESIGN/METHODOLOGY/APPROACH: A literature review was performed on issues, sources, management and approaches to HISs-induced errors. A critical review of selected models was performed in order to identify medical error dimensions and elements based on human, process, technology and organisation factors. FINDINGS: Various error classifications have resulted in the difficulty to understand the overall error incidents. Most classifications are based on clinical processes and settings. Medical errors are attributed to human, process, technology and organisation factors that influenced and need to be aligned with each other. Although most medical errors are caused by humans, they also originate from other latent factors such as poor system design and training. Existing evaluation models emphasise different aspects of medical errors and could be combined into a comprehensive evaluation model. RESEARCH LIMITATIONS/IMPLICATIONS: Overview of the issues and discourses in HIS-induced errors could divulge its complexity and enable its causal analysis. PRACTICAL IMPLICATIONS: This paper helps in understanding various types of HIS-induced errors and promising prevention and management approaches that call for further studies and improvement leading to good practices that help prevent medical errors. ORIGINALITY/VALUE: Classification of HIS-induced errors and its management, which incorporates a socio-technical and multi-disciplinary approach, could guide researchers and practitioners to conduct a holistic and systematic evaluation.


Assuntos
Sistemas de Informação em Saúde/organização & administração , Erros Médicos/classificação , Erros Médicos/estatística & dados numéricos , Protocolos Clínicos/normas , Técnicas e Procedimentos Diagnósticos/normas , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Meio Ambiente , Sistemas de Informação em Saúde/normas , Humanos , Erros Médicos/prevenção & controle , Erros de Medicação/classificação , Erros de Medicação/estatística & dados numéricos , Modelos Organizacionais , Alta do Paciente/normas , Alta do Paciente/estatística & dados numéricos , Carga de Trabalho
20.
Jt Comm J Qual Patient Saf ; 44(11): 674-682, 2018 11.
Artigo em Inglês | MEDLINE | ID: mdl-30122520

RESUMO

BACKGROUND: Delayed or incomplete test result follow-up, which can lead to missed and/or delayed diagnosis, is an important issue in the ambulatory setting. Delayed test result follow-up has been linked to poorer patient outcomes and increased risk of mortality and accounts for a large portion of medical malpractice claims. Yet improvements are difficult, reflecting the complexity of the test result follow-up process. Test result follow-up safety culture was investigated using qualitative and quantitative patient safety and quality of care data at an academic medical center. METHODS: After an environmental scan, five sources of data were used to compass multiple perspectives on safety culture-two national surveys (AHRQ MO SOPS for safety culture and CG-CAHPS for patient satisfaction); patient and family complaints; safety reports; and provider response times to test message results in the electronic health record. RESULTS: The following metrics were inspected: how patients and providers estimated the frequency for providing timely test results; how patients' satisfaction with their provider correlated with their provider's response time to test result messages; and qualitative themes in patient complaints and safety reports filed by clinic. The institution was compared to national benchmarks using surveys. As test result response time decreased, patient satisfaction increased (p = 0.0073). CONCLUSION: Test result follow-up culture was investigated using tools typically used to examine patient satisfaction and experience and staff culture. Use of these five sources of data led to an examination of multiple perspectives in follow-up culture and identification of possible explanations for inappropriate follow-up. These data sources can be further explored to identify possible solutions.


Assuntos
Assistência Ambulatorial/organização & administração , Técnicas e Procedimentos Diagnósticos/estatística & dados numéricos , Cultura Organizacional , Segurança do Paciente , Gestão da Segurança/organização & administração , Centros Médicos Acadêmicos , Assistência Ambulatorial/normas , Comunicação , Documentação , Humanos , Satisfação do Paciente , Percepção , Pesquisa Qualitativa , Melhoria de Qualidade/organização & administração , Análise de Causa Fundamental , Gestão da Segurança/normas , Fatores de Tempo
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