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1.
Ann R Coll Surg Engl ; 103(3): 208-217, 2021 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-33645267

RESUMO

INTRODUCTION: Tonsillectomy is a common surgical procedure performed chiefly for recurrent tonsillitis. The Scottish Intercollegiate Guidance Network (SIGN) introduced guidelines in 1998 to improve patient selection for tonsillectomy and reduce the potential harm to patients from surgical complications such as haemorrhage. Since the introduction of the guidance, the number of admissions for tonsillitis and its complications has increased. National Hospital Episode Statistics over a 20-year period were analysed to assess the trends in tonsillectomy, post-tonsillectomy haemorrhage, tonsillitis and its complications with reference to the guidance, procedures of limited clinical value and the associated costs and benefits. MATERIALS AND METHODS: A literature search was conducted via PubMed and the Cochrane Library to identify relevant research. Hospital Episode Statistics data were interrogated and relevant data compared over time to assess trends related to the implementation of national guidance. RESULTS: Over the period analysed, the incidence of deep neck space infections has increased almost five-fold, mediastinitis ten-fold and peritonsillar abscess by 1.7-fold compared with prior to SIGN guidance. Following procedures of limited clinical value implementation, the incidence of deep neck space infections has increased 2.4-fold, mediastinitis 4.1-fold and peritonsillar abscess 1.4-fold compared with immediately prior to clinical commissioning group rationing. The rate of tonsillectomy and associated haemorrhage (1-2%) has remained relatively constant at 46,299 (1999) compared with 49,447 (2009) and 49,141 (2016), despite an increase in the population of England by seven million over the 20-year period. DISCUSSION: The rise in admissions for tonsillitis and its complications appears to correspond closely to the date of SIGN guidance and clinical commissioning group rationing of tonsillectomy and is on the background of a rise in the population of the UK. The move towards daycase tonsillectomy has reduced bed occupancy after surgery but this has been counteracted by an increase in admissions for tonsillitis and deep neck space infections, sometimes requiring lengthy intensive care stays and a protracted course of rehabilitation. The total cost of treating the complications of tonsillitis in England in 2017 is estimated to be around £73 million. The cost of tonsillectomy and treating post-tonsillectomy haemorrhage is £56 million by comparison. The total cost per annum for tonsillectomy prior to the introduction of SIGN guidance was estimated at £71 million with tonsillitis and its complications accounting for a further £8 million.


Assuntos
Hospitalização/tendências , Mediastinite/epidemiologia , Abscesso Peritonsilar/epidemiologia , Hemorragia Pós-Operatória/epidemiologia , Abscesso Retrofaríngeo/epidemiologia , Tonsilectomia/tendências , Tonsilite/epidemiologia , Adenoidectomia/tendências , Adolescente , Adulto , Distribuição por Idade , Idoso , Idoso de 80 Anos ou mais , Criança , Pré-Escolar , Inglaterra/epidemiologia , Feminino , Custos de Cuidados de Saúde/tendências , Humanos , Incidência , Lactente , Recém-Nascido , Unidades de Terapia Intensiva , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Medicina Estatal , Tonsilite/cirurgia , Adulto Jovem
2.
Medicine (Baltimore) ; 100(9): e25035, 2021 Mar 05.
Artigo em Inglês | MEDLINE | ID: mdl-33655978

RESUMO

BACKGROUND: Adhesive small bowel obstruction (ASBO) is one of the most common complications and is a major cause of re-admission after intra-abdominal surgery. The initial management of patients with ASBO is nonoperative treatment such as nil per os and decompression using a nasogastric tube. However, the ideal management of ASBO remains controversial. METHODS: This study will be a prospective, single-center, double-blind randomized controlled trial. Ninety two participants diagnosed with ASBO will be randomly assigned to either the verum or the sham laser acupuncture (SLA) group in a 1:1 ratio. All participants will undergo laser acupuncture (LA) or SLA once a day on 6 acupoints (LI4, PC6, ST25, ST36, CV4 and CV12) for 6 consecutive days after enrollment. The primary outcome measure will be the success rate of conservative treatment for ASBO. Secondary outcomes will be time to oral intake and length of hospital stay. The serum levels of lipase, amylase, cortisol, motilin, ghrelin, and intestinal fatty acid binding protein (I-FABP) will also be measured before intervention, on day 4, and on the day of discharge, respectively. Data will be analyzed by Chi-Squared test or t test between 2 groups. OBJECTIVES: The aim of this protocol is to investigate the clinical efficacy of LA on ASBO. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT04318821. Registered on 24 March 2020.


Assuntos
Terapia por Acupuntura/métodos , Obstrução Intestinal/terapia , Intestino Delgado , Lasers , Aderências Teciduais/complicações , Adulto , Idoso , Idoso de 80 Anos ou mais , Método Duplo-Cego , Feminino , Humanos , Obstrução Intestinal/etiologia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Estudos Prospectivos , Resultado do Tratamento , Adulto Jovem
3.
Diabetes Metab Syndr ; 15(1): 447-454, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33592371

RESUMO

BACKGROUND: /Aim: Various reports of the occurrence of type 1 diabetes mellitus (T1DM) in patients with COVID-19 have been published, denoting an association between both diseases. Therefore, we conducted this systematic review to summarize the prevalence of T1DM in COVID-19 patients and to identify the clinical presentations and outcomes in this patient population. MATERIALS AND METHODS: Up to 10/27/2020, Medline, Embase, cochrane and google scholar databases were searched for original studies investigating the association between COVID-19 and T1DM. A manual search was conducted to identify missing studies. The quality of included studies was analyzed by the National Institute of Health (NIH) risk of bias tool. Outcomes included length of hospital stay, hospitalization, intensive care unit (ICU) admission, diabetic ketoacidosis (DKA), severe hypoglycemia, and death. RESULTS: Fifteen studies were included in the qualitative analysis. Included studies reported data of both adult and pediatric patients. The prevalence of T1DM in COVID-19 patients ranged from 0.15% to 28.98%, while the rate of COVID-19 in patients with T1DM ranged from 0% to 16.67%. Dry cough, nausea, vomiting, fever and elevated blood glucose levels were the most commonly reported presentations. The investigated outcomes varied widely among studied populations. CONCLUSIONS: The prevalence of T1DM in patients with COVID-19 ranged from 0.15% to 28.98%. The most common presentation of COVID-19 in patients with T1DM included fever, dry cough, nausea and vomiting, elevated blood glucose and diabetic ketoacidosis. The outcomes of COVID-19 in terms of length of hospital stay, hospitalization, ICU admission, DKA rate, and severe hypoglycemia were reported variably in included studies. Due to the heterogeneous study populations and the presence of many limitations, more studies are still warranted to reach a definitive conclusion.


Assuntos
/diagnóstico , Diabetes Mellitus Tipo 1/diagnóstico , Diabetes Mellitus Tipo 1/epidemiologia , Glicemia/metabolismo , Diabetes Mellitus Tipo 1/sangue , Humanos , Tempo de Internação/tendências
4.
Medicine (Baltimore) ; 100(3): e23941, 2021 Jan 22.
Artigo em Inglês | MEDLINE | ID: mdl-33545969

RESUMO

ABSTRACT: This study aimed to compare the effectiveness and safety of reduced-port laparoscopic surgery (RPLS) and conventional multi-port laparoscopic (CMPLS) surgery in the treatment of gastric diseases.The PubMed, Embase, Cochrane Library, Web of Science, and Chinese Biomedical Literature databases were systematically searched for randomized controlled trials, cohort studies, and case control studies on the use of RPLS vs conventional multi-port laparoscopic surgery in treating gastric diseases from their inception until March 10, 2019. The evaluated outcomes were the operative time, blood loss, length of hospital stay, number of dissected lymph nodes, postoperative complications, and conversions. All of these were compared using Stata software version 12.0.A total of 18 studies were included, which involved 2938 patients. In studies referring to the comparison between RPLS and CMPLS in treating gastric diseases, the former showed significantly inferior in terms of operative time (P = .011) and number of dissected lymph nodes (P = .031); but superior results in terms of the estimated blood loss (P = .000) and length of hospital stay (P = .001) than the latter did; however, the rates of postoperative complications (P = .830) and conversions (P = .102) were not statistically significant between the 2 groups.RPLS and CMPLS showed comparable effectiveness and safety in the treatment of gastric diseases in our meta-analysis. Based on the current evidence, we believe that RPLS is an efficacious surgical alternative to CMPLS in the management of gastric diseases because of the shorter hospital stay and reduced blood loss. However, large-scale, well-designed, multicenter studies are needed to further confirm the results of this study.


Assuntos
Equipamentos e Provisões/normas , Laparoscopia/instrumentação , Laparoscopia/normas , Gastropatias/cirurgia , Resultado do Tratamento , Equipamentos e Provisões/efeitos adversos , Humanos , Laparoscopia/métodos , Tempo de Internação/tendências , Duração da Cirurgia , Complicações Pós-Operatórias/etiologia , Gastropatias/complicações
6.
J Nurs Adm ; 51(1): 19-25, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-33278197

RESUMO

BACKGROUND: Hospital flow disruptions have been linked to treatment delays, longer length of stay (LOS), poor patient outcomes, and overburdened staff leading to disengagement. OBJECTIVE: This project was designed to evaluate and determine if the bed reaggregation was successful at meeting its goals. METHODS: Donabedian's framework guided the following evaluation points: 1) patient placement accuracy, 2) LOS variance, 3) emergency department (ED) boarding times, 4) hospital bypass hours, 5) operational declination rates, 6) patient satisfaction, and 7) RN engagement. Data were analyzed using pre-post percent change and χ analysis. RESULTS: Primary placement of patients, LOS variance, and operational declinations improved. Hours on bypass and ED boarding times were not reduced. RN engagement scores varied widely with significant decreases on 2 of the reaggregated units. Patient satisfaction scores varied, but overall did not decrease. CONCLUSION: Further consideration is needed for improving hospital bypass, ED boarding times, and RN engagement.


Assuntos
Centros Médicos Acadêmicos/tendências , Admissão do Paciente/normas , Centros Médicos Acadêmicos/organização & administração , Humanos , Tempo de Internação/tendências , Admissão do Paciente/tendências , Fatores de Tempo , População Urbana
7.
Turk Neurosurg ; 31(1): 73-75, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33372251

RESUMO

AIM: To demonstrate the various technical advantages of minimally invasive endoscopic untethering of tight filum terminale for the treatment of tethered cord syndrome (TCS). MATERIAL AND METHODS: In five pediatric cases of TCS, we performed untethering by using the endoscopic technique. The age of the patients were 6, 7, 8, 9, and 12 years old. We used a nasal speculum of the transsphenoidal approach during the endoscopic surgical procedure. RESULTS: All the procedures were performed uneventfully, except for one case with a split cord malformation that showed neurologic deterioration caused by excision of the diastematomyelic fibrous septum at the thoracic level (unrelated to the endoscopic procedure at the L5-S1 level). This patient was referred to a rehabilitation clinic 5 days after surgery and showed significant improvement by the third postoperative month. The other four patients were discharged 1 day after the operation. CONCLUSION: Endoscopic release of filum terminale is a safe technique especially if it is performed with neuromonitoring. This technique may shorten the length of hospital stay and reduce perioperative blood loss. However, futher studies with a larger number of patients and long-term follow-up are needed.


Assuntos
Cauda Equina/cirurgia , Endoscopia/métodos , Defeitos do Tubo Neural/cirurgia , Criança , Endoscopia/tendências , Feminino , Humanos , Tempo de Internação/tendências , Masculino , Defeitos do Tubo Neural/diagnóstico
8.
Crit Care ; 24(1): 696, 2020 12 14.
Artigo em Inglês | MEDLINE | ID: mdl-33317589

RESUMO

BACKGROUND: In the current SARS-CoV-2 pandemic, there has been worldwide debate on the use of corticosteroids in COVID-19. In the recent RECOVERY trial, evaluating the effect of dexamethasone, a reduced 28-day mortality in patients requiring oxygen therapy or mechanical ventilation was shown. Their results have led to considering amendments in guidelines or actually already recommending corticosteroids in COVID-19. However, the effectiveness and safety of corticosteroids still remain uncertain, and reliable data to further shed light on the benefit and harm are needed. OBJECTIVES: The aim of this systematic review and meta-analysis was to evaluate the effectiveness and safety of corticosteroids in COVID-19. METHODS: A systematic literature search of RCTS and observational studies on adult patients was performed across Medline/PubMed, Embase and Web of Science from December 1, 2019, until October 1, 2020, according to the PRISMA guidelines. Primary outcomes were short-term mortality and viral clearance (based on RT-PCR in respiratory specimens). Secondary outcomes were: need for mechanical ventilation, need for other oxygen therapy, length of hospital stay and secondary infections. RESULTS: Forty-four studies were included, covering 20.197 patients. In twenty-two studies, the effect of corticosteroid use on mortality was quantified. The overall pooled estimate (observational studies and RCTs) showed a significant reduced mortality in the corticosteroid group (OR 0.72 (95%CI 0.57-0.87). Furthermore, viral clearance time ranged from 10 to 29 days in the corticosteroid group and from 8 to 24 days in the standard of care group. Fourteen studies reported a positive effect of corticosteroids on need for and duration of mechanical ventilation. A trend toward more infections and antibiotic use was present. CONCLUSIONS: Our findings from both observational studies and RCTs confirm a beneficial effect of corticosteroids on short-term mortality and a reduction in need for mechanical ventilation. And although data in the studies were too sparse to draw any firm conclusions, there might be a signal of delayed viral clearance and an increase in secondary infections.


Assuntos
Corticosteroides/normas , /mortalidade , Corticosteroides/farmacologia , Corticosteroides/uso terapêutico , Adulto , Mortalidade Hospitalar/tendências , Humanos , Tempo de Internação/tendências
9.
Isr Med Assoc J ; 22(12): 733-735, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33381942

RESUMO

BACKGROUND: Patients diagnosed with coronavirus disease-19 (COVID-19) who deteriorate to respiratory failure and require mechanical ventilation may later need to be weaned from the ventilator and undergo a rehabilitation process. The rate of weaning COVID-19 patients from mechanical ventilation is unknown. OBJECTIVES: To present our experience with ventilator weaning of COVID-19 patients in a dedicated facility. METHODS: A retrospective cohort study was conducted of 18 patients hospitalized in a COVID-19 dedicated ventilator weaning unit. RESULTS: Eighteen patients were hospitalized in the dedicated unit between 6 April and 19 May 2020. Of these, 88% (16/18) were weaned and underwent decannulation, while two patients deteriorated and were re-admitted to the intensive care unit. The average number of days spent in our department was 12. There was no statistically significant correlation between patient characteristics and time to weaning from ventilation or with the time to decannulation. CONCLUSIONS: Despite the high mortality of COVID-19 patients who require mechanical ventilation, most of the patients in our cohort were weaned in a relatively short period of time. Further large-scale studies are necessary to assess the cost effectiveness of dedicated COVID-19 departments for ventilator weaning.


Assuntos
/terapia , Unidades de Terapia Intensiva , Pandemias , Respiração Artificial/métodos , Desmame do Respirador/métodos , Adulto , Idoso , Feminino , Seguimentos , Humanos , Israel/epidemiologia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Prognóstico , Estudos Retrospectivos , Adulto Jovem
10.
BMC Infect Dis ; 20(1): 831, 2020 Nov 11.
Artigo em Inglês | MEDLINE | ID: mdl-33176701

RESUMO

BACKGROUND: The discovery of antibiotics in the mid-twentieth century marked a major transition in tuberculosis (TB) treatment and control. There are few studies describing the duration of TB disease and its treatment from the pre-chemotherapy era and little data on how these treatments changed in response to the development of effective antibiotics. The goal of this research is to understand how inpatient treatment for high incidence populations, the First Nations peoples of Saskatchewan, Canada, changed in response to increasing availability of antibiotics effective against TB. We expected that as treatment regimens transitioned from convalescence-only to triple antibiotic therapy, the length of inpatient treatment would shorten. METHODS: Analyses were performed on records of sanatoria admissions and discharges occurring between 1933 and 1959 in Saskatchewan, Canada. Year of antibiotic discovery was taken as a proxy for treatment regimen: no chemotherapy (pre-1944), mono-therapy (Streptomycin, 1944-1946), dual-therapy (Streptomycin and PAS, 1946-1952), and triple-therapy (Streptomycin, PAS, and INH 1952-). A pooled linear regression of log-transformed length of first admission as predicted by year of admission was modeled to assess the relationship between admission length and year of admission, corrected for clinical and demographic variables. RESULTS: First admission length increased 19% in the triple-therapy era as compared to the pre-chemotherapy era, from 316 days (10.4 months) to 377 days (12.4 months). After the discovery of INH (1952), we find statistically significant increases in the proportion of successfully completed therapies (0.55 versus 0.60, p = 0.035), but also in patients who left hospital against medical advice (0.19 versus 0.29, p < 0.0001), indicating that as hospitalizations lengthened, more patients chose to discharge without the sanction of their physician. The readmission rate increased from 10 to 50% of all admissions while the province-level TB-specific death rate fell from 63.1 per 10,000 in 1933 to 4.7 per 10,000 in 1958. CONCLUSION: Counterintuitively, we find that the length of first admissions increased with the discovery of TB-treating antibiotics. Increasing admission volume and readmission rate indicate an intensification of inpatient TB treatment during this era. These analyses provide a novel estimate of the effect of changing treatment policy on sanatorium admissions in this population.


Assuntos
Antibacterianos/uso terapêutico , Tempo de Internação/tendências , Readmissão do Paciente/tendências , Tuberculose/tratamento farmacológico , Tuberculose/epidemiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Canadá/epidemiologia , Criança , Pré-Escolar , Feminino , Hospitais , Humanos , Incidência , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Alta do Paciente , Estudos Retrospectivos , Resultado do Tratamento , Tuberculose/microbiologia , Adulto Jovem
11.
Rev Gastroenterol Peru ; 40(3): 219-223, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33181807

RESUMO

INTRODUCTION: During the COVID-19 pandemic, endoscopic procedures are associated with a high risk of SARS-CoV-2 infection. However, in cases of upper gastrointestinal bleeding (UGIB), priority should be given to an early endoscopy. OBJECTIVE: The main objective was to compare the time since arrival at the hospital and the performance of the endoscopy between both groups. MATERIALS AND METHODS: We performed a retrospective study. Data contains information of patients who attended to the hospital with UGIB and underwent an endoscopy between October 19th, 2019 and June 6th, 2020. Patients were divided into 2 phases: pre-pandemic and pandemic. The time between arrival at the hospital and the performance of the endoscopy in both phases were compared as well as other indicators such hospital stay and in-hospital mortality. RESULTS: With information from 219 patients, the median age was 69 years. 154 and 65 endoscopies were performed in pre-pandemic and pandemic phase, respectively. The time between arrival at the hospital and the performance of the endoscopy was significantly longer during the pandemic (10.00 vs. 13.08 hours, p-value = 0.019). Nevertheless, there were no significant differences in hospital stay or mortality. CONCLUSION: The management of patients with UGIB during the COVID-19 pandemic is complex and requires the application of clinical judgment to decide the best timing to perform an endoscopy without affecting patient care.


Assuntos
Infecções por Coronavirus , Endoscopia Gastrointestinal/tendências , Hemorragia Gastrointestinal/diagnóstico por imagem , Pandemias , Pneumonia Viral , Padrões de Prática Médica/tendências , Tempo para o Tratamento/tendências , Trato Gastrointestinal Superior/diagnóstico por imagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Infecções por Coronavirus/prevenção & controle , Feminino , Hemorragia Gastrointestinal/etiologia , Hemorragia Gastrointestinal/mortalidade , Hemorragia Gastrointestinal/terapia , Mortalidade Hospitalar/tendências , Humanos , Controle de Infecções/métodos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Pandemias/prevenção & controle , Peru , Pneumonia Viral/prevenção & controle , Estudos Retrospectivos
12.
BMC Med ; 18(1): 270, 2020 09 03.
Artigo em Inglês | MEDLINE | ID: mdl-32878619

RESUMO

BACKGROUND: The COVID-19 pandemic has placed an unprecedented strain on health systems, with rapidly increasing demand for healthcare in hospitals and intensive care units (ICUs) worldwide. As the pandemic escalates, determining the resulting needs for healthcare resources (beds, staff, equipment) has become a key priority for many countries. Projecting future demand requires estimates of how long patients with COVID-19 need different levels of hospital care. METHODS: We performed a systematic review of early evidence on length of stay (LoS) of patients with COVID-19 in hospital and in ICU. We subsequently developed a method to generate LoS distributions which combines summary statistics reported in multiple studies, accounting for differences in sample sizes. Applying this approach, we provide distributions for total hospital and ICU LoS from studies in China and elsewhere, for use by the community. RESULTS: We identified 52 studies, the majority from China (46/52). Median hospital LoS ranged from 4 to 53 days within China, and 4 to 21 days outside of China, across 45 studies. ICU LoS was reported by eight studies-four each within and outside China-with median values ranging from 6 to 12 and 4 to 19 days, respectively. Our summary distributions have a median hospital LoS of 14 (IQR 10-19) days for China, compared with 5 (IQR 3-9) days outside of China. For ICU, the summary distributions are more similar (median (IQR) of 8 (5-13) days for China and 7 (4-11) days outside of China). There was a visible difference by discharge status, with patients who were discharged alive having longer LoS than those who died during their admission, but no trend associated with study date. CONCLUSION: Patients with COVID-19 in China appeared to remain in hospital for longer than elsewhere. This may be explained by differences in criteria for admission and discharge between countries, and different timing within the pandemic. In the absence of local data, the combined summary LoS distributions provided here can be used to model bed demands for contingency planning and then updated, with the novel method presented here, as more studies with aggregated statistics emerge outside China.


Assuntos
Infecções por Coronavirus , Alocação de Recursos para a Atenção à Saúde , Tempo de Internação , Pandemias/estatística & dados numéricos , Pneumonia Viral , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/terapia , Alocação de Recursos para a Atenção à Saúde/métodos , Alocação de Recursos para a Atenção à Saúde/tendências , Número de Leitos em Hospital , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Tempo de Internação/estatística & dados numéricos , Tempo de Internação/tendências , Pneumonia Viral/epidemiologia , Pneumonia Viral/terapia
13.
Medicine (Baltimore) ; 99(36): e22028, 2020 Sep 04.
Artigo em Inglês | MEDLINE | ID: mdl-32899057

RESUMO

Comparison of different anticoagulants in blood management and complications with tranexamic acid (TXA) in total hip arthroplasty (THA) is unclear. Our aim was to compare the efficacy and safety among receiving nadroparin calcium, enoxaparin sodium or rivaroxaban after TXA in THA.150 patients undergoing primary unilateral THA were received 15 mg/kg intravenous TXA (IV-TXA) before skin incision, followed by 1 of nadroparin calcium (Group A), enoxaparin sodium (Group B), or rivaroxaban (Group C) randomly during hospitalization. The primary outcome was hidden blood loss (HBL). Other outcomes such as the maximum hemoglobin (Hb) drop, total blood loss (TBL), the volume of drainage, transfusion rate, length of hospital stay (LOS), and complications were also compared.There were no statistically significant differences in HBL, the maximum hemoglobin (Hb) drop, transfusion rate, and complications among 3 groups. LOS was significantly higher for patients in Group B than Group A (P = .026). Neither deep venous thrombosis (DVT) nor pulmonary embolism (PE) occurred in any group.There were no differences in efficacy and safety in patients undergoing THA receiving nadroparin calcium, enoxaparin sodium, or rivaroxaban after anti-fibrinolysis with TXA.


Assuntos
Anticoagulantes/efeitos adversos , Antifibrinolíticos/efeitos adversos , Perda Sanguínea Cirúrgica/prevenção & controle , Ácido Tranexâmico/efeitos adversos , Administração Intravenosa , Idoso , Anticoagulantes/administração & dosagem , Antifibrinolíticos/administração & dosagem , Artroplastia de Quadril/efeitos adversos , Transfusão de Sangue/estatística & dados numéricos , China/epidemiologia , Enoxaparina/administração & dosagem , Enoxaparina/efeitos adversos , Feminino , Hemoglobinas/análise , Hospitalização , Humanos , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Nadroparina/administração & dosagem , Nadroparina/efeitos adversos , Sangue Oculto , Estudos Retrospectivos , Rivaroxabana/administração & dosagem , Rivaroxabana/efeitos adversos , Segurança , Ácido Tranexâmico/administração & dosagem , Resultado do Tratamento
14.
N Z Med J ; 133(1520): 35-49, 2020 08 21.
Artigo em Inglês | MEDLINE | ID: mdl-32994592

RESUMO

AIM: Early recognition and timely management, including prompt administration of antibiotics, has been fundamental in improving the mortality related to sepsis. We aimed to study the effect of the Sepsis Pathway Programme, a set of guidelines for sepsis, on the recognition, early investigation and management of septic patients in the emergency department. METHODS: We conducted a comparative prospective cohort study of patients who presented with suspected sepsis pre- and post-implementation of the Sepsis Pathway. Patients where the Sepsis Pathway was used were identified and followed prospectively to analyse outcomes. This group was compared to a pre-intervention control group who were identified retrospectively before the Sepsis Pathway was implemented to determine if there was any difference in outcomes. RESULTS: A total of 109 patients were identified to be septic in the emergency department following the implementation of the Sepsis Pathway. Of these, 52 cases involved the initiation and completion of the Sepsis Pathway. One hundred and fifty-seven cases were identified in the pre-intervention group of which 18 cases were excluded. The time to antibiotic administration decreased from 182 to 75 minutes (p<0.00001). The proportion of cases where antibiotics were given within the hour was higher in the pathway group (36.5% vs 8.6%, OR 6.09, 95% CI 2.69-13.81, p<0.0001). Similarly, the time to lactate measurement decreased from 64 minutes to 54.5 minutes (p=0.0117) and the proportion of cases where lactate was measured improved from 64% to 92.3% (p=0.0005). Blood culture rates improved from 79.1% to 100%. CONCLUSION: The implementation of the Sepsis Pathway improved time taken to perform investigations and manage patients with sepsis. Although it had improved, there was still a delay in recognition of sepsis and initiation of investigations and management, demonstrating that further strategies need to be employed to reduce poor outcomes associated with sepsis. However, it did not affect ICU admissions, length of stay or mortality.


Assuntos
Antibacterianos/uso terapêutico , Serviço Hospitalar de Emergência/organização & administração , Sepse/tratamento farmacológico , Antibacterianos/administração & dosagem , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Ácido Láctico/análise , Tempo de Internação/tendências , Avaliação de Resultados em Cuidados de Saúde , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Estudos Retrospectivos , Fatores de Risco , Sepse/diagnóstico , Sepse/mortalidade , Fatores de Tempo
15.
Am Surg ; 86(9): 1178-1184, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32935996

RESUMO

BACKGROUND: Nonoperative management of adhesive small bowel obstruction (ASBO) results in resolution for the majority of patients. Previous studies have demonstrated that outcomes for patients with ASBO are improved when patients are admitted to a surgical service, but the effect of general surgery resident coverage is unclear. This study measures quality outcomes for patients with ASBO after the establishment of a new general surgery residency program. METHODS: An institutional review board-approved retrospective chart review of admissions for ASBO was conducted following the implementation of a protocol for ASBO nested within a newly developed resident-run emergency general surgery (EGS) service. Patients successfully treated without operative intervention were analyzed. RESULTS: During the study period, 612 patients were admitted for ASBO. After initiation of the residency, 74% of ASBO were admitted to a surgical service compared with 35% prior to residency (P < .01). Length of stay was reduced by 0.77 days (P = .016), average direct total cost per patient was reduced by 24% (P = .002), and 30-day readmissions were reduced by 35.7% (P = .046). There was no significant difference in mortality (1.4% vs 1.0%). DISCUSSION: Admission to a resident-run surgical service was associated with statistically significant improvement in outcomes for patients with ASBO. These data corroborate prior studies demonstrating the positive impact of residency programs on patient outcomes and provide additional evidence that general surgery residency programs improve outcomes for patients with surgical disease.


Assuntos
Tratamento Conservador/métodos , Educação de Pós-Graduação em Medicina/métodos , Cirurgia Geral/educação , Internato e Residência/métodos , Obstrução Intestinal/terapia , Tempo de Internação/tendências , Readmissão do Paciente/tendências , Idoso , Feminino , Humanos , Intestino Delgado , Masculino , Estudos Retrospectivos
16.
Pediatrics ; 146(4)2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32917845

RESUMO

OBJECTIVES: To explore and define contemporary trends in the use of invasive mechanical ventilation (IMV) and noninvasive ventilation (NIV) in the treatment of children with asthma. METHODS: We performed a serial cross-sectional analysis using data from the Pediatric Health Information System. We examined 2014-2018 admission abstracts from patients aged 2 to 17 years who were admitted to member hospitals with a primary diagnosis of asthma. We report temporal trends in IMV use, NIV use, ICU admission, length of stay, and mortality. RESULTS: Over the study period, 48 hospitals reported 95 204 admissions with a primary diagnosis of asthma. Overall, IMV use remained stable at 0.6% between 2014 and 2018 (interquartile range [IQR]: 0.3%-1.1% and 0.2%-1.3%, respectively), whereas NIV use increased from 1.5% (IQR: 0.3%-3.2%) to 2.1% (IQR: 0.3%-5.6%). There was considerable practice variation among centers, with NIV rates more than doubling within the highest quartile of users (from 4.8% [IQR: 2.8%-7.5%] to 13.2% [IQR: 7.4%-15.2%]; P < .02). ICU admission was more common among centers with high NIV use, but centers with high NIV use did not differ from lower-use centers in mortality, IMV use, or overall average length of stay. CONCLUSIONS: The use of IMV is at historic lows, and NIV has replaced it as the primary mechanical support mode for asthma. However, there is considerable variability in NIV use. Increased NIV use was not associated with a change in IMV rates, which remained stable. Higher NIV use was associated with increased ICU admissions. NIV's precise contribution to the cost and quality of care remains to be determined.


Assuntos
Asma/terapia , Ventilação não Invasiva/tendências , Respiração Artificial/tendências , Adolescente , Asma/mortalidade , Criança , Pré-Escolar , Estudos Transversais , Feminino , Humanos , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Unidades de Terapia Intensiva Pediátrica/tendências , Tempo de Internação/tendências , Masculino , Fatores de Tempo
17.
Am J Cardiol ; 134: 32-40, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32919619

RESUMO

Up to 10% of non-ST-segment elevation myocardial infarction (NSTEMI) patients require coronary artery bypass graft (CABG) surgery during their hospitalization. Contemporary, real-world, data regarding CABG utilization and safety in NSTEMI patients are lacking. Our objectives were to investigate the contemporary trends in utilization and outcomes of CABG in patients admitted for NSTEMI. Using the 2003 to 2015 National Inpatient Sample data, we identified hospitalizations for NSTEMI, during which a CABG was performed. Patients' sociodemographic and clinical characteristics, incidence of surgical complications, length of stay, and mortality were analyzed. Multivariate analyses were performed to identify predictors of in-hospital complications and mortality. An estimated total of 440,371 CABG surgeries, during a hospitalization for NSTEMI, were analyzed. The utilization of CABG was steady over the years. The data show increasing prevalence of individual co-morbidities as well as cases with Deyo Co-morbidity Index ≥2 (p <0.001). High, 26.4%, complication rate was driven mainly by cardiac and pulmonary complications. The mortality rate declined from 3.6% in 2003 to an average of 2.4% during 2010 to 2015. Older age, female gender, heart failure, and delayed CABG timing were independent predictors of adverse outcomes. In conclusion, utilization of in-hospital CABG as the primary revascularization strategy in patients with NSTEMI remained steady over the years. These data reveal the raising prevalence of co-morbidities during the study. High complication rate was recorded; however, the mortality declined over the years to about 2.4%. Delaying CABG was associated with small but statistically significant worsening in outcomes.


Assuntos
Ponte de Artéria Coronária/tendências , Mortalidade Hospitalar/tendências , Tempo de Internação/tendências , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Complicações Pós-Operatórias/epidemiologia , Adolescente , Adulto , Idoso , Comorbidade , Diabetes Mellitus/epidemiologia , Feminino , Insuficiência Cardíaca/epidemiologia , Hospitalização , Humanos , Hipertensão/epidemiologia , Incidência , Falência Renal Crônica/epidemiologia , Masculino , Pessoa de Meia-Idade , Análise Multivariada , Doença Pulmonar Obstrutiva Crônica/epidemiologia , Fatores de Risco , Tempo para o Tratamento/tendências , Estados Unidos/epidemiologia , Adulto Jovem
18.
Am Surg ; 86(9): 1078-1082, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32845734

RESUMO

BACKGROUND: Enhanced recovery after surgery (ERAS) protocols are widely utilized for elective colorectal surgery to improve outcomes and decrease costs, but few studies have evaluated the impact of ERAS protocols on cost with respect to anatomic site of resection. This study evaluated the impact of ERAS protocol on elective colon resections by site and longitudinal impact over time. METHODS: A single-center retrospective cohort study of 598 consecutive patients undergoing elective colorectal resection before and after implementation of ERAS protocol from 2013 to 2017 was performed. The primary outcomes were length of stay (LOS) and cost. Comparative and multivariate inferential statistics were used to assess additional outcomes. RESULTS: A total of 598 patients (100 pre-ERAS vs 498 post-ERAS) were evaluated with an overall median LOS of 4 days for right and left colectomies and 3 days for transverse colectomies. When comparing type of resection before and after ERAS protocol introduction, an increased LOS for left hemicolectomies from 3.09 to 4.03 days (P = .047) was noted, with all other comparisons failing to reach statistical significance. Over time, an initial decrease in LOS for MIS approach after protocol introduction was observed; however, this effect diminished in the ensuing years and had no significant effect overall. Total cost of care was significantly increased post-ERAS for all cohorts except transverse colectomies. No further statistically significant differences were found. CONCLUSION: After an initial improvement in outcomes, continued utilization of ERAS protocols demonstrated no improvement in LOS compared to pre-ERAS data and increased cost overall for patients regardless of site of resection.


Assuntos
Colectomia/economia , Recuperação Pós-Cirúrgica Melhorada , Fidelidade a Diretrizes , Custos Hospitalares , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Colectomia/métodos , Custos e Análise de Custo , Procedimentos Cirúrgicos Eletivos/economia , Procedimentos Cirúrgicos Eletivos/métodos , Feminino , Seguimentos , Humanos , Tempo de Internação/economia , Tempo de Internação/tendências , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Retrospectivos , Adulto Jovem
19.
Pediatrics ; 146(3)2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32826340

RESUMO

CONTEXT: Postnatal length of hospital stay has reduced internationally but evidence-based policies to support earlier discharge are lacking. OBJECTIVE: To determine the effects of early postnatal discharge on infant outcomes. DATA SOURCES: CENTRAL (Cochrane Central Register of Controlled Trials), Medline, Embase, Cumulative Index to Nursing and Allied Health Literature , and SCI (Science Citation Index) were searched through to January 15, 2018. STUDY SELECTION: Studies reporting infant outcomes with early postnatal discharge versus standard discharge were included if they met Effective Practice and Organisation of Care study design criteria. DATA EXTRACTION: Two authors independently assessed eligibility and extracted data, resolving disagreements by consensus. Data from interrupted time series (ITS) studies were extracted and reanalyzed in meta-analyses. Meta-analyses of randomized controlled trials (RCTs) used random effects models. RESULTS: Of 9298 studies, 15 met the inclusion criteria. RCT meta-analyses revealed that infants discharged <48 hours after vaginal birth and <96 hours after cesarean birth were more likely to be readmitted to the hospital within 28 days compared to standard discharge (risk ratio: 1.70; 95% confidence interval [CI] 1.34 to 2.15). ITS meta-analyses revealed a reduction in the proportion of infants readmitted within 28 days after minimum postnatal stay policies and legislation were introduced (change in slope: -0.62; 95% CI -1.83 to 0.60), with increasing impact in the first and second years (effect estimate: -4.27 [95% CI -7.91 to -0.63] and -6.23 [95% CI -10.15 to -2.32]). LIMITATIONS: Withdrawals and crossover limited the value of RCTs in this context but not ITS evidence. CONCLUSIONS: Infants discharged early after birth were more likely to be admitted within 28 days. The introduction of postnatal minimum length of stay policies was associated with a long-term reduction in neonatal hospital readmission rates.


Assuntos
Tempo de Internação/tendências , Alta do Paciente/tendências , Readmissão do Paciente/tendências , Cuidado Pós-Natal/tendências , Ensaios Clínicos Controlados Aleatórios como Assunto , Aleitamento Materno/tendências , Feminino , Humanos , Lactente , Cuidado Pós-Natal/métodos , Gravidez , Ensaios Clínicos Controlados Aleatórios como Assunto/métodos , Fatores de Tempo
20.
Am Surg ; 86(9): 1083-1087, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32809844

RESUMO

INTRODUCTION: Robotic hiatal hernia repair offers potential advantages over traditional laparoscopy, most notably enhanced visualization, improved ergonomics, and articulating instruments. The clinical outcomes, however, have not been adequately evaluated. We report outcomes of laparoscopic and robotic hiatal hernia repairs. METHODS: A retrospective observational cohort study was performed of all hiatal hernia repairs performed from 2006 through 2019. Operative, demographic, and outcomes data were compared between laparoscopic and robotic groups. Discrete variables were analyzed with Chi-square of Fisher's exact test. Continuous variables were analyzed with Student's t test (mean) or Wilcoxon rank sum (medians). All analyses were performed using R statistical software. RESULTS: Laparoscopic repair was performed in 278 patients and robotic repair in 114. More recurrent hernias were repaired robotically (24.5% vs 12.9%, P = .08). Operative times were no different between groups (175 vs 179 minutes; P = .681). Robotic repair resulted in significantly shorter length of stay (LOS; 2.3 vs 3.3 days; P = .003). Rate of readmission was no different, and there were no differences in acute complications. For patients with at least 1 year of follow-up, recurrence rates were lower after robotic repair (13.3% vs 32.8%; P = .008); however, mean follow-up is significantly longer after laparoscopic repair (23.7 ± 28.4 vs 15.1 ± 14.9 months; P < .001). DISCUSSION: Robotic hiatal hernia repair offers technical advantages over laparoscopic repair with similar clinical outcomes.


Assuntos
Hérnia Hiatal/cirurgia , Herniorrafia/métodos , Laparoscopia/métodos , Robótica/métodos , Seguimentos , Humanos , Tempo de Internação/tendências , Duração da Cirurgia , Recidiva , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento
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