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1.
Curr Oncol ; 27(5): e501-e511, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33173390

RESUMO

Objective: We aimed to review data about delaying strategies for the management of hepatobiliary cancers requiring surgery during the covid-19 pandemic. Background: Given the covid-19 pandemic, many jurisdictions, to spare resources, have limited access to operating rooms for elective surgical activity, including cancer, thus forcing deferral or cancellation of cancer surgeries. Surgery for hepatobiliary cancer is high-risk and particularly resource-intensive. Surgeons must critically appraise which patients will benefit most from surgery and which ones have other therapeutic options to delay surgery. Little guidance is currently available about potential delaying strategies for hepatobiliary cancers when surgery is not possible. Methods: An international multidisciplinary panel reviewed the available literature to summarize data relating to standard-of-care surgical management and possible mitigating strategies to be used as a bridge to surgery for colorectal liver metastases, hepatocellular carcinoma, gallbladder cancer, intrahepatic cholangiocarcinoma, and hilar cholangiocarcinoma. Results: Outcomes of surgery during the covid-19 pandemic are reviewed. Resource requirements are summarized, including logistics and adverse effects profiles for hepatectomy and delaying strategies using systemic, percutaneous and radiation ablative, and liver embolic therapies. For each cancer type, the long-term oncologic outcomes of hepatectomy and the clinical tools that can be used to prognosticate for individual patients are detailed. Conclusions: There are a variety of delaying strategies to consider if availability of operating rooms decreases. This review summarizes available data to provide guidance about possible delaying strategies depending on patient, resource, institution, and systems factors. Multidisciplinary team discussions should be leveraged to consider patient- and tumour-specific information for each individual case.


Assuntos
Infecções por Coronavirus/complicações , Hepatectomia/estatística & dados numéricos , Controle de Infecções/métodos , Neoplasias Hepáticas/cirurgia , Pneumonia Viral/complicações , Guias de Prática Clínica como Assunto/normas , Cirurgiões/normas , Tempo para o Tratamento/estatística & dados numéricos , Betacoronavirus/isolamento & purificação , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/virologia , Humanos , Neoplasias Hepáticas/virologia , Pandemias , Administração dos Cuidados ao Paciente , Pneumonia Viral/epidemiologia , Pneumonia Viral/virologia
2.
Artigo em Inglês | MEDLINE | ID: mdl-33080869

RESUMO

There are different patterns in the COVID-19 outbreak in the general population and amongst nursing home patients. We investigate the time from symptom onset to diagnosis and hospitalization or the length of stay (LoS) in the hospital, and whether there are differences in the population. Sciensano collected information on 14,618 hospitalized patients with COVID-19 admissions from 114 Belgian hospitals between 14 March and 12 June 2020. The distributions of different event times for different patient groups are estimated accounting for interval censoring and right truncation of the time intervals. The time between symptom onset and hospitalization or diagnosis are similar, with median length between symptom onset and hospitalization ranging between 3 and 10.4 days, depending on the age of the patient (longest delay in age group 20-60 years) and whether or not the patient lives in a nursing home (additional 2 days for patients from nursing home). The median LoS in hospital varies between 3 and 10.4 days, with the LoS increasing with age. The hospital LoS for patients that recover is shorter for patients living in a nursing home, but the time to death is longer for these patients. Over the course of the first wave, the LoS has decreased.


Assuntos
Infecções por Coronavirus/mortalidade , Infecções por Coronavirus/terapia , Hospitalização/estatística & dados numéricos , Pneumonia Viral/mortalidade , Pneumonia Viral/terapia , Tempo para o Tratamento/estatística & dados numéricos , Adulto , Idoso , Bélgica/epidemiologia , Interpretação Estatística de Dados , Humanos , Tempo de Internação/estatística & dados numéricos , Pessoa de Meia-Idade , Casas de Saúde/estatística & dados numéricos , Pandemias , Resultado do Tratamento , Adulto Jovem
3.
Ann Palliat Med ; 9(5): 3373-3378, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-33065788

RESUMO

BACKGROUND: The coronavirus disease (COVID-19) poses an unprecedented challenge to health and epidemic prevention system, especially the healthcare of patients with cancer. We sought to study the impact of COVID-19 on lung cancer patients in our center. METHODS: We initiated a retrospectively study to analyze the impact of COVID-19 on lung cancer patients in our center, who were accepted for routine anticancer treatment before the epidemic and planned to return to hospital in January and February of 2020. RESULTS: A total of 161 cases of lung cancer were included in the final analysis. As of April 15, 95 patients had delayed their return visit, and 47 cases were finally designated as having delayed admission during the epidemic and having to discontinue or delay their regular anticancer treatments. Of these 47 delayed patients, 33 were evaluated for tumor status using a computed tomography scan, 6 of these 33 cases (18.18%) were diagnosed as progressive disease (PD), and 5 cases did not return for visit. CONCLUSIONS: This is the first study investigating impact of COVID-19 on non-COVID-19 lung cancer patients during the pandemic. The study demonstrates the significant impact of the COVID-19 crisis on oncological care, indicating the need for appropriate change of treatment decisions and continued follow-up and psycho-oncological support during this pandemic.


Assuntos
Antineoplásicos/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/terapia , Infecções por Coronavirus , Imunoterapia , Neoplasias Pulmonares/terapia , Pandemias , Pneumonia Viral , Radioterapia , Carcinoma de Pequenas Células do Pulmão/terapia , Tempo para o Tratamento/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , Carcinoma Pulmonar de Células não Pequenas/diagnóstico por imagem , Quimiorradioterapia , China , Assistência à Saúde , Progressão da Doença , Feminino , Humanos , Neoplasias Pulmonares/diagnóstico por imagem , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Estudos Retrospectivos , Carcinoma de Pequenas Células do Pulmão/diagnóstico por imagem
4.
Anatol J Cardiol ; 24(5): 334-342, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-33122486

RESUMO

OBJECTIVE: Delayed admission of myocardial infarction (MI) patients is an important prognostic factor. In the present nationwide registry (TURKMI-2), we evaluated the treatment delays and outcomes of patients with acute MI during the Covid-19 pandemic and compaired with a recentpre-pandemic registry (TURKMI-1). METHODS: The pandemic and pre-pandemic studies were conducted prospectively as 15-day snapshot registries in the same 48 centers. The inclusion criteria for both registries were aged ≥18 years and a final diagnosis of acute MI (AMI) with positive troponin levels. The only difference between the 2 registries was that the pre-pandemic (TURKMI-1) registry (n=1872) included only patients presenting within the first 48 hours after symptom-onset. TURKMI-2 enrolled all consecutive patients (n=1113) presenting with AMI during the pandemic period. RESULTS: A comparison of the patients with acute MI presenting within the 48-hour of symptom-onset in the pre-pandemic and pandemic registries revealed an overall 47.1% decrease in acute MI admissions during the pandemic. Median time from symptom-onset to hospital-arrival increased from 150 min to 185 min in patients with ST elevation MI (STEMI) and 295 min to 419 min in patients presenting with non-STEMI (NSTEMI) (p-values <0.001). Door-to-balloon time was similar in the two periods (37 vs. 40 min, p=0.448). In the pandemic period, percutaneous coronary intervention (PCI) decreased, especially in the NSTEMI group (60.3% vs. 47.4% in NSTEMI, p<0.001; 94.8% vs. 91.1% in STEMI, p=0.013) but the decrease was not significant in STEMI patients admitted within 12 hours of symptom-onset (94.9% vs. 92.1%; p=0.075). In-hospital major adverse cardiac events (MACE) were significantly increased during the pandemic period [4.8% vs. 8.9%; p<0.001; age- and sex-adjusted Odds ratio (95% CI) 1.96 (1.20-3.22) for NSTEMI, p=0.007; and 2.08 (1.38-3.13) for STEMI, p<0.001]. CONCLUSION: The present comparison of 2 nationwide registries showed a significant delay in treatment of patients presenting with acute MI during the COVID-19 pandemic. Although PCI was performed in a timely fashion, an increase in treatment delay might be responsible for the increased risk of MACE. Public education and establishing COVID-free hospitals are necessary to overcome patients' fear of using healthcare services and mitigate the potential complications of AMI during the pandemic. (Anatol J Cardiol 2020; 24: 334-42).


Assuntos
Infecções por Coronavirus/epidemiologia , Infarto do Miocárdio/terapia , Pandemias/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Angiografia Coronária/estatística & dados numéricos , Serviços Médicos de Emergência/estatística & dados numéricos , Feminino , Insuficiência Cardíaca/mortalidade , Insuficiência Cardíaca/terapia , Humanos , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/estatística & dados numéricos , Prognóstico , Sistema de Registros , Análise de Regressão , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Fatores de Tempo , Resultado do Tratamento , Turquia/epidemiologia
5.
Mayo Clin Proc ; 95(10): 2099-2109, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-33012341

RESUMO

OBJECTIVE: To study whether combining vital signs and electrocardiogram (ECG) analysis can improve early prognostication. METHODS: This study analyzed 1258 adults with coronavirus disease 2019 who were seen at three hospitals in New York in March and April 2020. Electrocardiograms at presentation to the emergency department were systematically read by electrophysiologists. The primary outcome was a composite of mechanical ventilation or death 48 hours from diagnosis. The prognostic value of ECG abnormalities was assessed in a model adjusted for demographics, comorbidities, and vital signs. RESULTS: At 48 hours, 73 of 1258 patients (5.8%) had died and 174 of 1258 (13.8%) were alive but receiving mechanical ventilation with 277 of 1258 (22.0%) patients dying by 30 days. Early development of respiratory failure was common, with 53% of all intubations occurring within 48 hours of presentation. In a multivariable logistic regression, atrial fibrillation/flutter (odds ratio [OR], 2.5; 95% CI, 1.1 to 6.2), right ventricular strain (OR, 2.7; 95% CI, 1.3 to 6.1), and ST segment abnormalities (OR, 2.4; 95% CI, 1.5 to 3.8) were associated with death or mechanical ventilation at 48 hours. In 108 patients without these ECG abnormalities and with normal respiratory vitals (rate <20 breaths/min and saturation >95%), only 5 (4.6%) died or required mechanical ventilation by 48 hours versus 68 of 216 patients (31.5%) having both ECG and respiratory vital sign abnormalities. CONCLUSION: The combination of abnormal respiratory vital signs and ECG findings of atrial fibrillation/flutter, right ventricular strain, or ST segment abnormalities accurately prognosticates early deterioration in patients with coronavirus disease 2019 and may assist with patient triage.


Assuntos
Arritmias Cardíacas/diagnóstico por imagem , Infecções por Coronavirus/fisiopatologia , Eletrocardiografia/estatística & dados numéricos , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pneumonia Viral/fisiopatologia , Tempo para o Tratamento/estatística & dados numéricos , Adulto , Betacoronavirus , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Prognóstico
6.
J Cardiovasc Med (Hagerstown) ; 21(11): 869-873, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-33009170

RESUMO

AIMS: The purpose of this study was to verify the impact on the number and characteristics of coronary invasive procedures for acute coronary syndrome (ACS) of two hub centers with cardiac catheterization facilities, during the first month of lockdown following the COVID-19 pandemic. MATERIALS AND METHODS: Procedural data of ACS patients admitted between 10 March and 10 April 2020 were compared with those of the same period of 2019. RESULTS: We observed a 23.4% reduction in ACS admissions during 2020, with a decrease for both ST-elevation myocardial infarction (STEMI) (-5.6%) and non-ST-elevation myocardial infarction (-34.5%), albeit not statistically significant (P = 0.2). During the first 15 days of the examined periods, the reduction in ACS admissions reached 52.5% (-25% for STEMI and -70.3% for non-ST-elevation myocardial infarction, P = 0.04). Among STEMI patients, the rate of those with a time delay from symptoms onset longer than 180 min was significantly higher during the lockdown period (P = 0.01). Radiograph exposure (P = 0.01) was higher in STEMI patients treated in 2020 with a slightly higher amount of contrast medium (P = 0.1) and number of stents implanted (P = 0.1), whereas the number of treated vessels was reduced (P = 0.03). Percutaneous coronary intervention procedural success and in-hospital mortality were not different between the two groups and in STEMI patients (P NS for all). CONCLUSION: During the early phase, the COVID-19 outbreak was associated with a lower rate of admissions for ACS, with a substantial impact on the time delay presentation of STEMI patients, but apparently without affecting the in-hospital outcomes.


Assuntos
Síndrome Coronariana Aguda , Infecções por Coronavirus , Hospitalização/estatística & dados numéricos , Infarto do Miocárdio , Pandemias , Intervenção Coronária Percutânea , Pneumonia Viral , Síndrome Coronariana Aguda/diagnóstico , Síndrome Coronariana Aguda/epidemiologia , Síndrome Coronariana Aguda/etiologia , Síndrome Coronariana Aguda/terapia , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Diagnóstico Tardio/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Controle de Infecções/métodos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Infarto do Miocárdio/complicações , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Infarto do Miocárdio/cirurgia , Avaliação de Processos e Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Intervenção Coronária Percutânea/estatística & dados numéricos , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Tempo para o Tratamento/estatística & dados numéricos
7.
Medicine (Baltimore) ; 99(44): e22896, 2020 Oct 30.
Artigo em Inglês | MEDLINE | ID: mdl-33126342

RESUMO

Many patients with chronic pancreatitis (CP) undergo a step-up approach with interventional procedures as first-line treatment and resection reserved for later stages. The aim of this study was to identify predictive factors for a significant clinical improvement (SCI) after surgical treatment.All patients operated for CP between September 2012 and June 2017 at our center was retrospectively reviewed. A prospective patient survey was conducted to measure patients postoperative outcome. The primary endpoint SCI was defined as stable health status, positive weight development and complete pain relief without routine pain medication. Additionally, risk factors for relaparotomy were analyzed.A total of 89 patients with a median follow-up of 38 months were included. In most cases, a duodenum-preserving pancreatic head resection (n = 48) or pancreatoduodenectomy (n = 28) was performed. SCI was achieved in 65.3% (n = 47) of the patients after the final medium follow-up of 15.0 months (IQR: 7.0-35.0 months), respectively. Patients with a longer mean delay (7.7 vs 4 years) between diagnosis and surgical resection were less likely to achieve SCI (P = .02; OR .88; 95%CI .80-98). An endocrine insufficiency was a negative prognostic factor for SCI (P = .01; OR .15; 95%CI .04-68). In total, 96.2% of the patients had a complete or major postoperative relief with a mean pain intensity reduction from 8.1 to 1.9 on the visual analogue scale.The results support that surgical resection for CP should be considered at early stages. Resection can effectively reduce postoperative pain intensity and improve long-term success.


Assuntos
Pancreatectomia , Pancreatite Crônica , Complicações Pós-Operatórias , Tempo para o Tratamento/estatística & dados numéricos , Manutenção do Peso Corporal , Tratamento Conservador/métodos , Insuficiência Pancreática Exócrina/epidemiologia , Insuficiência Pancreática Exócrina/etiologia , Feminino , Alemanha/epidemiologia , Humanos , Masculino , Pessoa de Meia-Idade , Medição da Dor/métodos , Pancreatectomia/efeitos adversos , Pancreatectomia/métodos , Pancreatite Crônica/enzimologia , Pancreatite Crônica/epidemiologia , Pancreatite Crônica/fisiopatologia , Pancreatite Crônica/terapia , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/cirurgia , Prognóstico , Reoperação/métodos , Reoperação/estatística & dados numéricos , Estudos Retrospectivos , Fatores de Risco , Resultado do Tratamento
9.
Ann Surg ; 272(4): 548-553, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32932304

RESUMO

OBJECTIVE: Patients may call urgent care centers (UCCs) with urgent surgical conditions but may not be properly referred to a higher level of care. This study aims to characterize how UCCs manage Medicaid and privately insured patients who present with an emergent condition. METHODS: Using a standardized script, we called 1245 randomly selected UCCs in 50 states on 2 occasions. Investigators posed as either a Medicaid or a privately-insured patient with symptoms of an incarcerated inguinal hernia. Rates of direct emergency department (ED) referral were compared between insurance types. RESULTS: A total of 1223 (98.2%) UCCs accepted private insurance and 981 (78.8%) accepted Medicaid. At the 971 (78.0%) UCCs that accepted both insurance types, direct-to-ED referral rates for private and Medicaid patients were 27.9% and 33.8%, respectively. Medicaid patients were significantly more likely than private patients to be referred to the ED [odds ratio (OR) 1.32, 95% confidence interval (CI) 1.09-1.60]. Private patients who were triaged by a clinician compared to nonclinician staff were over 6 times more likely to be referred to the ED (OR 6.46, 95% CI 4.63-9.01). Medicaid patients were nearly 9 times more likely to have an ED referral when triaged by a clinician (OR 8.72, 95% CI 6.19-12.29). CONCLUSIONS: Only one-third of UCCs across the United States referred an apparent emergent surgical case to the ED, potentially delaying care. Medicaid patients were more likely to be referred directly to the ED versus privately insured patients. All patients triaged by clinicians were significantly more likely to be referred to the ED; however, the disparity between private and Medicaid patients remained.


Assuntos
Instituições de Assistência Ambulatorial/estatística & dados numéricos , Tratamento de Emergência/estatística & dados numéricos , Cobertura do Seguro , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Humanos , Medicaid , Estados Unidos
10.
Am J Cardiol ; 134: 24-31, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32892989

RESUMO

Clinical trials have shown improved outcomes with an early invasive approach for non-ST-elevation myocardial infarction (NSTEMI). However, real-world data on clinical characteristics and outcomes based on time to revascularization are lacking. We aimed to analyze NSTEMI rates, revascularization timing, and mortality using the 2016 Nationwide Readmissions Database. We identify patients who underwent diagnostic angiography and subsequently received either percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG). Finally, revascularization timing and mortality rates (in-hospital and 30-day) were extracted. Our analysis included 748,463 weighted NSTEMI hospitalizations in 2016. Of these hospitalizations, 50.3% (376,695) involved diagnostic angiography, with 34.1% (255,199) revascularized. Of revascularized patients, 77.6% (197,945) underwent PCI and 22.4% (57,254) underwent CABG. Patients with more comorbidities tended to have more delayed revascularization. PCI was most commonly performed on the day of admission (32.9%; 65,155). This differs from CABG, which was most commonly performed on day 3 after admission (13.7%; 7,823). The in-hospital mortality rate increased after day 1 for PCI patients and after day 4 for CABG patients, whereas 30-day in-hospital mortality for both populations increased as revascularization was delayed. Our study shows that patients undergoing early revascularization differ from those undergoing later revascularization. Mortality is generally high with delayed revascularization, as these are sicker patients. Randomized clinical trials are needed to evaluate whether very early revascularization (<90 minutes) is associated with improved long-term outcomes in high-risk patients.


Assuntos
Ponte de Artéria Coronária/estatística & dados numéricos , Mortalidade Hospitalar , Infarto do Miocárdio sem Supradesnível do Segmento ST/cirurgia , Intervenção Coronária Percutânea/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Idoso de 80 Anos ou mais , Anemia/epidemiologia , Arritmias Cardíacas/epidemiologia , Transtornos da Coagulação Sanguínea/epidemiologia , Comorbidade , Angiografia Coronária , Diabetes Mellitus/epidemiologia , Intervenção Médica Precoce , Feminino , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Mortalidade , Revascularização Miocárdica/estatística & dados numéricos , Infarto do Miocárdio sem Supradesnível do Segmento ST/epidemiologia , Estados Unidos/epidemiologia
11.
Neurology ; 95(19): e2683-e2696, 2020 11 10.
Artigo em Inglês | MEDLINE | ID: mdl-32913024

RESUMO

OBJECTIVE: To identify factors associated with low benzodiazepine (BZD) dosing in patients with refractory status epilepticus (RSE) and to assess the impact of BZD treatment variability on seizure cessation. METHODS: This was a retrospective study with prospectively collected data of children with convulsive RSE admitted between June 2011 and January 2019. We analyzed the initial and total BZD dose within 10 minutes of treatment initiation. We used logistic regression modeling to evaluate predictors of low BZD dosing and multivariate Cox regression analysis to assess the impact of low BZD dosing on time to seizure cessation. RESULTS: We included 289 patients (55.7% male) with a median age of 4.3 (1.3-9.5) years. BZDs were the initial medication in 278 (96.2%). Of those, 161 patients (57.9%) received a low initial dose. Low initial BZD doses occurred in both out-of-hospital (57 of 106; 53.8%) and in-hospital (104 of 172; 60.5%) settings. One hundred three patients (37.1%) received low total BZD dose. Male sex (odds ratio [OR] 2, 95% confidence interval [CI] 1.18-3.49; p = 0.012), older age (OR 1.1, 95% CI 1.05-1.17; p < 0.001), no prior diagnosis of epilepsy (OR 2.1, 95% CI 1.23-3.69; p = 0.008), and delayed BZD treatment (OR 2.2, 95% CI 1.24-3.94; p = 0.007) were associated with low total BZD dose. Patients who received low total BZD dosing were less likely to achieve seizure cessation (hazard ratio 0.7, 95% CI 0.57-0.95). CONCLUSION: BZD doses were lower than recommended in both out-of-hospital and in-hospital settings. Factors associated with low total BZD dose included male sex, older age, no prior epilepsy diagnosis, and delayed BZD treatment. Low total BZD dosing was associated with decreased likelihood of Seizure cessation. CLASSIFICATION OF EVIDENCE: This study provides Class III evidence that patients with RSE who present with male sex, older age, no prior diagnosis of epilepsy, and delayed BZD treatment are more likely to receive low total BZD doses. This study provides Class III evidence that in pediatric RSE low total BZD dose decreases the likelihood of seizure cessation.


Assuntos
Anticonvulsivantes/administração & dosagem , Benzodiazepinas/administração & dosagem , Epilepsia Resistente a Medicamentos/tratamento farmacológico , Fidelidade a Diretrizes/estatística & dados numéricos , Guias de Prática Clínica como Assunto , Estado Epiléptico/tratamento farmacológico , Tempo para o Tratamento/estatística & dados numéricos , Adolescente , Fatores Etários , Anticonvulsivantes/uso terapêutico , Criança , Pré-Escolar , Relação Dose-Resposta a Droga , Epilepsia Resistente a Medicamentos/fisiopatologia , Feminino , Humanos , Lactente , Levetiracetam/uso terapêutico , Masculino , Análise Multivariada , Fenobarbital/uso terapêutico , Fenitoína/análogos & derivados , Fenitoína/uso terapêutico , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores Sexuais , Estado Epiléptico/fisiopatologia
12.
Am J Cardiol ; 134: 1-7, 2020 11 01.
Artigo em Inglês | MEDLINE | ID: mdl-32933753

RESUMO

Mortality in patients with STEMI-associated cardiogenic shock (CS) is increasing. Whether a comprehensive ST-elevation myocardial infarction (STEMI) protocol (CSP) can improve their care delivery and mortality is unknown. We evaluated the impact of a CSP on incidence and outcomes in patients with STEMI-associated CS. We implemented a 4-step CSP including: (1) Emergency Department catheterization lab activation; (2) STEMI Safe Handoff Checklist; (3) immediate catheterization lab transfer; (4) and radial-first percutaneous coronary intervention (PCI). We studied 1,272 consecutive STEMI patients who underwent PCI and assessed for CS incidence per National Cardiovascular Data Registry definitions within 24-hours of PCI, care delivery, and mortality before (January 1, 2011, to July 14, 2014; n = 723) and after (July 15, 2014, to December 31, 2016; n = 549) CSP implementation. Following CSP implementation, CS incidence was reduced (13.0% vs 7.8%, p = 0.003). Of 137 CS patients, 43 (31.4%) were in the CSP group. CSP patients had greater IABP-Shock II risk scores (1.9 ± 1.8 vs 2.8 ± 2.2, p = 0.014) with otherwise similar hemodynamic and baseline characteristics, cardiac arrest incidence, and mechanical circulatory support use. Administration of guideline-directed medical therapy was similar (89.4% vs 97.7%, p = 0.172) with significant improvements in trans-radial PCI (9.6% vs 44.2%, p < 0.001) and door-to-balloon time (129.0 [89:160] vs 95.0 [81:116] minutes, p = 0.001) in the CSP group, translating to improvements in infarct size (CK-MB 220.9 ± 156.0 vs 151.5 ± 98.5 ng/ml, p = 0.005), ejection fraction (40.8 ± 14.5% vs 46.7 ± 14.6%, p = 0.037), and in-hospital mortality (30.9% vs 14.0%, p = 0.037). In conclusion, CSP implementation was associated with improvements in CS incidence, infarct size, ejection fraction, and in-hospital mortality in patients with STEMI-associated CS. This strategy offers a potential solution to bridging the historically elusive gap in their care.


Assuntos
Anticoagulantes/uso terapêutico , Protocolos Clínicos , Mortalidade Hospitalar , Intervenção Coronária Percutânea/métodos , Inibidores da Agregação de Plaquetas/uso terapêutico , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Choque Cardiogênico/terapia , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Aspirina/uso terapêutico , Lista de Checagem , Gerenciamento Clínico , Serviço Hospitalar de Emergência , Oxigenação por Membrana Extracorpórea , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Antagonistas do Receptor Purinérgico P2Y/uso terapêutico , Artéria Radial , Infarto do Miocárdio com Supradesnível do Segmento ST/complicações , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Choque Cardiogênico/etiologia , Choque Cardiogênico/mortalidade , Volume Sistólico , Resultado do Tratamento
13.
Am Surg ; 86(9): 1129-1134, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32955355

RESUMO

INTRODUCTION: Using the National Cancer Database (NCDB), we seek to analyze the relationship of patient distance to hospital of treatment on mortality trends after surgery, since patients often travel large distances to referral centers. METHODS: A retrospective cohort study of the NCDB from 2004 to 2013 was performed, and patients with gastrointestinal, melanoma, and head and neck primary site tumors who underwent surgery were included. We excluded cases with no recorded mortality status or distance from the hospital. A multivariable logistic regression was conducted with adjustments for population density, treating facility location, age, race, gender, education, income, insurance, comorbidities (Charlson-Deyo score), days from diagnosis to treatment, positive margin, tumor stage and grade, and lymph or vascular invasion. RESULTS: A total of 1 424 482 patients were included. Overall median distance to hospital was 9.7 miles (range 4.2-23.7 miles); 696 647 (48.91%) of the sample traveled a distance greater than 10 miles to the institution where the procedure was performed. The multivariable regression analysis demonstrated overall lower mortality for those patients travelling a longer distance to care for multiple tumor types, including: liver (OR .87, .77-.99, P = .032), pancreas (OR .82, .76-.89, P < .001), colon (OR .92, .89-.95, P < .001), rectum (OR .90, .83-.96, P = .003), melanoma (OR .83, .79-.88, P < .001), and tumors of the larynx (OR .80, .69-.94, P = .005). DISCUSSION: Increased distance traveled for surgical treatment has a significant correlation with decreased odds of mortality for multiple cancers, highlighting the importance of centralized referral patterns for oncology care.


Assuntos
Neoplasias/mortalidade , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Sistema de Registros , Procedimentos Cirúrgicos Operatórios/métodos , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Neoplasias/cirurgia , Estudos Retrospectivos , Taxa de Sobrevida/tendências , Estados Unidos/epidemiologia
14.
PLoS One ; 15(9): e0238305, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32915811

RESUMO

BACKGROUND: High-quality data on time of stroke onset and time of hospital arrival is required for proper evaluation of points of delay that might hinder access to medical care after the onset of stroke symptoms. PURPOSE: Based on (SITS Dataset) in Egyptian stroke patients, we aimed to explore factors related to time of onset versus time of hospital arrival for acute ischemic stroke (AIS). MATERIAL AND METHODS: We included 1,450 AIS patients from two stroke centers of Ain Shams University, Cairo, Egypt. We divided the day to four quarters and evaluated relationship between different factors and time of stroke onset and time of hospital arrival. The factors included: age, sex, duration from stroke onset to hospital arrival, type of management, type of stroke (TOAST classification), National Institute of Health Stroke Scale (NIHSS) on admission and favorable outcome modified Rankin Scale (mRS ≤2). RESULTS: Pre-hospital: highest stroke incidence was in the first and fourth quarters. There was no significant difference in the mean age, sex, type of stroke in relation to time of onset. NIHSS was significantly less in onset in third quarter of the day. Percentage of patients who received thrombolytic therapy was higher with onset in the first 2 quarters of the day (p = <0.001). In-hospital: there was no difference in percentage of patients who received thrombolytic therapy nor in outcome across 4 quarters of arrival to hospital. CONCLUSION: Pre-hospital factors still need adjustment to improve percentage of thrombolysis, while in-hospital factors showed consistent performance.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Admissão do Paciente/estatística & dados numéricos , Sistema de Registros/estatística & dados numéricos , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/mortalidade , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Egito/epidemiologia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Taxa de Sobrevida , Fatores de Tempo , Resultado do Tratamento
16.
J Cardiovasc Med (Hagerstown) ; 21(11): 874-881, 2020 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-32941325

RESUMO

AIMS: The aim of this study was to report the prevalence, clinical features and outcomes of patients with ST-elevation myocardial infarction (STEMI) hospitalized during the Corona-Virus Disease 2019 (COVID-19) outbreak compared with those admitted in a previous equivalent period. METHODS AND RESULTS: Eighty-five patients admitted for STEMI at a high-volume Italian centre were included. Patients hospitalized during the COVID-19 outbreak (21 February-10 April 2020) (40%) were compared with those admitted in pre-COVID-19 period (3 January-20 February 2020) (60%). A 43% reduction in STEMI admissions was observed during the COVID-19 outbreak compared with the previous period. Time from symptom onset to first medical contact (FMC) and time from FMC to primary percutaneous coronary intervention (PPCI) were longer in patients admitted during the COVID-19 period compared with before [148 (79-781) versus 130 (30-185) min; P = 0.018, and 75 (59-148)] versus 45 (30-70) min; P < 0.001]. High-sensitive troponin T levels on admission were also higher. In-hospital mortality was 12% in the COVID-19 phase versus 6% in the pre-COVID-19 period. Incidence of the composite end-point, including free-wall rupture, severe left ventricular dysfunction, left ventricular aneurysm, severe mitral regurgitation and pericardial effusion, was higher during the COVID-19 than the pre-COVID-19 period (19.6 versus 41.2%; P = 0.030; odds ratio = 2.87; 95% confidence interval 1.09-7.58). CONCLUSION: The COVID-19 pandemic had a significant impact on the STEMI care system reducing hospital admissions and prolonging revascularization time. This translated into a worse patient prognosis due to more STEMI complications.


Assuntos
Infecções por Coronavirus , Aneurisma Cardíaco , Ruptura Cardíaca Pós-Infarto/epidemiologia , Pandemias , Intervenção Coronária Percutânea , Derrame Pericárdico , Pneumonia Viral , Infarto do Miocárdio com Supradesnível do Segmento ST , Betacoronavirus , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/prevenção & controle , Testes Diagnósticos de Rotina/estatística & dados numéricos , Feminino , Aneurisma Cardíaco/epidemiologia , Aneurisma Cardíaco/etiologia , Mortalidade Hospitalar , Hospitalização/estatística & dados numéricos , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Pandemias/prevenção & controle , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Derrame Pericárdico/epidemiologia , Derrame Pericárdico/etiologia , Pneumonia Viral/epidemiologia , Pneumonia Viral/prevenção & controle , Prevalência , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/mortalidade , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Tempo para o Tratamento/estatística & dados numéricos
17.
Gynecol Oncol ; 159(2): 470-475, 2020 11.
Artigo em Inglês | MEDLINE | ID: mdl-32981694

RESUMO

BACKGROUND: New York City was among the epicenters during the COVID-19 pandemic. Oncologists must balance plausible risks of COVID-19 infection with the recognized consequences of delaying cancer treatment, keeping in mind the capacity of the health care system. We sought to investigate treatment patterns in gynecologic cancer care during the first two months of the COVID-19 pandemic at three affiliated New York City hospitals located in Brooklyn, Manhattan and Queens. METHODS: A prospective registry of patients with active or presumed gynecologic cancers receiving inpatient and/or outpatient care at three affiliated New York City hospitals was maintained between March 1 and April 30, 2020. Clinical and demographic data were abstracted from the electronic medical record with a focus on oncologic treatment. Multivariable logistic regression analysis was explored to evaluate the independent effect of hospital location, race, age, medical comorbidities, cancer status and COVID-19 status on treatment modifications. RESULTS: Among 302 patients with gynecologic cancer, 117 (38.7%) experienced a COVID-19-related treatment modification (delay, change or cancellation) during the first two months of the pandemic in New York. Sixty-four patients (67.4% of those scheduled for surgery) had a COVID-19-related modification in their surgical plan, 45 (21.5% of those scheduled for systemic treatment) a modification in systemic treatment and 12 (18.8% of those scheduled for radiation) a modification in radiation. Nineteen patients (6.3%) had positive COVID-19 testing. On univariate analysis, hospital location in Queens or Brooklyn, age ≤65 years, treatment for a new cancer diagnosis versus recurrence and COVID-19 positivity were associated with treatment modifications. On multivariable logistic regression analysis, hospital location in Queens and COVID-19 positive testing were independently associated with treatment modifications. CONCLUSIONS: More than one third of patients with gynecologic cancer at three affiliated New York City hospitals experienced a treatment delay, change or cancellation during the first two months of the COVID-19 pandemic. Among the three New York City boroughs represented in this study, likelihood of gynecologic oncology treatment modifications correlated with the case burden of COVID-19.


Assuntos
Agendamento de Consultas , Infecções por Coronavirus/epidemiologia , Neoplasias dos Genitais Femininos/terapia , Hospitais/estatística & dados numéricos , Pandemias , Pneumonia Viral/epidemiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Betacoronavirus , Infecções por Coronavirus/diagnóstico , Registros Eletrônicos de Saúde , Feminino , Humanos , Pessoa de Meia-Idade , Cidade de Nova Iorque/epidemiologia , Pneumonia Viral/diagnóstico , Sistema de Registros , Tempo para o Tratamento/estatística & dados numéricos
18.
PLoS One ; 15(9): e0238813, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32936794

RESUMO

INTRODUCTION: We sought to assess the impact of Affordable Care Act Dependent Care Expansion (ACA-DCE), which allowed dependent coverage for adults aged 19-25, and Medicaid expansion on outcomes for men with testicular cancer. METHODS: Using a US-based cancer registry, we performed adjusted difference-in-difference (DID) analyses comparing outcomes between men aged 19-25 (n = 8,026) and 26-64 (n = 33,303) pre- (2007-2009) and post-ACA-DCE (2011-2016) and between men in states that expanded Medicaid (n = 2,296) to men in those that did not (n = 2,265)pre- (2011-2013) and post-Medicaid expansion (2015-2016). RESULTS: In ACA-DCE analysis, rates of uninsurance decreased (DID -5.64, 95% confidence interval [CI] -7.23 to -4.04%, p<0.001) among patients aged 19-25 relative to older patients aged 26-64. There was no significant DID in advanced stage at diagnosis (stage≥II; p = 0.6) or orchiectomy more than 14 days after diagnosis (p = 0.6). For patients who received chemotherapy or radiotherapy as their first course of treatment, treatment greater than 60 days after diagnosis decreased (DID -4.84%, 95% CI -8.22 to -1.45%, p = 0.005) among patients aged 19-25 relative to patients aged 26-64. In Medicaid expansion states, rates of uninsurance decreased (DID -4.20%, 95% CI -7.67 to -0.73%, p = 0.018) while patients receiving chemotherapy or radiotherapy greater than 60 days after diagnosis decreased (DID -8.76, 95% CI -17.13 to -0.38%, p = 0.040) compared to rates in non-expansion states. No significant DIDs were seen for stage (p = 0.8) or time to orchiectomy (p = 0.1). CONCLUSIONS: Men with testicular cancer had lower uninsurance rates and decreased time to delivery of chemotherapy or radiotherapy following ACA-DCE and Medicaid expansions. Time to orchiectomy and stage at diagnosis did not change following either insurance expansion.


Assuntos
Cobertura do Seguro/estatística & dados numéricos , Medicaid/estatística & dados numéricos , Neoplasias Testiculares , Adulto , Idoso , Humanos , Masculino , Pessoa de Meia-Idade , Patient Protection and Affordable Care Act/estatística & dados numéricos , Neoplasias Testiculares/diagnóstico , Neoplasias Testiculares/terapia , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos , Adulto Jovem
19.
MMWR Morb Mortal Wkly Rep ; 69(36): 1250-1257, 2020 Sep 11.
Artigo em Inglês | MEDLINE | ID: mdl-32915166

RESUMO

Temporary disruptions in routine and nonemergency medical care access and delivery have been observed during periods of considerable community transmission of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19) (1). However, medical care delay or avoidance might increase morbidity and mortality risk associated with treatable and preventable health conditions and might contribute to reported excess deaths directly or indirectly related to COVID-19 (2). To assess delay or avoidance of urgent or emergency and routine medical care because of concerns about COVID-19, a web-based survey was administered by Qualtrics, LLC, during June 24-30, 2020, to a nationwide representative sample of U.S. adults aged ≥18 years. Overall, an estimated 40.9% of U.S. adults have avoided medical care during the pandemic because of concerns about COVID-19, including 12.0% who avoided urgent or emergency care and 31.5% who avoided routine care. The estimated prevalence of urgent or emergency care avoidance was significantly higher among the following groups: unpaid caregivers for adults* versus noncaregivers (adjusted prevalence ratio [aPR] = 2.9); persons with two or more selected underlying medical conditions† versus those without those conditions (aPR = 1.9); persons with health insurance versus those without health insurance (aPR = 1.8); non-Hispanic Black (Black) adults (aPR = 1.6) and Hispanic or Latino (Hispanic) adults (aPR = 1.5) versus non-Hispanic White (White) adults; young adults aged 18-24 years versus adults aged 25-44 years (aPR = 1.5); and persons with disabilities§ versus those without disabilities (aPR = 1.3). Given this widespread reporting of medical care avoidance because of COVID-19 concerns, especially among persons at increased risk for severe COVID-19, urgent efforts are warranted to ensure delivery of services that, if deferred, could result in patient harm. Even during the COVID-19 pandemic, persons experiencing a medical emergency should seek and be provided care without delay (3).


Assuntos
Infecções por Coronavirus/psicologia , Pneumonia Viral/psicologia , Tempo para o Tratamento/estatística & dados numéricos , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Adolescente , Adulto , Idoso , Infecções por Coronavirus/epidemiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pandemias , Pneumonia Viral/epidemiologia , Estados Unidos/epidemiologia , Adulto Jovem
20.
J Card Surg ; 35(10): 2486-2488, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32743814

RESUMO

The coronavirus disease (COVID) pandemic and the decision-making process of whether to perform urgent procedures during a surge are issues that will likely not disappear in the near future as reflected by the current rise in COVID cases in the southern and western United States and the resurgent numbers of confirmed cases around that world leading to are leading to new lock-downs. Multi-disciplinary discussions will continue to be important to decide individual risk and benefit profiles for patients with asymptomatic COVID patients moving forward. While imperfect, this most recent study provides more insight to some of the risks that should be weighed in these discussions. Further prospective, longitudinal research and better understanding of the heterogeneity of the COVID positive patient will further enhance understanding the decision-making process in the cardiac surgical patient through these difficult times.


Assuntos
Betacoronavirus , Procedimentos Cirúrgicos Cardíacos/métodos , Infecções por Coronavirus/epidemiologia , Tomada de Decisões , Cardiopatias/cirurgia , Pneumonia Viral/epidemiologia , Tempo para o Tratamento/estatística & dados numéricos , Comorbidade , Cardiopatias/epidemiologia , Humanos , Pandemias , Estados Unidos/epidemiologia
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