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1.
PLoS Med ; 18(3): e1003415, 2021 03.
Artigo em Inglês | MEDLINE | ID: mdl-33657114

RESUMO

BACKGROUND: Convalescent plasma (CP), despite limited evidence on its efficacy, is being widely used as a compassionate therapy for hospitalized patients with COVID-19. We aimed to evaluate the efficacy and safety of early CP therapy in COVID-19 progression. METHODS AND FINDINGS: The study was an open-label, single-center randomized clinical trial performed in an academic medical center in Santiago, Chile, from May 10, 2020, to July 18, 2020, with final follow-up until August 17, 2020. The trial included patients hospitalized within the first 7 days of COVID-19 symptom onset, presenting risk factors for illness progression and not on mechanical ventilation. The intervention consisted of immediate CP (early plasma group) versus no CP unless developing prespecified criteria of deterioration (deferred plasma group). Additional standard treatment was allowed in both arms. The primary outcome was a composite of mechanical ventilation, hospitalization for >14 days, or death. The key secondary outcomes included time to respiratory failure, days of mechanical ventilation, hospital length of stay, mortality at 30 days, and SARS-CoV-2 real-time PCR clearance rate. Of 58 randomized patients (mean age, 65.8 years; 50% male), 57 (98.3%) completed the trial. A total of 13 (43.3%) participants from the deferred group received plasma based on clinical aggravation. We failed to find benefit in the primary outcome (32.1% versus 33.3%, odds ratio [OR] 0.95, 95% CI 0.32-2.84, p > 0.999) in the early versus deferred CP group. The in-hospital mortality rate was 17.9% versus 6.7% (OR 3.04, 95% CI 0.54-17.17 p = 0.246), mechanical ventilation 17.9% versus 6.7% (OR 3.04, 95% CI 0.54-17.17, p = 0.246), and prolonged hospitalization 21.4% versus 30.0% (OR 0.64, 95% CI, 0.19-2.10, p = 0.554) in the early versus deferred CP group, respectively. The viral clearance rate on day 3 (26% versus 8%, p = 0.204) and day 7 (38% versus 19%, p = 0.374) did not differ between groups. Two patients experienced serious adverse events within 6 hours after plasma transfusion. The main limitation of this study is the lack of statistical power to detect a smaller but clinically relevant therapeutic effect of CP, as well as not having confirmed neutralizing antibodies in donor before plasma infusion. CONCLUSIONS: In the present study, we failed to find evidence of benefit in mortality, length of hospitalization, or mechanical ventilation requirement by immediate addition of CP therapy in the early stages of COVID-19 compared to its use only in case of patient deterioration. TRIAL REGISTRATION: NCT04375098.


Assuntos
/terapia , Intervenção Médica Precoce/métodos , Tempo para o Tratamento , Adulto , Idoso , Idoso de 80 Anos ou mais , /mortalidade , Chile , Progressão da Doença , Intervenção Médica Precoce/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Imunização Passiva/métodos , Imunização Passiva/mortalidade , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Mortalidade , Respiração Artificial/mortalidade , Respiração Artificial/estatística & dados numéricos , Tempo para o Tratamento/normas , Resultado do Tratamento
2.
Dig Surg ; 38(2): 158-165, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-33640885

RESUMO

BACKGROUND: This survey aimed to register changes determined by the COVID-19 pandemic on pancreatic surgery in a specific geographic area (Germany, Austria, and Switzerland) to evaluate the impact of the pandemic and obtain interesting cues for the future. METHODS: An online survey was designed using Google Forms focusing on the local impact of the pandemic on pancreatic surgery. The survey was conducted at 2 different time points, during and after the lockdown. RESULTS: Twenty-five respondents (25/56) completed the survey. Many aspects of oncological care have been affected with restrictions and delays: staging, tumor board, treatment selection, postoperative course, adjuvant treatments, outpatient care, and follow-up. Overall, 60% of respondents have prioritized pancreatic cancer patients according to stage, age, and comorbidities, and 40% opted not to operate high-risk patients. However, for 96% of participants, the standards of care were guaranteed. DISCUSSION/CONCLUSIONS: The first wave of the COVID-19 pandemic had an important impact on pancreatic cancer surgery in central Europe. Guidelines for prompt interventions and prevention of the spread of viral infections in the surgical environment are needed to avoid a deterioration of care in cancer patients in the event of a second wave or a new pandemic. High-volume centers for pancreatic surgery should be preferred and their activity maintained. Virtual conferences have proven to be efficient during this pandemic and should be implemented in the near future.


Assuntos
/prevenção & controle , Acesso aos Serviços de Saúde/tendências , Pancreatectomia/tendências , Neoplasias Pancreáticas/cirurgia , Padrões de Prática Médica/tendências , Assistência ao Convalescente/métodos , Assistência ao Convalescente/normas , Assistência ao Convalescente/tendências , Atitude do Pessoal de Saúde , Europa (Continente)/epidemiologia , Pesquisas sobre Serviços de Saúde , Acesso aos Serviços de Saúde/normas , Humanos , Controle de Infecções/métodos , Controle de Infecções/tendências , Estadiamento de Neoplasias , Pancreatectomia/normas , Neoplasias Pancreáticas/diagnóstico , Neoplasias Pancreáticas/patologia , Pandemias , Aceitação pelo Paciente de Cuidados de Saúde , Assistência Perioperatória/métodos , Assistência Perioperatória/normas , Assistência Perioperatória/tendências , Guias de Prática Clínica como Assunto , Padrões de Prática Médica/normas , Tempo para o Tratamento/normas , Tempo para o Tratamento/tendências
5.
J Urol ; 205(1): 78-85, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32614274

RESUMO

PURPOSE: The time between radiographic identification of a renal tumor and surgery can be concerning for patients and clinicians due to fears of tumor progression while awaiting treatment. This study aimed to evaluate the association between surgical wait time and oncologic outcomes for patients with renal cell carcinoma. MATERIALS AND METHODS: The Canadian Kidney Cancer Information System is a multi-institutional prospective cohort initiated in January 2011. Patients with clinical stage T1b or greater renal cell carcinoma diagnosed between January 2011 and December 2019 were included in this analysis. Outcomes of interest were pathological up staging, cancer recurrence, cancer specific survival and overall survival. Time to recurrence and death were estimated using Kaplan-Meier estimates and associations were determined using Cox proportional hazards models. RESULTS: A total of 1,769 patients satisfied the study criteria. Median wait times were 54 days (IQR 29-86) for the overall cohort and 81 days (IQR 49-127) for cT1b tumors (1,166 patients), 45 days (IQR 27-71) for cT2 tumors (672 cases) and 35 days (IQR 18-61) for cT3/4 tumors (563). Adjusting for comorbidity, tumor size, grade, histological subtype, margin status and pathological stage, there was no association between prolonged wait time and cancer recurrence or death. CONCLUSIONS: In the context of current surgeon triaging practices surgical wait times up to 24 weeks were not associated with adverse oncologic outcomes after 2 years of followup.


Assuntos
Carcinoma de Células Renais/cirurgia , Neoplasias Renais/cirurgia , Recidiva Local de Neoplasia/epidemiologia , Nefrectomia/estatística & dados numéricos , Tempo para o Tratamento/estatística & dados numéricos , Idoso , Canadá/epidemiologia , Carcinoma de Células Renais/diagnóstico , Carcinoma de Células Renais/mortalidade , Carcinoma de Células Renais/patologia , Intervalo Livre de Doença , Feminino , Seguimentos , Humanos , Estimativa de Kaplan-Meier , Rim/diagnóstico por imagem , Rim/patologia , Rim/cirurgia , Neoplasias Renais/diagnóstico , Neoplasias Renais/mortalidade , Neoplasias Renais/patologia , Masculino , Margens de Excisão , Pessoa de Meia-Idade , Recidiva Local de Neoplasia/prevenção & controle , Estadiamento de Neoplasias , Nefrectomia/normas , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Radiografia/estatística & dados numéricos , Fatores de Tempo , Tempo para o Tratamento/normas , Triagem/normas , Triagem/estatística & dados numéricos
6.
J Urol ; 205(1): 152-158, 2021 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-32716743

RESUMO

PURPOSE: Early surgical intervention is an attractive option for acute ureteral colic but existing evidence does not clarify which patients benefit. We compared treatment failure rates in patients receiving early intervention and patients offered spontaneous passage to identify subgroups that benefit from early intervention. MATERIALS AND METHODS: We used administrative data and structured chart review to study consecutive patients attending 9 emergency departments in 2 Canadian provinces with confirmed 2.0 to 9.9 mm ureteral stones. We described patient, stone and treatment characteristics, and performed multivariable regression to identify factors associated with treatment failure, defined as intervention or hospitalization within 60 days. Our secondary outcome was emergency department revisit rate. RESULTS: Overall 1,168 of 3,081 patients underwent early intervention. Those with stones smaller than 5 mm experienced more treatment failures (31.5% vs 9.9%, difference 21.6%, 95% CI 16.9 to 21.2) and emergency department revisits (38.5% vs 19.7%, difference 18.8%, 95% CI 13.8 to 23.8) with early intervention than with spontaneous passage. Patients with stones 7.0 mm or larger experienced fewer treatment failures (34.7% vs 58.6%, risk difference 23.9%, 95% CI 11.3 to 36.6) and similar emergency department revisit rates with early intervention. Patients with 5.0 to 6.9 mm stones had fewer treatment failures with intervention (37.4% vs 55.5%, risk difference 18.1%, 95% CI 7.1 to 28.9) if stones were in the proximal or middle ureter. CONCLUSIONS: Early intervention improves outcomes for patients with large (greater than 7 mm) ureteral stones or 5 to 7 mm proximal or mid ureteral stones. Early intervention may increase morbidity for patients with stones smaller than 5 mm. These findings could help inform future guidelines.


Assuntos
Cólica/cirurgia , Tempo para o Tratamento/normas , Triagem/normas , Cálculos Ureterais/cirurgia , Adulto , Canadá , Cólica/diagnóstico , Cólica/etiologia , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Remissão Espontânea , Medição de Risco/estatística & dados numéricos , Fatores de Tempo , Falha de Tratamento , Ureter/cirurgia , Cálculos Ureterais/complicações , Cálculos Ureterais/diagnóstico
8.
JAMA Netw Open ; 3(12): e2030072, 2020 12 01.
Artigo em Inglês | MEDLINE | ID: mdl-33315115

RESUMO

Importance: Resource limitations because of pandemic or other stresses on infrastructure necessitate the triage of time-sensitive care, including cancer treatments. Optimal time to treatment is underexplored, so recommendations for which cancer treatments can be deferred are often based on expert opinion. Objective: To evaluate the association between increased time to definitive therapy and mortality as a function of cancer type and stage for the 4 most prevalent cancers in the US. Design, Setting, and Participants: This cohort study assessed treatment and outcome information from patients with nonmetastatic breast, prostate, non-small cell lung (NSCLC), and colon cancers from 2004 to 2015, with data analyzed January to March 2020. Data on outcomes associated with appropriate curative-intent surgical, radiation, or medical therapy were gathered from the National Cancer Database. Exposures: Time-to-treatment initiation (TTI), the interval between diagnosis and therapy, using intervals of 8 to 60, 61 to 120, 121 to 180, and greater than 180 days. Main Outcomes and Measures: 5-year and 10-year predicted all-cause mortality. Results: This study included 2 241 706 patients (mean [SD] age 63 [11.9] years, 1 268 794 [56.6%] women, 1 880 317 [83.9%] White): 1 165 585 (52.0%) with breast cancer, 853 030 (38.1%) with prostate cancer, 130 597 (5.8%) with NSCLC, and 92 494 (4.1%) with colon cancer. Median (interquartile range) TTI by cancer was 32 (21-48) days for breast, 79 (55-117) days for prostate, 41 (27-62) days for NSCLC, and 26 (16-40) days for colon. Across all cancers, a general increase in the 5-year and 10-year predicted mortality was associated with increasing TTI. The most pronounced mortality association was for colon cancer (eg, 5 y predicted mortality, stage III: TTI 61-120 d, 38.9% vs. 181-365 d, 47.8%), followed by stage I NSCLC (5 y predicted mortality: TTI 61-120 d, 47.4% vs 181-365 d, 47.6%), while survival for prostate cancer was least associated (eg, 5 y predicted mortality, high risk: TTI 61-120 d, 12.8% vs 181-365 d, 14.1%), followed by breast cancer (eg, 5 y predicted mortality, stage I: TTI 61-120 d, 11.0% vs. 181-365 d, 15.2%). A nonsignificant difference in treatment delays and worsened survival was observed for stage II lung cancer patients-who had the highest all-cause mortality for any TTI regardless of treatment timing. Conclusions and Relevance: In this cohort study, for all studied cancers there was evidence that shorter TTI was associated with lower mortality, suggesting an indirect association between treatment deferral and mortality that may not become evident for years. In contrast to current pandemic-related guidelines, these findings support more timely definitive treatment for intermediate-risk and high-risk prostate cancer.


Assuntos
Protocolos Antineoplásicos , Neoplasias da Mama , Neoplasias do Colo , Neoplasias Pulmonares , Neoplasias da Próstata , Tempo para o Tratamento , Idoso , Neoplasias da Mama/mortalidade , Neoplasias da Mama/patologia , Neoplasias da Mama/terapia , /prevenção & controle , Estudos de Coortes , Neoplasias do Colo/mortalidade , Neoplasias do Colo/patologia , Neoplasias do Colo/terapia , Bases de Dados Factuais/estatística & dados numéricos , Feminino , Humanos , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Neoplasias Pulmonares/terapia , Masculino , Pessoa de Meia-Idade , Mortalidade , Estadiamento de Neoplasias , Prognóstico , Neoplasias da Próstata/mortalidade , Neoplasias da Próstata/patologia , Neoplasias da Próstata/terapia , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia
9.
BMJ Case Rep ; 13(12)2020 Dec 17.
Artigo em Inglês | MEDLINE | ID: mdl-33334745

RESUMO

Optic pathway cavernous malformations represent less than 1% of all central nervous system cavernomas. They can lead to visual loss with indeterminate speed, and therefore, the timing of intervention is controversial. We present a patient with an optic nerve cavernoma, which was discovered incidentally 3 years before the onset of visual symptoms. The evolution of her symptoms, visual function and radiographic findings are reported in detail. The cavernoma was eventually removed via a transciliary orbitocranial keyhole approach with the goal to protect the optic chiasm from progressive involvement. The function in the affected optic nerve was not salvageable. This is the second reported case of a cavernoma selectively involving the intracranial portion of the optic nerve. The debate on the timing of intervention is highlighted with reference to the natural history of these rare lesions.


Assuntos
Cegueira/etiologia , Hemangioma Cavernoso do Sistema Nervoso Central/cirurgia , Procedimentos Neurocirúrgicos/métodos , Neoplasias do Nervo Óptico/cirurgia , Adulto , Feminino , Hemangioma Cavernoso do Sistema Nervoso Central/complicações , Hemangioma Cavernoso do Sistema Nervoso Central/diagnóstico , Hemangioma Cavernoso do Sistema Nervoso Central/patologia , Humanos , Achados Incidentais , Imagem por Ressonância Magnética , Nervo Óptico/patologia , Nervo Óptico/cirurgia , Neoplasias do Nervo Óptico/complicações , Neoplasias do Nervo Óptico/diagnóstico , Neoplasias do Nervo Óptico/patologia , Fatores de Tempo , Tempo para o Tratamento/normas , Conduta Expectante/normas
10.
Can J Surg ; 63(5): E431-E434, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33009897

RESUMO

SUMMARY: Hepato-pancreato-biliary (HPB) injuries can be extremely challenging to manage. This scoping review (8438 citations) offers a number of recommendations. If diagnosis and therapy are rapid, patients with major hepatic injuries who present in physiologic extremis have high survival rates despite prolonged hospital stays. Nonoperative management of major liver injuries, as diagnosed using computed tomography, is typically successful. Adjuncts (e.g., angioembolization, laparoscopic washouts, biliary stents) are essential in managing high-grade injuries. Injury to the extrahepatic biliary tree is rare. Cholecystectomy is indicated for all gallbladder trauma. Full-thickness common bile duct injuries require a hepaticojejunostomy, although damage control remains closed suction drainage. Injuries to the pancreatic head often involve concurrent trauma to regional vasculature. Damage control necessitates drainage after stopping hemorrhage. Injury to the left pancreas commonly requires a distal pancreatectomy. Outcomes for high-grade pancreatic and liver injuries are improved by involving an HPB team. Complications are multidisciplinary and should be managed without delay.


Assuntos
Traumatismos Abdominais/terapia , Sistema Biliar/lesões , Fígado/lesões , Pâncreas/lesões , Traumatismos Abdominais/complicações , Traumatismos Abdominais/diagnóstico , Traumatismos Abdominais/mortalidade , Sistema Biliar/diagnóstico por imagem , Tratamento Conservador/efeitos adversos , Tratamento Conservador/métodos , Tratamento Conservador/normas , Tratamento Conservador/estatística & dados numéricos , Humanos , Fígado/diagnóstico por imagem , Pâncreas/diagnóstico por imagem , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Guias de Prática Clínica como Assunto , Índice de Gravidade de Doença , Procedimentos Cirúrgicos Operatórios/efeitos adversos , Procedimentos Cirúrgicos Operatórios/métodos , Procedimentos Cirúrgicos Operatórios/normas , Procedimentos Cirúrgicos Operatórios/estatística & dados numéricos , Fatores de Tempo , Tempo para o Tratamento/normas , Tomografia Computadorizada por Raios X , Resultado do Tratamento
11.
Am Heart J ; 228: 98-108, 2020 10.
Artigo em Inglês | MEDLINE | ID: mdl-32871329

RESUMO

About half of patients with acute ST-segment elevation myocardial infarction (STEMI) present with multivessel coronary artery disease (MVD). Recent evidence supports complete revascularization in these patients. However, optimal timing of non-culprit lesion revascularization in STEMI patients is unknown because dedicated randomized trials on this topic are lacking. STUDY DESIGN: The MULTISTARS AMI trial is a prospective, international, multicenter, randomized, two-arm, open-label study planning to enroll at least 840 patients. It is designed to investigate whether immediate complete revascularization is non-inferior to staged (within 19-45 days) complete revascularization in patients in stable hemodynamic conditions presenting with STEMI and MVD and undergoing primary percutaneous coronary intervention (PCI). After successful primary PCI of the culprit artery, patients are randomized in a 1:1 ratio to immediate or staged complete revascularization. The primary endpoint is a composite of all-cause death, non-fatal myocardial infarction, ischemia-driven revascularization, hospitalization for heart failure, and stroke at 1 year. CONCLUSIONS: The MULTISTARS AMI trial tests the hypothesis that immediate complete revascularization is non-inferior to staged complete revascularization in stable patients with STEMI and MVD.


Assuntos
Vasos Coronários , Intervenção Coronária Percutânea , Complicações Pós-Operatórias , Infarto do Miocárdio com Supradesnível do Segmento ST , Tempo para o Tratamento/normas , Angiografia Coronária/métodos , Vasos Coronários/diagnóstico por imagem , Vasos Coronários/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/efeitos adversos , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/diagnóstico , Complicações Pós-Operatórias/prevenção & controle , Ensaios Clínicos Controlados Aleatórios como Assunto , Fatores de Risco , Infarto do Miocárdio com Supradesnível do Segmento ST/diagnóstico , Infarto do Miocárdio com Supradesnível do Segmento ST/cirurgia , Índice de Gravidade de Doença
14.
Surgery ; 168(3): 426-433, 2020 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-32611515

RESUMO

INTRODUCTION: Guidelines recommend early endoscopic retrograde cholangiopancreatography for the management of acute cholangitis, but the definition of the term "early" remains debatable. This study analyzed national trends in the timing of endoscopic retrograde cholangiopancreatography and identified the ideal time to perform preoperative endoscopic retrograde cholangiopancreatography in patients with acute cholangitis. METHODS: The 2005 to 2016 National Inpatient Sample was used to identify patients undergoing cholecystectomy for acute cholangitis. Severity of cholangitis was defined using the 2013 Tokyo Grading Criteria, where Tokyo grade III patients were defined as having organ dysfunction and non-Tokyo grade III patients were defined as grades I and II. Multivariable regressions (accounting for patient and hospital characteristics) were used to identify the timing of preoperative endoscopic retrograde cholangiopancreatography associated with the least mortality risk. RESULTS: Of 91,051 patients undergoing cholecystectomy for cholangitis, 55% underwent preoperative endoscopic retrograde cholangiopancreatography: 24% of patients received endoscopic retrograde cholangiopancreatography on the day of admission, 41% on hospital day 2, and the use of endoscopic retrograde cholangiopancreatography decreased gradually thereafter. Mortality rates remained under 1% if endoscopic retrograde cholangiopancreatography was performed during the first 3 days and increased as endoscopic retrograde cholangiopancreatography was performed during days 4 to 7 (P < .001). On multivariable regression, endoscopic retrograde cholangiopancreatography performed >72 hours after admission was associated with increased mortality (adjusted odds ratio 1.80, P = .01). Receiving endoscopic retrograde cholangiopancreatography P > 72 hours increased risk of death among Tokyo grade III patients (adjusted odds ratio 1.88, P = .01). Overall, during the study period, the utilization of preoperative endoscopic retrograde cholangiopancreatography for all grades of acute cholangitis increased from 39% of patients in 2005 to 51% in 2016 (P < .001). CONCLUSION: There has been an increase in the use of endoscopic retrograde cholangiopancreatography for acute cholangitis. Although endoscopic retrograde cholangiopancreatography on the day of admission was not associated with a decrease in mortality in patients with Tokyo grade III disease, endoscopic retrograde cholangiopancreatography within 72 hours of hospitalization was associated with decreased in-hospital mortality.


Assuntos
Colangiopancreatografia Retrógrada Endoscópica/tendências , Colangite/cirurgia , Colecistectomia/tendências , Cuidados Pré-Operatórios/tendências , Esfinterotomia Endoscópica/tendências , Tempo para o Tratamento/tendências , Doença Aguda/mortalidade , Doença Aguda/terapia , Idoso , Idoso de 80 Anos ou mais , Colangiopancreatografia Retrógrada Endoscópica/normas , Colangite/diagnóstico , Colangite/mortalidade , Colecistectomia/normas , Feminino , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Cuidados Pré-Operatórios/métodos , Cuidados Pré-Operatórios/normas , Estudos Retrospectivos , Índice de Gravidade de Doença , Esfinterotomia Endoscópica/normas , Análise de Sobrevida , Fatores de Tempo , Tempo para o Tratamento/normas , Estados Unidos/epidemiologia
15.
Stroke ; 51(8): 2339-2346, 2020 08.
Artigo em Inglês | MEDLINE | ID: mdl-32640947

RESUMO

BACKGROUND AND PURPOSE: Improving door-to-needle times (DNTs) for thrombolysis of acute ischemic stroke patients improves outcomes, but participation in DNT improvement initiatives has been mostly limited to larger, academic medical centers with an existing interest in stroke quality improvement. It is not known whether quality improvement initiatives can improve DNT at a population level, including smaller community hospitals. This study aims to determine the effect of a provincial improvement collaborative intervention on improvement of DNT and patient outcomes. METHODS: A pre post cohort study was conducted over 10 years in the Canadian province of Alberta with 17 designated stroke centers. All ischemic stroke patients who received thrombolysis in the Canadian province of Alberta were included in the study. The quality improvement intervention was an improvement collaborative that involved creation of interdisciplinary teams from each stroke center, participation in 3 workshops and closing celebration, site visits, webinars, and data audit and feedback. RESULTS: Two thousand four hundred eighty-eight ischemic stroke patients received thrombolysis in the pre- and postintervention periods (630 in the post period). The mean age was 71 years (SD, 14.6 years), and 46% were women. DNTs were reduced from a median of 70.0 minutes (interquartile range, 51-93) to 39.0 minutes (interquartile range, 27-58) for patients treated per guideline (P<0.0001). The percentage of patients discharged home from acute care increased from 45.6% to 59.5% (P<0.0001); the median 90-day home time increased from 43.3 days (interquartile range, 27.3-55.8) to 53.6 days (interquartile range, 36.8-64.6) (P=0.0015); and the in-hospital mortality decreased from 14.5% to 10.5% (P=0.0990). CONCLUSIONS: The improvement collaborative was likely the key contributing factor in reducing DNTs and improving outcomes for ischemic stroke patients across Alberta.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Medidas de Resultados Relatados pelo Paciente , Vigilância da População , Acidente Vascular Cerebral/tratamento farmacológico , Tempo para o Tratamento/normas , Ativador de Plasminogênio Tecidual/administração & dosagem , Idoso , Idoso de 80 Anos ou mais , Alberta/epidemiologia , Isquemia Encefálica/epidemiologia , Estudos de Coortes , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Vigilância da População/métodos , Acidente Vascular Cerebral/epidemiologia , Terapia Trombolítica/normas , Terapia Trombolítica/tendências , Tempo para o Tratamento/tendências
16.
Ann Hematol ; 99(7): 1615-1625, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32483668

RESUMO

Ibrutinib treatment has been shown to increase survival in patients with B cell malignancies. Real-life data suggest a large part of discontinuations are due to toxicities, impairing ibrutinib efficacy. We aimed to assess the impact of a pharmaceutical care program on the efficacy and safety of ibrutinib. This single-center, cohort, observational study enrolled patients with B cell malignancies. Patients were either assigned to the program or to receive usual care, based on physician decision. The program was conducted by clinical pharmacists specializing in oncology and included patient education for management of toxicities, adherence monitoring, interventions to reduce drug-drug interactions, and follow-up of transition from hospital to community. Between February 2014 and May 2017, we enrolled 155 patients, including 42 (27%) who were allocated to the program group and 113 (73%) to the usual care group. The effect of the program was beneficial in terms of time to treatment failure (p = 0.0005). The 30-month progression-free and overall survivals were significantly superior in the program group (respectively p = 0.002 and p = 0.004). Grade 3 or higher adverse events occurred more frequently for patients in the usual care group (15%) than program group (8%). A pharmaceutical care program provides a personalized environment for outpatient monitoring and control of the key risks associated with oral anticancer agents. This study shows evidence that management of ibrutinib treatment by clinical pharmacists results in significant improvement in survival and better tolerance than usual care.


Assuntos
Neoplasias/tratamento farmacológico , Neoplasias/mortalidade , Assistência Farmacêutica/normas , Pirazóis/uso terapêutico , Pirimidinas/uso terapêutico , Melhoria de Qualidade , Tempo para o Tratamento/normas , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Eficiência Organizacional , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Assistência Farmacêutica/organização & administração , Assistência Farmacêutica/tendências , Farmacêuticos/organização & administração , Farmacêuticos/normas , Análise de Sobrevida , Fatores de Tempo , Tempo para o Tratamento/organização & administração , Tempo para o Tratamento/tendências , Falha de Tratamento
17.
J Urol ; 204(6): 1256-1262, 2020 12.
Artigo em Inglês | MEDLINE | ID: mdl-32501124

RESUMO

PURPOSE: Obstructive pyelonephritis is considered a urological emergency but there is limited evidence regarding the importance of prompt decompression. We sought to investigate whether delay in decompression is an independent predictor of in-hospital mortality. Secondarily, we aimed to determine the impact of patient, hospital and disease factors on the likelihood of receipt of delayed vs prompt decompression. MATERIALS AND METHODS: Using the National Inpatient Sample from 2010 to 2015, all patients 18 years old or older with ICD-9 diagnosis of urinary tract infection who had either a ureteral stone or kidney stone with hydronephrosis (311,100) were identified. Two weighted sample multivariable logistic regression models assessed predictors of the primary outcome of death in the hospital and secondly, predictors of delayed decompression (2 or more days after admission). RESULTS: After controlling for patient demographics, comorbidity and disease severity, delayed decompression significantly increased odds of death by 29% (OR 1.29, 95% CI 1.03-1.63, p=0.032). Delayed decompression was more likely to occur with weekend admissions (OR 1.22, 95% CI 1.15-1.30, p <0.001), nonwhite race (OR 1.34, 95% CI 1.25-1.44, p <0.001) and lower income demographic (lowest income quartile OR 1.25, 95% CI 1.14-1.36, p <0.001). CONCLUSIONS: While the overall risk of mortality is fairly low in patients with obstructing upper urinary tract stones and urinary tract infection, a delay in decompression increased odds of mortality by 29%. The increased likelihood of delay associated with weekend admissions, minority patients and lower socioeconomic status suggests opportunities for improvement.


Assuntos
Descompressão Cirúrgica/estatística & dados numéricos , Pielonefrite/cirurgia , Sepse/mortalidade , Tempo para o Tratamento/estatística & dados numéricos , Cálculos Ureterais/complicações , Obstrução Ureteral/cirurgia , Adulto , Idoso , Estudos Transversais , Descompressão Cirúrgica/normas , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Grupos Minoritários/estatística & dados numéricos , Razão de Chances , Pielonefrite/etiologia , Pielonefrite/mortalidade , Melhoria de Qualidade , Medição de Risco/estatística & dados numéricos , Fatores de Risco , Sepse/diagnóstico , Sepse/etiologia , Sepse/cirurgia , Índice de Gravidade de Doença , Classe Social , Tempo para o Tratamento/normas , Cálculos Ureterais/mortalidade , Cálculos Ureterais/cirurgia , Obstrução Ureteral/etiologia , Obstrução Ureteral/mortalidade
18.
Stroke Vasc Neurol ; 5(2): 159-176, 2020 06.
Artigo em Inglês | MEDLINE | ID: mdl-32561535

RESUMO

AIM: Stroke is the leading cause of disability and death in China. Ischaemic stroke accounts for about 60%-80% of all strokes. It is of considerable significance to carry out multidimensional management of ischaemic cerebrovascular diseases. This evidence-based guideline aims to provide the latest detailed and comprehensive recommendations on the diagnosis, treatment and secondary prevention of ischaemic cerebrovascular diseases. METHODS: We had performed comprehensive searches of MEDLINE (via PubMed) (before 30 June 2019), and integrated the relevant information into charts and distributed to the writing group. Writing group members discussed and determined the recommendations through teleconference. We used the level of evidence grading algorithm of Chinese Stroke Association to grade each recommendation. The draft was reviewed by the Guideline Writing Committee of Chinese Stroke Association Stroke and finalised. This guideline is fully updated every 3 years. RESULTS: This evidence-based guideline is based on the treatment, care and prevention of ischaemic cerebrovascular diseases, which emphasises on pathogenesis evaluation, intravenous thrombolysis, endovascular therapy, antiplatelet therapy, prevention and treatment of complications, and risk factor management. CONCLUSIONS: This updated guideline presents a framework for the management of ischaemic cerebrovascular diseases. Timely first-aid measures, professional care in the acute stage, and proactive secondary prevention will be helpful to patients.


Assuntos
Isquemia Encefálica/terapia , Medicina Baseada em Evidências/normas , Neurologia/normas , Acidente Vascular Cerebral/terapia , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/epidemiologia , China/epidemiologia , Tomada de Decisão Clínica , Consenso , Técnicas de Apoio para a Decisão , Humanos , Valor Preditivo dos Testes , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/epidemiologia , Tempo para o Tratamento/normas , Resultado do Tratamento
20.
J Vasc Surg ; 72(3): 790-798, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32497747

RESUMO

The global SARS-CoV-2/COVID-19 pandemic has required a reduction in nonemergency treatment for a variety of disorders. This report summarizes conclusions of an international multidisciplinary consensus group assembled to address evaluation and treatment of patients with thoracic outlet syndrome (TOS), a group of conditions characterized by extrinsic compression of the neurovascular structures serving the upper extremity. The following recommendations were developed in relation to the three defined types of TOS (neurogenic, venous, and arterial) and three phases of pandemic response (preparatory, urgent with limited resources, and emergency with complete diversion of resources). • In-person evaluation and treatment for neurogenic TOS (interventional or surgical) are generally postponed during all pandemic phases, with telephone/telemedicine visits and at-home physical therapy exercises recommended when feasible. • Venous TOS presenting with acute upper extremity deep venous thrombosis (Paget-Schroetter syndrome) is managed primarily with anticoagulation, with percutaneous interventions for venous TOS (thrombolysis) considered in early phases (I and II) and surgical treatment delayed until pandemic conditions resolve. Catheter-based interventions may also be considered for selected patients with central subclavian vein obstruction and threatened hemodialysis access in all pandemic phases, with definitive surgical treatment postponed. • Evaluation and surgical treatment for arterial TOS should be reserved for limb-threatening situations, such as acute upper extremity ischemia or acute digital embolization, in all phases of pandemic response. In late pandemic phases, surgery should be restricted to thrombolysis or brachial artery thromboembolectomy, with more definitive treatment delayed until pandemic conditions resolve.


Assuntos
Betacoronavirus/patogenicidade , Infecções por Coronavirus/prevenção & controle , Pandemias/prevenção & controle , Pneumonia Viral/prevenção & controle , Guias de Prática Clínica como Assunto , Síndrome do Desfiladeiro Torácico/diagnóstico , Triagem/normas , Consenso , Infecções por Coronavirus/epidemiologia , Infecções por Coronavirus/transmissão , Infecções por Coronavirus/virologia , Descompressão Cirúrgica/normas , Procedimentos Cirúrgicos Eletivos/métodos , Procedimentos Cirúrgicos Eletivos/normas , Tratamento de Emergência/métodos , Tratamento de Emergência/normas , Humanos , Controle de Infecções/normas , Comunicação Interdisciplinar , Salvamento de Membro/métodos , Salvamento de Membro/normas , Seleção de Pacientes , Pneumonia Viral/epidemiologia , Pneumonia Viral/transmissão , Pneumonia Viral/virologia , Telemedicina/normas , Síndrome do Desfiladeiro Torácico/etiologia , Síndrome do Desfiladeiro Torácico/terapia , Terapia Trombolítica/métodos , Terapia Trombolítica/normas , Tempo para o Tratamento/normas
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