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1.
J Stroke Cerebrovasc Dis ; 29(2): 104552, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31839545

RESUMO

BACKGROUND AND AIM: Performance measures have been extensively studied for acute ischemic stroke, leading to guideline-established benchmarks. Factors influencing care efficiency for intracerebral hemorrhage (ICH) are not well delineated. We sought to identify factors associated with early recognition of ICH and to assess the association between early recognition and completion of emergency care tasks. METHODS: Consecutive patients with spontaneous ICH were enrolled in an observational cohort study conducted from 2009 to 2017 at an urban comprehensive stroke center, excluding patient transferred from other hospitals. We used stroke team activation as the indicator of early recognition and measured completion times for multiple ICH-relevant performance metrics including door to computed tomography (CT) acquisition and door to hemostatic medication initiation. RESULTS: We studied 204 cases. All stroke-related performance times were faster in patients managed with stroke team activation compared to no activation, including quicker door to CT acquisition (median 24 versus 48 minutes, P < .001) and door to hemostatic medication initiation (63 versus 99 minutes, P = .005). These associations were confirmed in adjusted models. Stroke codes were activated in 43% of cases and were more likely in patients with shorter onset-to-arrival times, higher National Institutes of Health Stroke Scale scores, and higher Glasgow Coma Scale scores. CONCLUSIONS: Stroke team activation was associated with more rapid diagnostic and therapeutic interventions for patients with ICH, but activation did not occur in the majority of cases, implying absence of early recognition. A stroke team activation process improves care performance, but leveraging the advantages of existing systems will require improved triage tools to identify ICH in the acute setting.


Assuntos
Hemorragia Cerebral/tratamento farmacológico , Serviço Hospitalar de Emergência/normas , Hemostáticos/administração & dosagem , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Tempo para o Tratamento/normas , Idoso , Idoso de 80 Anos ou mais , Hemorragia Cerebral/diagnóstico por imagem , Procedimentos Clínicos/normas , Esquema de Medicação , Diagnóstico Precoce , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Equipe de Assistência ao Paciente/normas , Estudos Prospectivos , Fatores de Tempo , Tomografia Computadorizada por Raios X/normas , Resultado do Tratamento
2.
Support Care Cancer ; 28(1): 123-130, 2020 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-30989430

RESUMO

PURPOSE: Lung cancer in non-smoking women is a distinct entity, but few studies have examined these patients' healthcare-related experiences. METHODS: Women with lung cancer and with no smoking history underwent a face-to-face semi-structured, audio-recorded interview that was analyzed with a qualitative inductive approach. RESULTS: Twenty-three patients were interviewed, and three themes emerged. The first theme centered on a delay in cancer diagnosis. One patient described, "The whole initial diagnostic process just fills me with rage… I didn't actually get my Tarceva® until the last week in April." Second, the diagnosis of lung cancer seemed especially challenging in view of patients' non-smoking history and otherwise good health; these factors seem to have contributed to the diagnostic delay. One patient explained, "Well, I was just so adamant that I didn't like smoking… maybe if I had been a smoker, they [the healthcare providers] would've been more resourceful." Finally, the stigma of a smoking-induced malignancy was clearly articulated, "Yeah. Because it's a stigma, and I had read that, too -- people go, 'Well, it's your own damn fault because you were a smoker.'" CONCLUSIONS: Non-smoking women with lung cancer appear to endure a long trajectory from symptoms to cancer diagnosis to the initiation of cancer therapy. An awareness and acknowledgement of this long trajectory might help healthcare providers render more compassionate cancer care to these patients.


Assuntos
Neoplasias Pulmonares/terapia , não Fumantes , Satisfação do Paciente/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Adulto , Idoso , Idoso de 80 Anos ou mais , Atitude do Pessoal de Saúde , Diagnóstico Tardio/estatística & dados numéricos , Empatia , Feminino , Pessoal de Saúde/psicologia , Pessoal de Saúde/normas , Pessoal de Saúde/estatística & dados numéricos , Humanos , Neoplasias Pulmonares/diagnóstico , Neoplasias Pulmonares/epidemiologia , Neoplasias Pulmonares/psicologia , Masculino , Pessoa de Meia-Idade , não Fumantes/psicologia , não Fumantes/estatística & dados numéricos , Relações Médico-Paciente , Padrões de Prática Médica/normas , Pesquisa Qualitativa , Estigma Social , Inquéritos e Questionários , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos
3.
Dis Colon Rectum ; 62(11): 1305-1315, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31567924

RESUMO

BACKGROUND: Delayed initiation of adjuvant chemotherapy negatively impacts long-term survival in patients with colorectal cancer. Colorectal enhanced recovery protocols result in decreased complications and length of stay; however, the impact of enhanced recovery on the timing of adjuvant chemotherapy remains unknown. OBJECTIVE: This study aimed to identify factors associated with on-time delivery of adjuvant chemotherapy after colorectal cancer surgery, hypothesizing that implementation of an enhanced recovery protocol would result in more patients receiving on-time chemotherapy. DESIGN: This was a retrospective cohort study comparing the rate of on-time adjuvant chemotherapy delivery after colorectal cancer resection before and after implementation of an enhanced recovery protocol. SETTINGS: The study was conducted at a large academic medical center. PATIENTS: All of the patients who underwent nonemergent colorectal cancer resections for curative intent from January 2010 to June 2017, excluding patients who had no indication for adjuvant chemotherapy, had received preoperative systemic chemotherapy, or did not have medical oncology records available were included. MAIN OUTCOME MEASURES: Patients before and enhanced recovery were compared, with the rate of on-time adjuvant chemotherapy delivery as the primary outcome. Adjuvant chemotherapy delivery was considered on time if initiated ≤8 weeks postoperatively, and treatment was considered delayed or omitted if initiated >8 weeks postoperatively (delayed) or never received (omitted). Multivariable logistic regression identified predictors of on-time chemotherapy delivery. RESULTS: A total of 363 patients met inclusion criteria, with 189 patients (52.1%) undergoing surgery after enhanced recovery implementation. Groups differed in laparoscopic approach and median procedure duration, both of which were higher after enhanced recovery. Significantly more patients received on-time chemotherapy after enhanced recovery implementation (p = 0.007). Enhanced recovery was an independent predictor of on-time adjuvant chemotherapy (p = 0.014). LIMITATIONS: The study was limited by its retrospective and nonrandomized before-and-after design. CONCLUSIONS: Enhanced recovery was associated with receiving on-time adjuvant chemotherapy. As prompt initiation of adjuvant chemotherapy improves survival in colorectal cancer, future investigation of long-term oncologic outcomes is necessary to evaluate the potential impact of enhanced recovery on survival. See Video Abstract at http://links.lww.com/DCR/B21. LA IMPLEMENTACIÓN DE UN PROTOCOLO DE RECUPERACIÓN ACELERADA SE ASOCIA CON EL INICIO A TIEMPO DE QUIMIOTERAPIA ADYUVANTE EN CÁNCER COLORRECTAL:: El inicio tardío de la quimioterapia adyuvante afecta negativamente la supervivencia a largo plazo en pacientes con cáncer colorrectal. Los protocolos de recuperación acelerada colorrectales dan lugar a una disminución de las complicaciones y la duración de estancia hospitalaria; sin embargo, el impacto de la recuperación acelerada en el momento de inicio de quimioterapia adyuvante sigue siendo desconocido.Este estudio tuvo como objetivo identificar los factores asociados con la administración a tiempo de la quimioterapia adyuvante después de la cirugía de cáncer colorrectal, con la hipótesis de que la implementación de un protocolo de recuperación acelerada daría lugar a que más pacientes reciban quimioterapia a tiempo.Estudio de cohorte retrospectivo que compara la tasa de administración de quimioterapia adyuvante a tiempo después de la resección del cáncer colorrectal antes y después de la implementación de un protocolo de recuperación acelerada.Centro médico académico grande.Todos los pacientes que se sometieron a resecciones de cáncer colorrectal no emergentes con intención curativa desde enero de 2010 hasta junio de 2017, excluyendo a los pacientes que no tenían indicación de quimioterapia adyuvante, que recibieron quimioterapia sistémica preoperatoria o no tenían registros médicos de oncología disponibles.Los pacientes se compararon antes y después de la implementación de la recuperación acelerada, con la tasa de administración de quimioterapia adyuvante a tiempo como el resultado primario. La administración de quimioterapia adyuvante se consideró a tiempo si se inició ≤8 semanas después de la operación, y el tratamiento se consideró retrasado / omitido si se inició> 8 semanas después de la operación (retrasado) o nunca fue recibido (omitido). La regresión logística multivariable identificó predictores de administración de quimioterapia a tiempo.363 pacientes cumplieron con los criterios de inclusión, con 189 (52.1%) pacientes sometidos a cirugía después de la implementación de recuperación acelerada. Los grupos difirieron en el abordaje laparoscópico y la duración media del procedimiento; ambos factores fueron mayores después de la recuperación acelerada. Significativamente más pacientes recibieron quimioterapia a tiempo después de la implementación de recuperación acelerada (p = 0.007). La recuperación acelerada fue un factor predictivo independiente de quimioterapia adyuvante a tiempo (p = 0.014).Diseño retrospectivo, tipo ¨antes y después¨ no aleatorizado.La recuperación acelerada se asoció con la recepción de quimioterapia adyuvante a tiempo. Debido a que el inicio rápido de la quimioterapia adyuvante mejora la supervivencia en el cáncer colorrectal, en el futuro será necesario investigar los resultados oncológicos a largo plazo para evaluar el impacto potencial de la recuperación acelerada en la supervivencia. Vea el Resumen en Video en http://links.lww.com/DCR/B21.


Assuntos
Antineoplásicos/uso terapêutico , Quimioterapia Adjuvante/métodos , Colectomia/reabilitação , Neoplasias Colorretais , Complicações Pós-Operatórias/prevenção & controle , Recuperação de Função Fisiológica/efeitos dos fármacos , Sobreviventes/estatística & dados numéricos , Tempo para o Tratamento , Protocolos Clínicos/normas , Colectomia/métodos , Neoplasias Colorretais/epidemiologia , Neoplasias Colorretais/patologia , Neoplasias Colorretais/reabilitação , Neoplasias Colorretais/terapia , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia
4.
J Stroke Cerebrovasc Dis ; 28(12): 104423, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31606319

RESUMO

BACKGROUND: The Mission Protocol was implemented in 2017 to expedite stroke evaluation and reduce door-to-needle (DTN) times at Zuckerberg San Francisco General Hospital. The key system changes were team-based evaluation of suspected stroke patients at ambulance entrance by an Emergency Department (ED) physician, ED nurse, and neurologist and immediate emergency medical service (EMS) provider transport of patients to CT. METHODS: Patients were eligible for a Mission Protocol prehospital stroke activation if an EMS provider found a positive Cincinnati Prehospital Stroke Scale and a last known normal time within 6 hours. We retrospectively compared treatment metrics between the first year of Mission Protocol patients and patients from the year prior also brought in via ambulance with suspected stroke and a last known normal time within 6 hours. Median Door to CT and DTN times were compared using 2 sample Wilcoxon rank-sum (Mann-Whitney) tests. RESULTS: There were 236 patients in the Mission Protocol group and 112 in the comparison group. The Mission Protocol was associated with a 10 minutes faster median door to CT time (P < .00001), a 6 minutes faster median DTN time (P = .0046), a 22% increase in the proportion of patients treated within 45 minutes of arrival (84% versus 62%), and a 12% increase in the proportion of patients treated within 60 minutes (92% versus 80%). There were 8 stroke mimics treated in the Mission Protocol cohort compared to 2 in the comparison cohort. Symptomatic intracranial hemorrhage occurred in one Mission Protocol patient with an ischemic stroke. CONCLUSIONS: The EMS direct to CT based Mission Protocol was associated with faster median door to CT and DTN times. There was a 22% increase in the proportion of thrombolysis patients treated within 45 minutes or less. More stroke mimic patients received thrombolysis but symptomatic intracranial hemorrhage only occurred in 1 ischemic stroke patient.


Assuntos
Isquemia Encefálica/tratamento farmacológico , Protocolos Clínicos/normas , Serviços Médicos de Emergência/normas , Fibrinolíticos/administração & dosagem , Melhoria de Qualidade/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Acidente Vascular Cerebral/tratamento farmacológico , Terapia Trombolítica/normas , Tempo para o Tratamento/normas , Idoso , Idoso de 80 Anos ou mais , Isquemia Encefálica/diagnóstico por imagem , Diagnóstico Diferencial , Serviço Hospitalar de Emergência/normas , Feminino , Fibrinolíticos/efeitos adversos , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico por imagem , Terapia Trombolítica/efeitos adversos , Fatores de Tempo , Tomografia Computadorizada por Raios X/normas , Resultado do Tratamento
6.
BMC Health Serv Res ; 19(1): 673, 2019 Sep 18.
Artigo em Inglês | MEDLINE | ID: mdl-31533711

RESUMO

BACKGROUND: To investigate timely access to and the time needed to complete the diagnostic path of children and adolescents with suspected attention deficit hyperactivity disorder (ADHD) in the 18 Italian Lombardy Region ADHD reference centers. METHODS: Data of children and adolescents enrolled in the Regional ADHD disease-oriented Registry for suspected ADHD who requested their first visit in 2013-2017 were analyzed. RESULTS: The sample comprised 2262 children and adolescents aged 5-17 years who accessed the ADHD centers for diagnostic classification and management. The median waiting time was of 177 days (range 66-375) from the request for the initial appointment to the completion of the diagnostic path, with a three - fold difference between centers. In addition to the center, the strongest significant predictors of long waiting times were age comorbidities, the severity of the disorder, and having already completed some diagnostic procedures provided by the common standard path. CONCLUSIONS: To guarantee an equal standard of care in ADHD centers for all children and adolescents there is a pressing need to reduce the times to complete the diagnostic path. It is the task of both policymakers and each center to optimize the quality of the service and of the care delivered.


Assuntos
Transtorno do Deficit de Atenção com Hiperatividade/diagnóstico , Tempo para o Tratamento/normas , Adolescente , Análise de Variância , Criança , Pré-Escolar , Comorbidade , Feminino , Humanos , Itália , Masculino , Encaminhamento e Consulta , Sistema de Registros , Tempo para o Tratamento/estatística & dados numéricos , Listas de Espera
7.
Zhonghua Wai Ke Za Zhi ; 57(10): 6-10, 2019 Oct 01.
Artigo em Chinês | MEDLINE | ID: mdl-31510725

RESUMO

With the development of minimally invasive concept, the treatment mode of severe acute pancreatitis has changed greatly. The tendency of surgical intervention has changed from excessive intervention to inadequate intervention. The timing of intervention has changed from earlier to later, and the mode of intervention has changed from openness as the main way to minimally invasive as the guidance. The transformation of surgical intervention tendency conforms to both minimally invasive trend and the step-up approach, but there are still some shortcomings: inadequate surgical intervention, inappropriate timing and indications, and over dependence on minimally invasive surgery. Correctly grasping the indications of surgical intervention, accurately grasping the timing of surgical intervention, and reasonably choosing the mode of surgical intervention are the keys to solve the insufficiency of surgical intervention. Laying emphasis on multidisciplinary team and correctly recognizing the role and status of surgical intervention can effectively reduce the mortality of severe acute pancreatitis patients.


Assuntos
Procedimentos Cirúrgicos Minimamente Invasivos/normas , Pancreatite Necrosante Aguda/cirurgia , Tempo para o Tratamento/normas , Doença Aguda , Humanos , Procedimentos Cirúrgicos Minimamente Invasivos/métodos , Equipe de Assistência ao Paciente
8.
J Stroke Cerebrovasc Dis ; 28(11): 104332, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31439524

RESUMO

INTRODUCTION: Telestroke has increased access to acute management of ischemic stroke in areas that lack stroke care expertise, yet delays persist in evaluation and treatment. We describe variation in time to alert a telestroke physician of suspected acute ischemic stroke patients potentially eligible for acute stroke therapies among community hospitals in our telestroke network, and explore demographic and spoke-related characteristics associated with delays. METHODS: From our telestroke registry, we identified suspected acute ischemic stroke patients who arrived within 6 hours of symptom onset and underwent video consultation at 1 of 17 community hospitals in our hub-and-spoke network. We compared time between patient arrival to telestroke alert (door-to-page-time) and to tissue plasminogen activator (tPA) administration for eligible patients (door-to-needle-time). We identified factors associated with prolonged metrics. RESULTS: Of 1020 cases between 9/2015 and 3/2017, 47% received tPA. Sixty percent had door-to-page-time more than 15 minutes (median 19.5; IQR, 11-34). Door-to-page-time more than 15 minutes was associated with an 8-fold increase in likelihood of door-to-needle-time more than 60 minutes. Patients with severe stroke experienced faster door-to-page-times. Hospitals with more beds had prolonged door-to-page-time. Full time in-house neurology presence, even when not covering emergent consultations, was associated with faster door-to-page-time over telestroke. Seventy-one percent of patients underwent CT brain prior to the telestroke physician alert; this scenario delayed door-to-page and door-to-needle times. CONCLUSIONS: Door-to-page-time varied considerably among spokes. Awaiting CT scan prior to alerting the telestroke consultant of a stroke code delayed metrics. Telestroke physician alert standards are needed, as are educational initiatives on acute ischemic stroke management and workflow.


Assuntos
Benchmarking/normas , Isquemia Encefálica/terapia , Prestação Integrada de Cuidados de Saúde/normas , Equipe de Assistência ao Paciente/normas , Padrões de Prática Médica/normas , Consulta Remota/normas , Acidente Vascular Cerebral/terapia , Terapia Trombolítica/normas , Tempo para o Tratamento/normas , Administração Intravenosa , Idoso , Isquemia Encefálica/diagnóstico , Isquemia Encefálica/fisiopatologia , Feminino , Fibrinolíticos/administração & dosagem , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Estudos Retrospectivos , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/fisiopatologia , Fatores de Tempo , Ativador de Plasminogênio Tecidual/administração & dosagem , Tomografia Computadorizada por Raios X/normas , Resultado do Tratamento , Videoconferência/normas , Fluxo de Trabalho
10.
J Thorac Cardiovasc Surg ; 157(3): 1219-1235, 2019 03.
Artigo em Inglês | MEDLINE | ID: mdl-31343410

RESUMO

OBJECTIVE: In this study we present historic data on adherence to and survival outcomes associated with recently introduced quality measures for the management of non-small-cell lung cancer. METHODS: The National Cancer Data Base was queried to identify all patients with non-small-cell lung cancer from 1998 to 2011. Adherence to guidelines was assessed for each of 3 Commission on Cancer-defined quality measures: (1) sampling 10 regional lymph nodes at surgery; (2a) surgery within 120 days of neoadjuvant chemotherapy or, (2b) 180 days of adjuvant chemotherapy; and (3) nonsurgical primary therapy in cN2 disease. The likelihood of measure adherence and the association of measure adherence with all-cause mortality were analyzed controlling for patient, hospital, and time period characteristics. RESULTS: Regional lymph node sampling was inadequate in 72.7% of cases. Only 28.7% began adjuvant chemotherapy within 180 days of surgery. However, 96.5% of patients who received neoadjuvant chemotherapy proceeded to surgery within 120 days and surgery was first-line treatment for cN2 disease in only 3.7% of patients. Uninsured or Medicaid status was an independent risk factor for a prolonged delay between neoadjuvant chemotherapy and surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.72) and surgery and adjuvant treatment (odds ratio, 1.92; 95% confidence interval, 1.69-2.19). Overall survival was significantly better in patients whose care conformed to quality standards for nodal sampling (measure 1), and timing of chemotherapy. CONCLUSIONS: Adherence rates for nodal sampling at the time of surgery and receipt of adjuvant chemotherapy were low. These findings highlight opportunities for improvement efforts, but more measures are needed to more broadly assess the quality of lung cancer care.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/terapia , Neoplasias Pulmonares/terapia , Excisão de Linfonodo/normas , Terapia Neoadjuvante/normas , Pneumonectomia/normas , Indicadores de Qualidade em Assistência à Saúde/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Carcinoma Pulmonar de Células não Pequenas/patologia , Quimioterapia Adjuvante/normas , Bases de Dados Factuais , Feminino , Fidelidade a Diretrizes/normas , Disparidades em Assistência à Saúde/normas , Humanos , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/patologia , Excisão de Linfonodo/efeitos adversos , Excisão de Linfonodo/mortalidade , Masculino , Pessoa de Meia-Idade , Terapia Neoadjuvante/efeitos adversos , Terapia Neoadjuvante/mortalidade , Pneumonectomia/efeitos adversos , Pneumonectomia/mortalidade , Guias de Prática Clínica como Assunto/normas , Padrões de Prática Médica/normas , Fatores de Risco , Fatores de Tempo , Tempo para o Tratamento/normas , Resultado do Tratamento , Estados Unidos/epidemiologia
11.
Geriatr Gerontol Int ; 19(8): 786-791, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31199567

RESUMO

AIM: To assess whether elderly patients are prioritized under the emergency triage system in Guangzhou, China. METHODS: This was a cross-sectional survey of clinical data from adult visitors to the emergency department of the Third Affiliated Hospital of Sun Yat-sen University between 1 August 2015 and 31 December 2017. The primary end-point was receiving the first medical service within the target waiting time, which varied according to the triage level of the patient. Multivariate logistic regression was used to determine whether age was an independent predictor of a shorter waiting time. RESULTS: Data from 262 282 emergency patients were analyzed. The mean age of patients was 35.97 years, and 7.5% were aged ≥65 years. In total, 88.3% of patients received medical service within the target waiting time, and 87.4% of elderly patients received medical service within the target waiting time. Multivariate logistic regression analysis showed that advanced age was independently associated with receiving medical service within the target waiting time (adjusted odds ratio 1.258, 95% confidence interval 1.198-1.321; P < 0.001). The triage level, type of emergency subdivision, availability of outpatient services and time of day were also associated with receiving medical service within the target waiting time. CONCLUSION: Under the emergency triage system of the hospital, older adults are more likely to receive medical service within the target waiting time than younger patients. Geriatr Gerontol Int 2019; 19: 786-791.


Assuntos
Serviço Hospitalar de Emergência , Tempo para o Tratamento , Triagem , Adulto , Fatores Etários , Idoso , China , Estudos Transversais , Serviço Hospitalar de Emergência/organização & administração , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Gravidade do Paciente , Gerenciamento do Tempo/organização & administração , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Triagem/métodos , Triagem/normas , Triagem/estatística & dados numéricos
12.
Arch Cardiovasc Dis ; 112(6-7): 374-380, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31160206

RESUMO

BACKGROUND: In France, when someone presents with chest pain, it is recommended to call a health emergency number. The patient talks with an emergency doctor at a medical dispatch centre, who decides whether (or not) to send a Mobile Intensive Care Unit (MICU). Patients with an ST-segment elevation myocardial infarction (STEMI) should have an MICU as their first medical contact, to speed up confirmation of diagnosis and enable them to benefit from reperfusion therapy as quickly as possible. AIM: To evaluate the proportion of patients with STEMI benefiting from an optimal care pathway, and to identify the key factors leading to this pathway. METHODS: RESCAMIP was a multicentre registry conducted between May 2015 and May 2017 in Midi-Pyrénées. All patients treated for STEMI within 12hours of symptoms onset, without initially going into cardiac arrest, were included. RESULTS: Data from 1371 patients with STEMI were analysed; 60% had an MICU as their first medical contact. In-hospital mortality was 4%. Factors associated with calling the medical dispatch centre when presenting chest pain were: age>65 years (odds ratio [OR] 1.37, 95% confidence interval [CI] 1.02-1.83), personal history of cardiovascular disease (OR 1.9, 95% CI 1.22-2.96) and having cardiovascular risk factors (OR 1.84, 95% CI 1.35-2.5). Factors associated with sending an MICU as first medical contact were: male sex (OR 2.11, 955 CI 1.49-2.99) and personal history of cardiovascular disease (OR 1.69, 95% CI 1.07-2.65). CONCLUSIONS: The proportion of patients with STEMI going through non-optimal pathways was 40% in our area. We note that there are sex-based inequalities in accessing MICUs.


Assuntos
Procedimentos Clínicos/normas , Serviços Médicos de Emergência/normas , Infarto do Miocárdio com Supradesnível do Segmento ST/terapia , Tempo para o Tratamento/normas , Idoso , Idoso de 80 Anos ou mais , Operador de Emergência Médica , Feminino , França , Acesso aos Serviços de Saúde/normas , Disparidades em Assistência à Saúde/normas , Humanos , Masculino , Pessoa de Meia-Idade , Sistema de Registros , Fatores de Risco , 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/fisiopatologia , Fatores Sexuais , Fatores de Tempo , Transporte de Pacientes/normas , Resultado do Tratamento
14.
J Neurointerv Surg ; 11(8): 781-784, 2019 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-31088943

RESUMO

BACKGROUND AND PURPOSE: Despite numerous optimization attempts, time delays are still a relevant problem in endovascular stroke treatment. We hypothesized that public display of the fastest procedural times in our institution would raise awareness, which would result in improved procedural times. METHODS: We established a competition, which lasted 6 months, in which the fastest neurovascular team in terms of procedural times (image to reperfusion) was displayed on a public board in our institution and rewarded with public praise. During this time no other relevant procedural or infrastructural means for improvement of procedural times were introduced in our institution. We prospectively evaluated procedural times in 496 patients who received endovascular stroke treatment 9 months before the competition, during the competition, and during the four 6-month time periods for 2 years after the competition. RESULTS: Median image-to-reperfusion times improved significantly from 98 min before the competition to 85 min during the competition (p=0.005) and remained stable with a median of 81 min 2 years after the competition (p=0.837). CONCLUSION: We were able to improve our procedural times significantly with a simple and cost-efficient competition. This effect was sustained 2 years after the competition was completed, implying that the improvement in procedural times was probably due to raised awareness.


Assuntos
Comportamento Competitivo , Procedimentos Endovasculares/tendências , Acidente Vascular Cerebral/diagnóstico por imagem , Acidente Vascular Cerebral/cirurgia , Tempo para o Tratamento/tendências , Idoso , Procedimentos Endovasculares/métodos , Procedimentos Endovasculares/normas , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Reperfusão/métodos , Trombectomia/métodos , Trombectomia/normas , Trombectomia/tendências , Fatores de Tempo , Tempo para o Tratamento/normas , Resultado do Tratamento
18.
J Drugs Dermatol ; 18(3): 255-260, 2019 Mar 01.
Artigo em Inglês | MEDLINE | ID: mdl-30909329

RESUMO

Atrophic acne scarring is a frequent occurrence among acne patients. These facial marks are often very emotionally distressing for the patient and can result in adverse impact to quality of life. While most clinicians consider scarring as a sequela of moderate to severe acne, recent studies have found that scars are also associated with mild acne. Risk factors include time to effective treatment, severity of acne, family history, and excoriations. New data shows that early and effective acne treatment can reduce the development of new scars, confirming the widespread perception of this approach in prevention. It is also becoming clear that the inflammatory process drives both the development of acne lesions and atrophic scars. This implies that inhibiting activation of inflammatory pathways early is key to preventing scars. Data also suggests a useful role for adapalene for the treatment of well-established acne scars with scar remodeling accompanied by the production of new collagen and elastic tissue. Acne guidelines and recommendations continue to highlight the central role of retinoids, with fixed-dose combination retinoids being particularly important due to targeting of multiple inflammatory pathophysiologic factors and for patient convenience. Higher concentrations of retinoids such as adapalene 0.3%/benzoyl peroxide 2.5% (A0.3/BPO2.5) have shown increased efficacy, particularly among patients with moderately severe and severe acne ­ a population at high risk for scarring. Further, controlled study of A0.3/BPO2.5 in patients with moderate acne (mean, 40 acne lesions per half face) and mild-moderate scarring demonstrated A0.3/BPO2.5 was significantly superior to vehicle in reducing scar counts from baseline over 24 weeks. While scar counts lessened on the A0.3/BPO2.5 side, counts increased on the vehicle side during the study. This occurred in the setting of active acne, where the efficacy of A/BPO is well known, emphasizing the dual actions of A0.3/BPO2.5 in both treatment and prevention. J Drugs Dermatol. 2019;18(3):255-260.


Assuntos
Acne Vulgar/tratamento farmacológico , Cicatriz/prevenção & controle , Fármacos Dermatológicos/administração & dosagem , Retinoides/administração & dosagem , Tempo para o Tratamento/normas , Acne Vulgar/complicações , Acne Vulgar/diagnóstico , Combinação Adapaleno e Peróxido de Benzoil/administração & dosagem , Combinação Adapaleno e Peróxido de Benzoil/normas , Administração Cutânea , Cicatriz/tratamento farmacológico , Cicatriz/etiologia , Fármacos Dermatológicos/normas , Humanos , Seleção de Pacientes , Guias de Prática Clínica como Assunto , Qualidade de Vida , Retinoides/normas , Medição de Risco , Índice de Gravidade de Doença , Fatores de Tempo , Resultado do Tratamento
19.
J Pediatr Orthop ; 39(3): 158-162, 2019 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30730421

RESUMO

INTRODUCTION: Musculoskeletal infection (MSI) is a common cause of morbidity and hospital resource utilization in the pediatric population. Many physicians prefer to withhold antibiotics until tissue cultures can be taken in an effort to improve culture yields. However, there is little evidence that this practice improves culture results or outcomes in pediatric MSI. Therefore, investigating the effects of antibiotic timing may lead to improved clinical practice guidelines for treating children with MSI. METHODS: An IRB-approved retrospective review was conducted that identified 113 patients aged 0 to 18 who presented to the pediatric emergency room at a tertiary care children's hospital with MSI from 2008 to 2013. Demographic data, culture results, severity markers, and intervention timing were obtained from the medical record. Logistic regression and Cox survival analysis were performed to determine the relationship of antibiotic timing with culture sensitivity and time to discharge. RESULTS: No difference was seen in culture sensitivity antibiotic administration in either the local (55% culture before antibiotics vs. 89% after antibiotics) or disseminated group (76% before vs. 79% after), which persisted when further accounting for disease severity with C-reactive protein. However, later administration of antibiotics in the local infection group correlated with a decreased likelihood of discharge (3.91 d when cultured before antibiotics vs. 2.93 d when cultured after antibiotics; hazard ratio, 0.53; P<0.05). In patients with disseminated infection, antibiotic administration was not shown to correlate with any difference in time to discharge (hazard ratio, 1.08). CONCLUSIONS: The authors were surprised to find that tissue culture sensitivities were not decreased by antibiotic administration in either local or disseminated MSI, suggesting that antibiotic administration should not be delayed to obtain tissue cultures. The correlation of earlier antibiotic administration with shorter length of stay in children with local MSI led the authors to conclude that antibiotics should be initiated as quickly as possible. Further study is necessary to confirm these findings and establish clinical practice guidelines. LEVEL OF EVIDENCE: Level III-retrospective cohort.


Assuntos
Antibacterianos/administração & dosagem , Testes de Sensibilidade Microbiana , Técnicas Microbiológicas/métodos , Doenças Musculoesqueléticas , Tempo para o Tratamento , Adolescente , Biomarcadores , Pré-Escolar , Feminino , Humanos , Recém-Nascido , /tratamento farmacológico , Masculino , Testes de Sensibilidade Microbiana/métodos , Testes de Sensibilidade Microbiana/estatística & dados numéricos , Doenças Musculoesqueléticas/classificação , Doenças Musculoesqueléticas/diagnóstico , Doenças Musculoesqueléticas/tratamento farmacológico , Estudos Retrospectivos , Índice de Gravidade de Doença , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos
20.
Chest ; 155(5): 938-946, 2019 05.
Artigo em Inglês | MEDLINE | ID: mdl-30779916

RESUMO

BACKGROUND: The impact of antibiotic timing on sepsis outcomes remains controversial due to conflicting results from previous studies. OBJECTIVES: This study investigated the association of door-to-antibiotic time with long-term mortality in ED patients with sepsis. METHODS: This retrospective cohort study included nontrauma adult ED patients with clinical sepsis admitted to four hospitals from 2013 to 2017. Only patients' first eligible encounter was included. Multivariable logistic regression was used to measure the adjusted association between door-to-antibiotic time and 1-year mortality. Secondary analyses used alternative antibiotic timing measures (antibiotic initiation within 1 or 3 h and separate comparison of antibiotic exposure at each hour up to hour 6), alternative outcomes (hospital, 30-day, and 90-day mortality), and alternative statistical methods to mitigate indication bias. RESULTS: Among 10,811 eligible patients, median door-to-antibiotic time was 166 min (interquartile range, 115-230 min), and 1-year mortality was 19%. After adjustment, each additional hour from ED arrival to antibiotic initiation was associated with a 10% (95% CI, 5-14; P < .001) increased odds of 1-year mortality. The association remained linear when each 1-h interval of door-to-antibiotic time was independently compared with door-to-antibiotic time ≤ 1 h and was similar for hospital, 30-day, and 90-day mortality. Mortality at 1 year was higher when door-to-antibiotic times were > 3 h vs ≤ 3 h (adjusted OR, 1.27; 95% CI, 1.13-1.43) but not > 1 h vs ≤ 1 h (adjusted OR, 1.26; 95% CI, 0.98-1.62). CONCLUSIONS: Delays in ED antibiotic initiation time are associated with clinically important increases in long-term, risk-adjusted sepsis mortality.


Assuntos
Antibacterianos/administração & dosagem , Serviços Médicos de Emergência , Serviço Hospitalar de Emergência/estatística & dados numéricos , Efeitos Adversos de Longa Duração , Sepse , Tempo para o Tratamento , Serviços Médicos de Emergência/métodos , Serviços Médicos de Emergência/normas , Feminino , Hospitalização/estatística & dados numéricos , Humanos , Tempo de Internação/estatística & dados numéricos , Efeitos Adversos de Longa Duração/etiologia , Efeitos Adversos de Longa Duração/mortalidade , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Sepse/diagnóstico , Sepse/tratamento farmacológico , Sepse/mortalidade , Tempo para o Tratamento/normas , Tempo para o Tratamento/estatística & dados numéricos , Estados Unidos/epidemiologia
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