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1.
Rev Bras Enferm ; 74(suppl 6): e20210032, 2021.
Artigo em Inglês, Português | MEDLINE | ID: mdl-34495215

RESUMO

OBJECTIVES: to validate, for the Portuguese population, the Clinical Decision-Making Nursing Scale© (CDMNS©). METHODS: this methodological study involved 496 nursing students who filled in a questionnaire created using sociodemographic and academic data, and the scale to evaluate the making of decisions in nursing. RESULTS: the confirmatory factorial analysis showed that the adjustment of the factorial structure has good quality, being made up by three factors (X2/gl = 2.056; GFI = 0.927; CFI = 0.917; RMSEA = 0.046; RMR = 0.039; SRMR = 0.050). For the scale to be reliable, it had to include only the reliability of the scale required it to be constituted by 23 items, with correlation values that varied from 0.184 and 0.610, and a global Cronbach's Alpha of 0.851, which showed its good reliability. CONCLUSIONS: the CDMNS-PT© is valid and reliable, showing a high potential to be used in clinical practice and investigation.


Assuntos
Estudantes de Enfermagem , Tomada de Decisão Clínica , Humanos , Psicometria , Reprodutibilidade dos Testes , Inquéritos e Questionários , Traduções
2.
Sci Rep ; 11(1): 17504, 2021 09 01.
Artigo em Inglês | MEDLINE | ID: mdl-34471196

RESUMO

Chemosensory impairments have been established as a specific indicator of COVID-19. They affect most patients and may persist long past the resolution of respiratory symptoms, representing an unprecedented medical challenge. Since the SARS-CoV-2 pandemic started, we now know much more about smell, taste, and chemesthesis loss associated with COVID-19. However, the temporal dynamics and characteristics of recovery are still unknown. Here, capitalizing on data from the Global Consortium for Chemosensory Research (GCCR) crowdsourced survey, we assessed chemosensory abilities after the resolution of respiratory symptoms in participants diagnosed with COVID-19 during the first wave of the pandemic in Italy. This analysis led to the identification of two patterns of chemosensory recovery, partial and substantial, which were found to be associated with differential age, degrees of chemosensory loss, and regional patterns. Uncovering the self-reported phenomenology of recovery from smell, taste, and chemesthetic disorders is the first, yet essential step, to provide healthcare professionals with the tools to take purposeful and targeted action to address chemosensory disorders and their severe discomfort.


Assuntos
COVID-19/complicações , Transtornos do Olfato/epidemiologia , Distúrbios do Paladar/epidemiologia , Adulto , Idoso , Tomada de Decisão Clínica , Feminino , Humanos , Itália/epidemiologia , Masculino , Pessoa de Meia-Idade , Transtornos do Olfato/etiologia , Autorrelato , Distúrbios do Paladar/etiologia , Adulto Jovem
3.
Sci Rep ; 11(1): 17787, 2021 09 07.
Artigo em Inglês | MEDLINE | ID: mdl-34493774

RESUMO

Despite COVID-19's significant morbidity and mortality, considering cost-effectiveness of pharmacologic treatment strategies for hospitalized patients remains critical to support healthcare resource decisions within budgetary constraints. As such, we calculated the cost-effectiveness of using remdesivir and dexamethasone for moderate to severe COVID-19 respiratory infections using the United States health care system as a representative model. A decision analytic model modelled a base case scenario of a 60-year-old patient admitted to hospital with COVID-19. Patients requiring oxygen were considered moderate severity, and patients with severe COVID-19 required intubation with intensive care. Strategies modelled included giving remdesivir to all patients, remdesivir in only moderate and only severe infections, dexamethasone to all patients, dexamethasone in severe infections, remdesivir in moderate/dexamethasone in severe infections, and best supportive care. Data for the model came from the published literature. The time horizon was 1 year; no discounting was performed due to the short duration. The perspective was of the payer in the United States health care system. Supportive care for moderate/severe COVID-19 cost $11,112.98 with 0.7155 quality adjusted life-year (QALY) obtained. Using dexamethasone for all patients was the most-cost effective with an incremental cost-effectiveness ratio of $980.84/QALY; all remdesivir strategies were more costly and less effective. Probabilistic sensitivity analyses showed dexamethasone for all patients was most cost-effective in 98.3% of scenarios. Dexamethasone for moderate-severe COVID-19 infections was the most cost-effective strategy and would have minimal budget impact. Based on current data, remdesivir is unlikely to be a cost-effective treatment for COVID-19.


Assuntos
COVID-19/tratamento farmacológico , COVID-19/terapia , Custos de Cuidados de Saúde/estatística & dados numéricos , Alocação de Recursos para a Atenção à Saúde/economia , Monofosfato de Adenosina/análogos & derivados , Monofosfato de Adenosina/economia , Monofosfato de Adenosina/uso terapêutico , Alanina/análogos & derivados , Alanina/economia , Alanina/uso terapêutico , COVID-19/diagnóstico , COVID-19/economia , COVID-19/mortalidade , COVID-19/virologia , Tomada de Decisão Clínica/métodos , Simulação por Computador , Análise Custo-Benefício , Dexametasona/economia , Dexametasona/uso terapêutico , Alocação de Recursos para a Atenção à Saúde/organização & administração , Humanos , Unidades de Terapia Intensiva/economia , Unidades de Terapia Intensiva/estatística & dados numéricos , Pessoa de Meia-Idade , Oxigênio/administração & dosagem , Oxigênio/economia , Anos de Vida Ajustados por Qualidade de Vida , Respiração Artificial/economia , SARS-CoV-2 , Índice de Gravidade de Doença , Resultado do Tratamento , Estados Unidos/epidemiologia
4.
Transfus Apher Sci ; 60(4): 103207, 2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34353706

RESUMO

Blood transfusions come with risks and high costs, and should be utilized only when clinically indicated. Decisions to transfuse are however not always well informed, and lack of clinician knowledge and education on good clinical transfusion practices contribute to the inappropriate use of blood. Low and middle-income countries in particular take much strain in their efforts to address blood safety challenges, demand-supply imbalances, high blood costs as well as high disease burdens, all of which impact blood usage and blood collections. Patient blood management (PBM), which is a patient-focused approach aimed at improving patient outcomes by preemptively diagnosing and correcting anaemia and limiting blood loss by cell salvage, coagulation optimization and other measures, has become a major approach to addressing many of the challenges mentioned. The associated decrease in the use of blood and blood products may be perceived as being in competition with blood conservation measures, which is the more traditional, but primarily product-focused approach. In this article, we hope to convey the message that PBM and blood conservation should not be seen as competing concepts, but rather complimentary strategies with the common goal of improving patient care. This offers opportunity to improve the culture of transfusion practices with relief to blood establishments and clinical services, not only in South Africa and LMICs, but everywhere. With the COVID-19 pandemic impacting blood supplies worldwide, this is an ideal time to call for educational interventions and awareness as an active strategy to improve transfusion practices, immediately and beyond.


Assuntos
Bancos de Sangue/organização & administração , Transfusão de Sangue , Procedimentos Médicos e Cirúrgicos sem Sangue , Anemia/terapia , Bancos de Sangue/economia , Perda Sanguínea Cirúrgica , Segurança do Sangue , Transfusão de Sangue/economia , Infecções Transmitidas por Sangue/prevenção & controle , Procedimentos Médicos e Cirúrgicos sem Sangue/economia , COVID-19 , Tomada de Decisão Clínica , Países em Desenvolvimento , Seleção do Doador/economia , Medicina Baseada em Evidências , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/prevenção & controle , Necessidades e Demandas de Serviços de Saúde , Humanos , Masculino , Pandemias , Hemorragia Pós-Parto/terapia , Guias de Prática Clínica como Assunto , Gravidez , Prevalência , Utilização de Procedimentos e Técnicas , SARS-CoV-2 , África do Sul/epidemiologia , Medicina Transfusional/educação
5.
AMIA Annu Symp Proc ; 2021: 305-314, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34457145

RESUMO

Reinforcement learning (RL) has the potential to significantly improve clinical decision making. However, treatment policies learned via RL from observational data are sensitive to subtle choices in study design. We highlight a simple approach, trajectory inspection, to bring clinicians into an iterative design process for model-based RL studies. We identify where the model recommends unexpectedly aggressive treatments or expects surprisingly positive outcomes from its recommendations. Then, we examine clinical trajectories simulated with the learned model and policy alongside the actual hospital course. Applying this approach to recent work on RL for sepsis management, we uncover a model bias towards discharge, a preference for high vasopressor doses that may be linked to small sample sizes, and clinically implausible expectations of discharge without weaning off vasopressors. We hope that iterations of detecting and addressing the issues unearthed by our method will result in RL policies that inspire more confidence in deployment.


Assuntos
Reforço Psicológico , Sepse , Tomada de Decisão Clínica , Humanos , Aprendizagem , Projetos de Pesquisa
6.
Comput Methods Programs Biomed ; 209: 106359, 2021 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-34438224

RESUMO

OBJECTIVE: Poor clinical data quality might affect clinical decision making and patient treatment. This study identifies quality defects in clinical data collected automatically by bedside monitoring devices in the Intensive Care Unit (ICU) and examines their effect on clinical decisions. METHODS: Real-world data collected from 7688 patients admitted to the general ICU in a tertiary referral hospital over seven years was retrospectively analyzed. Data quality defect detection methods that use time-series analysis techniques identified two types of data quality defects: (a) completeness: the extent of non-missing values, and (b) validity: the extent of non-extreme values within the continuous range of values. Data quality defects were compared to five scenarios of medication and procedure prescriptions that are common in ICU settings: Blood-pressure reduction, blood-pressure elevation, anesthesia medications, intubation procedures, and muscle relaxant medications. RESULTS: Results from a logistic regression revealed a strong connection between data quality and the clinical interventions examined: lower validity level increased the likelihood of prescription decisions for all five scenarios, and lower completeness level increased the likelihood of prescription decisions for some scenarios. DISCUSSION: The results highlight the possible effect of data quality defects on physicians' decisions. Lower validity of certain key clinical parameters, and in some scenarios lower completeness, correlated with stronger tendency to prescribe medications or perform invasive procedures. CONCLUSIONS: Data quality defects in clinical data affect decision making even without practitioners' awareness. Thus, it is important to emphasize these effects to ICU staff, as well as to medical device manufacturers.


Assuntos
Confiabilidade dos Dados , Unidades de Terapia Intensiva , Tomada de Decisão Clínica , Hospitalização , Humanos , Estudos Retrospectivos
7.
Turk J Ophthalmol ; 51(4): 231-242, 2021 08 27.
Artigo em Inglês | MEDLINE | ID: mdl-34461710

RESUMO

Immunomodulatory agents are often used in the systemic treatment of non-infectious uveitis. These drugs consist of corticosteroids, conventional immunosuppressives, and biological agents. As it is known that they suppress the immune system, the most important concern associated with immunomodulatory therapy (IMT) is the increased risk of infection. The World Health Organization declared COVID-19 a pandemic on 11 March 2020. Although severe acute respiratory distress syndrome secondary to SARS-CoV-2 infection may develop in all people, patients who receive IMT may be at higher risk in terms of both the transmission of the infection and more severe disease course. Therefore, guidelines on the management of patients receiving IMT due to uveitis during the pandemic are needed. In this review, we examined the immunomodulatory drugs used in the treatment of uveitis in terms of infectious complications and the data of patients who received IMT during the COVID-19 pandemic and discussed recommendations for the use of these drugs. According to the latest information, patients who receive IMT may continue their treatment as long as there are no disruptions in regular complete blood count (especially white blood cell count >4,000/µL) and liver and kidney function tests. Patients diagnosed with COVID-19 should be managed with a multidisciplinary approach.


Assuntos
COVID-19/epidemiologia , Glucocorticoides/uso terapêutico , Imunomodulação , Imunossupressores/uso terapêutico , SARS-CoV-2 , Uveíte/tratamento farmacológico , COVID-19/transmissão , Tomada de Decisão Clínica , Transmissão de Doença Infecciosa/prevenção & controle , Humanos , Testes de Função Renal , Contagem de Leucócitos , Testes de Função Hepática , Oftalmologia , Medição de Risco
8.
Reprod Health ; 18(1): 171, 2021 Aug 18.
Artigo em Inglês | MEDLINE | ID: mdl-34407851

RESUMO

BACKGROUND: Multiple oral insulin-sensitizing agents, such as metformin, thiazolidinediones, inositols, and berberine, have been proven safe and efficacious in improving the endocrine, metabolic, and reproductive abnormalities seen in polycystic ovary syndrome (PCOS), providing more options for healthcare providers and patients. These oral insulin sensitizers are more convenient, practical, and economic than agents that need to be injected. A comparison of the clinical effectiveness of the four different classes of oral insulin sensitizers in PCOS has not been explored, leading to clinical uncertainty about the optimal treatment pathway. The present study aims to compare the effects of oral insulin sensitizers on endocrine and metabolic profiles in women with PCOS. METHODS: We identified randomized controlled trials for PCOS from a variety of databases, published from January 2005 to October 2020. Outcomes included changes in menstrual frequency, improvements in hyperandrogenism and glucolipid metabolism and adverse side effects. A random-effects network meta-analysis was performed. RESULTS: Twenty-two trials comprising 1079 patients with PCOS were included in this study. Compared with metformin, treatment with myo-inositol + D-chiro-inositol was associated with a greater improvement in menstrual frequency (odds ratio 14.70 [95% confidence interval (CI) 2.31-93.58]). Myo-inositol + D-chiro-inositol and metformin + thiazolidinediones combination therapies were superior to respective monotherapies in reducing total testosterone levels. Thiazolidinediones, metformin + thiazolidinediones, and myo-inositol + D-chiro-inositol were associated with a lower insulin resistance index (HOMA-IR) compared with that in metformin alone (mean differences: - 0.72 [95% CI (- 1.11)-(- 0.34)] to - 0.89 [95% CI (- 1.460)-(- 0.32)]). Metformin + thiazolidinediones treatment was associated with lower triglyceride levels compared with that in metformin and thiazolidinediones monotherapy, while thiazolidinediones was superior to metformin in increasing high-density lipoprotein cholesterol and decreasing fasting plasma glucose, triglycerides, low-density lipoprotein cholesterol, and gastrointestinal adverse events. CONCLUSIONS: Ours is the first study to report that for women with PCOS, myo-inositol combined with D-chiro-inositol and metformin combined with thiazolidinediones appear superior to metformin alone in improving insulin resistance and decreasing total testosterone. Myo-inositol combined with D-chiro-inositol is particularly efficacious in menstrual recovery. Thiazolidinediones and metformin combined with thiazolidinediones improve lipid metabolism better than metformin alone. Trial registration PROSPERO CRD42020211524.


Assuntos
Berberina , Resistência à Insulina , Metformina , Síndrome do Ovário Policístico , Tiazolidinedionas , Tomada de Decisão Clínica , Feminino , Humanos , Hipoglicemiantes/uso terapêutico , Inositol/uso terapêutico , Insulina , Metaboloma , Metformina/uso terapêutico , Metanálise em Rede , Síndrome do Ovário Policístico/tratamento farmacológico , Tiazolidinedionas/uso terapêutico , Incerteza
9.
Open Heart ; 8(2)2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34376573

RESUMO

OBJECTIVES: To describe the use of echocardiography in patients hospitalised with suspected coronavirus infection and to assess its impact on clinical management. METHODS: We studied 79 adults from a prospective registry of inpatients with suspected coronavirus infection at a single academic centre. Echocardiographic indications included abnormal biomarkers, shock, cardiac symptoms, arrhythmia, worsening hypoxaemia or clinical deterioration. Study type (limited or complete) was assessed for each patient. The primary outcome measure was echocardiography-related change in clinical management, defined as intensive care transfer, medication changes, altered ventilation parameters or subsequent cardiac procedures within 24 hours of echocardiography. Coronavirus-positive versus coronavirus-negative patient groups were compared. The relationship between echocardiographic findings and coronavirus mortality was assessed. RESULTS: 56 patients were coronavirus-positive and 23 patients were coronavirus-negative with symptoms attributed to other diagnoses. Coronavirus-positive patients more often received limited echocardiograms (70% vs 26%, p=0.001). The echocardiographic indication for coronavirus-infected patients was frequently worsening hypoxaemia (43% vs 4%) versus chest pain, syncope or clinical heart failure (23% vs 44%). Echocardiography changed management less frequently in coronavirus-positive patients (18% vs 48%, p=0.01). Among coronavirus-positive patients, 14 of 56 (25.0%) died during hospitalisation. Those who died more often had echocardiography to evaluate clinical deterioration (71% vs 24%) and had elevated right ventricular systolic pressures (37 mm Hg vs 25 mm Hg), but other parameters were similar to survivors. CONCLUSIONS: Echocardiograms performed on hospitalised patients with coronavirus infection were often technically limited, and their findings altered patient management in a minority of patients.


Assuntos
COVID-19/diagnóstico por imagem , Ecocardiografia Doppler , Cardiopatias/diagnóstico por imagem , Coração/diagnóstico por imagem , Idoso , Idoso de 80 Anos ou mais , COVID-19/fisiopatologia , COVID-19/terapia , COVID-19/virologia , Tomada de Decisão Clínica , Feminino , Coração/fisiopatologia , Coração/virologia , Cardiopatias/fisiopatologia , Cardiopatias/terapia , Cardiopatias/virologia , Hospitalização , Humanos , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Prognóstico , Estudos Prospectivos
10.
Drug Des Devel Ther ; 15: 3349-3378, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34376971

RESUMO

Dalbavancin is a novel, long-acting lipoglycopeptide characterized by a long elimination half-life coupled with excellent in vitro activity against multidrug-resistant Gram-positives. Although it is currently approved only for the treatment of acute bacterial skin and skin structure infections, an ever-growing amount of evidence supports the efficacy of dalbavancin as a long-term therapy in osteomyelitis, prosthetic joint infections, endocarditis, and bloodstream infections. This article provides a critical reappraisal of real-world use of dalbavancin for off-label indications. A search strategy using specific keywords (dalbavancin, osteomyelitis, endocarditis, long-term suppressive therapy, bloodstream infection, pharmacokinetic/pharmacodynamic profile) until April 2021 was performed on the PubMed-MEDLINE database. As for other novel antibiotics, a conundrum between approved indications and potential innovative therapeutic uses has emerged for dalbavancin as well. The promising efficacy in challenging scenarios (i.e., osteomyelitis, endocarditis, prosthetic joint infections), coupled with the unique pharmacokinetic/pharmacodynamic properties, makes dalbavancin a valuable alternative to daily in-hospital intravenous or outpatient antimicrobial regimens in the treatment of long-term Gram-positive infections. This makes dalbavancin valuable in the current COVID-19 scenario, in which hospitalization and territorial medicine empowerment are unavoidable.


Assuntos
Assistência Ambulatorial , Antibacterianos/uso terapêutico , COVID-19 , Infecções por Bactérias Gram-Positivas/tratamento farmacológico , Uso Off-Label , Participação do Paciente , Teicoplanina/análogos & derivados , Algoritmos , Antibacterianos/efeitos adversos , Antibacterianos/farmacocinética , Tomada de Decisão Clínica , Técnicas de Apoio para a Decisão , Infecções por Bactérias Gram-Positivas/diagnóstico , Infecções por Bactérias Gram-Positivas/microbiologia , Humanos , Teicoplanina/efeitos adversos , Teicoplanina/farmacocinética , Teicoplanina/uso terapêutico , Resultado do Tratamento
11.
Ned Tijdschr Geneeskd ; 1652021 06 10.
Artigo em Holandês | MEDLINE | ID: mdl-34346637

RESUMO

In January 2020, the Dutch law on the medical treatment agreement was updated. In this update, shared decision-making is explicitly mentioned as a prerequisite during doctor-patient encounters. This entails explicit exploration of the patient's wishes, views and preferences and their integration in medical decision-making. There is growing interest in shared decision-making from patient advocacy and professional societies, the government, and healthcare insurers. However, both care professionals and patients are not yet used to applying this in their encounters. Creating awareness, training and organisational changes are essential aspects to foster shared decision-making. Various (umbrella) organisations in healthcare have developed (digital) tools for both care professionals and patients to support shared decision-making. This article addresses these tools to nudge all stakeholders towards shared decision-making.


Assuntos
Tomada de Decisões , Participação do Paciente , Tomada de Decisão Clínica , Tomada de Decisão Compartilhada , Humanos
12.
Ned Tijdschr Geneeskd ; 1652021 06 24.
Artigo em Holandês | MEDLINE | ID: mdl-34346660

RESUMO

Traditionally, diagnosis is the basis for clinical decision-making and regarded as the guide to prognosis and treatment. Although some patients may particularly benefit such a diagnosis-oriented approach (e.g., patients with acute pathology for which effective treatment is available), this approach is not suitable or sufficient for others (e.g., patients without a diagnosis, patients with a diagnosis for which no treatment is available, and patients for whom the current treatment is insufficient). Furthermore, other factors than diagnosis or diagnosis-guided treatment are likely to influence an individual's outcome (prognosis), including biological, clinical, and social factors. The authors propose a prognosis-oriented approach as an alternative starting point for medical decision-making: not only ask yourself 'what is the explanation for my patient's complaint?', but also 'which factors contribute to the future outcome of this complaint?' and 'can I address these to benefit my patient's outcome?'.


Assuntos
Tomada de Decisão Clínica , Tomada de Decisões , Previsões , Humanos , Prognóstico
13.
Medicine (Baltimore) ; 100(30): e26712, 2021 Jul 30.
Artigo em Inglês | MEDLINE | ID: mdl-34397703

RESUMO

ABSTRACT: In oral cancer surgery, the decision to perform a tracheotomy is often determined by the surgeon. In this study, we investigated the competency of clinical scoring systems in identifying patients who require tracheotomy and examined the degree of agreement between the surgeon's decision and the indications of various scoring systems. We identified 110 patients who were surgically treated for oral cancer. Of these, 67 patients (44 men and 23 women) who underwent resection and reconstruction were retrospectively analyzed. To derive the score, we evaluated the endpoint of the airway management score using clinical records and images. We divided the patients into two groups based on the Cameron and Gupta scores (tracheotomy and no-tracheotomy groups) and evaluated the degree of agreement with the surgeon's decision by calculating the κ coefficient. The κ coefficients of the Gupta and Cameron scores were 0.61 (95% confidence interval [CI]: 0.40-0.82) and 0.60 (95% CI: 0.38-0.82), respectively. The clinical evaluation of the κ coefficient indicated that the Cameron and Gupta scores agreed fairly with the surgeon's decision. In this study, the Cameron and Gupta scores fairly agreed with the decision of experienced surgeons and were confirmed as acceptable guides for making clinical judgments.


Assuntos
Neoplasias Bucais/cirurgia , Índice de Gravidade de Doença , Traqueotomia , Adulto , Idoso , Idoso de 80 Anos ou mais , Tomada de Decisão Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos
14.
Sci Rep ; 11(1): 15585, 2021 08 02.
Artigo em Inglês | MEDLINE | ID: mdl-34341415

RESUMO

Effective risk communication during the COVID-19 pandemic is critical for encouraging appropriate public health behaviors. One way that the public is informed about COVID-19 numbers is through reports of daily new cases. However, presenting daily cases has the potential to lead to a dynamic reasoning bias that stems from intuitive misunderstandings of accumulation. Previous work in system dynamics shows that even highly educated individuals with training in science and math misunderstand basic concepts of accumulation. In the context of COVID-19, relying on the single cue of daily new cases can lead to relaxed attitudes about the risk of COVID-19 when daily new cases begin to decline. This situation is at the very point when risk is highest because even though daily new cases have declined, the active number of cases are highest because they have been accumulating over time. In an experiment with young adults from the USA and Canada (N = 551), we confirm that individuals fail to understand accumulation regarding COVID-19, have less concern regarding COVID-19, and decrease endorsement for public health measures as new cases decline but when active cases are at the highest point. Moreover, we experimentally manipulate different dynamic data visualizations and show that presenting data highlighting active cases and minimizing new cases led to increased concern and increased endorsement for COVID-19 health measures compared to a control condition highlighting daily cases. These results hold regardless of country, political affiliation, and individual differences in decision making. This study has implications for communicating the risks of contracting COVID-19 and future public health issues.


Assuntos
COVID-19/epidemiologia , COVID-19/prevenção & controle , Tomada de Decisão Clínica , Pandemias , SARS-CoV-2 , Viés , Humanos , Percepção , Saúde Pública
15.
Prog Cardiovasc Dis ; 66: 70-79, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34332662

RESUMO

Electrical storm is present when a cluster of ventricular arrhythmias (VAs) occurs within a short time frame. The most widely accepted definition is 3 or more episodes of VA within a 24-h period, although prognostic risk begins to rise when 2 or more events occur within 3months. Electrical storm often presents as a medical emergency in the form of recurrent implantable cardiac defibrillator (ICD) shocks, recurrent syncope in patients with no ICD or low cardiac output symptoms. Management often requires a multimodality approach including ICD management, pharmacologic therapy, catheter ablation and modulations of the autonomic nervous system. In this article, we review the definition, prognosis and management of electrical storm.


Assuntos
Antiarrítmicos/uso terapêutico , Denervação Autônoma , Estimulação Cardíaca Artificial , Ablação por Cateter , Oxigenação por Membrana Extracorpórea , Taquicardia Ventricular/terapia , Fibrilação Ventricular/terapia , Potenciais de Ação/efeitos dos fármacos , Antiarrítmicos/efeitos adversos , Denervação Autônoma/efeitos adversos , Denervação Autônoma/mortalidade , Estimulação Cardíaca Artificial/efeitos adversos , Estimulação Cardíaca Artificial/mortalidade , Ablação por Cateter/efeitos adversos , Ablação por Cateter/mortalidade , Tomada de Decisão Clínica , Técnicas de Apoio para a Decisão , Oxigenação por Membrana Extracorpórea/efeitos adversos , Oxigenação por Membrana Extracorpórea/mortalidade , Sistema de Condução Cardíaco/efeitos dos fármacos , Sistema de Condução Cardíaco/fisiopatologia , Sistema de Condução Cardíaco/cirurgia , Frequência Cardíaca/efeitos dos fármacos , Humanos , Marca-Passo Artificial , Recidiva , Medição de Risco , Fatores de Risco , Taquicardia Ventricular/diagnóstico , Taquicardia Ventricular/mortalidade , Taquicardia Ventricular/fisiopatologia , Resultado do Tratamento , Fibrilação Ventricular/diagnóstico , Fibrilação Ventricular/mortalidade , Fibrilação Ventricular/fisiopatologia
16.
Prog Cardiovasc Dis ; 66: 86-91, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34332664

RESUMO

This article reviews and compares the rationale and evidence supporting high-power, short-duration radiofrequency (RF) ablation with those of conventional-power, conventional-duration RF ablation for atrial fibrillation (AF). The pros and cons of each approach, biophysics of ablation, pre-clinical studies informing clinical utilization, and the accumulated clinical evidence are presented. Both conventional-power, conventional-duration RF ablation and high-power, short-duration ablation are similarly safe, and effective approaches for AF ablation. Theoretical advantages of high-power, short-duration ablation, including greater procedure efficiency and limited conductive heating of collateral structures, must be weighed against the narrower safety margin related to rapid energy delivery during high power ablation.


Assuntos
Fibrilação Atrial/cirurgia , Ablação por Cateter , Veias Pulmonares/cirurgia , Potenciais de Ação , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/fisiopatologia , Ablação por Cateter/efeitos adversos , Ablação por Cateter/mortalidade , Tomada de Decisão Clínica , Frequência Cardíaca , Humanos , Veias Pulmonares/fisiopatologia , Recuperação de Função Fisiológica , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do Tratamento
17.
Prog Cardiovasc Dis ; 66: 92-100, 2021.
Artigo em Inglês | MEDLINE | ID: mdl-34332665

RESUMO

Stroke is a major driver of increased morbidity and mortality in patients with non-valvular atrial fibrillation (NVAF). While systemic oral anticoagulation (OAC) continues to be the mainstay for stroke reduction therapy in patients with NVAF, several barriers prevent the sustained long-term use of OAC, including increased risk of bleeding, non-compliance, cost, drug-drug interactions, and the need for ongoing laboratory testing. Given the need for continued stroke reduction therapies in patients who are intolerant of or non-compliant with OAC, percutaneous left atrial appendage (LAA) occlusion (LAAO) has emerged as a nonpharmacologic alternative to OAC. The development of percutaneous LAAO techniques is based on data suggesting that more than 90% of thrombi in patients with NVAF originate in the LAA. Two percutaneous LAAO devices are currently in widespread clinical use: Watchman (United States and Europe) and the Amplatzer type of devices (Europe); randomized trial data exist only for the Watchman device. Multiple randomized and nonrandomized trials and registries have demonstrated the safety and effectiveness of LAAO in patients who are suitable for short-term anticoagulation using a variety of post-procedural antithrombotic strategies. Ongoing randomized clinical trials on LAAO are focused on OAC-ineligible patients to compare efficacy of LAAO devices against a multitude of antithrombotic options. This review aims to discuss the rationale and evidence for LAAO and post procedural antithrombotic strategies and opportunities for research examination. In addition, we discuss the need for continued investigation of LAAO in populations not well represented in clinical trials or registries, including women, older patients, and underrepresented racial and ethnic groups.


Assuntos
Apêndice Atrial/fisiopatologia , Fibrilação Atrial/terapia , Cateterismo Cardíaco/instrumentação , Fibrinolíticos/uso terapêutico , Dispositivo para Oclusão Septal , Acidente Vascular Cerebral/prevenção & controle , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/mortalidade , Fibrilação Atrial/fisiopatologia , Cateterismo Cardíaco/efeitos adversos , Cateterismo Cardíaco/mortalidade , Tomada de Decisão Clínica , Fibrinolíticos/efeitos adversos , Humanos , Seleção de Pacientes , Desenho de Prótese , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/diagnóstico , Acidente Vascular Cerebral/mortalidade , Acidente Vascular Cerebral/fisiopatologia , Resultado do Tratamento
18.
J Med Microbiol ; 70(8)2021 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-34351258

RESUMO

Introduction. Enteric fever (caused by Salmonella enterica serovars Typhi and Paratyphi) frequently presents as an acute, undifferentiated febrile illness in returning travellers, requiring timely empirical antibiotics.Gap Statement. Determining which empirical antibiotics to prescribe for enteric fever requires up-to-date knowledge of susceptibility patterns.Aim. By characterising factors associated with antimicrobial resistance in cases of S. Typhi and S. Paratyphi imported to England, we aim to guide effective empirical treatment.Methodology. All English isolates of S. Typhi and S. Paratyphi 2014-2019 underwent antimicrobial susceptibility testing; results were compared to a previous survey in London 2005-2012. Risk factors for antimicrobial resistance were analysed with logistic regression models to predict adjusted odds ratios (aOR) for resistance to individual antibiotics and multi-drug resistance.Results. We identified 1088 cases of S. Typhi, 729 S. Paratyphi A, 93 S. Paratyphi B, and one S. Paratyphi C. In total, 93 % were imported. Overall, 90 % of S. Typhi and 97 % of S. Paratyphi A isolates were resistant to ciprofloxacin; 26 % of S. Typhi were multidrug resistant to ciprofloxacin, amoxicillin, co-trimoxazole, and chloramphenicol (MDR+FQ). Of the isolates, 4 % of S. Typhi showed an extended drug resistance (XDR) phenotype of MDR+FQ plus resistance to third-generation cephalosporins, with cases of XDR rising sharply in recent years (none before 2017, one in 2017, six in 2018, 32 in 2019). For S. Typhi isolates, resistance to ciprofloxacin was associated with travel to Pakistan (aOR=32.0, 95 % CI: 15.4-66.4), India (aOR=21.8, 95 % CI: 11.6-41.2), and Bangladesh (aOR=6.2, 95 % CI: 2.8-13.6) compared to travel elsewhere, after adjusting for rising prevalence of resistance over time. MDR+FQ resistance in S. Typhi isolates was associated with travel to Pakistan (aOR=3.5, 95 % CI: 2.4-5.2) and less likely with travel to India (aOR=0.07, 95 % CI 0.04-0.15) compared to travel elsewhere. All XDR cases were imported from Pakistan. No isolate was resistant to azithromycin. Comparison with the 2005-2012 London survey indicates substantial increases in the prevalence of resistance of S. Typhi isolates to ciprofloxacin associated with travel to Pakistan (from 79-98 %) and Africa (from 12-60 %).Conclusion. Third-generation cephalosporins and azithromycin remain appropriate choices for empirical treatment of enteric fever in most returning travellers to the UK from endemic countries, except from Pakistan, where XDR represents a significant risk.


Assuntos
Doença Relacionada a Viagens , Viagem , Febre Tifoide/epidemiologia , Adolescente , Adulto , Idoso , Antibacterianos/farmacologia , Antibacterianos/uso terapêutico , Criança , Pré-Escolar , Tomada de Decisão Clínica , Estudos Transversais , Gerenciamento Clínico , Farmacorresistência Bacteriana , Inglaterra/epidemiologia , Feminino , Pesquisas sobre Serviços de Saúde , História do Século XXI , Humanos , Lactente , Recém-Nascido , Masculino , Pessoa de Meia-Idade , Vigilância em Saúde Pública , Febre Tifoide/história , Febre Tifoide/terapia , Febre Tifoide/transmissão , Adulto Jovem
20.
Arthritis Care Res (Hoboken) ; 73(8): 1088-1105, 2021 08.
Artigo em Inglês | MEDLINE | ID: mdl-34235880

RESUMO

OBJECTIVE: To provide evidence-based recommendations and expert guidance for the management of antineutrophil cytoplasmic antibody-associated vasculitis (AAV), including granulomatosis with polyangiitis (GPA), microscopic polyangiitis (MPA), and eosinophilic granulomatosis with polyangiitis (EGPA). METHODS: Clinical questions regarding the treatment and management of AAV were developed in the population, intervention, comparator, and outcome (PICO) format (47 for GPA/MPA, 34 for EGPA). Systematic literature reviews were conducted for each PICO question. The Grading of Recommendations Assessment, Development and Evaluation methodology was used to assess the quality of evidence and formulate recommendations. Each recommendation required ≥70% consensus among the Voting Panel. RESULTS: We present 26 recommendations and 5 ungraded position statements for GPA/MPA, and 15 recommendations and 5 ungraded position statements for EGPA. This guideline provides recommendations for remission induction and maintenance therapy as well as adjunctive treatment strategies in GPA, MPA, and EGPA. These recommendations include the use of rituximab for remission induction and maintenance in severe GPA and MPA and the use of mepolizumab in nonsevere EGPA. All recommendations are conditional due in part to the lack of multiple randomized controlled trials and/or low-quality evidence supporting the recommendations. CONCLUSION: This guideline presents the first recommendations endorsed by the American College of Rheumatology and the Vasculitis Foundation for the management of AAV and provides guidance to health care professionals on how to treat these diseases.


Assuntos
Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/tratamento farmacológico , Anticorpos Anticitoplasma de Neutrófilos/sangue , Imunossupressores/uso terapêutico , Reumatologia/normas , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/diagnóstico , Vasculite Associada a Anticorpo Anticitoplasma de Neutrófilos/imunologia , Biomarcadores/sangue , Tomada de Decisão Clínica , Consenso , Técnicas de Apoio para a Decisão , Medicina Baseada em Evidências/normas , Humanos , Imunossupressores/efeitos adversos , Índice de Gravidade de Doença , Resultado do Tratamento
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