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1.
PLoS Negl Trop Dis ; 14(3): e0008003, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-32210436

RESUMO

BACKGROUND: Lymphatic filariasis (LF) is endemic in 72 countries of Africa, Asia, Oceania, and the Americas. An estimated 25 million men live with the disabling effects of filarial hydrocele. Hydrocele can be corrected with surgery with few complications. For most men, hydrocelectomy reduces or corrects filarial hydrocele and permits them to resume regular activities of daily living and gainful employment. METHODOLOGY AND PRINCIPAL FINDINGS: This study measures the economic loss due to filarial hydrocele and the benefits of hydrocelectomy and is based on pre- and post-operative surveys of patients in southern Malawi. We find the average number of days of work lost due to filarial hydrocele and daily earnings for men in rural Malawi. We calculate average annual lost earnings and find the present discounted value for all years from the time of surgery to the end of working life. We estimate the total costs of surgery. We compare the benefit of the work capacity restored to the costs of surgery to determine the benefit-cost ratio. For men younger than 65 years old, the average annual earnings loss attributed to hydrocele is US$126. The average discounted present value of lifetime earnings loss for those men is US$1684. The average budgetary cost of the hydrocelectomy is US$68. The ratio of the benefit of surgery to its costs is US$1684/US$68 or 24.8. Sensitivity analysis demonstrates that the results are robust to variations in cost of surgery and length of working life. CONCLUSION: The lifetime benefits of hydrocelectomy-to the man, his family, and his community-far exceed the costs of repairing the hydrocele. Scaling up subsidies to hydrocelectomy campaigns should be a priority for governments and international aid organizations to prevent and alleviate disability and lost earnings that aggravate poverty among the many millions of men with filarial hydrocele.


Assuntos
Filariose Linfática/complicações , Utilização de Procedimentos e Técnicas/economia , Procedimentos Cirúrgicos Operatórios/economia , Hidrocele Testicular/cirurgia , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Humanos , Malaui , Masculino , Pessoa de Meia-Idade , Inquéritos e Questionários , Adulto Jovem
3.
Clin Ter ; 170(1): e89-e98, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-31916427

RESUMO

Introduction: Uveal melanoma is the most common intraocular tumor in the adult population. It can affect any part of the uveal tract: the iris, ciliary body, and choroid. Historically, enucleation has been the mainstay of treatment for primary melanoma. In the last decade, however, radiotherapy has acquired an increasingly important role and has now become our first-line modality. However, it is still widely debated what is the most effective radiotherapy technique for this tumor. Purpose to perform a literature review on the utility of radiotherapy for primary ocular melanoma and determine the most effective radiotherapy technique Materials and Methods: We included all systematic and narrative reviews on the topic, published between September 2007 and November 2017 on PubMed and SCOPUS. Two independent reviewers assessed the eligibility criteria for each article using the PRISMA checklist. The methodological quality of narrative and systematic reviews was evaluated with the INSA and AMSTAR checklists, respectively Results: Our study analyzed a total of 23 studies, including 18 narrative reviews and 5 systematic reviews. Radiotherapy with Brachytherapy, Proton Therapy, SRS/SRT with gamma knife and cyber knife, are the most common choices for the treatment of primary ocular melanoma. These techniques allow for excellent lesion spread control, eye, and vision conservation, and improve overall patients' quality of life. Among the narrative reviews, the highest INSA score was 5/7, the lowest 2/7, the mean was 3.83/7 and median was 4/7. Among the systematic reviews, the highest AMSTAR score was 9/12, the lowest 4/12, the mean 5.6/7 and median 4/7 Conclusion: The number of studies available on this topic is scarce. Among those published, the methodological quality is modest, as assessed with the INSA and AMSTAR checklists. As a result, we are not able to determine what the most effective radiotherapy technique is


Assuntos
Neoplasias Oculares/radioterapia , Melanoma/radioterapia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Radioterapia/métodos , Radioterapia/estatística & dados numéricos , Doenças da Úvea/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Masculino , Pessoa de Meia-Idade
4.
Br J Sports Med ; 54(5): 286-291, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-30661013

RESUMO

OBJECTIVES: We investigated the temporal trend and the geographical variation in the rate of an anterior cruciate ligament (ACL) reconstruction and meniscal repair (MR) performed in England during a 20-year window. METHODS: All hospital episodes for patients undergoing ACL reconstruction or MR between 1 April 1997 and 31 March 2017 were extracted by procedure code from the national hospital episode statistics. Age-standardised and sex-standardised rates of surgery were calculated using Office for National Statistics population data as the denominator and analysed over time both nationally and regionally by National Health Service clinical commissioning group (CCG). RESULTS: Between 1997-1998 and 2016-2017, there were 133 270 cases of ACL reconstruction (124 489 patients) and 42 651 cases of MR (41 120 patients) (isolated or simultaneous). Nationally, the rate of ACL reconstruction increased 12-fold from 2.0/100K population (95% CI 1.9 to 2.1) in 1997-1998 to 24.2/100K (95% CI 23.8 to 24.6) in 2016-2017. The rate of MR increased more than twofold from 3.0/100K (95% CI 2.8 to 3.1) in 1997-1998 to 7.3/100K (95% CI 7.1 to 7.5) in 2016-2017. Of these cases, the rate of simultaneous ACL reconstruction and MR was 2.6/100K (95% CI 2.5 to 2.8) in 2016/2017. In 2016-2017, for patients aged 20-29, the sex-standardised rate of ACL reconstruction was 76.9/100K (95% CI 74.9 to 78.9) and for MR was 19.8/100K (95% CI 18.8 to 20.9). Practice varied by region-in 2016-2017, 14.5% (30/207) of the CCGs performed more than twice the national average rate of ACL reconstruction and 15.0% (31/207) performed more than twice the national average rate of MR. CONCLUSIONS: The rate of ACL reconstruction (12-fold) and MR (2.4-fold) has increased in England over the last two decades. There is variation in these rates across geographical regions and further work is required to deliver standardised treatment guidance for appropriate use.


Assuntos
Lesões do Ligamento Cruzado Anterior/cirurgia , Reconstrução do Ligamento Cruzado Anterior/estatística & dados numéricos , Artroplastia/estatística & dados numéricos , Lesões do Menisco Tibial/cirurgia , Adulto , Inglaterra/epidemiologia , Feminino , Hospitais/estatística & dados numéricos , Humanos , Masculino , Utilização de Procedimentos e Técnicas/tendências , Adulto Jovem
5.
Urology ; 136: 63-69, 2020 02.
Artigo em Inglês | MEDLINE | ID: mdl-31618657

RESUMO

OBJECTIVE: To understand patient and practice-level factors impacting postoperative imaging use after ureteroscopy (URS) for urinary stone disease. METHODS: The Michigan Urological Surgery Improvement Collaborative's Reducing Operative Complications from Kidney Stones (MUSIC ROCKS) initiative is a consortium of 52 urologists from 11 practices in Michigan. From June 2016 to July 2017, we prospectively collected clinical data for patients undergoing URS for stone treatment by MUSIC ROCKS participants. We measured the proportion of these patients who underwent US, AXR, and/or CT within the first 60 days after their procedure. We then assessed variation in the use of post-URS imaging according to patient characteristics and across MUSIC ROCKS practices. RESULTS: During the 13-month study period, we identified 2850 patients who were treated with URS for stone disease. Overall, only 47.6% of these patients underwent postoperative imaging. AXR was the most common modality used (55.0% of patients), followed by US (21.9%) and CT (11.1%). As shown in the Figure, use of post-URS imaging varied widely across participating practices (23.7%-73.6%; P <.01). Imaging receipt did not differ by patient age, gender, or insurance status. However, patients with more comorbidities, renal stones and those with larger stones were more likely to receive post-URS imaging (P <.05 for each comparison). CONCLUSION: Fewer than half of patients in Michigan undergo postoperative imaging after URS for stone disease. Moreover, there is substantial variation across providers in post-URS imaging use. These findings help identify opportunities to improve the quality of care for patients with urinary stone disease in the State.


Assuntos
Cálculos Renais/cirurgia , Cuidados Pós-Operatórios/estatística & dados numéricos , Complicações Pós-Operatórias/diagnóstico por imagem , Complicações Pós-Operatórias/prevenção & controle , Padrões de Prática Médica/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Melhoria de Qualidade , Ureteroscopia , Urologia , Adulto , Idoso , Feminino , Humanos , Masculino , Michigan , Pessoa de Meia-Idade , Estudos Prospectivos
6.
Urology ; 137: 38-44, 2020 03.
Artigo em Inglês | MEDLINE | ID: mdl-31843621

RESUMO

OBJECTIVE: To understand how treatment of patients with urinary stones by shockwave lithotripsy (SWL) aligns with current published practice guidelines. METHODS: We used the Michigan Urologic Surgery Improvement Collaborative Reducing Operative Complications for Kidney Stones registry to understand SWL use in the state of Michigan. This prospectively maintained clinical registry includes data from community and academic urology practices and contains clinical and operative data for patients undergoing SWL and ureteroscopy (URS). We identified patients undergoing SWL from 2016 to 2019. In accordance with AUA guidelines, we evaluated practice patterns in relation to recommendations for treatment selection for SWL as well as clinical implications of guideline nonadherence. RESULTS: Four thousand, two hundred and nine SWL procedures performed across 34 practices were analyzed. Perioperative antibiotics were administered to 61.3% of patients undergoing SWL. A ureteral stent was placed at the time of SWL in 2.7% of patients. For lower pole renal stones >1 cm or large (>2 cm) renal stones in the registry, 32.2% and 58.9% of patients, respectively, underwent SWL, while the remainder were treated with URS. In these instances, SWL was associated with inferior stone-free rate (SFR) relative to URS. In patients with residual stones after SWL, 34.6% were treated with repeat SWL with lower SFR than those treated with subsequent URS. Postoperatively, 42.1% of patients were prescribed alpha-blockers with no benefit seen in terms of SFR. CONCLUSION: Substantial variation exists among urology practices with regard to SWL use. These data serve to inform quality improvement efforts regarding appropriateness criteria for SWL in Michigan.


Assuntos
Fidelidade a Diretrizes/estatística & dados numéricos , Cálculos Renais/terapia , Litotripsia/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Humanos , Michigan , Estudos Prospectivos , Sociedades Médicas , Estados Unidos , Urologia
7.
Am J Surg ; 219(1): 49-53, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31537325

RESUMO

INTRODUCTION: Trauma video review (TVR) for quality improvement and education in the United States has been described for nearly three decades. The most recent information on this practice indicated a declining prevalence. We hypothesized that TVR utilization has increased since most recent estimates. METHODS: We conducted a survey of TVR practices at level I and level II US trauma centers. We distributed an electronic survey covering past, current, and future TVR utilization to the Eastern Association for the Surgery of Trauma membership. RESULTS: 45.0% of US level I and level II trauma centers completed surveys. 71/249 centers (28.5%) had active TVR programs. The use of TVR did not differ between level I and level II centers (28.8% vs. 27.8%, p = 0.87). Respondents using TVR were overwhelmingly positive about its perception (median score 8, [IQR 6-9]; 10 = 'best') at their institutions. CONCLUSIONS: TVR use at Level I centers has increased over the past decade. Increased TVR utilization may form the basis for multicenter studies comparing processes of care during trauma resuscitation.


Assuntos
Padrões de Prática Médica , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Gravação em Vídeo/estatística & dados numéricos , Ferimentos e Lesões/cirurgia , Pesquisas sobre Serviços de Saúde , Humanos , Procedimentos Cirúrgicos Operatórios , Centros de Traumatologia , Estados Unidos
8.
Isr Med Assoc J ; 12(21): 790-795, 2019 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-31814341

RESUMO

BACKGROUND: Patients with right bundle branch block (RBBB) prior to transcatheter aortic valve implantation (TAVI) are at high risk for immediate post-procedural heart block and long-term mortality when discharged without a pacemaker. OBJECTIVES: To test whether prophylactic permanent pacemaker implantation (PPI) is beneficial. METHODS: Of 795 consecutive patients who underwent TAVI, 90 patients had baseline RBBB. We compared characteristics and outcomes of the prophylactic PPI with post-TAVI PPI. Need for pacing was defined as  greater than 1% ventricular pacing. RESULTS: Forty patients with RBBB received a prophylactic PPI (group 1), and in 50 the decision was based on standard post-procedural indications (group 2). There were no significant differences in clinical baseline characteristics. One patient developed a tamponade after a PPI post-TAVI. A trend toward shorter hospitalization duration in group 1 patients was observed (P = 0.06). On long-term follow-up of 848 ± 56 days, no differences were found in overall survival (P = 0.77), the composite event-free survival of both mortality and hospitalizations (P = 0.66), or mortality and syncope (P = 0.65). On multivariate analysis, independent predictors of the need for pacing included baseline PR interval increase of 10ms (odds ratio [OR] 1.21 per 10 ms increment 95% confidence interval [95%CI] 1.02-1.44, P = 0.028), and the use of new generation valves (OR 3.92, 95%CI 1.23-12.46, P = 0.023). CONCLUSIONS: In patients with baseline pre-TAVI RBBB, no outcome differences were found with prophylactic PPI. On multivariate analysis, predictors of the need for pacing included baseline long PR interval, and the use of newer generation valves.


Assuntos
Bloqueio de Ramo , Estimulação Cardíaca Artificial , Complicações Pós-Operatórias , Cuidados Pré-Operatórios/métodos , Substituição da Valva Aórtica Transcateter , Idoso , Idoso de 80 Anos ou mais , Estenose da Valva Aórtica/epidemiologia , Estenose da Valva Aórtica/cirurgia , Bloqueio de Ramo/diagnóstico , Bloqueio de Ramo/terapia , Estimulação Cardíaca Artificial/métodos , Estimulação Cardíaca Artificial/estatística & dados numéricos , Feminino , Humanos , Israel/epidemiologia , Tempo de Internação/estatística & dados numéricos , Masculino , Mortalidade , Marca-Passo Artificial , Complicações Pós-Operatórias/mortalidade , Complicações Pós-Operatórias/prevenção & controle , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Substituição da Valva Aórtica Transcateter/efeitos adversos , Substituição da Valva Aórtica Transcateter/métodos
9.
PLoS One ; 14(12): e0226750, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31856265

RESUMO

PURPOSE: This study examined postoperative heart failure (HF) and respiratory failure (RF) complications and related healthcare utilization for one year following cardiac surgery. METHODS: This study identified adult patients undergoing isolated coronary artery bypass graft (CABG) and/or valve procedures from the Cerner Health Facts® database. It included patients experiencing postoperative HF or RF complications. We quantified healthcare utilization using the frequency of inpatient admissions, emergency department (ED) visits with or without hospital admission, and outpatient visits. We then determined direct hospital costs from the determined healthcare utilization. We analyzed trends over time for both HF and RF and evaluated the association between surgery type and HF complication. RESULTS: Of 10,298 patients with HF complications, 1,714 patients (16.6%) developed persistent HF; of the 10,385 RF patients, 175 (1.7%) developed persistent RF. Healthcare utilization for those with persistent complications over the one-year period following index hospital discharge comprised an average number of the following visit types: Inpatient (1.49 HF; 1.55 RF), Outpatient (2.02, 0.51), ED without hospital admission (0.33, 0.13), ED + Inpatient (0.08, 0.06). Per patient annual costs related to persistent complications of HF and RF were $20,857 and $30,745, respectively. There was a significant association between cardiac surgical type and the incidence of HF, with risk for isolated valve procedures (adjusted OR 2.60; 95% CI: 2.35-2.88) and CABG + valve procedures (adjusted OR 2.38; 95% CI: 2.17-2.61) exceeding risk for isolated CABG procedures. CONCLUSIONS: This study demonstrates that HF and RF complication rates post cardiac surgery are substantial, and complication-related healthcare utilization over the first year following surgery results in significant incremental costs. Given the need for both payers and providers to focus on healthcare cost reduction, this study fills an important gap in quantifying the mid-term economic impact of postoperative cardiac surgical complications.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Custos e Análise de Custo , Insuficiência Cardíaca/epidemiologia , Complicações Pós-Operatórias/epidemiologia , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Insuficiência Respiratória/epidemiologia , Adolescente , Adulto , Idoso , Procedimentos Cirúrgicos Cardíacos/economia , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Feminino , Insuficiência Cardíaca/economia , Humanos , Masculino , Pessoa de Meia-Idade , Complicações Pós-Operatórias/economia , Utilização de Procedimentos e Técnicas/economia , Insuficiência Respiratória/economia , Estados Unidos
10.
West J Emerg Med ; 20(6): 918-925, 2019 Oct 14.
Artigo em Inglês | MEDLINE | ID: mdl-31738719

RESUMO

INTRODUCTION: Emergency medicine residency programs have rigorous point-of-care ultrasound (POCUS) curricula. However, this training does not always readily translate to routine use in clinical decision-making. This study sought to identify and overcome barriers that could prevent resident physicians from performing POCUS during clinical shifts. METHODS: This was a two-step process improvement study. First, a survey was deployed to all residents of a three-year academic residency program to identify barriers to clinical use of POCUS. This survey identified the perceived lack of a uniform documenting protocol as the most important barrier to performing POCUS on shift. Second, as an intervention to overcome this barrier, a streamlined documentation protocol was developed and presented to residents. The primary outcome was the number of patients who had POCUS used in medical decision-making one year before and after intervention. Secondary outcomes were the level of training of residents performing exams and whether faculty overseeing exams were trained through an ultrasound fellowship program. RESULTS: POCUS use by residents increased from 82 to 223 patients before and after the intervention, respectively. Per resident, this translates to an absolute increase from 2.2 (95% confidence intervall [CI], 1.4, 3) to 5.8 (95% CI, 4, 7.6) or 3.6 (95% CI, 1.8, 5.4) exams/resident over the study period. We observed no significant difference in the proportions of scans attributable to the resident level of training (χ2 = 0.5, p = 0.47). The proportion of exams by non-ultrasound fellowship trained faculty increased significantly more compared to fellowship trained faculty (χ2 = 19, p<0.0001); however, both ultrasound fellowship trained and non-ultrasound fellowship trained faculty increased the absolute number of exams performed. CONCLUSION: A key perceived barrier to resident-performed POCUS is unfamiliarity with documenting ultrasounds for medical decision-making. Educating residents in person about a POCUS documentation protocol may help overcome this barrier. Incorporating resident input and motivation into POCUS incentivization may increase utilization. Future studies in optimizing POCUS on shift will need to focus on streamlining documentation, addressing time constraints, and faculty support for resident-performed POCUS.


Assuntos
Tomada de Decisão Clínica/métodos , Medicina de Emergência/educação , Internato e Residência , Sistemas Automatizados de Assistência Junto ao Leito , Padrões de Prática Médica/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Atitude do Pessoal de Saúde , Currículo , Serviço Hospitalar de Emergência/estatística & dados numéricos , Pesquisas sobre Serviços de Saúde , Humanos , Registros Médicos , Ultrassonografia/métodos , Estados Unidos
11.
Tidsskr Nor Laegeforen ; 139(14)2019 10 08.
Artigo em Norueguês | MEDLINE | ID: mdl-31592615

RESUMO

BACKGROUND: Acute dizziness may have a number of causes, including cerebrovascular stroke which can present as isolated acute vestibular syndrome. It is recommended that acute episodic dizziness be assessed using positioning tests, and acute persistent dizziness with a focus on the HINTS (Head Impulse, Nystagmus, Test of Skew) battery of tests, which can distinguish cerebrovascular stroke from vestibular neuritis. We wished to identify the prevalence, diagnostic spectrum and approach to acute dizziness in a neurological department. MATERIAL AND METHOD: We undertook a retrospective review of the medical records of all patients with acute dizziness as the primary symptom who where admitted to the department of neurology at Sørlandet Hospital, Kristiansand in 2015. RESULTS: Of 2 231 patients admitted to the department of neurology in 2015, altogether 243 (11 %) had dizziness as the primary symptom. A total of 106 patients (44 %) were examined using HINTS in its entirety. A cranial CT was performed in 213 (88 %) and MRI in 91 (37 %), and these showed relevant pathology in 1 and 4 patients, respectively. Upon discharge, 122 patients (50 %) were given a non-specific symptom diagnosis, 59 (24 %) received the diagnosis vestibular neuritis, 41 (17 %) benign paroxysmal positional vertigo, and 5 (2 %) were diagnosed with cerebrovascular stroke. Four out of five cases of cerebrovascular stroke could be classified retrospectively as acute vestibular syndrome, whereof three had typical findings determined by the HINTS test. INTERPRETATION: Acute dizziness is a frequent symptom in patients admitted to the department of neurology. Evidence-based diagnostic recommendations for the assessment of acute dizziness were not satisfactorily implemented in practice.


Assuntos
Tontura , Departamentos Hospitalares , Neurologia , Doença Aguda , Vertigem Posicional Paroxística Benigna/complicações , Vertigem Posicional Paroxística Benigna/diagnóstico , Tontura/diagnóstico , Tontura/etiologia , Medicina Baseada em Evidências , Medições dos Movimentos Oculares , Teste do Impulso da Cabeça , Humanos , Registros Médicos , Noruega , Nistagmo Patológico/diagnóstico , Admissão do Paciente , Posicionamento do Paciente , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Acidente Vascular Cerebral/complicações , Acidente Vascular Cerebral/diagnóstico , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Neuronite Vestibular/complicações , Neuronite Vestibular/diagnóstico
12.
J Low Genit Tract Dis ; 23(4): 253-258, 2019 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-31592972

RESUMO

OBJECTIVE: Cervical cancer screening is often conducted in excess of current screening guidelines. The objective of this study was to evaluate the effect of an electronic health record (EHR) clinical decision support alert to decrease guideline-nonadherent cervical cancer screening beyond the age limits of screening or posthysterectomy. MATERIALS AND METHODS: The proportion of guideline-nonadherent Pap tests in women younger than 21 years or older than 65 years or posthysterectomy were compared 4 months before and 3 months after implementation of an EHR clinical decision support alert warning providers that a Pap test is not indicated. Providers could cancel the Pap test or override the alert and place the order. Provider characteristics and Pap test indications were summarized by preintervention/postintervention period using descriptive statistics. The proportions of nonindicated Pap tests were compared by intervention period and provider characteristics using generalized estimating equation models. RESULTS: In women beyond the screening age limits or posthysterectomy, a total of 388 Pap tests were ordered before intervention, and 313 tests were ordered after intervention. Proportion of guideline-nonadherent tests was similar before (62%) and after intervention (63%); thus, implementation of the clinical decision support alert did not change the proportion of guideline-nonadherent Pap tests ordered (OR = 1.08, 95% CI = 0.77-1.52). It is notable that 52% of guideline-nonadherent tests were ordered by 11 providers. Even when controlling for providers who ordered more than 1 test during the study period, multivariate analysis showed that male providers were more likely to order guideline-nonadherent Pap tests (OR = 2.30, 95% CI = 1.36-3.89); no other differences by provider characteristics were observed. CONCLUSIONS: An EHR clinical decision support alert does not decrease guideline-nonadherent cervical cancer screening. These data suggest efforts to optimize clinical decision support should be focused on other aspects of cervical cancer prevention.


Assuntos
Técnicas de Apoio para a Decisão , Detecção Precoce de Câncer/métodos , Registros Eletrônicos de Saúde , Utilização de Procedimentos e Técnicas , Neoplasias do Colo do Útero/diagnóstico , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Humanos , Estudos Retrospectivos , Adulto Jovem
13.
Am J Surg ; 218(4): 712-715, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31542150

RESUMO

BACKGROUND: For female breast cancer (BC) patients undergoing mastectomy, post-mastectomy breast reconstruction (PMBR) confers significant psychosocial benefits and improved cosmetic outcomes. The objective of this study is to explore whether the utilization of PMBR varies by race, marital status, and geographical location of the patient. METHODS: Women ≥18 years old who underwent mastectomy for breast cancer diagnosed between 2000 and 2014 were eligible. Women with inflammatory BC, Stage IV BC diagnoses, and bilateral BC were excluded. Multivariable logistic regression, adjusting for patient and cancer characteristics, were used to assess the association between of race, marital status, and region on immediate PMBR utilization. RESULTS: 321,206 women were included and 24% underwent immediate PMBR (<4 months after mastectomy). Compared to white women, black and other non-white women (OR 0.67, 95% CI 0.65, 0.70 and OR 0.52, 95% CI 0.50, 0.53, respectively) were significantly less likely to receive PMBR. Additionally, women who were single (OR 0.72, 95% CI 0.70, 0.75) or no longer married (OR 0.84, 95% CI 0.82, 0.86) were significantly less likely to undergo breast reconstruction, compared to married women. Regional differences were also seen, with women in the Northeast (OR 2.11, 95% CI 2.05,2.17), Midwest (OR 1.53, 95% CI 1.48, 1.58) and South (OR 1.20, 95%CI 1.17, 1.23) all being more likely to undergo breast reconstruction compared to the West. DISCUSSION: Significant variations exist in the utilization of post-mastectomy breast reconstruction across race, marital status or geographical location of the patient. Further research is needed to elucidate these differences and identify areas for intervention to increase awareness, and access to reconstruction for all breast cancer patients.


Assuntos
Afro-Americanos/estatística & dados numéricos , Neoplasias da Mama/cirurgia , Grupo com Ancestrais do Continente Europeu/estatística & dados numéricos , Mamoplastia/estatística & dados numéricos , Mastectomia , Aceitação pelo Paciente de Cuidados de Saúde/etnologia , Adulto , Fatores Etários , Idoso , Neoplasias da Mama/etnologia , Feminino , Humanos , Estado Civil , Pessoa de Meia-Idade , Utilização de Procedimentos e Técnicas , Estados Unidos
14.
Med Sci Monit ; 25: 6943-6949, 2019 Sep 15.
Artigo em Inglês | MEDLINE | ID: mdl-31522188

RESUMO

BACKGROUND This study aimed to assess the utility and characteristics of preoperative ultrasonography (US) in patients transferred to referral hospitals from local clinics with a diagnosis of malignancy on US-guided fine-needle aspiration cytology of thyroid nodules. MATERIAL AND METHODS From January 2018 to June 2018, 109 transferred patients underwent preoperative US in our hospital for suspected thyroid malignancy on cytological analysis after US-guided fine-needle aspiration of thyroid nodules in local clinics. Preoperative US was performed by a single radiologist in all patients. Among them, 6 were excluded from the study because of refusal of thyroid surgery. Preoperative US and histopathological results were compared in all patients. RESULTS After thyroid surgery, pathological examination revealed papillary thyroid carcinoma (PTC) (n=98), follicular adenoma (n=1), and nodular hyperplasia (n=4). Of the 103 patients, 91 exhibited suspicious US findings on the preoperative US, whereas 12 did not. In the 91 patients with suspicious US findings, PTC (n=90) and follicular adenoma (n=1) were confirmed after thyroid surgery. In the 12 patients with no suspicious US findings, PTC (n=8) and nodular hyperplasia (n=4) were confirmed after thyroid surgery. On repeat analysis of the cytological slides of the 4 nodular hyperplasia cases from the local clinics, Bethesda category II (n=1) and III (n=3) were determined. CONCLUSIONS In the transferred patients with a malignant cytology, preoperative US might be helpful to detect false-positive cytology cases.


Assuntos
Cuidados Pré-Operatórios , Utilização de Procedimentos e Técnicas , Glândula Tireoide/diagnóstico por imagem , Glândula Tireoide/patologia , Nódulo da Glândula Tireoide/diagnóstico por imagem , Nódulo da Glândula Tireoide/patologia , Ultrassonografia , Adolescente , Adulto , Idoso , Biópsia por Agulha Fina , Carcinoma Papilar/diagnóstico por imagem , Carcinoma Papilar/patologia , Carcinoma Papilar/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Transferência de Pacientes , Estudos Retrospectivos , Glândula Tireoide/cirurgia , Neoplasias da Glândula Tireoide/diagnóstico por imagem , Neoplasias da Glândula Tireoide/patologia , Neoplasias da Glândula Tireoide/cirurgia , Nódulo da Glândula Tireoide/cirurgia , Adulto Jovem
15.
Tidsskr Nor Laegeforen ; 139(12)2019 Sep 10.
Artigo em Norueguês, Inglês | MEDLINE | ID: mdl-31502800

RESUMO

BACKGROUND: In July 2013, the Department of Paediatric and Adolescent Medicine at Østfold Hospital Trust introduced nitrous oxide as an option for procedural sedation of children and adolescents. MATERIAL AND METHOD: During the period 13 July 2013-25 August 2017, 311 procedures were performed with nitrous oxide in 238 patients aged 4-17 years. Age, sex, type and duration of procedure, any supplementary medications, complications and whether the procedure would previously have required general anaesthesia, were recorded in a form. The child rated the effectiveness of nitrous oxide using a graded age-appropriate 10-point pain scale, and the nurse rated it as good, moderate or none. RESULTS: The children reported a median pain score of 2/10 (interquartile range 0-4), and nurses rated effectiveness as good in 247 of 304 (81 %) cases. For 43 % of procedures, the nurse felt that general anaesthesia would have been necessary had the department not had access to nitrous oxide. Adverse effects, most often dizziness, were reported in 110 of 311 procedures (35 %). In 7 of 311 procedures (2 %), the patient experienced adverse effects that resulted in stoppage of the procedure. The procedure was completed in 286 (92 %) children. INTERPRETATION: Nitrous oxide is a useful option for children who require procedural sedation, and means that more procedures can be performed without general anaesthesia.


Assuntos
Anestésicos Inalatórios , Óxido Nitroso , Utilização de Procedimentos e Técnicas , Adolescente , Analgésicos/administração & dosagem , Analgésicos/efeitos adversos , Analgésicos/farmacologia , Anestesia Geral/estatística & dados numéricos , Anestesia Local , Anestésicos Inalatórios/administração & dosagem , Anestésicos Inalatórios/efeitos adversos , Anestésicos Inalatórios/farmacologia , Criança , Pré-Escolar , Contraindicações de Medicamentos , Feminino , Humanos , Masculino , Óxido Nitroso/administração & dosagem , Óxido Nitroso/efeitos adversos , Óxido Nitroso/farmacologia , Noruega , Enfermeiras e Enfermeiros , Medição da Dor , Utilização de Procedimentos e Técnicas/normas , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Resultado do Tratamento
16.
J Shoulder Elbow Surg ; 28(11): 2072-2078, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31420225

RESUMO

BACKGROUND: There is no consensus as to the treatment of proximal humeral fractures (PHFs), particularly in elderly patients. There is increasing evidence that nonoperative management may have similar functional outcomes to operative management, which is potentially conflicting with increasingly improved surgical techniques and implants. The aim of this study was to investigate the changes in the incidence and management of PHFs across Australia over a 10-year period. MATERIALS AND METHODS: We retrospectively reviewed all hospitalizations of patients with PHFs from 2 Australian national health care databases from 2008 to 2017. We recorded the incidence of PHFs and annual utilization rates of commonly used treatment options including nonoperative management, hemiarthroplasty (HA), reverse total shoulder arthroplasty (RTSA), and open reduction-internal fixation (ORIF). RESULTS: The incidence of PHFs increased from 26.8 per 100,000 person-years in 2008 to 45.7 per 100,000 person-years in 2017. There was a decrease in operative management from 2008 to 2017, with 32.5% and 22.8% of all PHFs treated operatively in 2008 and 2017, respectively (P = .001). ORIF use decreased significantly from 76.6% to 72.6% (P = .004). RTSA use increased significantly from 4.1% to 24.5% (P < .001). HA use decreased significantly from 19.3% to 3% (P < .001). CONCLUSIONS: Whereas the incidence of PHFs increased, the operative management of PHFs decreased significantly from 2008 to 2017, particularly in patients aged 65 years or older. This decrease in operative management was in part due to a significant decrease in ORIF and HA use in patients aged 65 years or older. There was a significant increase in RTSA use.


Assuntos
Artroplastia do Ombro/estatística & dados numéricos , Fixação Interna de Fraturas/estatística & dados numéricos , Hemiartroplastia/estatística & dados numéricos , Redução Aberta/estatística & dados numéricos , Fraturas do Ombro/cirurgia , Idoso , Idoso de 80 Anos ou mais , Austrália , Bases de Dados Factuais , Feminino , Hospitalização , Humanos , Incidência , Masculino , Pessoa de Meia-Idade , Utilização de Procedimentos e Técnicas , Estudos Retrospectivos , Fraturas do Ombro/epidemiologia
17.
Pediatr Blood Cancer ; 66(11): e27954, 2019 11.
Artigo em Inglês | MEDLINE | ID: mdl-31397075

RESUMO

INTRODUCTION: Sickle cell disease (SCD) is among the most common inherited hematologic diseases in sub-Saharan Africa (SSA). Historically, hydroxyurea administration in SSA has been restricted due to limited region-specific evidence for safety and efficacy. METHODS: We conducted a prospective observational cohort study of pediatric patients with SCD in Malawi. From January 2015 to November 2017, hydroxyurea at doses of 10-20 mg/kg/day was administered to children with clinically severe disease (targeted use policy). From December 2017 to July 2018, hydroxyurea was prescribed to all patients (universal use policy). RESULTS: Of 187 patients with SCD, seven (3.7%) died and 23 (12.3%) were lost to follow-up. The majority (135, 72.2%) were prescribed hydroxyurea, 59 (43.7%) under the targeted use policy and 76 (56.3%) under the universal use policy. There were no documented severe toxicities. Under the targeted use policy, children with SCD demonstrated absolute decreases in the rates of hospitalization (-4.1 per 1000 person-days; -7.2, -1.0; P = .004), fevers (-4.2 per 1000 person-days; -7.2, -1.1; P = .002), transfusions (-2.3 per 1000 person-days; 95% confidence interval: -4.9, 0.3; P = .06), and annual school absenteeism (-51.2 per person-year; -60.1, -42.3; P < .0001) within 6 months of hydroxyurea commencement. CONCLUSION: We successfully implemented universal administration of hydroxyurea to children with SCD at a tertiary hospital in Malawi. Similar to recently reported trials, hydroxyurea was safe and effective during routine programmatic experience, with clinical benefits particularly among high-risk children. This highlights the importance of continued widespread scale-up of hydroxyurea within SCD programs across SSA.


Assuntos
Anemia Falciforme/tratamento farmacológico , Países em Desenvolvimento , Hidroxiureia/uso terapêutico , Absenteísmo , Adolescente , Anemia Falciforme/epidemiologia , Transfusão de Sangue/estatística & dados numéricos , Criança , Pré-Escolar , Terapia Combinada , Feminino , Febre/epidemiologia , Febre/etiologia , Hemoglobinas/análise , Hospitalização/estatística & dados numéricos , Hospitais Públicos/estatística & dados numéricos , Humanos , Hidroxiureia/efeitos adversos , Hidroxiureia/provisão & distribução , Lactente , Cooperação Internacional , Malaui/epidemiologia , Masculino , North Carolina , Pacientes Desistentes do Tratamento , Utilização de Procedimentos e Técnicas , Estudos Prospectivos , Centros de Atenção Terciária/estatística & dados numéricos
18.
Urology ; 133: 50-56, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31404583

RESUMO

OBJECTIVE: To describe trends in computed tomography (CT) use and estimate the radiation exposure among stone formers using a national insurance claims database. METHODS: Within MarketScan, adult stone patients from 2007 to 2013 were identified using International Classification of Diseases-Revision 9, International Classification of Diseases-Revision 10, and Current Procedural Terminology codes. Patients were classified as "active" (≥2 diagnosis codes for nephrolithiasis, or receipt of stone surgery) or "inactive" (1 stone diagnosis) and compared to age- and gender-matched controls. CT utilization was tracked over 3 years for each group. Annual CT-related radiation exposure was estimated using previously published dose values and compared using Kruskal-Wallis and χ2 tests. Demographic factors associated with greater CT exposure were identified on multivariate logistic regression. RESULTS: Of active stone patients, 112,140 underwent surgery and 215,376 were managed nonoperatively. There were 175,228 inactive stone patients and 502,744 controls. On average, active stone patients received nearly 10 times as many CTs as controls at 3 years (P <.001), and more acute imaging (P <.001). About 25% and 15% of operative and nonoperative patients, respectively, received ≥3 CTs in 3 years. This was associated with female gender. For nonoperative patients, this was also associated with age, residence in the North-Central or South regions, and inversely associated with metropolitan residence (all P <.01). Over 10% of active stone patients are estimated to receive >20 mSv in the first year alone. CONCLUSION: CT use and nonsurgical radiation exposure for active stone patients is significant. Over 10% are estimated to exceed occupational limits in the first year. Judicious CT imaging and low-dose protocols are critical for stone patients.


Assuntos
Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/tendências , Exposição à Radiação/estatística & dados numéricos , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Cálculos Urinários/diagnóstico por imagem , Adolescente , Adulto , Idoso , Estudos de Coortes , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Adulto Jovem
19.
BMC Med Inform Decis Mak ; 19(1): 155, 2019 08 05.
Artigo em Inglês | MEDLINE | ID: mdl-31382971

RESUMO

BACKGROUND: The potential for smartphones to revolutionize the way that medical doctors practice has become a reality, particularly in specialities where visual examination is a principal step in assessing a medical case, like dermatology. Smartphones as devices hold similar capabilities to personal computers and laptops and could play an important role in supporting medical practitioners in clinical practice at the point of care and beyond. This study aimed to assess the role of smartphone technology use in dermatology practice in Kuwait, together with the potential of digital photography and users' concerns. METHODS: This cross-sectional survey involved a population of dermatology practitioners of all levels working in 11 dermatology centers distributed across six health regions in Kuwait. A validated self-reported questionnaire was used to collect data from the participants about their smartphone use. Quantitative analytical methods were undertaken to analyse the questionnaire responses. RESULTS: A total of 210 dermatologists were approached in their workplaces. Of these, 101 (48%) responded to the survey questionnaire, with a mean age of 39.1 years (±10.7 SD) and equal representation from both genders. All the respondents were using smartphone technology, wherein 94.1% used it to access medical information through various Internet search engines. The most prevalent applications used were medical and drug reference applications (69.3 and 66.3%, respectively). In all, 65% of the dermatologists were using smartphones to take clinical photographs of patients for special purposes, and this type of usage was significantly higher (p < 0.05) among females and those older than 40. CONCLUSION: This study concludes that smartphone technology has an impactful role in dermatology practice, and many of its functions can be employed to achieve better practice and better patient care. Recommendations are suggested for clinicians using smartphones in dermatology practice.


Assuntos
Dermatologia/métodos , Smartphone/estatística & dados numéricos , Adulto , Estudos Transversais , Feminino , Governo , Humanos , Kuweit , Masculino , Pessoa de Meia-Idade , Fotografação , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Autorrelato
20.
Urology ; 133: 103-108, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31377258

RESUMO

OBJECTIVE: To characterize shock wave lithotripsy (SWL) utilization and assess for regional variation in the use of this procedure across the United States. MATERIALS AND METHODS: We examined SWL and URS utilization among Medicare Beneficiaries with a diagnosis of nephrolithiasis for the years 2006, 2009, and 2014. Adjusted utilization rates were calculated per 1000 beneficiaries accounting for age, sex, and race. Utilization rates were examined nationally and by hospital referral region (HRR). RESULTS: A total of 511,495, 604,493, and 806,652 Medicare beneficiaries had a diagnosis of nephrolithiasis in 2006, 2009, and 2014, respectively. The adjusted rate of SWL per 1000 beneficiaries with nephrolithiasis decreased from 59.4/1000 in 2006 to 52.2/1000 and 45.5/1000 in 2009 and 2014 (13.9% decrease, P < .001). Variation was observed in SWL utilization; up to a 12-fold difference between HRRs (9.2/1000 in Winchester, VA to 105.8/1000 in Lincoln, NE). The adjusted rate of URS per 1000 beneficiaries increased by 10.2% (P < .001) between 2006 and 2014. However, the percent decrease in SWL utilization did not correlate with the percent increase in URS utilization when examined by HRR (P = .66). CONCLUSION: Variation exists in the utilization of SWL among Medicare beneficiaries (12-fold difference). This variation is likely secondary to a series of supply, urologist, and patient-specific factors. SWL utilization decreased between 2006 and 2014, while URS increased. Stone procedure type is likely highly dependent on where patients receive their urologic care.


Assuntos
Cálculos Renais/terapia , Litotripsia/estatística & dados numéricos , Padrões de Prática Médica/estatística & dados numéricos , Utilização de Procedimentos e Técnicas/estatística & dados numéricos , Idoso , Feminino , Humanos , Masculino , Medicare , Estados Unidos
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