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1.
Pediatr Crit Care Med ; 20(2): 172-177, 2019 02.
Artigo em Inglês | MEDLINE | ID: mdl-30395026

RESUMO

OBJECTIVES: Satellite inpatient facilities of larger children's hospitals often do not have on-site intensivist support. In-house rapid response teams and code teams may be difficult to operationalize in such facilities. We developed a system using telemedicine to provide pediatric intensivist involvement in rapid response team and code teams at the satellite facility of our children's hospital. Herein, we compare this model with our in-person model at our main campus. DESIGN: Cross-sectional. SETTING: A tertiary pediatric center and its satellite facility. PATIENTS: Patients admitted to the satellite facility. INTERVENTIONS: Implementation of a rapid response team and code team model at a satellite facility using telemedicine to provide intensivist support. MEASUREMENTS AND MAIN RESULTS: We evaluated the success of the telemedicine model through three a priori outcomes: 1) reliability: involvement of intensivist on telemedicine rapid response teams and codes, 2) efficiency: time from rapid response team and code call until intensivist response, and 3) outcomes: disposition of telemedicine rapid response team or code calls. We compared each metric from our telemedicine model with our established main campus model. MAIN RESULTS: Critical care was involved in satellite campus rapid response team activations reliably (94.6% of the time). The process was efficient (median response time 7 min; mean 8.44 min) and effective (54.5 % patients transferred to PICU, similar to the 45-55% monthly rate at main campus). For code activations, the critical care telemedicine response rate was 100% (6/6), with a fast response time (median 1.5 min). We found no additional risk to patients, with no patients transferred from the satellite campus requiring a rapid escalation of care defined as initiation of vasoactive support, greater than 60 mL/kg in fluid resuscitation, or endotracheal intubation. CONCLUSIONS: Telemedicine can provide reliable, timely, and effective critical care involvement in rapid response team and Code Teams at satellite facilities.


Assuntos
Cuidados Críticos/estatística & dados numéricos , Equipe de Respostas Rápidas de Hospitais/estatística & dados numéricos , Hospitais Satélites/estatística & dados numéricos , Telemedicina/estatística & dados numéricos , Cuidados Críticos/organização & administração , Estudos Transversais , Eficiência Organizacional , Equipe de Respostas Rápidas de Hospitais/organização & administração , Hospitais Pediátricos , Hospitais Satélites/organização & administração , Humanos , Lactente , Transferência de Pacientes/estatística & dados numéricos , Reprodutibilidade dos Testes , Telemedicina/organização & administração , Fatores de Tempo , Resultado do Tratamento
2.
J Bone Joint Surg Am ; 100(10): e70, 2018 May 16.
Artigo em Inglês | MEDLINE | ID: mdl-29762292

RESUMO

BACKGROUND: Providing high-value care for urgent orthopaedic trauma patients requires effective and timely treatment. Herein, we describe the implementation of an innovative program utilizing the operating room (OR) capacity of a satellite campus to decrease stress on a pediatric tertiary care center without jeopardizing patient safety. METHODS: In addition to the daily emergency surgical room on the main campus, a dedicated orthopaedic trauma surgery OR was established in a satellite hospital location for 3 days per week in the summer and for 2 days per week for the rest of the year. Nonemergency, non-multitrauma operative fracture cases presenting to our tertiary care facility emergency department or orthopaedic clinic were considered for satellite referral. Eligible patients required clearance for transfer via orthopaedic, emergency department, and anesthesia checklists. An opt-out policy was established for provider judgment or patient family concern to overrule transfer decisions. Selected patients were discharged home with satellite OR scheduling or approved for same-day satellite location admission. Short elective cases were performed when openings existed in the schedule. RESULTS: From June 1, 2016, through June 30, 2017, 480 cases (372 trauma, 108 elective) were completed in our satellite OR. The most common trauma cases that were treated in the satellite OR were type-II supracondylar humeral fractures (n = 76). Summer months averaged 41.75 trauma cases and 11.25 elective cases per month, with 3.15 trauma cases and 0.85 elective cases per day. Nonsummer months averaged 22.78 trauma cases and 7.00 elective cases per month, with 2.93 trauma and 0.90 elective cases per day. Of the 17 postoperative issues, the greatest number (n = 7 [41%]) involved symptomatic hardware. The remaining complications were not surgeon or geographic-site-specific. There were no intraoperative complications, compartment syndrome episodes, or patients who required transfer back to our tertiary care facility for unexpected or serious medical issues. CONCLUSIONS: With the proper screening protocols in place for appropriate patient selection, the use of a dedicated satellite orthopaedic trauma OR can increase capacity without compromising patient safety.


Assuntos
Serviço Hospitalar de Emergência , Fraturas Ósseas/cirurgia , Hospitais Satélites , Salas Cirúrgicas , Procedimentos Ortopédicos , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Fraturas Ósseas/diagnóstico , Fraturas Ósseas/epidemiologia , Hospitais Pediátricos , Humanos , Lactente , Masculino , Seleção de Pacientes , Avaliação de Programas e Projetos de Saúde , Centros de Atenção Terciária , Adulto Jovem
3.
Pediatr Emerg Care ; 34(4): 243-249, 2018 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-28169978

RESUMO

OBJECTIVE: Satellite pediatric emergency departments (PEDs) have emerged as a strategy to increase patient capacity. We sought to determine the impact on patient visits, physician fee collections, and value of emergency department (ED) time at the primary PED after opening a nearby satellite PED. We also illustrate the spatial distribution of patient demographics and overlapping catchment areas for the primary and satellite PEDs using geographical information system. METHODS: A structured, financial retrospective review was conducted. Aggregate patient demographic data and billing data were collected regarding physician fee charges, collections, and patient visits for both PEDs. All ED visits from January 2009 to December 2013 were analyzed. Geographical information system mapping using ArcGIS mapped ED patient visits. RESULTS: Patient visits at the primary PED were 53,050 in 2009 before the satellite PED opened. The primary PED visits increased after opening the satellite PED to 55,932 in 2013. The satellite PED visits increased to 21,590 in 2013. Collections per visit at the primary PED decreased from $105.13 per visit in 2011 to $86.91 per visit in 2013. Total collections at the satellite PED decreased per visit from $155.41 per visit in 2011 to $128.53 per visit in 2013. CONCLUSIONS: After opening a nearby satellite PED, patient visits at the primary PED did not substantially decrease, suggesting that there was a previously unrecognized demand for PED services. The collections per ED visit were greater at the satellite ED, likely due to a higher collection rate.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Hospitais Pediátricos/estatística & dados numéricos , Hospitais Satélites/estatística & dados numéricos , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Criança , Demografia , Serviço Hospitalar de Emergência/economia , Feminino , Hospitais Pediátricos/economia , Hospitais Satélites/economia , Humanos , Masculino , Estudos Retrospectivos
4.
Hosp Pediatr ; 7(12): 748-759, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29097448

RESUMO

BACKGROUND: Our institution recently completed an expansion of an acute care inpatient unit within a satellite hospital that does not include an on-site ICU or PICU. Because of expected increases in volume and acuity, new care models for Rapid Response Teams (RRTs) and Code Blue Teams were necessary. OBJECTIVES: Using simulation-based training, our objectives were to define the optimal roles and responsibilities for team members (including ICU physicians via telemedicine), refine the staffing of RRTs and code Teams, and identify latent safety threats (LSTs) before opening the expanded inpatient unit. METHODS: The laboratory-based intervention consisted of 8 scenarios anticipated to occur at the new campus, with each simulation followed by an iterative debriefing process and a 30-minute safety talk delivered within 4-hour interprofessional sessions. In situ sessions were delivered after construction and before patients were admitted. RESULTS: A total of 175 clinicians completed a 4-hour course in 17 sessions. Over 60 clinicians participated during 2 in situ sessions before the opening of the unit. Eleven team-level knowledge deficits, 19 LSTs, and 25 system-level issues were identified, which directly informed changes and refinements in care models at the bedside and via telemedicine consultation. CONCLUSIONS: Simulation-based training can assist in developing staffing models, refining the RRT and code processes, and identify LSTs in a new pediatric acute care unit. This training model could be used as a template for other facilities looking to expand pediatric acute care at outlying smaller, more resource-limited facilities to evaluate new teams and environments before patient exposure.


Assuntos
Equipe de Respostas Rápidas de Hospitais/organização & administração , Hospitais Satélites/organização & administração , Modelos Organizacionais , Treinamento com Simulação de Alta Fidelidade , Humanos , Estados Unidos
5.
Pediatrics ; 137(4)2016 04.
Artigo em Inglês | MEDLINE | ID: mdl-26983469

RESUMO

OBJECTIVES: In our previous work, providing medications in-hand at discharge was a key strategy to reduce asthma reutilization (readmissions and emergency revisits) among children in a large, urban county. We sought to spread this work to our satellite hospital in an adjacent county. A key initial barrier was the lack of an outpatient pharmacy on site, so we sought to determine if a partnership with community pharmacies could improve the percentage of patients with medications in-hand at discharge, thus decreasing reutilization. METHODS: A multidisciplinary team partnered with community pharmacies. Using rapid-cycle improvement methods, the team aimed to reduce asthma reutilization by providing medications in-hand at discharge. Run charts were used to display the proportion of patients with asthma discharged with medications in-hand and to track 90-day reutilization rates. RESULTS: During the intervention period, the median percentage of patients with asthma who received medications in-hand increased from 0% to 82%. A key intervention was the expansion of the medication in-hand program to all patients. Additional changes included expanding team to evening stakeholders, narrowing the number of community partners, and building electronic tools to support key processes. The mean percentage of patients with asthma discharged from the satellite who had a readmission or emergency department revisit within 90 days of their index admission decreased from 18% to 11%. CONCLUSIONS: Impacting population-level asthma outcomes requires partnerships between community resources and health providers. When hospital resources are limited, community pharmacies are a potential partner, and providing access to medications in-hand at hospital discharge can reduce asthma reutilization.


Assuntos
Asma/tratamento farmacológico , Asma/epidemiologia , Serviços Comunitários de Farmácia/tendências , Continuidade da Assistência ao Paciente/tendências , Hospitais Satélites/tendências , Readmissão do Paciente/tendências , Antiasmáticos/administração & dosagem , Asma/diagnóstico , Criança , Pré-Escolar , Feminino , Humanos , Lactente , Masculino
6.
HERD ; 8(2): 85-94, 2015.
Artigo em Inglês | MEDLINE | ID: mdl-25816384

RESUMO

OBJECTIVE: This article aims to define the major trends currently affecting space needs for academic medical center (AMC) cancer centers. It will distinguish between the trends that promote the concentration of services with those that promote decentralization as well as identify opportunities for achieving greater effectiveness in cancer care space planning. BACKGROUND: Changes in cancer care-higher survival rates, increased clinical trials, new technology, and changing practice models-increasingly fill hospitals' and clinicians' schedules and strain clinical space resources. Conflicts among these trends are concentrating some services and dispersing others. As a result, AMCs must expand and renovate intelligently to continue providing state-of-the-art, compassionate care. CONCLUSIONS: Although the typical AMC cancer center can expect to utilize more space than it would have 10 years ago, a deeper understanding of the cancer center enterprise can lead to opportunities for more effectively using available facility resources. Each AMC must determine for itself the appropriate balance of patient volume, clinical activity, and services between its main hospital campus and satellite branches. As well, space allocation should be flexible, as care trends, medical technology, and the provider's own priorities shift over time. The goal isn't necessarily more space-it's better space.


Assuntos
Centros Médicos Acadêmicos/tendências , Decoração de Interiores e Mobiliário/normas , Neoplasias/terapia , Serviço Hospitalar de Oncologia/tendências , Ambulatório Hospitalar/tendências , Cuidados Paliativos/tendências , Equipe de Assistência ao Paciente/tendências , Medicina de Precisão/tendências , Tecnologia Biomédica/tendências , Ensaios Clínicos como Assunto/métodos , Ensaios Clínicos como Assunto/estatística & dados numéricos , Hospitais Satélites/tendências , Humanos , Decoração de Interiores e Mobiliário/métodos , Determinação de Necessidades de Cuidados de Saúde , Neoplasias/epidemiologia , Equipe de Assistência ao Paciente/organização & administração , Relações Profissional-Família , Apoio Social , Sobreviventes/estatística & dados numéricos , Pesquisa Médica Translacional/tendências
7.
Nephrol Ther ; 9(3): 143-53, 2013 Jun.
Artigo em Francês | MEDLINE | ID: mdl-23410948

RESUMO

The ageing population, the need for patient care delivery closer to home and reducing travel cost and isolation and, not at least, optimising medical team activity lead to adapt treatment by hemodialysis. Telehealth is an alternative now enabled by recent regulatory changes. We summarize here the regulatory and organisational conditions in a monitored Medicalized Dialysis Unit (MDU) and report the local experience of Saint-Brieuc Hospital; the feasibility and functionality over time (5 years) of this approach was demonstrated in clinical practice with selected patients; over short-term and for a still-limited number of patients, its clinical results are comparable to those observed in a MDU running on a traditional regimen (weekly visits and on-call 24 hours on-site 24 of the nephrologist); the degree of patient satisfaction, some of them very old people, is high. Stability of communications mainly depending of the operators and audio-video quality needed for a friendly and efficient exchange, could be improved. Relevant analysis of cost is necessary to adjust compensation and to encourage the deployment of teledialysis. The development of this technique is suitable in order to maintain oldering populations close to home, to assure the fairest access to medical care and to serve its purpose, which is the care in all its dimensions.


Assuntos
Unidades Hospitalares de Hemodiálise/estatística & dados numéricos , Hospitais Satélites/estatística & dados numéricos , Diálise Renal/métodos , Telemedicina/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , França , Humanos , Masculino , Pessoa de Meia-Idade , Monitorização Ambulatorial/métodos , Satisfação do Paciente , Inquéritos e Questionários
8.
Saudi J Kidney Dis Transpl ; 24(1): 178-83, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23354221

RESUMO

Kidney biopsy is indicated to confirm the clinical diagnosis or to evaluate prognosis of a renal problem. It is a reliable and safe procedure, especially with real-time ultrasound guidance. This is a single-center, retrospective review of the biopsies performed in Hospital Tengku Ampuan Afzan, Pahang from 2000 to 2010. The demographic data, clinical parameters, and histological reports were extracted from clinic records and analyzed to determine the diagnostic adequacy of biopsy samples for both lupus and non-lupus patients. A total of 219 biopsies were performed throughout the period and only 74 were included in this review. Their mean age was 22.5 ± 10.5 years. 59.5% of the biopsies were performed on female patients. Malays comprised 79.7% (n = 59) of them, followed by Chinese (18.9%, n=14) and Indian (1.4%, n=1). About one-third of the biopsies(n = 25) were performed on patients with lupus nephritis and two-thirds (n = 49) on non-lupus nephritis patients. At the time of biopsy, their serum creatinine values were normal, serum albumin 28.4 ± 10 g/L and total cholesterol 8.9 ± 4.6 mmol/L (mean ± SD). The urine dipstick was 3+ for both proteinuria and hematuria and daily protein excretion was 3.6 ± 3.2 g. Sixty-seven specimens were considered adequate and only six (8%) were inadequate for histological interpretations. The mean number of glomeruli in the biopsy specimens was 16 ± 9.9 (range: 0-47 glomeruli). In non-lupus patients, focal segmental glomerulosclerosis was the commonest histological diagnosis (n = 15, 30.6%), followed by minimal change disease (n = 13, 26.5%) and mesangial proliferative glomerulonephritis (n = 7, 14.3%). Membranous nephropathy was diagnosed in four (8.2%) and membranoproliferative glomerulonephritis in two (4.1%) specimens. Both post-infectious glomerulonephritis and advanced glomerulosclerosis were found in one specimen each. Among the lupus nephritis patients (n = 25), 88% of them were females (P <0.05) and lupus nephritis WHO class IV was the commonest variant (n = 12, 48%) followed by WHO class III (n = 7, 28%). Membranous glomerulopathy or lupus nephritis WHO class V was found in three (12%), and two (8%) had lupus nephritis WHO class II. Serum albumin, urinalysis findings, and daily urinary protein excretion were comparable for both lupus and non-lupus patients. In conclusion, renal biopsy in our center is adequate and sufficient for histological interpretations and management of patients with renal problems.


Assuntos
Biópsia/estatística & dados numéricos , Hospitais Satélites , Nefropatias/patologia , Rim/patologia , Serviços de Saúde Suburbana , Diagnóstico Diferencial , Feminino , Humanos , Malásia , Masculino , Reprodutibilidade dos Testes , Estudos Retrospectivos , Adulto Jovem
9.
J Thorac Oncol ; 8(1): 68-72, 2013 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-23242439

RESUMO

INTRODUCTION: There is a wide variation in the lung cancer resection rate in England. We assessed the effect of the regional provision of thoracic surgery service on the variation in lung cancer resection rate. METHODS: A retrospective observational study correlating National Lung Cancer Audit data with thoracic surgery workforce data was performed to review the lung cancer resection rate in England in 2008 and 2009. RESULTS: In 2008, there was a sixfold variation in resection rate, with a higher resection rate in hospitals where surgeons were based (base hospitals) than in peripheral hospitals (20.0% versus 11.6%, p < 0.001). The resection rate was also higher in cancer networks, which were served by two or more specialist thoracic surgeons (14.6% versus 12.7%, p = 0.028), and where surgeons were present in more than two-thirds of the lung cancer multidisciplinary team meetings (14.4% versus 12.0%, p = 0.046). In 2009, the overall resection rate increased from 14.5% to 18.4%. Four units increased their number of specialist thoracic surgeons and had a significantly higher increase in resection rate than units without expansion (relative rise 66.3% versus 19.2%; p = 0.022). CONCLUSIONS: The large variation in the resection rate seems, in part, to be related to the local availability of specialist thoracic surgeons. The greatest improvement in the resection rate was in units with expansion of specialist thoracic surgeons. We suggest the expansion of specialist thoracic surgeons will improve the resection rate and thereby the overall survival of lung cancer in England. This has significant implications for the future of training in cardiothoracic surgery and organization of cancer services.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/cirurgia , Hospitais/estatística & dados numéricos , Neoplasias Pulmonares/cirurgia , Pneumonectomia/estatística & dados numéricos , Cirurgia Torácica , Inglaterra , Hospitais Satélites/estatística & dados numéricos , Humanos , Auditoria Médica , Equipe de Assistência ao Paciente/organização & administração , Estudos Retrospectivos , Estatísticas não Paramétricas , Recursos Humanos
10.
Br J Oral Maxillofac Surg ; 50(3): 215-20, 2012 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-21636187

RESUMO

Serious delay in patients presenting with head and neck cancer is associated with poor outcomes. We aimed to examine the influence of deprivation on professional delay in the Mersey region from 2004 to 2006. The study sample comprised 6681 patients who were referred between January 2004 and December 2006. The dataset was dominated by the largest hospital (H1), which received 48% of all cases. Median referral overall was 12 days (IQR 8-15 days), and 74% of patients were referred in 14 days or less. Professional delay (percentage 14 days or less) was associated with hospital (from 58% H1 to 97% H5), year of referral (from 64% in 2004 to 80% in 2006), age (from 69% under 55 years to 80% over 75 years), and deprivation (Index of Multiple Deprivation 2000 from 67% most deprived (IMD 1) to 85% least deprived (IMD 5)). Hospital location was associated with these factors and the results imply that by far, the most important variable in predicting professional delay was the hospital that received the referral. Trends over time in age, and to a lesser extent, for deprivation were noted in H1, but were largely absent across other hospitals. Some of them needed to make substantial improvements to meet the two-week referral pathway and it would be interesting to compare these results with current practice. This study highlights the importance of maintaining the standards of the current policy on two-week referrals for suspected head and neck malignancy.


Assuntos
Neoplasias de Cabeça e Pescoço/diagnóstico , Encaminhamento e Consulta/estatística & dados numéricos , Populações Vulneráveis/estatística & dados numéricos , Fatores Etários , Idoso , Auditoria Clínica , Diagnóstico Tardio/estatística & dados numéricos , Inglaterra , Feminino , Hospitais Satélites/estatística & dados numéricos , Hospitais Estaduais/estatística & dados numéricos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Tempo
11.
Ann Biol Clin (Paris) ; 69(5): 605-8, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22008143

RESUMO

Respiratory cryptosporidiosis is recognized as a late-stage complication in persons with AIDS. We report two cases of respiratory cryptosporidiosis in patients with HIV infection. The first patient was a 46-year-old person with chronic diarrhea, a two-month history of low-grade fever, progressive dyspnea and productive cough. The search for acid-fast bacillus, Pneumocystis jirovecii, Toxoplasma gondii and Cryptococcus sp. in sputum was negative on several samples. The modified Ziehl has shown oocysts of Cryptosporidium sp. in induced sputum. The patient's death occurred, due to electrolytes disorders. The second patient was a 45-year-old person hospitalized for chronic fluid diarrhea, complicated with weight loss, dry cough, dyspnea stage II and low-grade fever. The patient was HIV-positive with low CD4 count and pancytopenia. Acid-fast oocysts of Cryptosporidium sp. were observed in stool samples and induced sputum. The patient was treated daily with azithromycin 500  mg resulting of disappearance of gastrointestinal and respiratory disorders.


Assuntos
Criptosporidiose/diagnóstico , Criptosporidiose/etiologia , Infecções por HIV/complicações , Doenças Respiratórias/diagnóstico , Doenças Respiratórias/etiologia , Infecções Oportunistas Relacionadas com a AIDS/complicações , Criptosporidiose/patologia , Hospitais Satélites , Humanos , Masculino , Pessoa de Meia-Idade , Marrocos , Doenças Respiratórias/patologia
13.
PLoS One ; 6(2): e17214, 2011 Feb 18.
Artigo em Inglês | MEDLINE | ID: mdl-21364757

RESUMO

BACKGROUND: Sputum microscopy is the only tuberculosis (TB) diagnostic available at peripheral levels of care in resource limited countries. Its sensitivity is low, particularly in high HIV prevalence settings. Fluorescence microscopy (FM) can improve performance of microscopy and with the new light emitting diode (LED) technologies could be appropriate for peripheral settings. The study aimed to compare the performance of LED-FM versus Ziehl-Neelsen (ZN) microscopy and to assess feasibility of LED-FM at a low level of care in a high HIV prevalence country. METHODS: A prospective study was conducted in an urban health clinic in Nairobi, Kenya. Three sputum specimens were collected over 2 days from suspected TB patients. Each sample was processed with Auramine O and ZN methods and a 4(th) specimen was collected for TB culture reference standard. Auramine smears were read using the same microscope, equipped with the FluoLED™ fluorescence illuminator. Inter-reader agreement, reading time and technicians' acceptability assessed feasibility. RESULTS: 497 patients were included and 1394 specimens were collected. The detection yields of LED-FM and ZN microscopy were 20.3% and 20.6% (p = 0.64), respectively. Sensitivity was 73.2% for LED-FM and 72% for ZN microscopy, p = 0.32. It was 96.7% and 95.9% for specificity, p = 0.53. Inter-reader agreement was high (kappa = 0.9). Mean reading time was three times faster than ZN microscopy with very good acceptance by technicians. CONCLUSIONS: Although it did not increase sensitivity, the faster reading time combined with very good acceptance and ease of use supports the introduction of LED-FM at the peripheral laboratory level of high TB and HIV burden countries.


Assuntos
Tuberculose/diagnóstico , Adolescente , Adulto , Algoritmos , Eficiência , Estudos de Viabilidade , Feminino , Hospitais Satélites , Humanos , Quênia , Lasers Semicondutores , Luz , Masculino , Microscopia de Fluorescência/instrumentação , Microscopia de Fluorescência/métodos , Pessoa de Meia-Idade , Modelos Biológicos , Mycobacterium tuberculosis/isolamento & purificação , Sensibilidade e Especificidade , Escarro/química , Escarro/microbiologia , Tuberculose/epidemiologia , Tuberculose/microbiologia , Adulto Jovem
14.
Endocr Pract ; 17(3): 369-76, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-21134883

RESUMO

OBJECTIVE: To analyze the clinical presentation, diagnostic evaluation, treatment modalities, and follow-up of pediatric patients with Cushing disease. METHODS: In this retrospective analysis, we reviewed records of children (younger than 20 years) with Cushing disease who had undergone transsphenoidal adenomectomy in a tertiary health care center in India during the period of 1988 to 2008. Endogenous hypercortisolism was identified by a serum cortisol value ≥1.8 µg/dL during a low-dose dexamethasone suppression test (LDDST) with or without elevated midnight serum cortisol (≥3.2 µg/dL). Corticotropin dependence was defined by a basal plasma corticotropin concentration ≥5 pg/mL. Patients with normal pituitary imaging underwent bilateral inferior petrosal sinus sampling (BIPSS). Those with persistent or recurrent disease after surgery were treated with second-line interventions on a case-by-case basis. RESULTS: Twenty-nine boys and 19 girls were included. Mean age was 14.85 (±2.5) years. Weight gain (98%), round facies (98%), and growth arrest (83%) were the most common manifestations. LDDST and midnight cortisol had 100% sensitivity for detecting endogenous hypercortisolism, while midnight corticotropin measurement had 100% sensitivity for defining corticotropin dependence. Magnetic resonance imaging and unstimulated BIPSS had 71% and 89% sensitivity, respectively, for diagnosing Cushing disease. Twenty-seven patients (56%) achieved remission after the first transsphenoidal operation with higher remission rates in those with microadenoma (75%). Basal serum cortisol <5 mg/dL on the fifth postoperative day predicted cure. Eight patients received postoperative radiotherapy, with 4 achieving remission. CONCLUSIONS: Clinical presentation and diagnostic yield with various tests were similar to those previously reported in the literature. Remission rates were poor after first transsphenoidal operation in patients with macroadenoma and outcome was dismal with a second transsphenoidal operation. Serum cortisol concentration <5 mg/dL on the fifth postoperative day predicted cure.


Assuntos
Hipersecreção Hipofisária de ACTH/terapia , Adenoma/complicações , Adenoma/epidemiologia , Adenoma/cirurgia , Adolescente , Adulto , Criança , Feminino , Seguimentos , Hospitais Satélites , Humanos , Índia/epidemiologia , Masculino , Hipersecreção Hipofisária de ACTH/epidemiologia , Hipersecreção Hipofisária de ACTH/etiologia , Hipersecreção Hipofisária de ACTH/cirurgia , Neoplasias Hipofisárias/complicações , Neoplasias Hipofisárias/epidemiologia , Neoplasias Hipofisárias/cirurgia , Estudos Retrospectivos , Fatores de Tempo , Resultado do Tratamento , Adulto Jovem
15.
Am J Disaster Med ; 6(5): 275-84, 2011.
Artigo em Inglês | MEDLINE | ID: mdl-22235599

RESUMO

OBJECTIVE: To describe factors associated with inpatient mortality in a field hospital established following the 2010 Haiti earthquake. DESIGN: Data were abstracted from medical records of patients admitted to the University of Miami Global Institute/Project Medishare hospital. Decedents were compared to survivors in terms of age, sex, length of stay, admission ward, diagnosis, and where relevant, injury mechanism and surgical procedure. Three multivariate logistic regression models were constructed to determine predictors of death among all patients, injured patients, and noninjured patients. RESULTS: During the study period, 1,339 patients were admitted to the hospital with 100 inpatient deaths (7.5 percent). The highest proportion of deaths occurred among patients aged < or = 15 years. Among all patients, adult intensive care unit (ICU) admission (adjusted odds ratio [AOR] = 7.6 and 95% confidence interval [CI] = 3.4-16.8), neonatal ICU/pediatric ICU (NICU/PICU) admission (AOR = 7.8 and 95% CI = 2.7-22.9), and cardiac/respiratory diagnoses (AOR = 8.5 and 95% CI = 4.9-14.8) were significantly associated with death. Among injured patients, adult ICU admission (AOR = 7.4 and 95% CI = 1.7-33.3) and penetrating injury (AOR = 3.3 and 95% CI = 1.004-11.1) were significantly associated with death. Among noninjured patients, adult ICU admission (AOR = 6.6 and 95% CI = 2.7-16.4), NICU/PICU admission (AOR = 8.2 and 95% CI = 2.1-31.8), and cardiac/ respiratory diagnoses (AOR = 6.5 and 95% CI = 3.6-12.0) were significantly associated with death. CONCLUSIONS: Following earthquakes in resource-limited settings, survivors may require care in field hospitals for injuries or exacerbation of chronic medical conditions. Planning for sustained post-earthquake response should address these needs and include pediatric-specific preparation and long-term critical care requirements.


Assuntos
Cuidados Críticos/organização & administração , Terremotos/mortalidade , Serviço Hospitalar de Emergência/organização & administração , Mortalidade Hospitalar , Hospitais Satélites , Ferimentos e Lesões/mortalidade , Adolescente , Adulto , Idoso , Criança , Pré-Escolar , Feminino , Haiti , Humanos , Lactente , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Análise de Sobrevida , Ferimentos e Lesões/etiologia , Ferimentos e Lesões/terapia , Adulto Jovem
16.
Zhonghua Yi Shi Za Zhi ; 40(3): 165-70, 2010 May.
Artigo em Chinês | MEDLINE | ID: mdl-21029712

RESUMO

Central Medical Hospital were established in 1929. And then, based on the "Memorandum of Organization of Central Medical Hospital, Provincial and Municipal Branch", branch hospitals were set up in all provinces. Guangdong Branch and the county hospitals were established in 1931, and a variety of activities were carried out. However, because of the failure of striving for administrative power by Central Medical Hospital, the local Branch hospitals were defined as association. In addition, lack of powerful leaders and support of government led to the weakening of its function. They failed to develop traditional Chinese medicine further.


Assuntos
Hospitais de Condado/história , Hospitais Satélites/história , China , História do Século XX , Humanos
17.
Ann Thorac Surg ; 90(3): 805-12, 2010 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-20732500

RESUMO

BACKGROUND: In 2003, a satellite cardiac surgery program (SAT) was implemented at an affiliated community hospital located in an area historically served by an academic medical center (AMC). This study assessed the financial consequences and the changes in case-mix that occurred at the AMC after SAT implementation. METHODS: From June 2002 through December 2005, 4593 adult patients underwent cardiac operations at the AMC. Excluded were 400 patients operated on during the 4-month transition period after SAT implementation and 1210 patients living more than 35 miles from the AMC. Multivariable regression was used to compare changes in case-mix and propensity-score adjusted costs for AMC patients referred from SAT area (N(before/after =) 328/291) vs other patients (N(before/after =) 897/1467). RESULTS: The SAT area referral rate decreased by 55%. Compared with other patients, AMC patients referred from the SAT area showed a greater increase in age in the second period (p = 0.013). The nursing workload and adjusted mean costs increased more for patients from the SAT area (p = 0.015 and 0.014, respectively). The hospital margin decreased in the second period for both referral areas (p < 0.001). For the patient subgroup undergoing coronary artery bypass grafting, this hospital margin decrease was greater for SAT area patients (p = 0.017). CONCLUSIONS: After implementation of SAT program, fewer patients of lower complexity came to the AMC from the SAT area, and there was a significant increase in nursing workload and costs. During this interval, hospital margin for cardiac operations decreased from both referral areas but decreased significantly more for coronary artery bypass graft patients from the SAT area.


Assuntos
Centros Médicos Acadêmicos/economia , Centros Médicos Acadêmicos/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos/economia , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Hospitais Satélites/economia , Hospitais Satélites/estatística & dados numéricos , Idoso , Custos e Análise de Custo , Feminino , Humanos , Masculino
19.
Clin J Am Soc Nephrol ; 4(3): 603-8, 2009 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-19261829

RESUMO

BACKGROUND AND OBJECTIVES: In Ontario, Canada, hemodialysis services are organized in a "hub and spoke" model comprised of regional centers (hubs), satellites, and independent health facilities (IHFs; spokes). Rarely is a nephrologist on site when dialysis treatments take place at satellite units or IHFs. Situations occur that require transfer of the patient back ("fallbacks") to the regional center that necessitate either in- or outpatient care. Growth in the satellite dialysis population has led to an increased burden on the regional centers. This study was carried out to determine the incidence, nature, and outcome of such fallbacks to aid resource planning. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Data were collected on 565 patients from five regional centers over 1 yr. These regional centers controlled 19 satellite dialysis centers including 7 IHFs. RESULTS: There were 681 fallbacks in 328 patients: 1.21 incidents per patient or 2.1 incidents per patient year. Multiple fallbacks occurred in 170 patients. Fallback episodes lasted a mean of 10.3 d, requiring 4.6 dialysis treatments. Forty-five percent of fallbacks required hospitalization with a mean stay of 16.7 d. Access-related problems (33%) and nondialysis medical causes (32%) were the major causes of fallback. Resolution of the problem occurred in 87.8%, with the patient returning to the satellite. By the end of the study 77.3% were still satellite patients, 10.8% died, 3.8% returned to the regional center, 3.4% were transplanted, and 4.7% were transferred to other treatment modalities. CONCLUSIONS: Fallbacks are common, yet the model operates well.


Assuntos
Centros Comunitários de Saúde/organização & administração , Atenção à Saúde/organização & administração , Hospitais Satélites/organização & administração , Nefrologia/organização & administração , Avaliação de Processos e Resultados em Cuidados de Saúde , Transferência de Pacientes/organização & administração , Regionalização da Saúde/organização & administração , Diálise Renal , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Feminino , Hospitalização , Humanos , Transplante de Rim , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Programas Nacionais de Saúde/organização & administração , Ontário/epidemiologia , Admissão e Escalonamento de Pessoal/organização & administração , Diálise Renal/efeitos adversos , Diálise Renal/mortalidade , Medição de Risco , Fatores de Risco , Resultado do Tratamento , Adulto Jovem
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