Trends in the Use of Chemotherapy before and after Radical Cystectomy in Patients with Muscle-invasive Bladder Cancer in Korea

We investigated trends in perioperative chemotherapy use, and determined factors associated with neoadjuvant chemotherapy (NAC) and adjuvant chemotherapy (AC) use in Korean patients with muscle-invasive bladder cancer (MIBC). We recruited 1,324 patients who had MIBC without nodal invasion or metastases and had undergone radical cystectomies (RC) between 2003 and 2013. The study's cut-off time for AC was three months after surgery, and the study's timespan was divided into three periods based on NAC use, namely, 2003-2005, 2006-2009, and 2010-2013. Complete remission was defined as histologically confirmed T0N0M0 after RC. NAC and AC were administered to 7.3% and 18.1% of the patients, respectively. The median time interval between completing NAC and undergoing RC was 32 days and the mean number of cycles was 3.2. The median time interval between RC and AC was 43 days and the mean number of cycles was 4.1. Gemcitabine and cisplatin were most frequently used in combination for NAC (49.0%) and AC (74.9%). NAC use increased significantly from 4.6% between 2003 and 2005 to 8.4% between 2010 and 2013 (P < 0.05), but AC use did not increase. Only 1.9% of patients received NAC and AC. Complete remission after NAC was achieved in 12 patients (12.5%). Multivariable modeling revealed that an advanced age, the earliest time period analyzed, and clinical tumor stage < or = cT2 bladder cancer were negatively associated with NAC use (P < 0.05). While NAC use has slowly increased over time, it remains an underutilized therapeutic approach in Korean clinical practice.

O agir leigo e o cuidado em saúde: a produção de mapas de cuidado / Lay agency and healthcare: producing healthcare maps / Agencia laica y producción de salud: elaboración de mapas de salud

O estudo teve como objetivo caracterizar que outras lógicas de regulação, para além da governamental, resultam na produção do cuidado, por meio de pesquisa qualitativa realizada em dois municípios do ABCD Paulista, São Paulo, Brasil, em duas etapas. Na primeira, foram realizadas entrevistas com atores estratégicos (gestores e políticos) e atores-trabalhadores-chave. Na segunda, foram coletadas histórias de vida de 18 pessoas com elevada frequência de utilização de serviços de saúde. A análise de implicação dos pesquisadores com o campo permitiu uma melhor compreensão das narrativas. Foram caracterizados quatro regimes de regulação (governamental, profissional, clientelístico e leigo), indicando que a regulação é campo em permanente disputa, é uma produção social. Com o seu agir, os usuários produzem mapas de cuidado que nos indicam como há outros arranjos possíveis de sistemas de saúde, representando um convite para experimentarmos a cogestão do cuidado entre equipes e usuários, como caminho promissor para a inadiável necessidade de reinvenção da saúde.

This study aimed to characterize which regulatory logics (other than government regulation) result in healthcare output, using a two-stage qualitative study in two municipalities in the ABCD Paulista region in São Paulo State, Brazil. The first stage included interviews with strategic actors (managers and policymakers) and key health professionals. The second phase collected life histories from 18 individuals with high health-services utilization rates. An analysis of the researchers’ involvement in the field allowed a better understanding of the narratives. Four regulatory systems were characterized (governmental, professional, clientelistic, and lay), indicating that regulation is a field in constant dispute, a social production. Users’ action produces healthcare maps that reveal the existence of other possible health system arrangements, calling on us to test shared management of healthcare between health teams and users as a promising path to the urgent need to reinvent health.

El estudio tuvo como objetivo caracterizar otras lógicas de regulación en la producción de salud, además de la gubernamental. Se trata de una investigación cualitativa en dos etapas, realizada en dos distritos del ABCD Paulista, São Paulo, Brasil. En la primera se llevaron a cabo entrevistas con actores estratégicos (políticos) y con los actores-trabajadores-clave. En la segunda se recogieron historias de vida de 18 personas con un alto nivel de uso de servicios. El análisis de la implicación en el estudio campo permitió a los investigadores una mejor comprensión de los relatos. Se encontraran cuatro sistemas regulatorios (gubernamental, profesional, clientelista y laico), lo que indica que la regulación es un terreno en disputa permanente, una producción social. Los usuarios producen mapas de cuidado que apuntan a otras posibles soluciones para los sistemas de salud, una invitación a experimentar la cogestión entre los equipos y usuarios, como una forma prometedora de la urgente necesidad de reinvención de la salud.

Uso excessivo do cateter vesical em pacientes internados em enfermarias de hospital universitário / The excessive use of urinary catheters in patients hospitalized in university hospital wards / Uso excesivo del catéter vesical en pacientes internados en enfermerías de Hospital Universitario

Este estudo de corte incluiu 254 pacientes adultos que usaram cateter vesical (CV) durante a hospitalização em enfermarias de um hospital universitário. Foram avaliados: utilização do cateter, indicação, tempo de permanência, densidade de infecção urinária, mortalidade e permanência hospitalar. Durante o período de estudo, 14 por cento dos pacientes internados usaram CV, totalizando 1.735 CV-dia. Em 23 por cento dos casos, o procedimento não foi prescrito, nem sua indicação foi documentada. O tempo médio de uso do CV foi de 6,8 dias. Entre os pacientes clínicos, a indicação do CV foi inadequada em 29 por cento; o tempo de permanência foi considerado inadequado em 49 por cento dos pacientes clínicos e em 66,9 por cento dos pacientes cirúrgicos. Pacientes com uso inadequado do CV tiveram mais infecção do trato urinário (RR 1,86 IC95 por cento 1,4 a 3,04) e maior tempo de permanência hospitalar (11,9 e 8,9 dias, p=0,002). O estudo permitiu identificar no processo assistencial falhas potencialmente modificáveis e importantes para a prevenção da infecção do trato urinário por cateter vesical.

This cohort study included 254 adult patients who used a urinary catheter (UC) during their hospitalization in a university hospital ward. The following were evaluated: catheter use, indication, time of permanence, urinary infection density, mortality, and hospital stay. Throughout the studied period, 14 percent of the hospitalized patients received UC, totaling 1735 UC-day. In 23 percent of cases, the procedure had not been prescribed, and neither was its indication documented. The average time of UC use was 6.8 days. Among clinical patients, the indication for UC was inadequate in 29 percent; time of permanence was considered inadequate in 49 percent of clinical patients and in 66.9 percent of surgical patients. Patients with inadequate UC use had more urinary tract infections (RR 1.86 IC95 percent 1.4 to 3.04) and longer hospital stay (11.9 and 8.9 days, p=0.002). This study permitted to identify flaws in the care process that are potentially changeable and important to avoid urinary tract infection by urinary catheter use.

Estudio de coorte incluyendo 254 pacientes adultos que recibieron catéter vesical (CV) durante hospitalización en enfermerías de hospital universitario. Se evaluó: utilización del catéter, indicación, tiempo de permanencia, densidad de infección urinaria, mortalidad y permanencia hospitalaria. Durante el período de estudio, 14 por ciento de los internados usaron CV, totalizando 1753 CV-día. En 23 por ciento de los casos no fue prescripto, ni documentada su indicación. El tiempo medio de uso del CV fue 6,8 días. Entre pacientes clínicos, la indicación del CV fue inadecuada en 29 por ciento; el tiempo de permanencia se consideró inadecuado en 49 por ciento de pacientes clínicos y en 66,9 por ciento de pacientes quirúrgicos. Los pacientes con uso inadecuado del CV sufrieron más infecciones del tracto urinario (RR 1,86 IC95 por ciento 1,4 a 3,044) y mayor permanencia hospitalaria (11,9 y 8,9 días, p=0,002). El estudio identificó fallas del proceso asistencial, potencialmente modificables, importantes para prevención de infección del tracto urinario por catéter vesical.

Inappropriate use of emergency services: a systematic review of prevalence and associated factors: [review] / Prevalência e fatores associados ao uso inadequado do serviço de emergência: uma revisão sistemática da literatura: [revisão]

This systematic review aimed to measure the prevalence of inappropriate emergency department (ED) use by adults and associated factors. The review included 31 articles published in the last 12 years. Prevalence of inappropriate ED use varied from 20 to 40 percent and was associated with age and income. Female patients, those without co-morbidities, without a regular physician, without a regular source of care, and those not referred to the ED by a physician also showed more inappropriate ED use, with the relative risk varying from 1.12 to 2.42. Difficulties in accessing primary health care (difficulties in setting appointments, longer waiting periods, and short business hours at the primary health care service) were also associated with inappropriate ED use. Thus, primary care requires fully qualified patient reception and efficient triage to promptly attend cases that cannot wait. It is also necessary to orient the population on situations in which they should go to the ED and on the disadvantages of consulting the ED when the case is not really urgent.

Esta revisão sistemática objetivou medir a prevalência e fatores associados ao uso inadequado do serviço de emergência, em adultos. Foram incluídos 31 artigos publicados nos últimos 12 anos. A prevalência de uso inadequado variou principalmente entre 20 e 40 por cento e foi diretamente associada à idade e nível econômico. Mulheres, pessoas sem co-morbidades, menor gasto em saúde, sem médico regular ou local regular de cuidado e que consultavam por conta própria também consultavam mais inadequadamente com risco relativo variando entre 1,12 e 2,42. Dificuldades de acesso à atenção primária à saúde, como dificuldade de agendamento, maior time de espera para consultar e o local de atenção primária ficar menos time aberto por dia, também estiveram associados com uso inadequado. Esta revisão indica que problemas no acesso à atenção primária à saúde são determinantes de uso inadequado. Assim, a atenção primária à saúde necessita realizar um acolhimento qualificado, com uma triagem eficiente de forma a atender rapidamente os casos que não podem esperar. Além disso, é preciso esclarecer a população acerca das situações em que devem procurar o serviço de emergência e sobre as desvantagens de se consultar no serviço de emergência quando o caso não é realmente urgente.

The Contributing Factors to Surplus Medicine by Long-Term Users of Medical Aid in Korea / 예방의학회지

OBJECTIVES: The amount of medical utilization by Medical Aid recipients was 3.7 times that of patients with Korean Medical Insurance. This study aims to describe the surplus medicine and the medication-related utilization, and to determine factors contributing to surplus medicine. METHODS: Among those who used copayment-free Class I Medical Aid in 2005, 146,880 subjects who were > or =19 year-old and received >365 days medical treatment per year were studied with their case managers by conducting face-to-face interviews. The analytic methods were description, chi-square, t-tests, ANCOVA and multiple logistic regressions. RESULTS: Most subjects were female (68.6%), the elderly (62.5%), and the separated (61.6%), had an elementary graduation or less (74.8%), and had disabilities (33.2%). The percentage of subjects with surplus medicine was 18.5%. However, the percentage of females, the elderly, those with non-disabilities, the separated, the uneducated, those with a very poor perceived health status and those with an economical burden for medical treatment was 19.3%, 18.9%, 19.0%, 19.3%, 19.0%, 20.2% and 24.3%, respectively. For subjects with surplus medicine, averages for the number of used pharmacies, the pharmacy-visit days and the medication costs were 4.6 drugstores, 34.9 days and approximately 1,124 thousand Won. These values were higher than those without surplus medicine (4.4 drugstores , 33.8 days, and 1,110 thousand won, respectively). The odds ratios of the contributing factors to surplus medicine were female 1.11 (95% CI=1.07-1.14), the elderly 1.06 (95% CI=1.02-1.10), those with non-disabilities 1.08 (95% CI=1.05-1.12), the separated 1.14 (95% CI=1.10-1.18), the unmarried 1.12 (95% CI=1.07-1.18), the uneducated 1.03 (95% CI=1.01-1.08), those with a very poor perceived health status 1.04 (95% CI=1.01-1.08) and experiencing an economical burden for medical treatment 2.33 (95% CI=2.26-2.40). CONCLUSIONS: 18.5% of subjects had surplus medicine with a higher mean of medication cost. Therefore, health education and health promotion programs to prevent surplus medicine and to improve the appropriate usage of medication are necessary.

Non-urgent patients in an Emergency Medical Service

BACKGROUND: Emergency Medical Services (ES) are medical-surgical facilities where extremely ill patients, victims of accidents, intoxications and other urgent clinical situations should be rapidly and efficiently attended. However, a worldwide experience is that a large proportion of patients who require attention in an ES do not qualify as emergencies and they obstruct the possibilities of other patients that should be attended immediately. AIM: To evaluate the medical records in our ES and to assess whether patients understand what is a true emergency and which is the role of an ES. METHODS: Patients attended in the ES of Haydarpasa Military Teaching Hospital in 2001-2002 were classified according to their diagnosis. A random sample of patients and relatives were surveyed about why they required medical attention in the ES. RESULTS: 77,134 patients (39,327 female, 51%) were attended. The most common illness diagnosed was upper respiratory tract infection (18,423 patients, 23.9%). The true emergency condition rate in patients presenting to our ES was lower (44%) than the non-emergency condition rate. CONCLUSIONS: Improvements in public education are needed to solve this problem. Also, Primary Care facilities should be improved in order to reduce the demand for medical attention in ES by non-urgent patients.

Antecedentes: Los Servicios de Urgencia son unidades médico-quirúrgicas donde deberían atenderse rápida y eficientemente pacientes graves, víctimas de accidentes, intoxicaciones y otras situaciones clínicas urgentes. Sin embargo, es una experiencia mundial que una proporción importante de los consultantes en Servicios de Urgencia no califican como emergencias, pero dificultan las posibilidades de atención para otros pacientes que deberían ser atendidos de inmediato. Propósito: Evaluar las fichas clínicas en nuestro Servicio de Urgencia y averiguar si los pacientes comprenden cuál es una verdadera emergencia y cuál es la función de un Servicio de Urgencia. Métodos: Los pacientes atendidos en el Servicio de Urgencia del Hospital Clínico Militar Haydarpasa (Estambul, Turquía) en 2001-2002 fueron calificados retrospectivamente según sus diagnósticos. Una muestra al azar de pacientes y sus parientes acompañantes fueron encuestados sobre sus razones para solicitar atención en el Servicio de Urgencia. Resultados: Se atendieron 77.134 pacientes (39.327 del sexo femenino, 51%). El diagnóstico más frecuente correspondió a infección del tracto respiratorio (18.423 pacientes, 23,9%). La proporción de pacientes que calificaron como reales urgencias (44%) fue menor que los calificados como no-urgentes. Conclusiones: Para disminuir la demanda de atención en Servicios de Urgencia por pacientes no-urgentes se requiere mejorar la educación del público y aumentar la disponibilidad de policlínicas de atención primaria, ampliando su horario de atención.

Prescribing rationality and availability of antimalarial drugs in Hajjah, Yemen

This study in 3 districts of Hajjah governorate, Yemen, used WHO core indicators to investigate irrational prescribing of antimalarial drugs in public and private health facilities. Laboratory diagnosis rates were low in public facilities [21.2% of encounters]. Informal prescriptions were issued in > 70% of encounters [public and private]. Important patient and drug information was missing from many prescriptions. Both public and private facilities had high rates of prescribing multiple drugs [mean 3.0 and 4.0 respectively per encounter, maximum 11], brand-name drugs [32.9% and 64.2%] and injections [17.2% and 33.5%]. The total number of antimalarial drugs registered in the country was found to be 98, with 52 different formulations and strengths of chloroquine. Efforts should be made to promote rational prescribing of antimalarials

Migración y salud: la consecuencia social y médica del exilio y la repatriación / Migration and health: social and medical consequences of exile and repatriation

Three hundred thirty eight latinamerican refugees living in Lund Sweden, 51 that lived in Lund and were repatriated to Chile and 1132 Swedish subjected were interviewed using the survey of the Swedish National Statistics Institute. Data were analyzed using an unconditional logistic regression model, controlling possible confounders. Refugees living in Lund and repatriated to Chile considered their health as bad in a higher proportion than their swedish counterparts, with an odds ratio of 3.48 (2.03-5.66) and 4.78 (2.1-10.25) respectively. Refugees and repatriated subjects had a higher risk of suffering long lasting illneses with odds ratio of 2.84 and 2.64 respectively. It is concluded that there are greater differences in life standards, housing and social relationships between Swedish people, Latinamerican refugees and repatriated individuals