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1.
Clin Case Rep ; 12(4): e8724, 2024 Apr.
Artigo em Inglês | MEDLINE | ID: mdl-38560283

RESUMO

Key Clinical Message: Percutaneous aspiration for debulking of vegetations in right-sided infective endocarditis has been well-described, however, this technique can be employed successfully for left-sided vegetations in select high-risk patients. Abstract: We report a case of percutaneous aspiration of an aortic valve vegetation in a patient with prosthetic valve endocarditis. This novel approach was selected after patient declined surgical intervention for an enlarging vegetation despite antibiotic therapy. The procedure was successful, resulting in the complete removal of solid vegetation without complications.

2.
Interact Cardiovasc Thorac Surg ; 34(4): 548-555, 2022 03 31.
Artigo em Inglês | MEDLINE | ID: mdl-34871377

RESUMO

OBJECTIVES: Most strokes associated with atrial fibrillation (AF) result from left atrial appendage thrombi. Oral anticoagulation can reduce stroke risk but is limited by complication risk and non-compliance. Left atrial appendage exclusion (LAAE) is a new surgical option to reduce stroke risk in AF. The study objective was to evaluate the safety and feasibility of standalone thoracoscopic LAAE in high stroke risk AF patients. METHODS: This was a retrospective, multicentre study of high stroke risk AF patients who had oral anticoagulation contraindications and were not candidates for ablation nor other cardiac surgery. Standalone thoracoscopic LAAE was performed using 3 unilateral ports access and epicardial clip. Periprocedural adverse events, long-term observational clinical outcomes and stroke rate were evaluated. RESULTS: Procedural success was 99.4% (174/175 patients). Pleural effusion occurred in 4 (2.3%) patients; other periprocedural complications were <1% each. One perioperative haemorrhagic stroke occurred (0.6%). No phrenic nerve palsy or cardiac tamponade occurred. Predicted annual ischaemic stroke rate of 4.8/100 patient-years (based on median CHA2DS2-VASc score of 4.0) was significantly higher than stroke risk observed in follow-up after LAAE. No ischaemic strokes occurred (median follow-up: 12.5 months), resulting in observed rate of 0 (95% CI 0-2.0)/100 patient-years (P < 0.001 versus predicted). Six all-cause (non-device-related) deaths occurred during follow-up. CONCLUSIONS: Study proved that a new surgical option, standalone thoracoscopic LAAE, is feasible and safe. With this method, long-term stroke rate may be reduced compared to predicted for high-risk AF population.


Assuntos
Apêndice Atrial , Fibrilação Atrial , Isquemia Encefálica , Acidente Vascular Cerebral , Tromboembolia , Anticoagulantes/efeitos adversos , Apêndice Atrial/cirurgia , Fibrilação Atrial/complicações , Fibrilação Atrial/diagnóstico , Fibrilação Atrial/cirurgia , Humanos , Estudos Retrospectivos , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/etiologia , Acidente Vascular Cerebral/prevenção & controle , Tromboembolia/etiologia , Resultado do Tratamento
4.
Clin Infect Dis ; 71(2): 415-418, 2020 07 11.
Artigo em Inglês | MEDLINE | ID: mdl-31676905

RESUMO

Delamanid should be effective against highly resistant strains of Mycobacteriumtuberculosis, but uptake has been slow globally. In the endTB (expand new drug markets for TB) Observational Study, which enrolled a large, heterogeneous cohorts of patients receiving delamanid as part of a multidrug regimen, 80% of participants experienced sputum culture conversion within 6 months. Clinical Trials Registration. NCT02754765.


Assuntos
Mycobacterium tuberculosis , Nitroimidazóis , Tuberculose Resistente a Múltiplos Medicamentos , Antituberculosos/uso terapêutico , Humanos , Nitroimidazóis/uso terapêutico , Oxazóis/uso terapêutico , Resultado do Tratamento , Tuberculose Resistente a Múltiplos Medicamentos/tratamento farmacológico
5.
Ther Adv Gastrointest Endosc ; 12: 2631774519843401, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31192315

RESUMO

BACKGROUND AND AIM: The BreathID ® Hp urea breath test provides several advantages over other 13C breath analyzers for the detection of Helicobacter pylori. We evaluated the sensitivity and specificity of a new BreathID ® Hp Lab System (Exalenz Bioscience Ltd, Israel), a 13C-urea breath test system using breath sampling bags that facilitates multiple testing in a multicenter international clinical study. METHODS: A total of 257 subjects with evaluable results for urea breath test, rapid urease test, and histology were enrolled into two study groups: 189 naïve subjects were included in the pre-therapy group, and 68 subjects comprised the post-eradication therapy group. Analytical studies were conducted to evaluate the stability, reproducibility, and repeatability of the 13C-urea breath test results using a delta over baseline cut-off value of 5. RESULTS: Among the pre-therapy subjects evaluated with the composite results from the rapid urease test and histology/immunohistochemistry, 176 results matched those of the urea breath test, resulting in an overall agreement of 98.3% with a sensitivity of 100% and specificity of 97.9%. In the post-eradication therapy cohort, the overall agreement between the urea breath test and the biopsy diagnosis was 98.5%; the sensitivity of the urea breath test in this cohort was 92.3% and the specificity was 100%. There was uniformly high overall reproducibility (99.48%) of the test results over different batches of breath sample bags, when analyzed on different days and under different storage conditions, showing stability of the breath samples in the breath collection bags. CONCLUSION: The BreathID ® Hp Lab System is a highly accurate and dependable method for the diagnosis of H. pylori infection.

7.
Bull World Health Organ ; 96(1): 10-17, 2018 Jan 01.
Artigo em Inglês | MEDLINE | ID: mdl-29403096

RESUMO

OBJECTIVE: To evaluate the implementation of a time-driven activity-based costing analysis at five community health facilities in Haiti. METHODS: Together with stakeholders, the project team decided that health-care providers should enter start and end times of the patient encounter in every fifth patient's medical dossier. We trained one data collector per facility, who manually entered the time recordings and patient characteristics in a database and submitted the data to a cloud-based data warehouse each week. We calculated the capacity cost per minute for each resource used. An automated web-based platform multiplied reported time with capacity cost rate and provided the information to health-facilities administrators. FINDINGS: Between March 2014 and June 2015, the project tracked the clinical services for 7162 outpatients. The cost of care for specific conditions varied widely across the five facilities, due to heterogeneity in staffing and resources. For example, the average cost of a first antenatal-care visit ranged from 6.87 United States dollars (US$) at a low-level facility to US$ 25.06 at a high-level facility. Within facilities, we observed similarly variation in costs, due to factors such as patient comorbidities, patient arrival time, stocking of supplies at facilities and type of visit. CONCLUSION: Time-driven activity-based costing can be implemented in low-resource settings to guide resource allocation decisions. However, the extent to which this information will drive observable changes at patient, provider and institutional levels depends on several contextual factors, including budget constraints, management, policies and the political economy in which the health system is situated.


Assuntos
Centros Comunitários de Saúde/economia , Atenção à Saúde/economia , Recursos em Saúde , Orçamentos , Criança , Custos e Análise de Custo , Feminino , Haiti , Humanos , Gravidez
9.
J Thorac Cardiovasc Surg ; 154(3): 886-892, 2017 09.
Artigo em Inglês | MEDLINE | ID: mdl-28495063

RESUMO

OBJECTIVES: Atrial fibrillation (AF) is a common complication after cardiac surgery. Topical amiodarone on the epicardium may help prevent postoperative AF while avoiding the side effects of its systemic administration. The purpose of this study was to evaluate the all-comer strategy of epicardial amiodarone application for the prevention of postoperative AF. METHODS: A retrospective observational study was performed that evaluated the incidence of new-onset AF in a consecutive series of cardiac surgery patients who were treated with either no amiodarone (historical control, n = 100), epicardial application of amiodarone mixed in a topical hydrogel (n = 50), or epicardial application of an amiodarone-soaked sealant patch (n = 50). Perioperative data were compared between the 3 groups, with all patients receiving continuous postoperative telemetry to monitor for new-onset AF. RESULTS: The cohort consisted of 200 cardiac surgery patients (coronary bypass 82%, valve surgery 24%) who had no history of AF (mean age 71.0 years, 28% female). Among the 3 groups, the incidence of postoperative AF did not significantly differ, with 29 of 100 (29%) patients in the historical control group having new AF, compared with 18 of 50 (36%) in the amiodarone-hydrogel group, and 18 of 50 (36%) in the amiodarone-patch group (P = .56). The results did not differ when the analysis was restricted to coronary bypass patients only (n = 142, 27% vs 38% vs 32%, no-amiodarone vs amiodarone-hydrogel vs amiodarone-patch, respectively, P = .56). In multivariate logistic regression analysis, only older age (P = .001) was significantly associated with new-onset AF, but the use of topical amiodarone was not. CONCLUSIONS: Routine epicardial application of topical amiodarone was not associated with a reduction in the incidence of new-onset postoperative AF in this observational study of older patients, leading us to question its role in contemporary cardiac surgical practice.


Assuntos
Amiodarona/administração & dosagem , Antiarrítmicos/administração & dosagem , Fibrilação Atrial/epidemiologia , Fibrilação Atrial/prevenção & controle , Administração Tópica , Fatores Etários , Idoso , Ponte de Artéria Coronária , Feminino , Implante de Prótese de Valva Cardíaca , Estudo Historicamente Controlado , Humanos , Hidrogéis , Masculino , Análise Multivariada , Pericárdio , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Estudos Retrospectivos
10.
J Hosp Med ; 11(9): 658-61, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27596543

RESUMO

Accountable care organizations (ACOs) have shown promise in reducing healthcare spending growth, but have proven to be financially unsustainable for many healthcare organizations. Even ACOs with shared savings have experienced overall losses because the shared savings bonuses have not covered the costs of delivering population health. As physicians and former ACO leaders, we believe in the concept of accountable care, but ACOs need to evolve if they are to have a viable future. We propose the novel possibility of allowing ACOs to bill fee-for-service for their population health interventions, a concept we call population health billing. Journal of Hospital Medicine 2016;11:658-661. © 2016 Society of Hospital Medicine.


Assuntos
Organizações de Assistência Responsáveis/economia , Atenção à Saúde/métodos , Planos de Pagamento por Serviço Prestado , Atenção à Saúde/economia , Humanos , Medicare/economia , Patient Protection and Affordable Care Act , Estados Unidos
11.
Acad Med ; 90(9): 1272-7, 2015 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-26312606

RESUMO

PROBLEM: Community health centers (CHCs) face challenges recruiting and retaining primary care clinicians. Providing advanced training that enhances clinical skills within a public health framework, teaches leadership, protects time for scholarly activities, and focuses on the social mission may be a successful career development strategy. APPROACH: In July 2012, the Kraft Center for Community Health Leadership developed and implemented two 2-year programs to develop physician and nursing leaders with blended academic-community career paths and identities. The fellowship program for physicians and the practitioner program for early-career physicians and advanced practice nurses include mentored practice in a CHC; monthly learning days; completion of a community-based research project; and, for fellows, matriculation in an MPH program and engagement in a bimonthly leadership seminar. OUTCOMES: The first classes of 5 fellows and 14 practitioners graduated in June 2014. All 5 fellowship graduates were offered full-time positions at the CHCs where they practiced, and 2 have accepted leadership positions at their CHCs. All 14 practitioner graduates remain in community health, 5 have accepted leadership positions, and 2 have obtained grants to support ongoing projects. NEXT STEPS: The authors are tracking graduates' career paths and the programs' impact on CHCs while modifying the programs on the basis of feedback; identifying elements of the programs that may be amenable to more cost-effective delivery; and exploring the potential for federal funding to support expansion of the practitioner program, and for the practitioner program to increase the return on investment provided by the National Health Service Corps.


Assuntos
Escolha da Profissão , Centros Comunitários de Saúde , Currículo , Educação de Pós-Graduação em Medicina/organização & administração , Bolsas de Estudo/organização & administração , Médicos de Atenção Primária/provisão & distribuição , Atenção Primária à Saúde , Desenvolvimento de Programas , Prática Avançada de Enfermagem , Boston , Centros Comunitários de Saúde/organização & administração , Educação de Pós-Graduação em Medicina/métodos , Humanos , Médicos de Atenção Primária/educação , Recursos Humanos
12.
J Health Serv Res Policy ; 20(4): 261-4, 2015 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-26079144

RESUMO

Following the global economic recession, health care systems have experienced intense political pressure to contain costs without compromising quality. One response is to focus on improving the continuity and coordination of care, which is seen as beneficial for both patients and providers. However, cultural and structural barriers have proved difficult to overcome in the quest to provide integrated care for entire populations. By holding groups of providers responsible for the health outcomes of a designated population, in the United States, Accountable Care Organizations are regarded as having the potential to foster collaboration across the continuum of care. They could have a similar role in England's National Health Service. However, it is important to consider the difference in context before implementing a similar model, adapted to suit the system's strengths. Working together, general practice federations and the Academic Health Science Networks could form the basis of accountable care in England.


Assuntos
Organizações de Assistência Responsáveis/organização & administração , Prestação Integrada de Cuidados de Saúde/organização & administração , Reforma dos Serviços de Saúde/organização & administração , Modelos Organizacionais , Inglaterra , Humanos
14.
Health Aff (Millwood) ; 32(2): 321-7, 2013 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-23381525

RESUMO

Patient-centeredness--the idea that care should be designed around patients' needs, preferences, circumstances, and well-being--is a central tenet of health care delivery. For CEOs of health care organizations, patient-centered care is also quickly becoming a business imperative, with payments tied to performance on measures of patient satisfaction and engagement. In A CEO Checklist for High-Value Health Care, we, as executives of eleven leading health care delivery institutions, outlined ten key strategies for reducing costs and waste while improving outcomes. In this article we describe how implementation of these strategies benefits both health care organizations and patients. For example, Kaiser Permanente's Healthy Bones Program resulted in a 30 percent reduction in hip fracture rates for at-risk patients. And at Virginia Mason Health System in Seattle, nurses reorganized care patterns and increased the time they spent on direct patient care to 90 percent. Our experiences show that patient-engaged care can be delivered in ways that simultaneously improve quality and reduce costs.


Assuntos
Controle de Custos/métodos , Atenção à Saúde/organização & administração , Participação do Paciente/métodos , Melhoria de Qualidade/organização & administração , Lista de Checagem , Tomada de Decisões , Atenção à Saúde/economia , Atenção à Saúde/métodos , Atenção à Saúde/normas , Eficiência Organizacional , Medicina Baseada em Evidências/métodos , Necessidades e Demandas de Serviços de Saúde , Humanos , Qualidade da Assistência à Saúde/normas
15.
Am J Geriatr Psychiatry ; 18(2): 117-27, 2010 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-20104068

RESUMO

Cognitive and brain reserve are well studied in the context of age-associated cognitive impairment and dementia. However, there is a paucity of research that examines the role of cognitive or brain reserve in delirium. Indicators (or proxy measures) of cognitive or brain reserve (such as brain size, education, and activities) pose challenges in the context of the long prodromal phase of Alzheimer disease but are diminished in the context of delirium, which is of acute onset. This article provides a review of original articles on cognitive and brain reserve across many conditions affecting the central nervous system, with a focus on delirium. The authors review current definitions of reserve. The authors identify indicators for reserve used in earlier studies and discuss these indicators in the context of delirium. The authors highlight future research directions to move the field ahead. Reserve may be a potentially modifiable characteristic. Studying the role of reserve in delirium can advance prevention strategies for delirium and may advance knowledge of reserve and its role in aging and neuropsychiatric disease generally.


Assuntos
Envelhecimento/psicologia , Encefalopatias/complicações , Transtornos Cognitivos/psicologia , Delírio/psicologia , Adaptação Psicológica , Delírio/complicações , Delírio/patologia , Humanos , Transtornos Mentais/complicações , Plasticidade Neuronal , Fatores de Risco
17.
Am J Geriatr Psychiatry ; 15(7): 604-10, 2007 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-17586784

RESUMO

OBJECTIVE: To assess the relationships among depressive signs and symptoms and left versus right temporal-parietal cerebral blood volumes (CBVs) in elderly patients with a primary complaint of memory loss. METHODS: Total Geriatric Depression Scale Short Form (GDS-SF) scores, left and right temporal-parietal cerebral blood volume values, and other prospectively recorded data were obtained via chart review of 24 patients aged >/=65 years, evaluated between 1995 and 2000 at McLean Hospital for a primary complaint of memory loss. Multivariate regression analyses were carried out with GDS-SF total scores as outcome variables, with CBV values as explanatory factors and with several patient characteristics as covariates. RESULTS: Depressive symptoms, as measured by the GDS-SF, were significantly associated with decreased left/right temporal-parietal CBV ratios (beta regression coefficient = -20.7; t [df = 22] = -2.96, p = 0.007). These findings remained statistically significant after controlling for age, sex, Mini-Mental State Exam (MMSE) score, years of education, years of memory loss, and handedness (beta regression coefficient = -16.7; t [df = 16] = -2.67, p = 0.017). CONCLUSION: In this study, severity of depressive symptoms as measured by the GDS-SF in patients >/=65 years old who presented with a primary complaint of memory loss was associated with decreased left/right temporal-parietal CBV ratios, independently of age, sex, MMSE score, years of education, years of memory loss, and handedness. These findings suggest that in the presence of cognitive decline, increased depressive signs and symptoms may be associated with decreased left/right temporal-parietal CBV ratios.


Assuntos
Transtorno Depressivo Maior , Lateralidade Funcional/fisiologia , Imageamento por Ressonância Magnética , Transtornos da Memória , Lobo Parietal/irrigação sanguínea , Lobo Parietal/fisiopatologia , Lobo Temporal/irrigação sanguínea , Lobo Temporal/fisiopatologia , Idoso , Idoso de 80 Anos ou mais , Circulação Cerebrovascular/fisiologia , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/epidemiologia , Transtorno Depressivo Maior/fisiopatologia , Feminino , Humanos , Masculino , Transtornos da Memória/diagnóstico , Transtornos da Memória/epidemiologia , Transtornos da Memória/fisiopatologia , Testes Neuropsicológicos , Estudos Prospectivos , Estudos Retrospectivos , Índice de Gravidade de Doença , Inquéritos e Questionários
18.
Am J Psychiatry ; 164(5): 712-9, 2007 May.
Artigo em Inglês | MEDLINE | ID: mdl-17475728

RESUMO

In 2001, a seminal Institute of Medicine report, Crossing the Quality Chasm: A New Health System for the 21st Century, put forth a comprehensive strategy for improving the quality of U.S. health care. This strategy attained considerable traction within the overall U.S. health care system and subsequent attention in the mental health community as well. A new Institute of Medicine report, Improving the Quality of Health Care for Mental and Substance Use Conditions, examines the quality chasm strategy in light of the distinctive features of mental and substance use health care, including concerns about patient decision-making abilities and coercion into care, a less developed quality measurement and improvement infrastructure, lagging use of information technology and participation in the development of the National Health Information Infrastructure, greater separations in care delivery accompanied by more restrictions on sharing clinical information, a larger number of provider types licensed to diagnose and treat, more solo practice, and a differently structured marketplace. This article summarizes the Institute of Medicine's analysis of these issues and recommendations for improving mental and substance use health care and discusses the implications for psychiatric practice and related advocacy efforts of psychiatrists, psychiatric organizations, and other leaders in mental and substance use health care.


Assuntos
Atenção à Saúde/normas , Reforma dos Serviços de Saúde/métodos , Transtornos Mentais/terapia , Psiquiatria/métodos , Qualidade da Assistência à Saúde/normas , Transtornos Relacionados ao Uso de Substâncias/terapia , Humanos , National Academies of Science, Engineering, and Medicine, U.S., Health and Medicine Division , Psiquiatria/organização & administração , Estados Unidos
19.
Arch Gen Psychiatry ; 60(7): 664-72, 2003 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-12860770

RESUMO

OBJECTIVES: To review progress made during the past decade in late-life mood disorders and to identify areas of unmet need in health care delivery and research. PARTICIPANTS: The Consensus Development Panel consisted of experts in late-life mood disorders, geriatrics, primary care, mental health and aging policy research, and advocacy. EVIDENCE: (1) Literature reviews addressing risk factors, prevention, diagnosis, treatment, and delivery of services and (2) opinions and experiences of primary care and mental health care providers, policy analysts, and advocates. CONSENSUS PROCESS: The Consensus Development Panel listened to presentations and participated in discussions. Workgroups considered the evidence and prepared preliminary statements. Workgroup leaders presented drafts for discussion by the Consensus Development Panel. The final document was reviewed and edited to incorporate input from the entire Consensus Development Panel. CONCLUSIONS: Despite the availability of safe and efficacious treatments, mood disorders remain a significant health care issue for the elderly and are associated with disability, functional decline, diminished quality of life, mortality from comorbid medical conditions or suicide, demands on caregivers, and increased service utilization. Discriminatory coverage and reimbursement policies for mental health care are a challenge for the elderly, especially those with modest incomes, and for clinicians. Minorities are particularly underserved. Access to mental health care services for most elderly individuals is inadequate, and coordination of services is lacking. There is an immediate need for collaboration among patients, families, researchers, clinicians, governmental agencies, and third-party payers to improve diagnosis, treatment, and delivery of services for elderly persons with mood disorders.


Assuntos
Atenção à Saúde/normas , Necessidades e Demandas de Serviços de Saúde , Transtornos do Humor/diagnóstico , Transtornos do Humor/terapia , Fatores Etários , Idoso , Envelhecimento/psicologia , Atitude do Pessoal de Saúde , Transtorno Bipolar/diagnóstico , Transtorno Bipolar/terapia , Comorbidade , Transtorno Depressivo Maior/diagnóstico , Transtorno Depressivo Maior/terapia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/normas , Pesquisa , Fatores de Risco , Estados Unidos
20.
Am J Psychiatry ; 159(7): 1225-7, 2002 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-12091203

RESUMO

OBJECTIVE: This study investigated the efficacy and safety of short-term estrogen therapy in decreasing noncognitive signs and symptoms of dementia in demented elderly patients. METHOD: Sixteen moderately to severely demented elderly patients with aggressive behavioral disturbances were randomly assigned to receive conjugated equine estrogens or placebo in a 4-week clinical trial. Frequency and severity of noncognitive signs and symptoms of dementia, as assessed with the Dementia Signs and Symptoms Scale, were compared between estrogen and placebo groups. Data were analyzed with intent-to-treat and regression modeling methods. RESULTS: Estrogen therapy was associated with a significantly greater improvement on the Dementia Signs and Symptoms Scale total score than placebo. All five Dementia Signs and Symptoms Scale subscale comparisons favored estrogen therapy. No adverse effects were observed. CONCLUSIONS: These preliminary data suggest that short-term estrogen therapy may safely decrease the frequency and severity of noncognitive signs and symptoms of dementia in elderly patients.


Assuntos
Demência/diagnóstico , Demência/tratamento farmacológico , Estrogênios Conjugados (USP)/uso terapêutico , Fatores Etários , Idoso , Idoso de 80 Anos ou mais , Agressão/psicologia , Comorbidade , Demência/epidemiologia , Demência/psicologia , Método Duplo-Cego , Esquema de Medicação , Estrogênios Conjugados (USP)/administração & dosagem , Feminino , Humanos , Masculino , Placebos , Escalas de Graduação Psiquiátrica , Índice de Gravidade de Doença , Resultado do Tratamento
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