RESUMO
IMPORTANCE: The benefit of an electronic support system for the prescription and adherence to oral anticoagulation therapy among patients with atrial fibrillation (AF) and atrial flutter at heightened risk for of stroke and systemic thromboembolism is unclear. OBJECTIVE: To evaluate the effect of a combined alert intervention and shared decision-making tool to improve prescription rates of oral anticoagulation therapy and adherence. DESIGN, SETTING, AND PARTICIPANTS: A prospective single arm study of 939 consecutive patients treated at a large tertiary healthcare system. EXPOSURES: An electronic support system comprising 1) an electronic alert to identify patients with AF or atrial flutter, a CHA2DS2-VASc score ≥ 2, and not on oral anticoagulation and 2) electronic shared decision-making tool to promote discussions between providers and patients regarding therapy. MAIN OUTCOMES AND MEASURES: The primary endpoint was prescription rate of anticoagulation therapy. The secondary endpoint was adherence to anticoagulation therapy defined as medication possession ratio ≥ 80% during the 12 months of follow-up. RESULTS: Between June 13, 2018 and August 31, 2018, the automated intervention identified and triggered a unique alert for 939 consecutive patients with AF or atrial flutter, a CHA2DS2-VASc score ≥2 who were not on oral anticoagulation. The median CHA2DS2-VASc score among all patients identified by the alert was 2 and the median untreated duration prior to the alert was 495 days (interquartile range 123 - 1,831 days). Of the patients identified by the alert, 345 (36.7%) initiated anticoagulation therapy and 594 (63.3%) did not: 68.7% were treated with a non-Vitamin K antagonist oral anticoagulant (NOAC), 22.0% with warfarin, and 9.3 % combination of NOAC and warfarin. Compared with historical anticoagulation rates, the electronic alert was associated with a 23.6% increase in anticoagulation prescriptions. The overall 1-year rate of adherence to anticoagulant therapy was 75.4% (260/345). CONCLUSION AND RELEVANCE: An electronic automated alert can successfully identify patients with AF and atrial flutter at high risk for stroke, increase oral anticoagulation prescription, and support high rates of adherence.
Assuntos
Fibrilação Atrial , Acidente Vascular Cerebral , Administração Oral , Anticoagulantes , Fibrilação Atrial/complicações , Fibrilação Atrial/tratamento farmacológico , Eletrônica , Humanos , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Acidente Vascular Cerebral/induzido quimicamente , Acidente Vascular Cerebral/prevenção & controle , VarfarinaRESUMO
In low-income countries, infectious diseases still account for a large proportion of deaths, highlighting health inequities largely caused by economic differences. Vaccination can cut health-care costs and reduce these inequities. Disease control, elimination or eradication can save billions of US dollars for communities and countries. Vaccines have lowered the incidence of hepatocellular carcinoma and will control cervical cancer. Travellers can be protected against "exotic" diseases by appropriate vaccination. Vaccines are considered indispensable against bioterrorism. They can combat resistance to antibiotics in some pathogens. Noncommunicable diseases, such as ischaemic heart disease, could also be reduced by influenza vaccination. Immunization programmes have improved the primary care infrastructure in developing countries, lowered mortality in childhood and empowered women to better plan their families, with consequent health, social and economic benefits. Vaccination helps economic growth everywhere, because of lower morbidity and mortality. The annual return on investment in vaccination has been calculated to be between 12% and 18%. Vaccination leads to increased life expectancy. Long healthy lives are now recognized as a prerequisite for wealth, and wealth promotes health. Vaccines are thus efficient tools to reduce disparities in wealth and inequities in health.
Assuntos
Pessoas com Deficiência , Saúde Global , Promoção da Saúde , Disparidades nos Níveis de Saúde , Programas de Imunização , Mortalidade/tendências , Serviços Preventivos de Saúde , Vacinação , Doença Aguda , Doença Crônica , Política de Saúde , Humanos , Pobreza , Saúde Pública , Fatores SocioeconômicosRESUMO
OBJECTIVE: To pilot informed consent materials developed for Aboriginal parents in a vaccine trial, and evaluate their design and the informed consent process. METHODS: Cross sectional quantitative and qualitative survey of 20 Aboriginal and 20 non-Aboriginal women in Alice Springs. Information about the proposed research was presented to Aboriginal participants by an Aboriginal researcher, using purpose designed verbal, visual, and written materials. Non-Aboriginal participants received standard materials developed by the sponsor. Questionnaires were used to evaluate recall and understanding immediately and five days later. Qualitative analysis of Aboriginal participants' interviews was performed. RESULTS: There were no differences between the groups in understanding of diseases prevented by the vaccine, the potential risks of participating, or the voluntary nature of participation. Most Aboriginal participants had difficulty with the concept of a "licensed" versus "unlicensed" vaccine. The non-Aboriginal group had a good understanding of this. Aboriginal participants identified the use of the flipchart, along with a presentation by a doctor and Aboriginal health worker, as preferred delivery modes. Group presentations were preferred rather than one-on-one discussions. The use of the questionnaire posed considerable methodological difficulties. CONCLUSIONS: A one-off oral presentation to Aboriginal participants is unlikely to produce "informed consent". Key but unfamiliar concepts require identification and particularly considered presentation.
Assuntos
Ensaios Clínicos como Assunto , Consentimento Livre e Esclarecido , Havaiano Nativo ou Outro Ilhéu do Pacífico , Cognição , Comunicação , Estudos Transversais , Feminino , Conhecimentos, Atitudes e Prática em Saúde , Humanos , Entrevistas como Assunto , Licenciamento , Northern Territory , Projetos Piloto , Vacinas Pneumocócicas/uso terapêutico , Inquéritos e Questionários , Vacinas Conjugadas/uso terapêuticoRESUMO
The real risk posed by biological weapons was demonstrated with the distribution of anthrax spores via the USA postal service in 2001. This review outlines the central roles of physicians in optimizing biopreparedness in Australia, including maintaining awareness of the risk, promptly recognizing an event, notifying appropriate authorities upon suspicion of an event, and instituting appropriate management. Management aspects covered include appropriate diagnostic tests, infection control procedures, and empirical therapy of agents considered possible biological weapons. The critical role of physicians as public health advocates working to prevent the use of biological weapons is also outlined.
Assuntos
Bioterrorismo , Planejamento em Desastres , Papel do Médico , Antraz/diagnóstico , Antraz/terapia , Austrália , Botulismo/diagnóstico , Botulismo/terapia , Humanos , Controle de Infecções/métodos , Peste/diagnóstico , Peste/terapia , Saúde Pública , Varíola/diagnóstico , Varíola/terapia , Tularemia/diagnóstico , Tularemia/terapiaRESUMO
Between 1990 and 1996, 133 accidents occurred and 23 mine workers were killed when haulage trucks used in surface mines collided with another smaller vehicle, a mine structure, or a pedestrian worker. These accidents were caused by a lack of visibility from the cab of the truck. Similar accidents are common with other types of equipment, such as front-end loaders and shovels. There are several methods for improving the operator's awareness of objects or people around the equipment including improved mirror designs, video cameras, and sensor technologies. Researchers at the National Institute for Occupational Safety and Health (NIOSH) are evaluating collision warning systems that are based on radar technology. These systems are mounted on the mining equipment to monitor one or more of the blind areas. An alarm is provided to the operator if an object or person enters the radar's detection area. Tests consisted of mounting the systems on a 50-ton-capacity truck typically used in quarries and a 240-ton-capacity truck used at a surface mine. This article summarizes the test procedure and results of evaluations of several off-the-shelf and prototype radar systems. False alarm rates and reliable detection zones for pedestrians were recorded for various mounting configurations on the rear of the trucks. Mounting radar systems on large equipment presents several challenges; however, the technology does show promise for this application.
Assuntos
Acidentes de Trabalho/prevenção & controle , Acidentes de Trânsito/prevenção & controle , Mineração , Veículos Automotores , Radar , Coleta de Dados , Desenho de Equipamento , Reações Falso-Positivas , HumanosRESUMO
Mining has long remained one of America's most hazardous occupations. Researchers believe that by developing realistic, affordable VR training software, miners will be able to receive accurate training in hazard recognition and avoidance. In addition, the VR software will allow miners to follow mine evacuation routes and safe procedures without exposing themselves to danger. This VR software may ultimately be tailored to provide training in other industries, such as the construction, agricultural, and petroleum industries.
Assuntos
Instrução por Computador , Capacitação em Serviço/métodos , Mineração/educação , Saúde Ocupacional , Gestão da Segurança/métodos , Interface Usuário-Computador , Instrução por Computador/economia , Análise Custo-Benefício , Humanos , Capacitação em Serviço/economia , Gestão da Segurança/economia , Sensibilidade e Especificidade , Ferimentos e Lesões/prevenção & controleRESUMO
The aims of this project were: (1) to determine the extent to which infant hepatitis B immunisation is preventing chronic hepatitis B infection in children living in a sample of Pacific Island countries; and (2) to identify factors associated with the successful prevention of hepatitis B infection in these populations. A regional hepatitis B immunisation project which supplied hepatitis B vaccine to 10 Pacific Island countries began in 1995. Seroepidemiological surveys were conducted in Fiji, Kiribati, Tonga and Vanuatu in early 1998. These included immunised pre-school children and their biological mothers, and a historical control group of unimmunised students. Prevalence rates for hepatitis B surface antigen (HBsAg) in the populations of students, mothers and their pre-school children were respectively: Fiji: 6.9, 6.6, 0.7%; Kiribati: 27.4, 15.1, 3.8%; Tonga: 11.1, 18.6, 3.8%; Vanuatu: 16.3, 12.3, 3.0%; and for all four countries: 13.2, 12.5, 2.6%. Compared to the historical control group of students, the pre-school population had a much lower probability of HBsAg positivity (relative risk [RR]=0.19 [95%CI: 0.12-0.31]). Statistically significant differences in risk were apparent for all the countries: Fiji: RR=0.10; Kiribati: RR=0.14; Tonga: RR=0.34; Vanuatu: RR=0.19. This is equivalent to an overall program effectiveness of 81% (95%CI: 69-88%) in reducing chronic carriage. Also, the overall protective effectiveness against vertical hepatitis B transmission resulting in HBsAg positivity among children exposed to HBeAg positive and negative carrier mothers, was estimated to be 70%. By age 6 months, when all children should have had three vaccine doses, completed immunisation rates ranged from 22 (Fiji) to 84% (Vanuatu). Coverage of the first dose being given within 2 days of birth varied from 43% in Kiribati to 92% in Tonga. In conclusion hepatitis B immunisation of infants in these four countries is having a substantial beneficial effect in preventing chronic hepatitis B infection. Nevertheless, there is significant scope for further improving the timeliness of immunisation.
Assuntos
Vacinas contra Hepatite B/imunologia , Hepatite B Crônica/prevenção & controle , Adolescente , Fatores Etários , Criança , Pré-Escolar , Anticorpos Anti-Hepatite B/sangue , Antígenos E da Hepatite B/análise , Humanos , Imunização , Imunoglobulinas/imunologia , Lactente , Fatores de RiscoRESUMO
We evaluated the immunogenicity of hepatitis B (HB) vaccine in UniJect, a pre-filled, non-reusable injection device, stored at tropical temperatures for up to one month and used to give the first dose of HB vaccine to newborns. Infants in Tabanan district, Bali, Indonesia, were given their first dose of HB vaccine with UniJect stored out of the cold chain, UniJect stored in the cold chain; or standard syringe, needle and multidose vial stored in the cold chain. Subsequent doses were given by usual means and blood samples drawn 4-6 weeks after the third dose. No significant differences were found in seroconversion rates or geometric mean titres of HB surface antibody between the three groups.
Assuntos
Vacinas contra Hepatite B/administração & dosagem , Imunização/instrumentação , Injeções/instrumentação , Temperatura Baixa , Anticorpos Anti-Hepatite B/sangue , Vacinas contra Hepatite B/imunologia , Humanos , Recém-NascidoRESUMO
BACKGROUND: Malaria prevention in travellers is typically the most complex travel health issue faced by practitioners. Approximately 300 to 500 million people in the world are infected with malaria and between 1.5 and 2.7 million people die from it every year. Although the disease is mainly confined to the tropical areas of Africa, Asia and Latin America, it remains a serious and worsening health problem. OBJECTIVE: In this article recommendations are provided to assist doctors giving advice to travellers visiting regions where malaria is endemic. The focus is on prophylactic medications and self treatment regimens. DISCUSSION: Advice to travellers should include information on the need for prompt diagnosis and treatment of febrile illness, on minimising exposure to mosquitoes, and the use of repellents and contact insecticides. A simplified chemoprophylaxis regimen is chloroquine for chloroquine sensitive malaria areas, mefloquine or doxycycline for areas with chloroquine resistant malaria and doxycycline for areas with mefloquine resistant malaria. With the advent of new self treatment regimens and 'in the field' rapid diagnostic tests, self treatment has become a reasonable option in certain circumstances.
Assuntos
Antimaláricos/uso terapêutico , Malária/prevenção & controle , Viagem , Adulto , África , Sudeste Asiático , Austrália , Contraindicações , Humanos , Malária/diagnóstico , Malária/tratamento farmacológico , Autocuidado , América do SulRESUMO
In just under a quarter of a century, the Expanded Programme on Immunisation has been associated with an increase in infant immunisation coverage from around 5% to 80%, and the prevention of at least 3 million deaths annually, at very low cost. The global target of poliomyelitis eradication by the year 2000 appears feasible. Measles is the next likely target for eradication via immunisation, through 'catch-up', 'keep up' and 'follow-up' strategies which have proven highly effective in the Americas. Yet much needs to be done in order to extend readily achievable immunisation benefits equitably to all the world's people and to realise the potential of existing and soon to be available vaccines for disease control and eradication, as experience with yellow fever and hepatitis B vaccines demonstrates. Unsafe injection practices are widespread, have received inadequate attention, and cause a substantial global burden of blood-borne infections. The risk of increasing global inequity in immunisation highlights the centrality of resource allocation priorities in determining the extent to which the benefits of immunisation will be realised, particularly for new vaccines which are significantly more costly than established EPI vaccines. WHO/UNICEF strategies to target more effectively immunisation support to the neediest countries, to prioritise new vaccines, and to target carefully vaccine procurement and encourage sharply tiered vaccine pricing support both equity and sustainability. However, increasing the resources available to immunisation is vital and requires powerful advocacy on public health, moral, cost-effectiveness and legal grounds. More appropriate resource allocation priorities could readily provide the means necessary to address both technical and operational immunisation challenges.
Assuntos
Países em Desenvolvimento , Vacinação/métodos , Viroses/prevenção & controle , Criança , Pré-Escolar , Custos e Análise de Custo , Hepatite B/prevenção & controle , Humanos , Lactente , Poliomielite/prevenção & controle , Vacinação/economia , Febre Amarela/prevenção & controleRESUMO
AIM: To evaluate the influence of premorbid personality on adaptation to placement in a long-term care facility. SUBJECTS: Twenty-eight persons with probable Alzheimer disease (AD) residing in an academically affiliated nursing home for 6-9 months. METHODS: Premorbid personality was described retrospectively by two informants for each resident using the revised NEO Personality Inventory (NEO-PI-R). Standardized tests and rating scales were used on admission to the facility to assess cognition, mood state, physical dependency and general health. Nurses rated each AD resident's social behaviour, participation in activities and quality of sleep. RESULTS: Poorer adjustment was associated with more severe dementia but better physical health. None of the NEO-PI-R domain scores predicted adjustment. CONCLUSIONS: Contrary to popular belief, premorbid personality is relatively inconsequential for an AD patient's adaptation to a long-term care facility.
Assuntos
Adaptação Psicológica , Doença de Alzheimer/psicologia , Personalidade , Idoso , Idoso de 80 Anos ou mais , Feminino , Previsões , Humanos , Assistência de Longa Duração , Masculino , Pessoa de Meia-IdadeRESUMO
PURPOSE: This phase II study was performed to assess the feasibility of organ preservation after combined chemotherapy and radical radiation therapy in patients with resectable, locally advanced head and neck cancer. MATERIALS AND METHODS: Twenty-four patients had surgically resectable stage III (n = 9) and stage IV (n = 15) squamous cell carcinoma of the head and neck. Initially, they received two to three courses of neoadjuvant chemotherapy (5-fluorouracil and cisplatin). Patients in whom response was seen were then treated definitively with two courses of cisplatin chemotherapy administered concomitantly with radical radiation therapy. Patients in whom no response was seen underwent salvage surgery or other standard therapy. RESULTS: The response rate after induction chemotherapy was 84% (including 42% complete remission). Complete remission after concomitant chemotherapy and radical radiation therapy was 83%. After a median follow-up of 18 months (maximum, 3.5 years), 18 patients (75%) remained recurrence free. Grade 3 or 4 treatment-related toxicity was experienced, but there was no treatment-related mortality. CONCLUSION: Combined chemotherapy and radical radiation therapy used in this study resulted in organ and function preservation in the majority of patients with resectable stage III and IV head and neck cancer.
Assuntos
Protocolos de Quimioterapia Combinada Antineoplásica/uso terapêutico , Carcinoma de Células Escamosas/radioterapia , Neoplasias de Cabeça e Pescoço/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Antimetabólitos Antineoplásicos/administração & dosagem , Quimioterapia Adjuvante , Cisplatino/administração & dosagem , Árvores de Decisões , Intervalo Livre de Doença , Estudos de Viabilidade , Feminino , Fluoruracila/administração & dosagem , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Indução de RemissãoRESUMO
To determine hepatitis B immunisation rates in infants from ethnic groups with hepatitis B surface antigen chronic carrier prevalence over 5 per cent, a questionnaire was sent to all Maternal and Child Health Centres in Victoria, requesting information on the hepatitis B and diphtheria-tetanus-pertussis (DTP) or combined diphtheria-tetanus (CDT) immunisation status for all infants born between 1 July 1992 and 30 June 1993 and at risk of hepatitis B infection because of maternal ethnicity. We received data on 3611 of 5744 infants (62.9 per cent) in targeted ethnic groups. Of these, 12.8 per cent had not received hepatitis B vaccine, and 81.6 per cent, 76.8 per cent and 64.0 per cent had received at least one, two and three doses respectively, while 84 per cent had received at least three doses of DTP vaccine and/or CDT vaccine. Coverage with DTP or CDT was higher than for hepatitis B vaccine (P < 0.001), and coverage was better in areas with a higher percentage of infants in high-prevalence ethnic groups (P < 0.001). Changes in the program in Victoria in terms of timing of the first dose of vaccine plus greater attention to follow-up may lead to improved hepatitis B immunisation rates among infants in targeted ethnic groups. Adoption of universal infant hepatitis B immunisation, by increasing familiarity with hepatitis B vaccine, is likely to be the best way to increase immunisation coverage for these infants.
Assuntos
Portador Sadio/etnologia , Antígenos de Superfície da Hepatite B/sangue , Vacinas contra Hepatite B , Hepatite B/etnologia , Havaiano Nativo ou Outro Ilhéu do Pacífico , Vacinação/estatística & dados numéricos , Portador Sadio/sangue , Doença Crônica , Vacina contra Difteria, Tétano e Coqueluche , Hepatite B/sangue , Humanos , Lactente , Prevalência , Inquéritos e Questionários , Vitória/epidemiologiaRESUMO
Infants born to HBsAg- (hepatitis B surface antigen) carrier mothers are highly likely to become chronic hepatitis B (HB) carriers themselves unless their status is recognised at birth and they are immunised with three doses of HB vaccine, the first within 48 hours of birth, concurrent with hepatitis B immune globulin (HBIG). This study was designed to determine how many infants born in Victoria to carrier mothers completed three doses of HB vaccine. We sent the names of all infants of HBsAg-carrier mothers notified in Victoria between 1.7.91 and 30.6.92 to the appropriate local government immunisation providers and requested information on how many doses of HB vaccine, DTP (diphtheria-tetanus-pertussis) or CDT (combined diphtheria-tetanus), and OPV (oral polio vaccine) they had received. The HBsAg-carrier prevalence of women giving birth in Victoria in 1991-92 was at least 0.52%. Of the 336 infants notified, 239 (71.1%) were recorded in local government records. Of these 239, 90.8% received at least two doses and 80.8% received at least three doses of hepatitis B vaccine. There was no significant difference in the number who received three doses of HB vaccine compared with three doses of DTP or CDT vaccine. Of the entire cohort of 336, only 57.4% were documented as being completely immunised against hepatitis B. HB immunisation coverage for these infants needs to be improved. The high rate of loss to follow-up, especially between the maternity hospital and the community, is disturbing. Mechanisms for intensive prospective follow-up of these infants should be developed to prevent loss to follow-up and to encourage full immunisation against HB. Improving HB immunisation coverage of infants in high HBsAg-prevalence ethnic groups and introduction of universal infant HB immunisation may lead to increased coverage of infants of carriers by serving as back-up mechanisms for those lost to follow-up.
Assuntos
Portador Sadio/transmissão , Vacinas contra Hepatite B/administração & dosagem , Hepatite B/prevenção & controle , Hepatite B/transmissão , Programas de Imunização/organização & administração , Transmissão Vertical de Doenças Infecciosas/prevenção & controle , Portador Sadio/epidemiologia , Doença Crônica , Estudos de Coortes , Vacina contra Difteria, Tétano e Coqueluche/administração & dosagem , Feminino , Hepatite B/epidemiologia , Maternidades , Humanos , Esquemas de Imunização , Lactente , Recém-Nascido , Vacina Antipólio de Vírus Inativado/administração & dosagem , Gravidez , Prevalência , Avaliação de Programas e Projetos de Saúde , Vitória/epidemiologiaAssuntos
Vacinas contra Hepatite B , Hepatite B/complicações , Hepatite B/prevenção & controle , Vacinas Antimaláricas , Malária/complicações , Malária/prevenção & controle , Proteínas de Protozoários , Proteínas Recombinantes , Vacinas Sintéticas , Portador Sadio , Criança , Pré-Escolar , Gâmbia , Humanos , Ensaios Clínicos Controlados Aleatórios como Assunto , VacinaçãoRESUMO
Many HIV-infected people travel abroad, and although most can travel in relative safety there are a range of issues and risks to be considered by their medical advisers.