Do hospitals react to random demand pressure by early discharges?

This project tries to assess whether hospitals react to random demand pressure by discharging patients earlier than expected. As a matter of fact, combining an unpredictable demand for medical services with limited and, to some extent, fixed medical resources, generates strong incentives to discharge patients earlier than expected when demand is high − increasing the risk of readmission and decreasing the benefit from treatment. This work was conducted as a way to determine whether those incentives actually affect discharging decisions. Analysis of Portuguese hospitals data shows that hospital utilization levels at the time of admission, prior to the admission and post admission do have a negative impact over the length of stay in hospital, although this impact is quantitatively irrelevant. More than that, larger utilization levels have a positive impact over the probability of being discharged at certain days of the week, indicating that an early discharges problem may exist.

Integrative literature review of the reported uses of serological tests in leprosy management

Abstract: An integrative literature review was conducted to synthesize available publications regarding the potential use of serological tests in leprosy programs. We searched the databases Literatura Latino-Americana e do Caribe em Ciências da Saúde, Índice Bibliográfico Espanhol em Ciências da Saúde, Acervo da Biblioteca da Organização Pan-Americana da Saúde, Medical Literature Analysis and Retrieval System Online, Hanseníase, National Library of Medicine, Scopus, Ovid, Cinahl, and Web of Science for articles investigating the use of serological tests for antibodies against phenolic glycolipid-I (PGL-I), ML0405, ML2331, leprosy IDRI diagnostic-1 (LID-1), and natural disaccharide octyl-leprosy IDRI diagnostic-1 (NDO-LID). From an initial pool of 3.514 articles, 40 full-length articles fulfilled our inclusion criteria. Based on these papers, we concluded that these antibodies can be used to assist in diagnosing leprosy, detecting neuritis, monitoring therapeutic efficacy, and monitoring household contacts or at-risk populations in leprosy-endemic areas. Thus, available data suggest that serological tests could contribute substantially to leprosy management.

Pelvic lymphoscintigraphy: contribution to the preoperative staging of rectal cancer

PURPOSE: Preservation of the anal sphincter in surgery for cancer of the distal rectum in an attempt to avoid colostomy has been a main concern of colorectal surgeons. Various proposed procedures contradict oncological principles, especially with respect to pelvic lymphadenectomy. Therefore, prior knowledge of pelvic lymph node involvement is an important factor in choosing the operative technique, i.e., radical or conservative resection. Introduction of ultrasound, computerized tomography, and magnetic resonance have made preoperative study of the area possible. Nevertheless, these resources offer information of an anatomical nature only. Lymphoscintigraphy enables the morphological and functional evaluation of the pelvic area and contributes toward complementing the data obtained with the other imaging techniques. The objective of this prospective study is twofold: to standardize the lymphoscintigraphy technique and to use it to differentiate patients with rectal cancer from those with other coloproctologic diseases. CASUISTIC AND METHODS: Sixty patients with various coloproctologic diseases were studied prospectively. Ages ranged from 21 to 96 years (average, 51 and median, 55 years). Twenty-six patients were male and 34 were female. Thirty patients had carcinoma of the distal rectum as diagnosed by proctologic and anatomic-pathologic examinations, 20 patients had hemorrhoids, 5 had chagasic megacolon, 2 had diverticular disease, 2 had neoplasm of the right colon, and 1 had ulcerative colitis as diagnosed by proctologic exam and/or enema. The lymphoscintigraphy method consisted of injecting 0.25 mL of a dextran solution marked with radioactive technetium-99m into the right and left sides of the perianal region and obtaining images with a gamma camera. The results were analyzed statistically with a confidence level of 95% (P < .05) using the following statistical techniques: arithmetic and medium average, Fisher exact test, chi-square test corrected for continuity according to Yates, and distribution tables for the number of patients. RESULTS: In rectal cancer, the tracer progresses unilaterally or is absent; in other patients, the progress of the tracer is bilateral and symmetrical, although its progress may be slow. Statistical tests showed with high significance that the agreement index between the clinical diagnosis and the result of the lymphoscintigraphic exam was 93%. CONCLUSIONS: Lymphoscintigraphy is a standardized, painless, and harmless test that can be performed in all cases; it differentiates patients with rectal cancer from those with other coloproctological diseases.

Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis : from guidelines to clinical practice

Endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis: From guidelines to clinical practice.

Neoplastic pericardial disease. Analysis of 26 patients

PURPOSE: To characterize patients with neoplastic pericardial disease diagnosed by clinical presentation, complementary test findings, and the histological type of tumor. METHODS: Twenty-six patients with neoplastic pericardial disease were retrospectively analyzed. RESULTS: Clinical manifestations and abnormalities in chest roentgenograms and electrocardiograms were frequent, but were not specific. Most patients underwent surgery. There was a high positivity of the pericardial biopsy when associated with the cytological analysis of the pericardial liquid used to determine the histological type of the tumor, particularly when the procedure was performed with the aid of pericardioscopy. CONCLUSION: The correct diagnosis of neoplastic pericardial disease involves suspicious but nonspecific findings during clinical examination and in screen tests. The suspicious findings must be confirmed through more invasive diagnostic approaches, in particular pericardioscopy with biopsy and cytological study.

Arrhythmogenic cardiomyopathy of the right ventricle. Predictive value of QT interval dispersion to assess arrhythmogenic risk and sudden death

OBJECTIVE: To determine in arrhythmogenic right ventricular cardiomyopathy the value of QT interval dispersion for identifying the induction of sustained ventricular tachycardia in the electrophysiological study or the risk of sudden cardiac death. METHODS: We assessed QT interval dispersion in the 12-lead electrocardiogram of 26 patients with arrhythmogenic right ventricular cardiomyopathy. We analyzed its association with sustained ventricular tachycardia and sudden cardiac death, and in 16 controls similar in age and sex. RESULTS: (mean ± SD). QT interval dispersion: patients = 53.8±14.1ms; control group = 35.0±10.6ms, p=0.001. Patients with induction of ventricular tachycardia: 52.5±13.8ms; without induction of ventricular tachycardia: 57.5±12.8ms, p=0.420. In a mean follow-up period of 41±11 months, five sudden cardiac deaths occurred. QT interval dispersion in this group was 62.0±17.8, and in the others it was 51.9±12.8ms, p=0.852. Using a cutoff > or = 60ms to define an increase in the degree of the QT interval dispersion, we were able to identify patients at risk of sudden cardiac death with a sensitivity of 60%, a specificity of 57%, and positive and negative predictive values of 25% and 85%, respectively. CONCLUSION: Patients with arrhythmogenic right ventricular cardiomyopathy have a significant increase in the degree of QT interval dispersion when compared with the healthy population. However it, did not identify patients with induction of ventricular tachycardia in the electrophysiological study, showing a very low predictive value for defining the risk of sudden cardiac death in the population studied.

Coronary stent implantation in diabetic versus nondiabetic patients. Early and late outcomes

OBJECTIVE: To assess whether coronary stenting in diabetic patients provides in-hospital results and clinical evolution similar to those in nondiabetic patients. METHODS: From July `97 to April '99 we performed coronary stent implantation in 386 patients with coronary heart disease, who were divided into two groups: diabetic patients and nondiabetic patients. The in-hospital results and the clinical evolution of each group were retrospectively analyzed. RESULTS: The nondiabetic group comprised 305 (79%) patients and the diabetic group 81 (21%) patients. Basic clinical and angiographic characteristics were similar. Angiographic success was in diabetics = 96.6% vs in nondiabetics = 97.9% (p=ns). Among the major complications in the in-hospital phase, the rate of myocardial infarction was higher in the diabetic group (7.4% vs 1.9%) (p=0.022). In the follow-up, a favorable and homogeneous evolution occurred in regard to asymptomatic patients, myocardial infarction, and death in the groups. A greater need for revascularization, however, existed in the diabetic patients (15% vs 2.4%, p<0.001). CONCLUSION: Coronary stenting in diabetic patients is an efficient procedure, with a high angiographic and clinical success rate similar to that in nondiabetic patients. Diabetic patients, however, had a higher incidence of in-hospital myocardial infarction and a greater need for additional myocardial revascularization.

Critical events in mechanically ventilated patients

Mechanical Ventilation is an artificial way to help a Patient to breathe. This procedure is used to support patients with respiratory diseases however in many cases it can provoke lung damages, Acute Respiratory Diseases or organ failure. With the goal to early detect possible patient breath problems a set of limit values was defined to some variables monitored by the ventilator (Average Ventilation Pressure, Compliance Dynamic, Flow, Peak, Plateau and Support Pressure, Positive end-expiratory pressure, Respiratory Rate) in order to create critical events. A critical event is verified when a patient has a value higher or lower than the normal range defined for a certain period of time. The values were defined after elaborate a literature review and meeting with physicians specialized in the area. This work uses data streaming and intelligent agents to process the values collected in real-time and classify them as critical or not. Real data provided by an Intensive Care Unit were used to design and test the solution. In this study it was possible to understand the importance of introduce critical events for Mechanically Ventilated Patients. In some cases a value is considered critical (can trigger an alarm) however it is a single event (instantaneous) and it has not a clinical significance for the patient. The introduction of critical events which crosses a range of values and a pre-defined duration contributes to improve the decision-making process by decreasing the number of false positives and having a better comprehension of the patient condition.

Value of the Qrs-T Angle in Predicting the Induction of Ventricular Tachyarrhythmias in Patients with Chagas Disease

Background:The QRS-T angle correlates with prognosis in patients with heart failure and coronary artery disease, reflected by an increase in mortality proportional to an increase in the difference between the axes of the QRS complex and T wave in the frontal plane. The value of this correlation in patients with Chagas heart disease is currently unknown.Objective:Determine the correlation of the QRS-T angle and the risk of induction of ventricular tachycardia / ventricular fibrillation (VT / VF) during electrophysiological study (EPS) in patients with Chagas disease.Methods:Case-control study at a tertiary center. Patients without induction of VT / VF on EPS were used as controls. The QRS-T angle was categorized as normal (0-105º), borderline (105-135º) or abnormal (135-180º). Differences between groups for continuous variables were analyzed with the t test or Mann-Whitney test, and for categorical variables with Fisher's exact test. P values < 0.05 were considered significant.Results:Of 116 patients undergoing EPS, 37.9% were excluded due to incomplete information / inactive records or due to the impossibility to correctly calculate the QRS-T angle (presence of left bundle branch block and atrial fibrillation). Of 72 patients included in the study, 31 induced VT / VF on EPS. Of these, the QRS-T angle was normal in 41.9%, borderline in 12.9% and abnormal in 45.2%. Among patients without induction of VT / VF on EPS, the QRS-T angle was normal in 63.4%, borderline in 14.6% and abnormal in 17.1% (p = 0.04). When compared with patients with normal QRS-T angle, those with abnormal angle had a fourfold higher risk of inducing ventricular tachycardia / ventricular fibrillation on EPS [odds ratio (OR) 4; confidence interval (CI) 1.298-12.325; p = 0.028]. After adjustment for other variables such as age, ejection fraction (EF) and QRS size, there was a trend for the abnormal QRS-T angle to identify patients with increased risk of inducing VT / VF during EPS (OR 3.95; CI 0.99-15.82; p = 0.052). The EF also emerged as a predictor of induction of VT / VF: for each point increase in EF, there was a 4% reduction in the rate of sustained ventricular arrhythmia on EPS.Conclusions:Changes in the QRS-T angle and decreases in EF were associated with an increased risk of induction of VT / VF on EPS.

Reproducibility and Reliability of the Quality of Life Questionnaire in Patients With Atrial Fibrillation

Abstract Background: Studies have shown the impact of atrial fibrillation (AF) on the patients' quality of life. Specific questionnaires enable the evaluation of relevant events. We previously developed a questionnaire to assess the quality of life of patients with AF (AFQLQ version 1), which was reviewed in this study, and new domains were added. Objective: To demonstrate the reproducibility of the AFQLQ version 2 (AFQLQ v.2), which included the domains of fatigue, illness perception and well-being. Methods: We applied 160 questionnaires (AFQLQ v.2 and SF-36) to 40 patients, at baseline and 15 days after, to measure inter- and intraobserver reproducibility. The analysis of quality of life stability was determined by test-retest, applying the Bartko intraclass correlation coefficient (ICC). Internal consistency was assessed by Cronbach's alpha test. Results: The total score of the test-retest (n = 40) had an ICC of 0.98 in the AFQLQ v.2, and of 0.94 in the SF36. In assessing the intra- and interobserver reproducibility of the AFQLQ v.2, the ICC reliability was 0.98 and 0.97, respectively. The internal consistency had a Cronbach's alpha coefficient of 0.82, compatible with good agreement of the AFQLQ v.2. Conclusion: The AFQLQ v.2 performed better than its previous version. Similarly, the domains added contributed to make it more comprehensive and robust to assess the quality of life of patients with AF.

Estudo bacteriológico de escarros de leprosos-tuberculosos em tratamento com a Estreptomicina

Fourteen samples of sputum from fourteen lepers with pulmonary tuberculosis, were treated by PETROFF method and its sediments were smeared on LOEWENSTEIN medium and incubated at 37°C. These fourteen patients are under treatment by Streptomycin. They are advanced cases of active leprosy associated with pulmonary tuberculosis, according to X ray diagnosis. Between 15 to 45 days thirteen out of fourteen (92,85%) sputa gave cultures of acid-fast bacilli with all characteristics of KOCH'S bacillus, eugonic type. Nine out of thirteen positive cases produced eugonic colonies in all ten tubes smeared with each sample. These facts proved that Streptomycin did not affect the pulmonary flora. Three out of fourteen patients died within two months after positive cultures of KOCH'S bacillus. New fact - Three out of those thirteen positive patients gave non-chromogenic cultures, eugonic type, associated with chromogenic ones, quite similar to cultures of acid-fast bacilli isolated previously by the author from leprous material. One of the three patients who died showed in smear of fresh sputum only characteristics globies (globies of MARCHOUX not globi of NEISSER) of HANSEN'S Bacillus. Probably he died from leprous-pneumonia. The eugonic type cultures are being inoculated in guinea-pigs and the choromogenic ones, similar to leprosy-culture, will be inoculated in white rats and mice.

Readiness to participate in psychiatric research.

BACKGROUND: The feasibility of clinical trials depends, among other factors, on the number of eligible patients, the recruitment process, and the readiness of patients to participate in research. Seeking patients' views about their experience in research projects may allow investigators to develop more effective recruitment and retention strategies. METHODS: A total of 100 patients consecutively admitted to a psychiatric university hospital were interviewed with respect to their willingness to participate in a study. For a different study scenario, patients were asked whether they would be ready to participate if such a study were organized in the service and to indicate their reasons for refusing or for participating. RESULTS: The general readiness to participate in a study ranged between 70% and 96%. The prospect of remuneration did not notably augment the potential consent rate. The most common and spontaneous motivation for agreeing to take part in a study was to help science progress and to allow future patients to benefit from improved diagnosis and treatment (87%). The presence or lack of a financial incentive was rarely chosen as an argument to agree (23%) or to refuse (7%) to participate. Patients relied mainly on their treating physicians when contemplating possible participation in a study (family physician [65%] and hospital physician [54%]). CONCLUSIONS: Clinicians and, in particular, treating doctors can play an important role in facilitating the recruitment process.

Critical evaluation of outcome scales to assess outcome after lateral ankle ligament repair

Introduction: Several scores are commonly used to evaluate patients' postoperative satisfaction after lateral ankle ligament repair, including: AOFAS, FAAM, CAIT and CAIS. Comparing published studies in the literature is difficult, as the same patient can have markedly different results depending on which scoring system is used. The current study aims to address this gap in the literature by developing a system to compare these tests, to allow better analysis and comparison of published studies. Patients and methods: This is a retrospective cohort study of 47 patients following lateral ankle ligament repair using a modified Broström-Gould technique. All patients were operated between 2005 and 2010 by a single surgeon and followed the same post operative rehabilitation protocol. Six patients were excluded from the study because of concomitant surgery. Patients were assessed by an independent observer. We used the Pearson correlation coefficient to analyse the concordance of the scores, as well as scatter plots to assess the linear relationship between them. Results: A linear distribution between the scores was found when the results were analysed using scatter plots. We were thus able to use the Pearson correlation coefficient to evaluate the relationship between each of the different postoperative scores. The correlation was found to be above 0.5 in all cases except for the comparison between the CAIT and the FAAM for the activities of daily living (0.39). We were, therefore, able to compare the results obtained and assess the relative concordance of the scoring systems. The results showed that the more specific the scale is, the worst the score is and inversely. So the CAIT and the CAIS appeared to be more severe than the AOFAS and the FAAM measuring the activities of daily living. The sports subscale of the FAAM demonstrated intermediate results. Conclusion: This study outlines a system to compare different postoperative scores commonly used to evaluate outcome after ankle stabilization surgery. The impact of this study is that it makes comparison of published studies easier, even though they use a variety of different clinical scores, thus facilitating better outcome analysis of operative techniques.

Appropriateness criteria for surgery improve clinical outcomes in patients with low back pain and/or sciatica.

STUDY DESIGN: Prospective, controlled, observational outcome study using clinical, radiographic, and patient/physician-based questionnaire data, with patient outcomes at 12 months follow-up. OBJECTIVE: To validate appropriateness criteria for low back surgery. SUMMARY OF BACKGROUND DATA: Most surgical treatment failures are attributed to poor patient selection, but no widely accepted consensus exists on detailed indications for appropriate surgery. METHODS: Appropriateness criteria for low back surgery have been developed by a multispecialty panel using the RAND appropriateness method. Based on panel criteria, a prospective study compared outcomes of patients appropriately and inappropriately treated at a single institution with 12 months follow-up assessment. Included were patients with low back pain and/or sciatica referred to the neurosurgical department. Information about symptoms, neurologic signs, the health-related quality of life (SF-36), disability status (Roland-Morris), and pain intensity (VAS) was assessed at baseline, at 6 months, and at 12 months follow-up. The appropriateness criteria were administered prospectively to each clinical situation and outside of the clinical setting, with the surgeon and patients blinded to the results of the panel decision. The patients were further stratified into 2 groups: appropriate treatment group (ATG) and inappropriate treatment group (ITG). RESULTS: Overall, 398 patients completed all forms at 12 months. Treatment was considered appropriate for 365 participants and inappropriate for 33 participants. The mean improvement in the SF-36 physical component score at 12 months was significantly higher in the ATG (mean: 12.3 points) than in the ITG (mean: 6.8 points) (P = 0.01), as well as the mean improvement in the SF-36 mental component score (ATG mean: 5.0 points; ITG mean: -0.5 points) (P = 0.02). Improvement was also significantly higher in the ATG for the mean VAS back pain (ATG mean: 2.3 points; ITG mean: 0.8 points; P = 0.02) and Roland-Morris disability score (ATG mean: 7.7 points; ITG mean: 4.2 points; P = 0.004). The ATG also had a higher improvement in mean VAS for sciatica (4.0 points) than the ITG (2.8 points), but the difference was not significant (P = 0.08). The SF-36 General Health score declined in both groups after 12 months, however, the decline was worse in the ITG (mean decline: 8.2 points) than in the ATG (mean decline: 1.2 points) (P = 0.04). Overall, in comparison to ITG patients, ATG patients had significantly higher improvement at 12 months, both statistically and clinically. CONCLUSION: In comparison to previously reported literature, our study is the first to assess the utility of appropriateness criteria for low back surgery at 1-year follow-up with multiple outcome dimensions. Our results confirm the hypothesis that application of appropriateness criteria can significantly improve patient outcomes.

Adjuvant early breast cancer systemic therapies according to daily used technologies.

Prognosis of early breast cancer patients is significantly improved with the use of adjuvant therapies. Various guidelines have been proposed to select patients who will derive the most benefit from such treatments. However, classifications have limited usefulness in subsets of patients such as those with node negative breast cancer. The 2007 St. Paul de Vence Clinical Practice Recommendations proposed to consider adjuvant therapy in accordance with the 10-year relapse-free survival reduction estimated by Adjuvant! Online. However, many limitations remain regarding the use of Adjuvant! Online. Among them, adverse prognostic and/or predictive factors such as vascular invasion, mitotic activity, progesterone receptor negativity, and HER-2 expression are not incorporated in the routine clinical decision process. Our group has therefore issued guidelines based on the consideration of both Adjuvant! Online calculations and the prognostic and/or predictive effects of these markers. In addition, web-accessible comprehensive tables summarizing these recommendations are provided.