RESUMEN
The evidence supporting best practices when treating children in the prehospital setting or even the effect emergency medical services (EMS) has on patient outcomes is limited. Standardizing the critical outcomes for EMS research will allow for focused and comparable effort among the small but growing group of pediatric EMS investigators on specific topics. Standardized outcomes will also provide the opportunity to collectively advance the science of EMS for children and demonstrate the effect of EMS on patient outcomes. This article describes a consensus process among stakeholders in the pediatric emergency medicine and EMS community that identified the critical outcomes for EMS care in five clinical areas (traumatic brain injury, general injury, respiratory disease/failure, sepsis, and seizures). These areas were selected based on both their known public health importance and their commonality in EMS encounters. Key research outcomes identified by participating stakeholders using a modified nominal group technique for consensus building, which included small group brainstorming and independent voting for ranking outcomes that were feasible and/or important for the field.
Asunto(s)
Investigación sobre Servicios de Salud/normas , Evaluación de Resultado en la Atención de Salud/normas , Niño , Humanos , Medicina de Urgencia Pediátrica/organización & administraciónRESUMEN
OBJECTIVES: The Institute of Medicine (IOM)'s "Future of Emergency Care" report recommended the categorization and regionalization of emergency care, but no uniform system to categorize hospital emergency care capabilities has been developed. The absence of such a system limits the ability to benchmark outcomes, to develop regional systems of care, and of patients to make informed decisions when seeking emergency care. The authors sought to pilot the deployment of an emergency care categorization system in two states. METHODS: A five-tiered emergency department (ED) categorization system was designed, and a survey of all Pennsylvania and Wisconsin EDs was conducted. This 46-item survey described hospital staffing, characteristics, resources, and practice patterns. Based on responses, EDs were categorized as limited, basic, advanced, comprehensive, and pediatric critical care capable. Prehospital transport times were then used to determine population access to each level of care. RESULTS: A total of 247 surveys were received from the two states (247 of 297, 83%). Of the facilities surveyed, roughly one-quarter of hospitals provided advanced care, 10.5% provided comprehensive care, and 1.6% provided pediatric critical care. Overall, 75.1% of the general population could reach an advanced or comprehensive ED within 60 minutes by ground transportation. Among the pediatric population (age 14 years and younger), 56.2% could reach a pediatric critical care or comprehensive ED, with another 19.5% being able to access an advanced ED within 60 minutes. CONCLUSIONS: Using this categorization system, fewer than half of all EDs provide advanced or comprehensive emergency care. While the majority of the population has access to advanced or comprehensive care within an hour, a significant portion (25%) does not. This article describes how an ED categorization scheme could be developed and deployed across the United States. There are implications for prehospital planning, patient decision-making, outcomes measurement, interfacility transfer coordination, and development of regional emergency care systems.
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Servicios Médicos de Urgencia/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Niño , Femenino , Encuestas de Atención de la Salud , Hospitales , Humanos , Masculino , Pennsylvania , Proyectos Piloto , WisconsinAsunto(s)
América Latina , Electricidad , Política Ambiental , Consumo de Energía , Gestión Ambiental , Legislación , JúpiterRESUMEN
BACKGROUND & AIMS: Different parameters are considered predictors of bleeding and death in alcoholic cirrhosis. The aim of this study was to establish the prognostic value of a prospective and sequential evaluation of portal pressure, variceal size, and Pugh's score in portal-hypertensive patients with alcoholic cirrhosis but no previous bleeding. METHODS: Thirty patients were evaluated for 42 +/- 5 months (median, 39 months). After baseline studies, 30 patients underwent an additional evaluation (follow-up 1; median, 10 months), 20 patients a second evaluation (follow-up 2; median, 25 months), and 13 patients a third evaluation (follow-up 3; median, 45 months). No prophylactic treatment for bleeding was given. End points were bleeding and/or death. RESULTS: Seventeen patients died, and 10 patients bled. At follow-up 1, portal pressure decreased both in survivors and nonbleeders (from 18.7 +/- 1.0 to 15.2 +/- 1.3 mm Hg [P < 0.01] and from 18.9 +/- 0.8 to 16.5 +/- 1.0 mm Hg [P < 0.05], respectively). On multivariate analysis (Cox model), portal pressure at follow-up 1 had the best prognostic and independent value for both bleeding and survival. Subsequent studies showed similar trends. CONCLUSIONS: Measurements of portal pressure provide unique prognostic information for predicting portal hypertensive-related bleeding and mortality in patients with alcoholic cirrhosis.
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Venas Hepáticas/fisiopatología , Hipertensión Portal/fisiopatología , Cirrosis Hepática Alcohólica/fisiopatología , Presión Venosa , Adulto , Consumo de Bebidas Alcohólicas , Cateterismo , Endoscopía , Várices Esofágicas y Gástricas/complicaciones , Várices Esofágicas y Gástricas/patología , Femenino , Hemodinámica , Hemorragia/etiología , Humanos , Hipertensión Portal/complicaciones , Hipertensión Portal/mortalidad , Cirrosis Hepática Alcohólica/complicaciones , Cirrosis Hepática Alcohólica/mortalidad , Masculino , Persona de Mediana Edad , Análisis Multivariante , Pronóstico , Estudios Prospectivos , Análisis de SupervivenciaRESUMEN
The cellular nature of the infiltrate in the skin of patients with American cutaneous leishmaniasis was characterized by immunohistochemistry. The study population consisted of patients in Ceara, Brazil, an area where Leishmania braziliensis is endemic. Biopsies were taken from lesions present for 0.5-4 months duration and sections were stained with antibodies to T cells, T cell subsets, B cells, and macrophage markers to quantitate these cell types. The T cells accounted for 37.0 +/- 7.6% (mean +/- SD) of the infiltrate. The average percentages of CD4- and CD8-positive T cells were similar to each other, 20.4 +/- 9.0% and 19.9 +/- 6.7%, respectively. Interleukin-2 receptor-positive cells and B cells were infrequent, 3.7 +/- 3.0% and 2.3 +/- 3.1%, respectively. When the relationship between the age of the lesion at biopsy and the cellular phenotype was examined, it was noted that the percentage of positive cells remained fixed for all cell types except for that of gamma delta cells, which decreased with time. It is likely that gamma delta T cells are important in the early phase of the immune response to L. braziliensis and may, in general, be important in the early immune response of granulomatous diseases.
Asunto(s)
Leishmania braziliensis/inmunología , Leishmaniasis Cutánea/inmunología , Piel/inmunología , Adolescente , Adulto , Animales , Anticuerpos Monoclonales/inmunología , Biopsia , Relación CD4-CD8 , Niño , Preescolar , Femenino , Humanos , Inmunidad Celular , Técnicas para Inmunoenzimas , Inmunofenotipificación , Lactante , Leishmania braziliensis/aislamiento & purificación , Masculino , Persona de Mediana Edad , Piel/parasitología , Piel/patologíaRESUMEN
To development a reliable murine model of Leishmania braziliensis braziliensis infection, parasites were injected into BALB/c mice in the presence of phlebotomine sand fly salivary gland lysates, which have previously been shown to greatly increase the infectivity of L. major in mice. When injected with salivary gland lysates, L. braziliensis braziliensis produced progressively enlarging cutaneous nodules, containing many macrophages filled with Leishmania amastigotes. In contrast, L. braziliensis injected without gland extracts produced small and rapidly regressing lesions. Isoenzyme analysis, monoclonal antibodies, and the polymerase chain reaction with L. braziliensis-specific oligonucleotide primers and probes confirmed that parasites causing the lesions were L. braziliensis.