RESUMEN
Animal data have demonstrated increased block duration after local anaesthetic injections in diabetic rat models. Whether the same is true in humans is currently undefined. We, therefore, undertook this prospective cohort study to test the hypothesis that type-2 diabetic patients suffering from diabetic peripheral neuropathy would have increased block duration after ultrasound-guided popliteal sciatic nerve block when compared with patients without neuropathy. Thirty-three type-2 diabetic patients with neuropathy and 23 non-diabetic control patients, scheduled for fore-foot surgery, were included prospectively. All patients received an ultrasound-guided popliteal sciatic nerve block with a 30 ml 1:1 mixture of lidocaine 1% and bupivacaine 0.5%. The primary outcome was time to first opioid request after block procedure. Secondary outcomes included the time to onset of sensory blockade, and pain score at rest on postoperative day 1 (numeric rating scale 0-10). These outcomes were analysed using an accelerated failure time regression model. Patients in the diabetic peripheral neuropathy group had significantly prolonged median (IQR [range]) time to first opioid request (diabetic peripheral neuropathy group 1440 (IQR 1140-1440 [180-1440]) min vs. control group 710 (IQR 420-1200 [150-1440] min, p = 0.0004). Diabetic peripheral neuropathy patients had a time ratio of 1.57 (95%CI 1.10-2.23, p < 0.01), experienced a 59% shorter time to onset of sensory blockade (median time ratio 0.41 (95%CI 0.28-0.59), p < 0.0001) and had lower median (IQR [range]) pain scores at rest on postoperative day 1 (diabetic peripheral neuropathy group 0 (IQR 0-1 [0-5]) vs. control group 3 (IQR 0-5 [0-9]), p = 0.001). In conclusion, after an ultrasound-guided popliteal sciatic nerve block, patients with diabetic peripheral neuropathy demonstrated reduced time to onset of sensory blockade, with increased time to first opioid request when compared with patients without neuropathy.
Asunto(s)
Diabetes Mellitus Tipo 2/fisiopatología , Pie Diabético/fisiopatología , Pie Diabético/cirugía , Bloqueo Nervioso/métodos , Adulto , Anciano , Anciano de 80 o más Años , Analgésicos Opioides/administración & dosificación , Anestésicos Locales/administración & dosificación , Anestésicos Locales/farmacología , Estudios de Casos y Controles , Diabetes Mellitus Tipo 2/complicaciones , Pie Diabético/etiología , Esquema de Medicación , Femenino , Pie/cirugía , Humanos , Masculino , Persona de Mediana Edad , Dimensión del Dolor/métodos , Dolor Postoperatorio/prevención & control , Estudios Prospectivos , Nervio Ciático/diagnóstico por imagen , Nervio Ciático/efectos de los fármacos , Nervio Ciático/fisiopatología , Sensación/efectos de los fármacos , Factores de Tiempo , Ultrasonografía Intervencional , Adulto JovenRESUMEN
Up to 75% of pre-hospital trauma patients experience moderate to severe pain but this is often poorly recognised and treated with insufficient analgesia. Using multi-level logistic regression analysis, we aimed to identify the determinants of pre-hospital analgesia administration and choice of analgesic agent in a single helicopter-based emergency medical service, where available analgesic drugs were fentanyl and ketamine. Of the 1156 patients rescued for isolated limb injury, 657 (57%) received analgesia. Mean (SD) initial pain scores (as measured by a numeric rating scale) were 2.8 (1.8), 3.3 (1.6) and 7.4 (2.0) for patients who did not receive, declined, and received analgesia, respectively (p < 0.001). Fentanyl as a single agent, ketamine in combination with fentanyl and ketamine as a single agent were used in 533 (84%), 94 (14%) and 10 (2%) patients, respectively. A high initial on-scene pain score and a presumptive diagnosis of fracture were the main determinants of analgesia administration. Fentanyl was preferred for paediatric patients and ketamine was preferentially administered for severe pain by physicians who had more medical experience or had trained in anaesthesia.
Asunto(s)
Ambulancias Aéreas , Analgesia/métodos , Analgésicos/uso terapéutico , Servicios Médicos de Urgencia/métodos , Fracturas Óseas/complicaciones , Dolor/tratamiento farmacológico , Adulto , Analgésicos Opioides/uso terapéutico , Femenino , Fentanilo/uso terapéutico , Humanos , Ketamina/uso terapéutico , Masculino , Dolor/etiología , Dimensión del Dolor/estadística & datos numéricos , Estudios RetrospectivosRESUMEN
OBJECTIVES: Although infectious disease (ID) consultation has been associated with lower mortality in Staphylococcus aureus bloodstream infections, it is still not mandatory in many centers. This study aimed at assessing the impact of ID consultation on diagnostic and therapeutic management of methicillin-resistant S. aureus (MRSA) bacteremia. METHODS: Retrospective cohort study of all patients with MRSA bacteremia from 2001 to 2010. ID consultations were obtained on request between 2001 and 2006 and became mandatory since 2007. RESULTS: 156 episodes of MRSA bacteremia were included, mostly from central venous catheter (32%) and skin and soft tissue (19%) infections. ID consultation coverage was 58% between 2001 and 2006 and 91% between 2007 and 2010. ID consultation was associated with more echocardiography (59% vs. 26%, p < 0.01), vancomycin trough level measurements (99% vs. 77%, p < 0.01), follow-up blood cultures (71% vs. 50%, p = 0.05), deep-seated infections (43% vs. 16%, p < 0.01), more frequent infection source control (83% vs. 57%, p = 0.03), a longer duration of MRSA-active therapy (median and IQR: 17 days, 13-30, vs. 12, 3-14, p < 0.01) and a 20% reduction in 7-day, 30-day and in-hospital mortality. CONCLUSIONS: ID consultation was associated with a better management of patients with MRSA bacteremia and a reduced mortality.
Asunto(s)
Bacteriemia/tratamiento farmacológico , Bacteriemia/microbiología , Staphylococcus aureus Resistente a Meticilina , Derivación y Consulta , Infecciones de los Tejidos Blandos/tratamiento farmacológico , Infecciones Cutáneas Estafilocócicas/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Antibacterianos/administración & dosificación , Antibacterianos/sangre , Bacteriemia/diagnóstico , Bacteriemia/mortalidad , Sangre/microbiología , Infección Hospitalaria/diagnóstico , Infección Hospitalaria/tratamiento farmacológico , Infección Hospitalaria/microbiología , Infección Hospitalaria/mortalidad , Ecocardiografía , Femenino , Mortalidad Hospitalaria/tendencias , Humanos , Infectología , Masculino , Persona de Mediana Edad , Política Organizacional , Guías de Práctica Clínica como Asunto , Derivación y Consulta/tendencias , Estudios Retrospectivos , Infecciones de los Tejidos Blandos/diagnóstico , Infecciones de los Tejidos Blandos/microbiología , Infecciones de los Tejidos Blandos/mortalidad , Infecciones Cutáneas Estafilocócicas/diagnóstico , Infecciones Cutáneas Estafilocócicas/microbiología , Infecciones Cutáneas Estafilocócicas/mortalidad , Vancomicina/administración & dosificación , Vancomicina/sangreRESUMEN
BACKGROUND: Concerns about increased mortality could question the role of COPD chronic disease management (CDM) programmes. We aimed at extending a recent Cochrane review to assess the effects of CDM on mortality in patients with COPD. METHODS: Mortality data were available for 25 out of 29 trials identified in a COPD integrated care systematic review. Meta-analysis using random-effects models was performed, followed by subgroup analyses according to study length (3-12â months vs >12â months), main intervention component (exercise, self-management, structured follow-up) and use of an action plan. RESULTS: The meta-analysis showed no impact of CDM on mortality (pooled OR: 1.00, 95% CI 0.79 to 1.28). CONCLUSIONS: These results do not suggest that CDM programmes expose patients with COPD to excessive mortality risk.
Asunto(s)
Manejo de la Enfermedad , Enfermedad Pulmonar Obstructiva Crónica/mortalidad , Enfermedad Pulmonar Obstructiva Crónica/terapia , Humanos , Ensayos Clínicos Controlados Aleatorios como AsuntoRESUMEN
BACKGROUND: Prehospital oligoanalgesia is prevalent among trauma victims, even when the emergency medical services team includes a physician. We investigated if not only patients' characteristics but physicians' practice variations contributed to prehospital oligoanalgesia. METHODS: Patient records of conscious adult trauma victims transported by our air rescue helicopter service over 10 yr were reviewed retrospectively. Oligoanalgesia was defined as a numeric rating scale (NRS) >3 at hospital admission. Multilevel logistic regression analysis was used to predict oligoanalgesia, accounting first for patient case-mix, and then physician-level clustering. The intraclass correlation was expressed as the median odds ratio (MOR). RESULTS: A total of 1202 patients and 77 physicians were included in the study. NRS at the scene was 6.9 (1.9). The prevalence of oligoanalgesia was 43%. Physicians had a median of 5.7 yr (inter-quartile range: 4.2-7.5) of post-graduate training and 27% were female. In our multilevel analysis, significant predictors of oligoanalgesia were: no analgesia [odds ratio (OR) 8.8], National Advisory Committee for Aeronautics V on site (OR 4.4), NRS on site (OR 1.5 per additional NRS unit >4), female physician (OR 2.0), and years of post-graduate experience [>4.0 to ≤5.0 (OR 1.3), >3.0 to ≤4.0 (OR 1.6), >2.0 to ≤3.0 (OR 2.6), and ≤2.0 yr (OR 16.7)]. The MOR was 2.6, and was statistically significant. CONCLUSIONS: Physicians' practice variations contributed to oligoanalgesia, a factor often overlooked in analyses of prehospital pain management. Further exploration of the sources of these variations may provide innovative targets for quality improvement programmes to achieve consistent pain relief for trauma victims.
Asunto(s)
Dolor Agudo/tratamiento farmacológico , Dolor Agudo/epidemiología , Servicios Médicos de Urgencia/métodos , Heridas y Lesiones/terapia , Dolor Agudo/etiología , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Aeronaves , Analgesia/estadística & datos numéricos , Analgésicos Opioides/uso terapéutico , Femenino , Fentanilo/uso terapéutico , Escala de Coma de Glasgow , Necesidades y Demandas de Servicios de Salud , Humanos , Funciones de Verosimilitud , Masculino , Persona de Mediana Edad , Manejo del Dolor , Dimensión del Dolor , Curva ROC , Estudios Retrospectivos , Factores Sexuales , Centros Traumatológicos , Heridas y Lesiones/complicaciones , Adulto JovenRESUMEN
BACKGROUND: Hypotension, a common intra-operative incident, bears an important potential for morbidity. It is most often manageable and sometimes preventable, which renders its study important. Therefore, we aimed at examining hospital variations in the occurrence of intra-operative hypotension and its predictors. As secondary endpoints, we determined to what extent hypotension relates to the risk of post-operative incidents and death. METHODS: We used the Anaesthesia Databank Switzerland, built on routinely and prospectively collected data on all anaesthesias in 21 hospitals. The three outcomes were assessed using multi-level logistic regression models. RESULTS: Among 147,573 anaesthesias, hypotension ranged from 0.6% to 5.2% in participating hospitals, and from 0.3% up to 12% in different surgical specialties. Most (73.4%) were minor single events. Age, ASA status, combined general and regional anaesthesia techniques, duration of surgery and hospitalization were significantly associated with hypotension. Although significantly associated, the emergency status of the surgery had a weaker effect. Hospitals' odds ratios for hypotension varied between 0.12 and 2.50 (P < or = 0.001), even after adjusting for patient and anaesthesia factors, and for type of surgery. At least one post-operative incident occurred in 9.7% of the procedures, including 0.03% deaths. Intra-operative hypotension was associated with a higher risk of post-operative incidents and death. CONCLUSION: Wide variations remain in the occurrence of hypotension among hospitals after adjustment for risk factors. Although differential reporting from hospitals may exist, variations in anaesthesia techniques and blood pressure maintenance may also have contributed. Intra-operative hypotension is associated with morbidities and sometimes death, and constant vigilance must thus be advocated.
Asunto(s)
Anestesia , Hipotensión/epidemiología , Complicaciones Intraoperatorias/epidemiología , Adulto , Anciano , Estudios de Cohortes , Bases de Datos Factuales , Femenino , Hospitales/estadística & datos numéricos , Humanos , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Evaluación de Resultado en la Atención de Salud , Medición de Riesgo , Factores de Riesgo , Suiza , Adulto JovenRESUMEN
It is debated whether chronic hypertension increases the risk of cardiovascular incidents during anaesthesia. We studied all elective surgical operations performed in adults under general or regional anaesthesia between 2000 and 2004, in 24 hospitals collecting computerised clinical data on all anaesthetics since 1996. The focus was on cardiovascular incidents, though other anaesthesia-related incidents were also evaluated. Among 124,939 interventions, 27,881 (22%) were performed in hypertensive patients. At least one cardiovascular incident occurred in 7549 interventions (6% (95% CI 5.9-6.2%)). The average adjusted odds ratio of cardiovascular risk for chronic hypertension was 1.38 (95% CI 1.27-1.49). However, across hospitals, adjusted odd ratios varied from 0.41 up to 2.25. Hypertension did not increase the risk of other incidents. Hypertensive patients are still at risk of intra-operative cardiovascular incidents, while risk heterogeneity across hospitals, despite taking account of casemix and hospital characteristics, suggests variations in anaesthetic practices.
Asunto(s)
Hipertensión/complicaciones , Complicaciones Intraoperatorias/epidemiología , Adolescente , Adulto , Anciano , Anestesia/efectos adversos , Anestesia/métodos , Enfermedades Cardiovasculares/epidemiología , Enfermedades Cardiovasculares/etiología , Enfermedad Crónica , Procedimientos Quirúrgicos Electivos , Humanos , Hipertensión/epidemiología , Persona de Mediana Edad , Suiza/epidemiología , Adulto JovenRESUMEN
OBJECTIVES: Evaluation of the impact of the implementation of practice guidelines, with or without their reinforcement by a pharmacist, on the intra-hospital use of antibiotics. MATERIALS AND METHODS: The duration of antibiotic treatment, their cost, and the length of patient stay were compared in three secondary-care hospitals, before and after interventions that were designed to promote rational antibiotic use. After randomization, hospital A received no intervention (control), local practice guidelines were implemented in hospital B (low grade intervention), and these guidelines were reinforced by a clinical pharmacist in hospital C (high grade intervention). Adherence to the guidelines was measured in hospitals B and C. Multivariable statistical analyses were carried out to adjust for confounding factors. RESULTS: None of the outcomes measured in the 1200 included patients decreased between the two study periods in any hospital. Hospital A was significantly and independently associated with an increase in the duration of antibiotic treatments, the cost of antibiotics (acquisition and global costs), and the length of stay. Although these differences were not statistically significant, increases in hospital B were higher than in hospital C. Adherence to guidelines was significantly higher in hospital C. CONCLUSIONS: Even though interdisciplinary interventions aiming at rationalizing antibiotic use could not diminish the duration of treatments, their costs or the length of stay, they proved useful to control the progression of these parameters.
Asunto(s)
Antibacterianos/uso terapéutico , Grupo de Atención al Paciente , Servicio de Farmacia en Hospital , Guías de Práctica Clínica como Asunto , Antibacterianos/economía , Humanos , Tiempo de Internación/economía , Estudios ProspectivosRESUMEN
OBJECTIVES: To compare the response to ritonavir (RTV) plus saquinavir (SQV) with single protease inhibitor (PI) therapies among PI-naive HIV-1 infected individuals. METHODS: Response to treatment was analysed according to the intent-to-treat principle in a prospective observational cohort study of 177 patients who between May 1995 and March 2000 started a double PI therapy with RTV and SQV (nonboosting dosages) plus at least one nucleoside reverse transcriptase inhibitor (NRTI) and 2,214 patients with a single PI therapy plus two NRTIs. We used survival analysis and Cox's proportional hazard regression methods. The primary endpoint was the time to a plasma viral load of < 400 copies/mL. Secondary endpoints were taken as a gain in the CD4 count of >100 cells/microL, and change of initial PI for any reason. RESULTS: Baseline characteristics in both treatment groups were balanced. Median follow-up in both groups was 10.4 months. Time to an HIV-1 viral load of < 400 copies/mL and an increase in the CD4 count of >100 x 10(6) cells/L was shorter for RTV plus SQV compared with single PI regimens (log rank test for each endpoint P < 0.05). The adjusted hazard ratios of RTV plus SQV compared with single PI regimens were 1.21 (95% confidence interval 0.99-1.47) for achieving an HIV-1 viral load of < 400 copies/mL, 1.12 (0.88-1.42) for an increase in the CD4 count of > 100 cells/microL, and 0.90 (0.73-1.11) for change of first PI regimen. CONCLUSIONS: Treatment with RTV plus SQV compared with single PI regimens appeared to give similar results for virological or immunological response.
Asunto(s)
Infecciones por VIH/tratamiento farmacológico , Inhibidores de la Proteasa del VIH/administración & dosificación , Inhibidores de la Transcriptasa Inversa/administración & dosificación , Ritonavir/administración & dosificación , Saquinavir/administración & dosificación , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Recuento de Linfocito CD4 , Estudios de Cohortes , Quimioterapia Combinada , Femenino , Estudios de Seguimiento , Humanos , Masculino , Persona de Mediana Edad , Estudios Prospectivos , ARN Viral/sangre , Carga ViralRESUMEN
HIV infection, even when well controlled, may be associated with important mental health problems. We sought to investigate anxiety, depression, and health-related quality of life using screening measurements in patients with HIV infection and to examine their dependency on biosocial parameters relating to HIV. Prospective clinical, virologic, and immunologic data were obtained in a cross-sectional study within the Swiss HIV Cohort Study. Four self-reported questionnaires were used in 397 HIV-infected individuals. The scores for anxiety and depression were high as measured by the Hospital Anxiety and Depression Scale (HADS) and the State Trait Anxiety Inventory (STAI). Half the population scored <75 on a visual analog scale (VAS) Patients were also affected in their quality of life as measured by the HIV Medical Outcome Study (HIV-MOS). Almost all scores were significantly worse for intravenous drug users compared with other transmission groups. People who were employed, with a higher education or with higher CD4 count tended to score better, whereas those who had been hospitalized within the last 6 months, infected for a longer time, with higher viral load, or loss of weight scored significantly worse. A multivariate analysis showed higher education, being employed, low viral load, female gender, and shorter HIV disease duration to be associated with better scores. This study highlights the importance of mental health assessment regardless of HIV-disease parameters.
Asunto(s)
Atención Ambulatoria , Infecciones por VIH/psicología , Salud Mental , Adolescente , Adulto , Anciano , Ansiedad/etiología , Estudios de Cohortes , Femenino , Infecciones por VIH/complicaciones , Humanos , Masculino , Persona de Mediana Edad , Evaluación de Resultado en la Atención de SaludRESUMEN
OBJECTIVES: The aim of this retrospective study was to evaluate treatment outcome and characterize the pattern of genotype mutations in subjects with treatment failure on highly active antiretroviral therapy (HAART) containing nelfinavir or indinavir. STUDY DESIGN AND METHODS: The database of the Swiss HIV Cohort Study was screened for all subjects naive to protease inhibitor (PI) treatment who started HAART with nelfinavir or indinavir, responded initially (HIV-RNA <400 copies/ml) and received >24 weeks of treatment. Responders with subsequent treatment failure (HIV-RNA >1000 copies/ml, bordered by HIV-RNA >400 copies/ml) were selected for genotypic analysis. RESULTS: Initial treatment response, maintenance of response and subsequent virological failure were observed at a comparable frequency in 1143 nelfinavir and 1555 indinavir subjects. Of the treatment-naive patients, 13% who took nelfinavir and 16% who took indinavir had HIV-RNA >1000 copies/ml at least once. These values increased to 24 and 27%, respectively, for reverse transcriptase inhibitor-experienced subjects. Genotypic analysis in a subset of subjects with virological failure identified 30N as the only primary mutation in the nelfinavir subjects (8 out of 21, 38%) whereas isolated or combined 82A/T and 461/L mutations were detected in the indinavir subjects (9 out of 20, 45%). CONCLUSIONS: In this population of previously PI-naive subjects, the rate of virological failure and the frequency of resistance mutations at the time of virological failure were comparable in subjects receiving nelfinavir- or indinavir-containing HAART. In nelfinavir subjects, 30N was the only primary mutation whereas isolated or combined 82A/T and 461/L mutations were detected in indinavir subjects.
Asunto(s)
Síndrome de Inmunodeficiencia Adquirida/tratamiento farmacológico , Terapia Antirretroviral Altamente Activa , Farmacorresistencia Viral/genética , Inhibidores de la Proteasa del VIH/administración & dosificación , VIH-1 , Indinavir/efectos adversos , Mutación , Nelfinavir/administración & dosificación , Secuencia de Bases , Recuento de Linfocito CD4 , Humanos , Datos de Secuencia Molecular , ARN Viral/análisis , Inhibidores de la Transcriptasa Inversa/administración & dosificaciónRESUMEN
BACKGROUND AND OBJECTIVES: The Swiss HIV Cohort Study (SHCS) was initiated in 1988 and represented the main scientific component of the comprehensive response to the AIDS epidemic in Switzerland. It brought together physicians and scientists from five university hospitals (Basel, Berne, Geneva, Lausanne and Zurich) and two Cantonal hospitals (Lugano and St. Gallen). The objective of SHCS was, and still is, to produce rapid, high quality patient-oriented medical research in the field of HIV infection. METHODS: SHCS is a prospective population-based cohort study. Any HIV-infected person aged > or = 16 years is eligible to participate. Data collection and study procedures are standardised. Data quality and protocol monitoring are conducted at the coordination and data centre in Lausanne. Detailed information on demographics, income, mode of HIV acquisition, risk behaviours, clinical events, laboratory results, treatment and treatment tolerance is collected at registration and at 6-monthly intervals. RESULTS: Since 1996, 10,600 persons have been enrolled and the SHCS study population is considered fairly representative of the HIV-infected population in Switzerland, at least in terms of gender and mode of HIV acquisition. In 1999, 4600 patients were actively followed up and more than 70% of patients were receiving highly active antiretroviral therapy (HAART). As a consequence, mortality and the incidence of HIV-related opportunistic infections have decreased significantly in the recent past. Between 1996 and 2000, 91 original manuscripts have been published by SHCS scientists and physicians, almost exclusively in peer-reviewed journals. A wide range of scientific questions have been addressed, including HIV primary infection, the natural history of HIV infection, the clinical and biological impact of HAART, drug resistance, risk factors for disease evolution including the timing of treatment initiation, the role of CD4 receptors, the validity of HIV surveillance reports, determinants of treatment access and tolerance, clinical trials of new drug combinations, the interruption of prophylaxis following a favourable response to HAART and issues relating to quality of life and interaction between income, social level and disease evolution. CONCLUSION: The SHCS has had, and continues to have, a significant impact on medical practice, public health and research in Switzerland and beyond. It represents a network of excellence which has brought together and fostered intensive collaboration between physicians and institutions throughout this country and beyond. This was possible thanks to the support of the Federal Office of Public Health and the commitment of primary care physicians, researchers and patients. This project may be model for focused and prioritised multicentre and transdisciplinary research programmes.