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ABSTRACT: We conducted a systematic literature review and meta-analysis to assess the efficacy of alternative treatments for neurosyphilis. We searched MEDLINE, Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science from database inception to September 2023, for studies in neurosyphilis that compared penicillin monotherapy with other treatments. We focused on the impact of these therapies on treatment response, but also assessed data regarding reinfection and adverse drug events. Random-effect models were used to obtain pooled mean differences. Of 3415 screened studies, 6 met the inclusion criteria for the systematic literature review. Three studies provided quantitative data that allowed for inclusion in the meta-analysis. Our analysis revealed that the efficacy of intravenous (IV) ceftriaxone 2 g daily for 10 days (51 patients) did not appear statistically different compared with IV penicillin G 18 to 24 million units daily for 10 days (185 patients) for neurosyphilis (pooled odds ratio, 2.85; 95% confidence interval, 0.41-19.56; I 2 = 49%). No statistical difference between ceftriaxone and penicillin was identified in people living with human immunodeficiency virus (HIV) (pooled odds ratio, 4.51; 95% confidence interval, 0.50-40.49; I 2 = 34%). We concluded that alternative therapy with IV ceftriaxone appears similar to penicillin, potentially expanding treatment options for neurosyphilis. Other treatment options including doxycycline warrant further study.
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Antibacterianos , Neurossífilis , Humanos , Masculino , Antibacterianos/administração & dosagem , Antibacterianos/efeitos adversos , Ceftriaxona/administração & dosagem , Ceftriaxona/efeitos adversos , Infecções por HIV/tratamento farmacológico , Infecções por HIV/complicações , Neurossífilis/complicações , Neurossífilis/tratamento farmacológico , Penicilina G/administração & dosagem , Penicilina G/efeitos adversos , Penicilinas/administração & dosagem , Penicilinas/efeitos adversos , Resultado do TratamentoRESUMO
Background: Penicillin's long-standing role as the reference standard in syphilis treatment has led to global reliance. However, this dependence presents challenges, prompting the need for alternative strategies. We performed a systematic literature review and meta-analysis to evaluate the efficacy of these alternative treatments against nonneurological syphilis. Methods: We searched MEDLINE, the Cumulative Index to Nursing and Allied Health Literature, Embase, Cochrane, Scopus, and Web of Science from database inception to 28 August 2023, and we included studies that compared penicillin or amoxicillin monotherapy to other treatments for the management of nonneurological syphilis. Our primary outcome was serological cure rates. Random-effect models were used to obtain pooled mean differences, and heterogeneity was assessed using the I2 test. Results: Of 6478 screened studies, 27 met the inclusion criteria, summing 6710 patients. The studies were considerably homogeneous, and stratified analyses considering each alternative treatment separately revealed that penicillin monotherapy did not outperform ceftriaxone (pooled odds ratio, 1.66 [95% confidence interval, .97-2.84]; I2 = 0%), azithromycin (0.92; [.73-1.18]; I2 = 0%), or doxycycline (0.82 [.61-1.10]; I2 = 1%) monotherapies with respect to serological conversion. Conclusions: Alternative treatment strategies have serological cure rates equivalent to penicillin, potentially reducing global dependence on this antibiotic.
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BACKGROUND: Mechanical ventilation can injure lung tissue and respiratory muscles. The aim of the present study is to assess the effect of the amount of spontaneous breathing during mechanical ventilation on patient outcomes. METHODS: This is an analysis of the database of the 'Medical Information Mart for Intensive Care (MIMIC)'-III, considering intensive care units (ICUs) of the Beth Israel Deaconess Medical Center (BIDMC), Boston, MA. Adult patients who received invasive ventilation for at least 48 hours were included. Patients were categorized according to the amount of spontaneous breathing, i.e., ≥50% ('high spontaneous breathing') and <50% ('low spontaneous breathing') of time during first 48 hours of ventilation. The primary outcome was the number of ventilator-free days. RESULTS: In total, the analysis included 3,380 patients; 70.2% were classified as 'high spontaneous breathing', and 29.8% as 'low spontaneous breathing'. Patients in the 'high spontaneous breathing' group were older, had more comorbidities, and lower severity scores. In adjusted analysis, the amount of spontaneous breathing was not associated with the number of ventilator-free days [20.0 (0.0-24.2) vs. 19.0 (0.0-23.7) in high vs. low; absolute difference, 0.54 (95% CI, -0.10 to 1.19); P=0.101]. However, 'high spontaneous breathing' was associated with shorter duration of ventilation in survivors [6.5 (3.6 to 12.2) vs. 7.6 (4.1 to 13.9); absolute difference, -0.91 (95% CI, -1.80 to -0.02); P=0.046]. CONCLUSIONS: In patients surviving and receiving ventilation for at least 48 hours, the amount of spontaneous breathing during this period was not associated with an increased number of ventilator-free days.
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OBJECTIVE: Severity of illness scores used in critical care for benchmarking, quality assurance and risk stratification have been mainly created in high-income countries. In low and middle-income countries (LMICs), they cannot be widely utilized due to the demand for large amounts of data that may not be available (e.g. laboratory results). We attempt to create a new severity prognostication model using fewer variables that are easier to collect in an LMIC. SETTING: Two intensive care units, one private and one public, from São Paulo, Brazil PATIENTS: An ICU for the first time. INTERVENTIONS: None. MEASUREMENTS AND MAINS RESULTS: The dataset from the private ICU was used as a training set for model development to predict in-hospital mortality. Three different machine learning models were applied to five different blocks of candidate variables. The resulting 15 models were then validated on a separate dataset from the public ICU, and discrimination and calibration compared to identify the best model. The best performing model used logistic regression on a small set of 10 variables: highest respiratory rate, lowest systolic blood pressure, highest body temperature and Glasgow Coma Scale during the first hour of ICU admission; age; prior functional capacity; type of ICU admission; source of ICU admission; and length of hospital stay prior to ICU admission. On the validation dataset, our new score, named SEVERITAS, had an area under the receiver operating curve of 0.84 (0.82 - 0.86) and standardized mortality ratio of 1.00 (0.91-1.08). Moreover, SEVERITAS had similar discrimination compared to SAPS-3 and better discrimination than the simplified TropICS and R-MPM. CONCLUSIONS: Our study proposes a new ICU mortality prediction model using simple logistic regression on a small set of easily collected variables may be better suited than currently available models for use in low and middle-income countries.
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Estado Terminal/mortalidade , Países em Desenvolvimento , Mortalidade Hospitalar/tendências , Unidades de Terapia Intensiva/estatística & dados numéricos , Modelos Estatísticos , Índice de Gravidade de Doença , Benchmarking , Brasil/epidemiologia , Estado Terminal/epidemiologia , Feminino , Humanos , Aprendizado de Máquina , Masculino , Pessoa de Meia-Idade , Valor Preditivo dos Testes , Estudos RetrospectivosRESUMO
BACKGROUND: Datathons are increasingly organized in the healthcare field. The goal is to assemble people with different backgrounds to work together as a team and engage in clinically relevant research or develop algorithms using health-related datasets. Criteria to assess the return of investment on such events have traditionally included publications produced, patents for prediction, classification, image recognition and other types of software, and start-up companies around the application of machine learning in healthcare. Previous studies have not evaluated whether a datathon can promote affective learning and effective teamwork. METHODS: Fifty participants of a health datathon event in São Paulo, Brazil at Hospital Israelita Albert Einstein (HIAE) were divided into 8 groups. A survey with 25 questions, using the Affective Learning Scale and Team-Review Questionnaire, was administered to assess team effectiveness and affective learning during the event. Multivariate regression models and Pearson's correlation tests were performed to evaluate the effect of affective learning on teamwork. RESULTS: Majority of the participants were male 76% (37/49); 32% (16/49) were physicians. The mean score for learning (scale from 1 to 10) was 8.38, while that for relevance of the perceived teamwork was 1.20 (scale from 1 to 5; "1" means most relevant). Pearson's correlation between the learning score and perception of teamwork showed moderate association (râ¯=â¯0.36, pâ¯=â¯0.009). Five learning and 10 teamwork variables were on average positively graded in the event. The final regression model includes all learning and teamwork variables. Effective leadership was strongly correlated with affective learning (ßâ¯=â¯-0.27, pâ¯<â¯0.01, R2â¯=â¯75%). Effective leadership, team accomplishment, criticism, individual development and creativity were the variables significantly associated with higher levels of affective learning. CONCLUSION: It is feasible to enhance affective knowledge and the skill to work in a team during a datathon. We found that teamwork is associated with higher affective learning from participants' perspectives. Effective leadership is essential for teamwork and is a significant predictor of learning.
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Competência Clínica , Comportamento Cooperativo , Mineração de Dados/métodos , Informática Médica/métodos , Equipe de Assistência ao Paciente , Software , Adulto , Brasil , Feminino , Humanos , Liderança , Masculino , Pessoa de Meia-Idade , Percepção , Adulto JovemRESUMO
OBJECTIVE: Severity of illness scores rest on the assumption that patients have normal physiologic values at baseline and that patients with similar severity of illness scores have the same degree of deviation from their usual state. Prior studies have reported differences in baseline physiology, including laboratory markers, between obese and normal weight individuals, but these differences have not been analyzed in the ICU. We compared deviation from baseline of pertinent ICU laboratory test results between obese and normal weight patients, adjusted for the severity of illness. DESIGN: Retrospective cohort study in a large ICU database. SETTING: Tertiary teaching hospital. PATIENTS: Obese and normal weight patients who had laboratory results documented between 3 days and 1 year prior to hospital admission. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Seven hundred sixty-nine normal weight patients were compared with 1,258 obese patients. After adjusting for the severity of illness score, age, comorbidity index, baseline laboratory result, and ICU type, the following deviations were found to be statistically significant: WBC 0.80 (95% CI, 0.27-1.33) × 10/L; p = 0.003; log (blood urea nitrogen) 0.01 (95% CI, 0.00-0.02); p = 0.014; log (creatinine) 0.03 (95% CI, 0.02-0.05), p < 0.001; with all deviations higher in obese patients. A logistic regression analysis suggested that after adjusting for age and severity of illness at least one of these deviations had a statistically significant effect on hospital mortality (p = 0.009). CONCLUSIONS: Among patients with the same severity of illness score, we detected clinically small but significant deviations in WBC, creatinine, and blood urea nitrogen from baseline in obese compared with normal weight patients. These small deviations are likely to be increasingly important as bigger data are analyzed in increasingly precise ways. Recognition of the extent to which all critically ill patients may deviate from their own baseline may improve the objectivity, precision, and generalizability of ICU mortality prediction and severity adjustment models.
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Estado Terminal/classificação , Obesidade/complicações , Índice de Gravidade de Doença , Idoso , Estudos de Casos e Controles , Feminino , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Estudos RetrospectivosRESUMO
The creation of medical notes in software applications poses an intrinsic problem in workflow as the technology inherently intervenes in the processes of collecting and assembling information, as well as the production of a data-driven note that meets both individual and healthcare system requirements. In addition, the note writing applications in currently available electronic health records (EHRs) do not function to support decision making to any substantial degree. We suggest that artificial intelligence (AI) could be utilized to facilitate the workflows of the data collection and assembly processes, as well as to support the development of personalized, yet data-driven assessments and plans.
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OBJECTIVE: Physician shift schedules are regularly created manually, using paper or a shared online spreadsheet. Mistakes are not unusual, leading to last minute scrambles to cover a shift. We developed a web-based shift scheduling system and a mobile application tool to facilitate both the monthly scheduling and shift exchanges between physicians. The primary objective was to compare physician satisfaction before and after the mobile application implementation. METHODS: Over a 9-month period, three surveys, using the 4-point Likert type scale were performed to assess the physician satisfaction. The first survey was conducted three months prior mobile application release, a second survey three months after implementation and the last survey six months after. RESULTS: 51 (77%) of the physicians answered the baseline survey. Of those, 32 (63%) were males with a mean age of 37.8 ± 5.5 years. Prior to the mobile application implementation, 36 (70%) of the responders were using more than one method to carry out shift exchanges and only 20 (40%) were using the official department report sheet to document shift exchanges. The second and third survey were answered by 48 (73%) physicians. Forty-eight (98%) of them found the mobile application easy or very easy to install and 47 (96%) did not want to go back to the previous method. Regarding physician satisfaction, at baseline 37% of the physicians were unsatisfied or very unsatisfied with shift scheduling. After the mobile application was implementation, only 4% reported being unsatisfied (OR = 0.11, p < 0.001). The satisfaction level improved from 63% to 96% between the first and the last survey. Satisfaction levels significantly increased between the three time points (OR = 13.33, p < 0.001). CONCLUSION: Our web and mobile phone-based scheduling system resulted in better physician satisfaction.
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Médicos/psicologia , Adulto , Agendamento de Consultas , Atitude do Pessoal de Saúde , Feminino , Pesquisas sobre Atenção à Saúde/métodos , Humanos , Masculino , Aplicativos Móveis , Satisfação Pessoal , Relações Médico-PacienteRESUMO
INTRODUCTION: Current guidelines and consensus recommend arterial and venous samples as equally acceptable for blood glucose assessment in point-of-care devices, but there is limited evidence to support this recommendation. We evaluated the accuracy of two devices for bedside point-of-care blood glucose measurements using arterial, fingerstick and catheter venous blood samples in ICU patients, and assessed which factors could impair their accuracy. METHODS: 145 patients from a 41-bed adult mixed-ICU, in a tertiary care hospital were prospectively enrolled. Fingerstick, central venous (catheter) and arterial blood (indwelling catheter) samples were simultaneously collected, once per patient. Arterial measurements obtained with Precision PCx, and arterial, fingerstick and venous measurements obtained with Accu-chek Advantage II were compared to arterial central lab measurements. Agreement between point-of-care and laboratory measurements were evaluated with Bland-Altman, and multiple linear regression models were used to investigate interference of associated factors. RESULTS: Mean difference between Accu-chek arterial samples versus central lab was 10.7 mg/dL (95% LA -21.3 to 42.7 mg/dL), and between Precision PCx versus central lab was 18.6 mg/dL (95% LA -12.6 to 49.5 mg/dL). Accu-chek fingerstick versus central lab arterial samples presented a similar bias (10.0 mg/dL) but a wider 95% LA (-31.8 to 51.8 mg/dL). Agreement between venous samples with arterial central lab was the poorest (mean bias 15.1 mg/dL; 95% LA -51.7 to 81.9). Hyperglycemia, low hematocrit, and acidosis were associated with larger differences between arterial and venous blood measurements with the two glucometers and central lab. Vasopressor administration was associated with increased error for fingerstick measurements. CONCLUSIONS: Sampling from central venous catheters should not be used for glycemic control in ICU patients. In addition, reliability of the two evaluated glucometers was insufficient. Error with Accu-chek Advantage II increases mostly with central venous samples. Hyperglycemia, lower hematocrit, acidosis, and vasopressor administration increase measurement error.
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Análise Química do Sangue/normas , Glicemia/análise , Cuidados Críticos/normas , Sistemas Automatizados de Assistência Junto ao Leito/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Análise Química do Sangue/instrumentação , Cateteres Venosos Centrais/normas , Estudos Transversais , Precisão da Medição Dimensional , Feminino , Humanos , Unidades de Terapia Intensiva , Masculino , Pessoa de Meia-IdadeRESUMO
Biomarkers such as procalcitonin (PCT) have been studied to guide duration of antibiotic therapy. We aimed to assess whether a decrease in PCT levels could be used to reduce the duration of antibiotic therapy in intensive care unit (ICU) patients with a proven infection without risking a worse outcome. We assessed 265 patients with suspected sepsis, severe sepsis, or septic shock in our ICU. Of those, we randomized 81 patients with a proven bacterial infection into 2 groups: an intervention group in which the duration of the antibiotic therapy was guided by a PCT protocol and a control group in which there was no PCT guidance. In the per-protocol analysis, the median antibiotic duration was 9 days in the PCT group (n = 20) versus 13 days in the non-PCT group (n = 31), P = 0.008. This study demonstrates that PCT can be a useful tool for limiting antimicrobial therapy in ICU patients with documented bacterial infection.
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Antibacterianos/uso terapêutico , Infecções Bacterianas/sangue , Calcitonina/sangue , Precursores de Proteínas/sangue , Choque Séptico/tratamento farmacológico , Adulto , Idoso , Idoso de 80 Anos ou mais , Antibacterianos/economia , Infecções Bacterianas/tratamento farmacológico , Infecções Bacterianas/economia , Infecções Bacterianas/mortalidade , Biomarcadores/sangue , Peptídeo Relacionado com Gene de Calcitonina , Redução de Custos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Choque Séptico/sangue , Choque Séptico/economia , Choque Séptico/mortalidade , Resultado do TratamentoRESUMO
BACKGROUND: Approximately 150 million central venous catheters (CVC) are used each year in the United States. Catheter-related bloodstream infections (CR-BSI) are one of the most important complications of the central venous catheters (CVCs). Our objective was to compare the in-hospital mortality when the catheter is removed or not removed in patients with CR-BSI. METHODS: We reviewed all episodes of CR-BSI that occurred in our intensive care unit (ICU) from January 2000 to December 2008. The standard method was defined as a patient with a CVC and at least one positive blood culture obtained from a peripheral vein and a positive semi quantitative (>15 CFU) culture of a catheter segment from where the same organism was isolated. The conservative method was defined as a patient with a CVC and at least one positive blood culture obtained from a peripheral vein and one of the following: (1) differential time period of CVC culture versus peripheral culture positivity of more than 2 hours, or (2) simultaneous quantitative blood culture with ≥ 5:1 ratio (CVC versus peripheral). RESULTS: 53 CR-BSI (37 diagnosed by the standard method and 16 by the conservative method) were diagnosed during the study period. There was a no statistically significant difference in the in-hospital mortality for the standard versus the conservative method (57% vs. 75%, p = 0.208) in ICU patients. CONCLUSION: In our study there was a no statistically significant difference between the standard and conservative methods in-hospital mortality.