RESUMO
OBJECTIVES: More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures. METHODS: We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program. RESULTS: Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%). CONCLUSIONS: Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.
Assuntos
Serviço Hospitalar de Emergência/organização & administração , Telemedicina/métodos , Triagem/métodos , Adulto , Benchmarking , Feminino , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pacientes Desistentes do Tratamento/estatística & dados numéricos , Fatores de Tempo , Recusa do Paciente ao Tratamento/estatística & dados numéricosRESUMO
BACKGROUND: Voriconazole is an antifungal agent with in vitro activity and clinical efficacy against yeasts, molds, and dimorphic fungi (eg, Paracoccidioides brasiliensis). The safety profile of voriconazole includes transient visual adverse events (VAEs) that resolve while undergoing treatment or after its discontinuation. OBJECTIVE: The goal of this study was to assess the long-term (ie, 6-12 months) visual safety of voriconazole in adult patients with paracoccidioidomycosis. METHODS: Ophthalmic data were prospectively collected as part of a multicenter, open-label, comparative study. Patients aged ≥18 years with paracoccidioidomycosis were randomized in a 2:1 ratio to receive either voriconazole (200 mg BID orally, after the loading dose of 400 mg BID on day 1) or itraconazole (100 mg BID orally, with no loading dose). Patients were expected to receive treatment for a minimum of 6 months, or longer if needed as determined by the investigator (maximum duration, 1 year). Visual function tests and safety assessments were performed at baseline, week 12, week 24, end of treatment (EOT), and 8 weeks post-EOT. Ophthalmic examinations included visual acuity, color vision, contrast sensitivity, visual field, funduscopy, and slit lamp biomicroscopy. Treatment compliance was monitored via pill counts at each study visit. RESULTS: Thirty-five patients (mean age, 48 years; 96.2% male; 83.0% white) were randomized to receive voriconazole and 18 to receive itraconazole. Fourteen voriconazole-treated patients received >6 months of treatment (median, 169 days). Efficacy and overall safety results have been published previously. Sixteen voriconazole-treated patients and 2 itraconazole-treated patients experienced drug-related VAEs; none was considered serious or severe or led to dose reductions or resulted in discontinuation. Overall, visual examination results were not clinically significantly different between patients treated with voriconazole or itraconazole. There was no apparent relationship between changes in visual function test results and the occurrence of VAEs in either treatment group. CONCLUSION: Clinical assessment in this study found no evidence of an effect of voriconazole on long-term visual function in these adult patients with paracoccidioidomycosis.
Assuntos
Antifúngicos/efeitos adversos , Olho/efeitos dos fármacos , Paracoccidioidomicose/tratamento farmacológico , Pirimidinas/efeitos adversos , Triazóis/efeitos adversos , Visão Ocular/efeitos dos fármacos , Antifúngicos/administração & dosagem , Antifúngicos/uso terapêutico , Brasil , Esquema de Medicação , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Oftalmoscópios , Pirimidinas/administração & dosagem , Pirimidinas/uso terapêutico , Fatores de Tempo , Triazóis/administração & dosagem , Triazóis/uso terapêutico , Acuidade Visual/efeitos dos fármacos , Testes de Campo Visual , VoriconazolRESUMO
OBJECTIVES: We studied a novel pancreatic enzyme product, ALTU-135, a proprietary formulation of microbially derived lipase, protease, and amylase, to determine its efficacy and safety in treatment of pancreatic insufficiency (PI) in patients with cystic fibrosis (CF). STUDY DESIGN: Ambulatory subjects with CF-PI (n = 117) had baseline coefficient of fat and nitrogen absorption (CFA and CNA, respectively) determined in an inpatient setting while not receiving pancreatic enzyme replacement therapy. Subjects were then randomized to treatment with ALTU-135 containing 5000 (low), 25,000 (mid), or 100,000 (highest) units of lipase (1:1:0.15 of lipase:protease:amylase) for 28 days. After 14 days, CFA and CNA were re-measured. The primary outcomes were change from baseline in CFA and CNA between treatments. RESULTS: Treatment CFA was significantly greater in the mid and highest dose groups compared with that in the low dose group (P = .0229 and P =.0041, respectively); findings were similar for CNA. Subjects with baseline CFA < or = 40% and > 40% in the 2 higher dose groups had a mean increase of 31 and 8 percentage points in CFA, respectively (P < .0001). CONCLUSION: ALTU-135 was efficacious during the 1-month study period at the dose of 25,000 units of lipase, 25,000 units of protease, and 3750 units of amylase.
Assuntos
Amilases/uso terapêutico , Fibrose Cística/complicações , Insuficiência Pancreática Exócrina/tratamento farmacológico , Insuficiência Pancreática Exócrina/enzimologia , Lipase/uso terapêutico , Peptídeo Hidrolases/uso terapêutico , Adolescente , Adulto , Amilases/administração & dosagem , Amilases/efeitos adversos , Análise de Variância , Glicemia/metabolismo , Criança , Fibrose Cística/enzimologia , Relação Dose-Resposta a Droga , Método Duplo-Cego , Insuficiência Pancreática Exócrina/complicações , Gorduras/análise , Gorduras/metabolismo , Fezes/química , Feminino , Seguimentos , Humanos , Absorção Intestinal/efeitos dos fármacos , Lipase/administração & dosagem , Lipase/efeitos adversos , Masculino , Nitrogênio/análise , Nitrogênio/metabolismo , Peptídeo Hidrolases/administração & dosagem , Peptídeo Hidrolases/efeitos adversos , Resultado do TratamentoRESUMO
Arbuscular mycorrhizal fungi (AMF) are able to increase root enzymatic activity of acid and alkaline phosphatases. However, the role of AMF on phosphatase activity has not been reported in papaya (Carica papaya L.), which is frequently established at places with soil phosphorus (P) deficiencies. The goals of this research were to determine the effect of Glomus claroideum (Gc), and plant growth promoting rhizobacterium Azospirillum brasilense strain VS7 [Ab]) on root phosphatase activity and seedling growth of Carica papaya L. cv. Red Maradol under low P conditions. There were four treatments-colonization with: 1) Gc, 2) Ab, 3) Gc+Ab, and 4) non-inoculated seedlings. Plants were established in a coarse sand:sandy loam substrate under P-limitation (11 microg P ml(-1)), supplied with a modified Long Ashton Nutrient Solution. Seedling growth was severely reduced by low P. Gc+Ab inoculated plants had greater total dry matter and leaf area than non-colonized plants. Gc-inoculated plants had greater leaf area than non-colonized plants. Treatments did not differ in leaf area ratio, specific leaf area and, total chlorophyll content. There was a non-significant effect on stem relative growth rate with Gc and Gc+Ab plants. Mycorrhizal colonization enhanced the bacterial population 3.4-fold in the Gc+Ab treatment compared with the population quantified in Ab treatment. Soluble and extractable root acid phosphatase activity (RAPA) was higher in Gc inoculated plants. We discussed on the possible relation among both inoculated microorganisms and also with the P-limitation which plants were established.
Assuntos
Fosfatase Ácida/análise , Azospirillum brasilense/fisiologia , Carica/microbiologia , Fungos/fisiologia , Micorrizas/fisiologia , Proteínas de Plantas/análise , Raízes de Plantas/enzimologia , Agricultura/métodos , Carica/enzimologia , Carica/crescimento & desenvolvimento , Clorofila/análise , Fósforo/farmacologia , Folhas de Planta/crescimento & desenvolvimento , Raízes de Plantas/microbiologia , Brotos de Planta/crescimento & desenvolvimento , Plântula/crescimento & desenvolvimento , Solo/análiseRESUMO
OBJECTIVE: To examine complications and treatment of varicella-zoster virus (VZV) infections in children infected with human immunodeficiency virus type 1 (HIV-1). METHODS: Cases of VZV infection were identified retrospectively by reports to the department of health services and review of medical charts. The CD4+ cell counts were correlated with severity and frequency of VZV episodes. RESULTS: We identified 117 episodes of VZV infection in 73 HIV-1-infected children between Aug. 21, 1986, and Dec. 1, 1993. The most common complications were recurrence and persistence; 38 children (53%) had 69 recurrent episodes of VZV infection. The majority of children (61%) had zoster during the first recurrent episode, and 32% had a disseminated eruption typical of varicella. There was a strong association between an increasing number of episodes of VZV infection and low CD4+ cell count (p = 0.0008). In a subgroup followed for at least 2 years after their primary varicella episode, 10 of 22 children had a recurrence. Persistence of VZV infection was documented in 10 of 73 children, whereas other complications were rare. Thirty-three children (45%) were hospitalized and received acyclovir intravenously. CONCLUSION: Primary, recurrent, and persistent VZV infections are a frequent cause of morbidity and hospitalization for HIV-1-infected children. Studies of improved preventive and therapeutic agents are urgently needed in this population.