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IntroductionRates of aneurysm occlusion with the pipeline embolization device (PED) has varied widely in the literature from 55.7% to 93.3% at 6 months, which may reflect a difference in technique including sizing and number of devices used.Methods140 cases at our institution were retrospectively reviewed, and aneurysms treated with a single PED vs. multiple were compared.ResultsComplete aneurysm occlusion was achieved in 86.9% at 6 months, 91.8% at 1 year, and 97.6% at longest follow-up. Retreatment with an additional device was required in 7 (5.1%). Major and minor complication rate within 30 days was 1.4% and 5.0%, and at greater than 30 days was 0.8% and 3.1%.Patients treated with multiple PEDs had significantly higher rates of aneurysm occlusion at 6 months (92.9% vs. 75.6%, p = 0.017) and 12 months (98.4% vs. 81.1%, p = 0.014), with no difference in complications. The two groups were similar aside from a higher number of ophthalmic and paraophthalmic aneurysms treated with multiple PEDs (23.4% vs. 6.5%, p = 0.004; and 35.1% vs. 17.4%, p = 0.020), and more posterior communicating artery and recurrent aneurysms treated with a single PED (28.3% vs. 3.2%, p = 0.001; 23.9% vs. 8.5%, p = 0.031). The use of multiple PEDs was found to be an independent predictor of aneurysm occlusion in a multivariate analysis (p = 0.015).ConclusionsThe use of multiple PEDs for intracranial aneurysms leads to significantly higher occlusion rates without added morbidity. This benefit is particularly appropriate for ophthalmic segment aneurysms, while more distal segments with eloquent perforating branches should be managed with caution. 相似文献
33.
Ángela M. Ortega-Galán M. Dolores Ruiz-Fernández Rocío Ortiz-Amo José Cabrera-Troya Inés M. Carmona-Rega Olivia Ibáñez-Masero 《Enfermería clínica》2019,29(1):10-17
Objective
To discover the experiences of end-of-life patients attended by the emergency services, through the discourse of the family caregivers who accompanied the family member in this care transit.Method
A qualitative approach study, based on the paradigm of hermeneutical phenomenology. In total, 81 family caregivers participated. The techniques used were the in-depth interview and the discussion group, with a total of 5 discussion groups and 41 interviews. The period of data collection was carried out between January 2013 and June 2014.Results
In the network of discourses obtained with respect to “Urgent Care”, all the codes were grouped in relation to a single argumentative line: deficiencies in urgent care. Among them, we found different dimensions that are established depending on the different times of care, or the different determinant aspects of these deficiencies: disorganization of the care received, lack of experience of the professionals in emergencies, application of general protocols in the emergency services, inadequate care in the treatment received, delays in emergency care.Conclusions
In general, we highlight the dissatisfaction of the family members with respect to the care received from the emergency services. The needs of these types of situation are not covered from these services and are of low quality. Therefore, it is necessary to reorient the care protocols for these patients. 相似文献34.
Holly Wagoner 《Teaching and learning in medicine》2019,31(3):270-278
Phenomenon: Academic health centers face significant challenges trying to improve medical education while meeting patient care needs. In response to problems with traditional forms of didactic education, many residency programs have transitioned to Academic Half Day (AHD), a curricular model in which learning is condensed into half-day blocks. In this model, trainees have protected educational time free from clinical responsibilities. However, an understanding of the impact on attending physicians and patient care when residents depart clinical sites for learning activities has not been well described. We sought to explore attending physicians’ perspectives when residents depart clinical sites to attend AHD. Approach: We performed a qualitative study with a grounded theory approach using individual semistructured interviews (December 2016–April 2017) of attending physicians who worked at inpatient and emergency department clinical sites from which residents departed to attend AHD. We used the constant comparative method, generating codes using an iterative approach and continuing sampling until saturation was reached. Major themes were identified and disagreements were resolved by consensus. Findings: Fifteen attending physicians from 6 clinical services were interviewed. Data analysis yielded 5 themes: emotional strain of workload, technology and systems challenges, patient safety and care concerns, disrupted resident learning, and the challenge to optimize resident education. Attending physicians, already working on busy services, felt frustrated and perceived having an increased workload when residents departed for AHD. They were concerned about safely entering orders in the electronic health record, impeded patient workflow, and further disruption of resident schedules already disrupted by duty hour restrictions and continuity clinic. Attending physicians described the importance of experiential learning from caring for patients and from structured didactic learning; however, the optimal balance was uncertain. Insights: We found that attending physicians experienced significant emotional strain, faced technological challenges, and were concerned about impeded workflow and patient safety when residents departed clinical sites for AHD. This is likely to be true whenever residents are pulled out of the clinical setting for any reason. Educators need to partner with hospital administrators to provide appropriate support for attending physicians when residents leave clinical sites, evaluate the effectiveness of different educational models, and determine how structured learning activities fit into the overall curriculum. 相似文献
35.
《Anaesthesia and Intensive Care Medicine》2020,21(8):422-426
A major incident is one that causes casualties on a scale beyond the usual capabilities of the emergency and healthcare services usual ability to manage. Major incident planning and rehearsal is vital to ensuring an appropriate response. Delivery of a major incident response requires command and co-ordination within and between emergency services, hospitals and specialist charitable organizations. Casualty management will require the set up of major incident infrastructure on scene to effectively extricate, triage, treat and transport casualties to appropriate facilities. There is a role for specialist doctors within the pre-hospital phase of managing a major incident, either within the ambulance command structure or operationally. Debrief and reviewing previous major incidents may identify individual, local and systemic factors that could be altered to improve the response to a future incident. 相似文献
36.
Yosuke Homma Takashi Shiga Hiraku Funakoshi Dai Miyazaki Atsushi Sakurai Yoshio Tahara Ken Nagao Naohiro Yonemoto Arino Yaguchi Naoto Morimura 《The American journal of emergency medicine》2019,37(2):241-248
Objective
This study assessed the association between the timing of first epinephrine administration (EA) and the neurological outcomes following out-of-hospital cardiac arrests (OHCAs) with both initial shockable and non-shockable rhythms.Methods
This was a post-hoc analysis of a multicenter prospective cohort study (SOS-KANTO 2012), which registered OHCA patients in the Kanto region of Japan from January 2012 to March 2013. We included consecutive adult OHCA patients who received epinephrine. The primary result included 1-month favorable neurological outcomes defined as cerebral performance category (CPC) 1 or 2. Secondary results included 1-month survival and return of spontaneous circulation (ROSC) after arrival at the hospital. Multivariable logistic regression analysis determined the association between delay per minute of the time from call to first EA in both pre- or in-hospital settings and outcomes.Results
Of the 16,452 patients, 9344 were eligible for our analyses. In univariable analysis, the delay in EA was associated with decreased favorable neurological outcomes only when the initial rhythm was a non-shockable rhythm. In multivariable analyses, delay in EA was associated with decreased ROSC (adjusted odds ratio [OR] for one minute delay, 0.97; 95% confidence interval [CI], 0.96–0.98) and 1-month survival (adjusted OR, 0.95; 95% CI, 0.92–0.97) when the initial rhythm was a non-shockable rhythm, whereas during a shockable rhythm, delay in EA was not associated with decreased ROSC and 1-month survival.Conclusions
While assessing the effectiveness of epinephrine for OHCA, we should consider the time-limited effects of epinephrine. Additionally, consideration of early EA based on the pathophysiology is needed. 相似文献37.
电子医疗数据已成为大数据时代开展药品安全主动监测的重要资源。基于此确认药品与不良事件是否存在关联,要回归传统的流行病学研究设计,选取恰当的对照进行对比。本文主要阐述不同对照选取的原理、适用情形,介绍、评价并比较各种对照选取的思路与参数,引入对照选择批量化实现的进展性成果,以期为我国利用电子医疗数据开展上市后药品安全性监测提供方法学参考。 相似文献
38.
39.
Rotary ventricular assist devices (VADs) are less sensitive to preload than the healthy heart, resulting in inadequate flow regulation in response to changes in patient cardiac demand. Starling‐like physiological controllers (SLCs) have been developed to automatically regulate VAD flow based on ventricular preload. An SLC consists of a cardiac response curve (CRC) which imposes a nonlinear relationship between VAD flow and ventricular preload, and a venous return line (VRL) which determines the return path of the controller. This study investigates the importance of a physiological VRL in SLC of dual rotary blood pumps for biventricular support. Two experiments were conducted on a physical mock circulation loop (MCL); the first compared an SLC with an angled physiological VRL (SLC‐P) against an SLC with a vertical VRL (SLC‐V). The second experiment quantified the benefit of a dynamic VRL, represented by a series of specific VRLs, which could adapt to different circulatory states including changes in pulmonary (PVR) and systemic (SVR) vascular resistance versus a fixed physiological VRL which was calculated at rest. In both sets of experiments, the transient controller responses were evaluated through reductions in preload caused by the removal of fluid from the MCL. The SLC‐P produced no overshoot or oscillations following step changes in preload, whereas SLC‐V produced 0.4 L/min (12.5%) overshoot for both left and right VADs. Additionally, the SLC‐V had increased settling time and reduced controller stability as evidenced by transient controller oscillations. The transient results comparing the specific and standard VRLs demonstrated that specific VRL rise times were improved by between 1.2 and 4.7 s ( = 3.05 s), while specific VRL settling times were improved by between 2.8 and 16.1 seconds ( = 8.38 s) over the standard VRL. This suggests only a minor improvement in controller response time from a dynamic VRL compared to the fixed VRL. These results indicate that the use of a fixed physiologically representative VRL is adequate over a wide variety of physiological conditions. 相似文献
40.