Outpatient Follow-up Of Patients Research Articles

Remote Symptom Monitoring Using Patient-Reported Outcomes in Patients With Chronic Kidney Disease: Process Evaluation of a Randomized Controlled Trial.

In Denmark, outpatient follow-up for patients with chronic kidney disease (CKD) is changing from in-hospital visits toward more remote health care delivery. The nonuse of remote patient-reported outcomes (PROs) is a well-known challenge, and it can be difficult to explain which mechanisms of interventions influence the outcome. Process evaluation may, therefore, be used to answer important questions on how and why interventions work, aiming to enhance the implications for clinical practice. This study aimed to provide insight into the intervention process by evaluating (1) the representativity of the study population, (2) patient and physician use patterns, (3) patient adherence to the intervention, and (4) clinical engagement. A process evaluation determining the reach, dose, fidelity, and clinical engagement was carried out, alongside a multicenter randomized controlled trial (RCT). We developed and implemented an intervention using PRO measures to monitor outpatients remotely. Data were collected for the PRO intervention arms in the RCT from 4 sources: (1) PRO data from the participants to determine personal factors, (2) the web-based PRO system to identify key usage intervention patterns, (3) medical records to identify clinical factors relating to the use of the intervention, and (4) semistructured interviews conducted with involved physicians. Of the 320 patients invited, 152 (47.5%) accepted to participate. The study population reflected the target population. The mean adherence rate to the PRO intervention arms was 82% (95% CI 76-87). The questionnaire response rate was 539/544 (99.1%). A minority of 13 (12.9%) of 101 patients needed assistance to complete study procedures. Physicians assessed 477/539 (88.5%) of the questionnaires. Contact was established in 417/539 (77.4%) of the cases, and 122/539 (22.6%) of the patients did not have contact. Physicians initiated 288/417 (69.1%) and patients requested 129/417 (30.9%) of all the contacts. The primary causes of contact were clinical data (242/417, 58%), PRO data (92/417, 22.1%), and medication concerns and precautionary reasons (83/417, 19.9%). Physicians found the use of PRO measures in remote follow-up beneficial for assessing the patient's health. The inclusion of self-reported clinical data in the questionnaire motivated physicians to assess patient responses. However, some barriers were emphasized, such as loss of a personal relationship with the patient and the risk of missing important symptoms in the absence of a face-to-face assessment. This study demonstrates the importance and practical use of remote monitoring among patients with CKD. Overall, the intervention was implemented as intended. We observed high patient adherence rates, and the physicians managed most questionnaires. Some physicians worried that distance from the patients made it unfeasible to use their "clinical glance," posing a potential risk of overlooking crucial patients' symptoms. These findings underscore key considerations for the implementation of remote follow-up. Introducing a hybrid approach combining remote and face-to-face consultations may address these concerns. ClinicalTrials.gov NCT03847766; https://clinicaltrials.gov/study/NCT03847766.

(O-22) EPIDEMIOLOGICAL PROFILE OF PATINTS UNDERGOING VASECTOMY REVERSATION AT PEDRO ERNESTO UNIVERSITY HOSPITAL

Abstract Introduction Review of vasectomy reversal cases operated in the Urology department of HUPE. From January 2012 to January 2023, 61 vasectomy reversals were performed at Hospital Universitário Pedro Ernesto to correct obstructive azoospermia, with patients' ages ranging from 33 to 70 years and vasectomy time ranging from 2 to 15 years. Patients, except those who did not return for followup despite instructions, were followed up on an outpatient basis with sperm analysis 30 days after surgery and then every six months until the end of follow-up. Among the 42 patients who maintained outpatient follow-up (68% of the total), our casuistry presents 31 reverted patients (73% of this group), that is, with viable spermatozoa present in the spermogram. Of these, 4 patients managed to generate a pregnancy (12% of the reverted ones), with children still alive to date, 5 are no longer trying for personal reasons (16% of the reverted ones), and 22 are still trying (70% of the reverted ones). 11 patients were unsuccessful in reversal (26% of those who followed up). 19 patients lost outpatient follow-up (32% of the total). Objectives To observe the epidemiology of operated patients, analyzing the effectiveness of the procedure and understanding the fate of operated patients. Methods Work without control group, case series. Results High reversal rate, but with a low pregnancy rate and significant rate of loss to outpatient followup. Conclusion Through the analytical observation of epidemiology, outline conducts mainly regarding the outpatient follow-up of patients, given the high rate of loss to follow-up. Financing No conflict.

Left Gastric Vein Direct Anastomosis as Alternative to Portal Flow Reconstruction in Liver Transplantation.

The most relevant limiting factor for performing end-to-end anastomosis is portal vein thrombosis (PVT), which leads to challenging vascular reconstructions. This study aimed to analyze a single center's experience using the left gastric vein (LGV) for portal flow reconstruction in liver transplantation (LT). This retrospective observational study reviewed laboratory and imaging tests, a description of the surgical technique, and outpatient follow-up of patients with portal system thrombosis undergoing LT with portal flow reconstruction using the LGV. This study was conducted at a single transplant reference center in the northeast region of Brazil from January 2016 to December 2021. Between January 2016 and December 2021, 848 transplants were performed at our center. Eighty-two patients (9.7%) presented with PVT, most of whom were treated with thrombectomy. Nine patients (1.1% with PVT) had extensive thrombosis of the portal system (Yerdel III or IV), which required end-to-side anastomosis between the portal vein and the LGV without graft, and had no intraoperative complications. All patients had successful portal flow in Doppler ultrasound control evaluations. The goal was to reestablish physiological flow to the graft. A surgical strategy includes using the LGV graft. According to our reports, using LGV fulfilled the requirements for excellent vascular anastomosis and even allowed the dispensing of venous grafts. This is the largest case series in a single center of reconstruction of portal flow with direct anastomosis with the LGV without needing a vascular graft.

Effectiveness of Drug Therapy in Abortion on Medical Indications in Hospital Conditions

BACKGROUND: The model in the Specialized Hospital of Obstetrics and Gynecology in Varna is becoming more and more widespread. The medical abortion, as a means of choice for behavior in abortion on medical indications, in hospital conditions, after the opinion of the commission to a hospital institution with a profile of specialty gynecology, and in case of abortion on request in hospital or pre-hospital medical activity. In Europe, this model has been in place for 30 years, and clinical experience shows that complications and mortality are many times lower than with surgery. MATERIALS AND METHODS: Conducted own survey for the period January 2021-July 2023 of 37 patients who went through a pregnancy termination committee on medical grounds. RESULTS AND DISCUSSION: About 89.2% of cases have a positive opinion of the commission in the hospital structure. Patients with higher education had better outpatient follow-up (χ2 = 12,662, p = 0.002). The greatest effectiveness is the three-fold administration of a drug regimen between 6 and 12 h (χ2 = 74,000, p = 0.000) and the gestation period of 12–20 g.w. (χ2 = 38.858, p = 0.025), and single drug administration during pregnancy (8–13 g.w.) (χ2 = 30.537, p = 0.006) and effect up to the 6th h (χ2 = 8.133, p = 0.004). CONCLUSION: The choice of a method of medical behavior is the result of a complex approach with regard to a number of factors related to pregnancy, general somatic status, and carried out diagnostic activities. An applied therapeutic approach reduces hospital costs, and the patient has a quick recovery period. Early and timely diagnosis and outpatient follow-up of patients in pre-hospital care are important informative values.

The Study of Adherence to Drug Therapy at the Stage of Outpatient Follow-up in Patients with Acute Myocardial Infarction (Data from the PROFIL-IM Registry)

Aim. To assess adherence to the recommended therapy at the stage of outpatient follow-up and its impact on long-term outcomes in patients after acute myocardial infarction based on the materials of the prospective PROFILE-IM registry.Material and methods. The PROFILE-IM register included 160 patients who applied to one of the polyclinics in Moscow after a myocardial infarction. The combined endpoint (CE) included death from any cause, cardiovascular events (nonfatal myocardial infarction, nonfatal cerebral stroke), emergency hospitalizations for cardiovascular diseases, significant cardiac arrhythmias. Patients' adherence to therapy was assessed using the original questionnaire "Scale of Adherence of the National Society of Evidence-based Pharmacotherapy" (NODF) and a direct standardized patient survey by a doctor about taking medications. Visits to the doctor were carried out every two months, data from the first year of patient follow-up are presented.Results. In a personal interview with a doctor, the ratio of the proportion of committed, partially committed and non-committed patients did not change significantly over the entire follow-up period, while the proportion of committed patients was 81-85%. The "NODF Adherence Scale" showed that the proportion of non-committed patients was about 10 times higher than with direct patient responses to the doctor, and the proportion of non-committed and partially committed patients remained high at all stages of follow-up (respectively 28% and 10% at the beginning of the study, 18% and 10% at the end of the study). Among the main factors of non-commitment, there was a decrease in the importance of forgetfulness and an increase in factors such as fear of side effects of medications, doubt about the need for long-term use of medications and well-being. A direct relationship of adherence with the male sex, the presence of hypertension, a feedback relationship with alcohol consumption was revealed. The risk of CE in non-committed patients was higher compared to the group of committed and partially committed patients (p<0.01).Conclusion. The proportion of non-committed and partially committed patients remained high at all stages of follow-up. There was a direct relationship between adherence to therapy with the male sex, the presence of hypertension in the anamnesis, and a feedback relationship with alcohol consumption. Low adherence to therapy significantly increased the risk of cardiovascular events.

Remote follow-up based on patient-reported outcomes in patients with chronic kidney disease: A qualitative study of patient perspectives.

Patient-reported outcomes (PROs) are increasingly used in outpatient follow-up. PRO-based remote follow-up offers a new healthcare delivery model, where PROs are used as the basis for outpatient follow-up in patients with chronic kidney disease. However, the patient's perspective of this novel remote care delivery remains unknown. This study aimed to explore the patients' experiences using PROs in remote care and how this mode of follow-up may enhance patient engagement. A qualitative approach was employed, guided by Focused Ethnography and Interpretive Description. Purposively, 15 patients with chronic kidney disease experienced with PRO-based remote follow-up in 3 renal outpatient clinics in the Central Denmark Region, were recruited. Field studies comprising participant observation in remote PRO consultations and individual, semi-structured interviews with the patients constituted the empirical data. Thematic analysis was performed according to Braun and Clarke's six-phase process. PRO-based remote follow-up may enhance patient engagement by a) improving communication, b) increasing disease knowledge, c) inducing flexibility, d) ensuring clinician feedback on PRO data, and e) prompting clinical action. Barriers to enhanced patient engagement were identified as a) lack of feedback on PRO data, b) lower disease knowledge, c) PRO in competition with biomedical data, and d) loss of personal relation. PRO-based follow-up in remote care holds several advantages for the patients. However, some barriers need clinical awareness before PROs may enhance the patients' engagement in remote follow-up. Future studies should explore the impact of involving relatives in PRO-based follow-up.

Bladder cancer: what's new in 2020-2021

This article aims to give an up-to-date review of studies on the diagnosis and treatment of patients with bladder cancer (BCa). We emphasize that the assessment of treatment and prognosis using specific markers is a promising method. However, clinical data currently outpace the results of molecular testing. Patients with luminal BCa demonstrate worse response to pharmacotherapy than those with other BCa types. The implementation of new drugs such as avelumab, enfortumab, and new drug combinations into clinical practice raised hopes to improve treatment outcomes of patients with locally advanced and metastatic bladder cancer. The development of new pharmacotherapy and immunotherapy regimens will improve treatment outcomes. We describe the experience of some foreign countries with the treatment and outpatient follow-up of patients after radical cystectomy. The article also contains the guidelines by the European Association of Urology on the treatment of patients with urinary tract cancers during the COVID-19 pandemic.

Results of specialized outpatient follow-up of patients with embolic stroke of undetermined source

Background. The article considers with the current problem of cryptogenic stroke and embolic stroke of undetermined source.The objective was to analyzed the results of follow-up of patients with embolic stroke of undetermined source in a specialized outpatient center.Methods and materials. The data of 169 patients who completed a two-year follow-up period with embolic stroke of undetermined source (ESUS) and cardioembolic stroke were analyzed.Results. We presented comparative results on the structure of incidence rate, age differences, comorbid pathology, as well as on the frequency of repeated cardiovascular events in groups with cardioembolic stroke and embolic stroke of undetermined source.Conclusions. Patients with ESUS are an extremely difficult category of patients for diagnostic search, for whom the actual task is to develop an examination algorithm for the earliest possible detection of the cause of stroke and to determine the optimal methods of secondary prevention.

Factors Associated With Adherence to Outpatient Follow-Up in Patients With Idiopathic Intracranial Hypertension (IIH).

Idiopathic intracranial hypertension (IIH) is a chronic condition characterized by raised intracranial pressure of undetectable origin, that causes morbidity due to debilitating headaches and vision loss. Continuity of outpatient care is important to monitor for permanent vision loss, manage symptoms and limit emergency care. The purpose of this retrospective study was to identify factors associated with neuro-ophthalmology follow-up appointment completion among patients with IIH at a US academic medical center in order to establish evidence-based interventions to improve adherence patterns. Included are 111 completed or no-show neuro-ophthalmology return outpatient appointments by 23 subjects with IIH. Generalized estimating equation models were used to assess association between appointment completion status and factors previously shown to be associated with appointment adherence. Appointments were more likely to be completed during the summer (p=0.08) and by subjects with headache symptoms (p=0.06), however none of the patient factors reached statistical significance. Completed and no-show appointments did not differ by subject demographic or insurance factors. Further studies are needed to identify risk factors for lack of appointment adherence by patients with IIH, particularly those amenable to intervention, in order to improve continuity of care for IIH.

Clinical Significance of the Head-Up Tilt Test in Improving Prognosis in Patients with Possible Neurally Mediated Syncope.

Simple SummarySeveral diseases can cause syncope, which is commonly known as fainting; however, syncope triggered by a reflex mechanism, also termed neurally mediated syncope (NMS), is one of the most common forms. While NMS is considered a benign disease, it can cause critical clinical events, such as severe trauma due to syncope. The head-up tilt test (HUTT) is one of the modalities for the diagnosis of NMS. The clinical significance of HUTT in the prognosis of NMS, such as recurrence rate of syncope and mortality, are still to be elucidated. This research aimed to clarify the value of HUTT for the diagnosis of NMS, and to investigate the prognosis of patients with NMS by analyzing the data of 101 patients with syncope and their close long-term (four years at the longest) follow-up. Furthermore, as insertable cardiac monitors (ICMs) are considered effective in patients with syncope, this study also aimed to evaluate the usefulness of ICM in patients with negative HUTT results. Finally, our research contributes to the improvement of the clinical management for patients with syncope.Syncope is commonly encountered in daily clinical practice. Depending on its etiology (benign or life-threatening conditions or environmental triggers), syncope can be neurally mediated (reflex), cardiac, or orthostatic. Furthermore, neurologic disease can cause symptoms that mimic syncope. However, there is limited research on neurally mediated syncope (NMS), which is considered a benign disorder, and close follow-ups are rarely performed. NMS can cause serious clinical events, including severe trauma and car accidents. The head-up tilt test (HUTT) is the gold standard for diagnosing NMS; however, its clinical significance remains unknown, and its relevance to NMS prognosis requires further research. This retrospective study aimed to assess the clinical significance of the HUTT for NMS. We reviewed the charts of 101 patients who underwent HUTT at Tokai University Hospital in Japan between January 2016 and March 2019. During the HUTT, 72 patients (69.2%) experienced syncope. Patients were followed up for 886.1 ± 457.7 days (interquartile range: 518–1293 days). The syncope recurrence rate was 16.9%; however, no significant difference was observed between the two groups (HUTT positive vs. negative) (13.8% vs. 18.1%, p = 0.772). Four of 29 (13.9%) and two of 72 (2.8%) patients in the negative and positive HUTT groups, respectively, experienced cardiac events (p = 0.019). Negative HUTT results may assist in anticipating unexpected clinical events within a few years. A negative HUTT result may allow us to reconsider the NMS diagnosis based on clinical information. Close outpatient follow-up of patients with negative HUTT results is warranted.

Феномен втрати маси тіла в пацієнтів із хронічною серцевою недостатністю

A characteristic sign of chronic heart failure (CHF) is a high frequency of comorbid conditions, one of which is the phenomenon of weight loss. Cardiac cachexia is a systemic metabolic disorder characterized by an unintentional decrease in body weight due to loss of all body components, namely, skeletal muscle, adipose tissue and bone tissue, and identified as a marker of nutritional status, has prognostic value in patients with CHF, regardless of age, NYHA class, left ventricular ejection fraction, and peak oxygen consumption. The article discusses the prevalence, criteria, prognostic significance of cardiac cachexia, as well as immune, metabolic and neurohormonal pathogenetic mechanisms that lead to anabolic-catabolic imbalance and contribute to the progression of CHF. Given the methodological difficulties of proper assessment of unintentional body weight loss over a certain previous period of outpatient follow-up in patients with CHF, it becomes urgent to determine the objective («static») characteristics of the nutritional status of patients, which are associated with an unfavorable clinical prognosis. The article demonstrates the results of our own research to determine prognostic factors based on indicators of the nutritional status of patients the clinical significance of the loss of individual body components is highlighted, preventive and therapeutic approaches to influence body weight loss in patients with CHF are described – nutritional support, neurohormonal blockade, the effect on the intestinal microflora, correction of anemia and iron deficiency, the use of appetite stimulants, immunomodulatory agents, anabolic hormones and physical training.

Comparison of Body Compositions Evaluated with Bioelectrical Impedance Analysis (BIA) with Metabolic, Hormonal and Anthropometric Measurements in PCOS Patients

Aim: In this study, it was aimed to compare the body composition parameters measured by BIA(Bioelectrical Impedance Analysis) and the metabolic, anthropometric and hormonal parameters of the PCOS patients with the healthy control group and to examine the effect of PCOS on body composition parameters. It is aimed to give a better direction to PCOS follow-up and treatment. Material and Method: 23 non-obese PCOS patients were involved to this prospective study. PCOS diagnosis was made according to the Rotterdam Consensus. Antropometric, metabolic and hormonal parameters were measured. Body compositions were measured by BIA. Results: When the relationship between body composition parameters and metabolic and hormonal values were examined, significant correlations were found. There was a negative correlation between AUC-insulin levels and SHBG while a significant positive correlation between free testosterone in hirsute women with PCOS. There was a significant negative correlation between free testosterone level increase and body fat ratio while a significant positive correlation between SHBG and body fat ratio. There was a significant negative correlation between DHEAS and BMI and the hip circumference. When the relationship between body composition and antropometric parameters were examined, a significant positive correlation was found between BMI and body fat ratio, total body water and basal metabolic rate in women with PCOS. Conclusion: In this study, significant correlations were found between body compositions and hormonal, metabolic and anthropometric parameters in patients with PCOS. Based on these findings, we believe that BIA can play an important role in outpatient follow-up of patients with PCOS.

Cardiometabolic Biomarkers and Their Temporal Patterns Predict Poor Outcome in Chronic Heart Failure (Bio-SHiFT Study).

Multiple hormonal and metabolic alterations occur in chronic heart failure (CHF), but their proper monitoring during clinically silent progression of CHF remains challenging. Hence, our objective was to explore whether temporal patterns of six emerging cardiometabolic biomarkers predict future adverse clinical events in stable patients with CHF. In 263 patients with CHF, we determined the risk of a composite end point of heart failure hospitalization, cardiac death, left ventricular assist device implantation, and heart transplantation in relation to serially assessed blood biomarker levels and slopes (i.e., rate of biomarker change per year). During 2.2 years of follow-up, we repeatedly measured IGF binding proteins 1, 2, and 7 (IGFBP-1, IGFBP-2, IGFBP-7), adipose fatty acid binding protein 4 (FABP-4), resistin, and chemerin (567 samples in total). Serially measured IGFBP-1, IGFBP-2, IGFBP-7, and FABP-4 levels predicted the end point [univariable hazard ratio (95% CI) per 1-SD increase: 3.34 (2.43 to 4.87), 2.86 (2.10 to 3.92), 2.45 (1.91 to 3.13), and 2.46 (1.88 to 3.24), respectively]. Independently of the biomarkers' levels, their slopes were also strong clinical predictors [per 0.1-SD increase: 1.20 (1.11 to 1.31), 1.27 (1.14 to 1.45), 1.23 (1.11 to 1.37), and 1.27 (1.12 to 1.48)]. All associations persisted after multivariable adjustment for patient baseline characteristics, baseline N-terminal pro-hormone brain natriuretic peptide and cardiac troponin T, and pharmacological treatment during follow-up. The temporal patterns of IGFBP-1, IGFBP-2, IGFBP-7, and adipose FABP-4 predict adverse clinical outcomes during outpatient follow-up of patients with CHF and may be clinically relevant as they could help detect more aggressive CHF forms and assess patient prognosis, as well as ultimately aid in designing more effective biomarker-guided therapy.

Exploring organisational mechanisms in PRO-based follow-up in routine outpatient care - an interpretive description of the clinician perspective

BackgroundPatient-reported outcome (PRO)-based follow-up is a new model of service delivery, where PRO measures are used as the very basis for demand-driven outpatient follow-up in patients with chronic diseases. Adopting the clinicians’ perspective, we aimed to explore what happens when PRO-based follow-up is implemented in routine clinical practice. We also aimed to identify organisational mechanisms related to PRO-based follow-up.MethodsThe methodological approach of this interview study is interpretive description, informed by a perspective of critical realism. Semi-structured interviews were conducted with 13 clinicians (eight nurses and five physicians) working with PRO-based follow-up in outpatient care for epilepsy in the Central Denmark Region.ResultsPRO-based follow-up gave rise to ambivalence in clinicians. Seen from the clinicians’ perspective, PRO-based follow-up could both increase and decrease the quality of follow-up. Moreover, PRO-based follow-up both enhanced and impaired clinicians’ work experiences. Additionally, the clinicians used strategies to ease some of the perceived disadvantages. The clinicians did extra tasks and worked around the scope of PRO-based follow-up. Thus, clinicians constituted a professional buffer as they deflected some of the negative mechanisms associated with PRO-based follow-up.ConclusionsAs a model of a service delivery, PRO-based follow-up is highly dependent on the clinicians’ day-to-day management of the system, and mechanisms related to routine use of PRO measures in outpatient follow-up are complex. Paying attention to the organisational settings is critical for PRO-based follow-up to improve quality of care and enhance patient-centred care.

Early ID Outpatient Follow-up of OPAT Patients Reduces 30-day Readmission

BackgroundAlthough weekly outpatient follow-up for patients discharged on outpatient parenteral antimicrobial therapy (OPAT) has been recommended, few practitioners follow this recommendation. No studies have examined the relationship between outpatient follow-up and patient outcomes for this population. We examined the association between outpatient ID follow-up and the risk for 30-day readmission for patients discharged on OPAT.MethodsWe conducted a retrospective cohort study using EMR data comprising 1102 OPAT patients treated between January 2012 and December 2014 at a major tertiary care medical center. We sought to determine whether ID outpatient follow-up was associated with a lower risk of 30-day readmission, after adjusting for patient demographics, infection diagnosis, outpatient antibiotics, and comorbidities (mainly diabetes mellitus, renal failure and immunosuppression).ResultsOf 1102 cases, 201 of 1102 (18%, 95 females, 106 males) were readmitted within 30 days, of whom 133 (66%) were re-admitted in the first 2 weeks post discharge. 837 (76%) were seen in ID outpatient follow-up within 30 days of discharge, of whom 396 (47%) were seen in first 2 weeks. By univariate analysis OPAT patients seen in ID outpatient follow-up within 2 weeks of discharge were less likely to get readmitted within 30 days of hospital discharge (OR: 0.6, CI: 0.4–0.9, P < 0.02). Patients with immunosuppression (OR: 1.9, 95% CI: 1.3–2.7, P < 0.0001) or discharged on 3 or more antimicrobials (OR: 2.1, 95% CI:1.4–3.2, P < 0.0001) were more likely to have 30-day readmission. By multivariate analysis patients seen in outpatient ID follow-up within 2 weeks (OR: 0.6, CI: 0.4–0.9, P < 0.006) or those receiving ceftriaxone alone (OR: 0.6, CI: 0.3–0.9, P < 0.015) were less likely to have 30-day readmission. Patients who were immunosuppressed (OR: 1.9, CI: 1.3–3.0, P < 0.003) or those discharged on 3 or more antimicrobials (OR: 2.1, CI: 1.4–3.2, P < 0.001) were more likely to have 30-day readmission.ConclusionInfectious disease outpatient follow-up within 2 weeks for patients discharged on OPAT reduces all-cause 30-day readmission. Early outpatient follow-up is especially important for patients who are immunosuppressed and those receiving multiple antibiotics.Disclosures All authors: No reported disclosures.

Mirizzi syndrome grades III and IV: surgical treatment.

: to evaluate the epidemiology and outcomes of surgical treatment of patients with Mirizzi Syndrome (MS) grades III and IV, the most advanced according to Csendes classification. : we conducted a retrospective, cross-sectional study by reviewing records of thirteen patients with grades III and IV MS operated from December 2001 to September 2013, among the 3,691 cholecystectomies performed in the period. : the incidence of MS was 0.6% (23 cases) and grades III and IV amounted to 0.35% of this number. There was a predominance of type IV (12 cases). The preoperative diagnosis was possible in 53.8% of cases. The preferred approach was biliary-digestive derivation (10 cases), and "T" tube drainage with suture of the bile duct was the choice in three special occasions. Three patients had biliary fistula resolved with clinical management, and one coliperitoneum case required reoperation. In the outpatient follow-up of patients who underwent biliodigestive anastomosis (eight), 50% are asymptomatic, 25% had anastomotic stricture and 25% lost follow-up. The mean follow-up was 41.8 months. : MS in advanced degrees has low incidence, preoperative diagnosis in only half of cases, and has the biliodigestive anastomosis as the best conduct, but not without morbidity. avaliar a epidemiologia e os resultados do tratamento cirúrgico de doentes portadores de graus III e IV, mais avançados, da Síndrome de Mirizzi (SM) de acordo com a classificação de Csendes. estudo retrospectivo, de corte transversal através da revisão de prontuários de 13 pacientes portadores de graus III e IV da SM operados de dezembro de 2001 a setembro de 2013, entre 3691 colecistectomias realizadas neste período. a incidência da SM foi 0,6% (23 casos) e os graus III e IV perfizeram 0,35% deste número. Houve um predomínio de tipo IV (12 casos). O diagnóstico pré-operatório foi possível em 53,8% dos casos. A conduta preferencial foi derivação biliodigestiva (10 casos) e foi optado por drenagem com tubo "T" e sutura da via biliar em três ocasiões especiais. Três pacientes apresentaram fístula biliar resolvida com conduta expectante e um caso de coleperitônio necessitou reoperação. No seguimento ambulatorial dos pacientes que realizaram a anastomose biliodigestiva (oito), 50% estão assintomáticos, 25% apresentaram estenose da anastomose e 25% perderam seguimento. O tempo médio de acompanhamento foi 41,8 meses. de incidência baixa e de diagnóstico pré-operatório em apenas metade dos casos, a SM em graus avançados tem na anastomose biliodigestiva sua melhor conduta, porém não isenta de morbimortalidade.

An Evaluation of BreastHealth Outpatient Follow-Up for Patients after Breast Cancer Surgery

An Evaluation of BreastHealth Outpatient Follow-Up for Patients after Breast Cancer Surgery

A Comparison of the Cost-Effectiveness of Hospital-Based Home Care With That of a Conventional Outpatient Follow-up for Patients With Mental Illness

The purpose of this study was to compare the outcomes of a hospital-based home-care model with those of a conventional outpatient follow-up for mentally ill patients in Taiwan by means of cost-effectiveness analysis. The study design was a two group posthoc design. We interviewed 40 mentally ill patients who were followed up in the psychiatric outpatient department. Another 40 mentally ill patients who participated in a hospital based home care program were also interviewed. The outcome measures we used for interviews were disease maintenance behavior, psychotic symptoms, social function, service satisfaction, and cost. The cost for each patient was the sum of costs for all direct mental health services. The cost-effectiveness ratio showed that the costs of the hospital-based home care model (4.3) were lower than those of conventional outpatient follow-up (13.5) and that over a one-year period, the hospital-based home care model was associated with improvements in mental conditions, social functional outcomes, and service satisfaction. The improved outcomes and the lower costs in the hospital-based home care program support the view that it is the most cost-effective of the two. Policy makers may consider this analysis as they allocate resources and develop policy for the care of mentally ill patients.

Bone turnover during inpatient nutritional therapy and outpatient follow-up in patients with anorexia nervosa compared with that in healthy control subjects

Osteopenia and osteoporosis are among the most frequent and severe complications in adolescents with anorexia nervosa. The aim of this study was to assess the influence of nutritional therapy on bone metabolism during adolescent anorexia nervosa. We studied 19 anorectic patients aged 14.1 +/- 1.4 y (x +/- SD) with a body mass index (BMI; in kg/m(2)) of 14.2 +/- 1.4 and 19 age-matched control subjects aged 15.1 +/- 2.3 y with a BMI of 20.8 +/- 1.9 for 1 y. Blood samples were taken for the measurement of bone markers, insulin-like growth factor I (IGF-I), and leptin. BMI rose significantly from 14.2 +/- 1.4 at baseline to 17.4 +/- 0.6 (P < 0.0001) at week 15. Compared with concentrations in the control subjects, concentrations of the bone formation markers procollagen type I propeptide (PICP) and bone alkaline phosphatase (bAP) in the anorectic patients were lower at baseline (PICP: P = 0.0071; bAP: P = 0.0012), increased with nutritional therapy (PICP: P = 0.0060, bAP: P = 0.0147), and were no longer significantly different (P > 0.05) during the follow-up period. Concentrations of IGF-I and leptin were significantly lower (P < 0.0001 for both) in the anorectic patients than in the control subjects at baseline. IGF-I increased with nutritional therapy but was still significantly lower (P = 0.0036) than that in the control group and decreased again during the follow-up period (P = 0.0126). In contrast, serum C-telopeptide decreased with nutritional therapy (P = 0.0446). Nutritional therapy improves concentrations of bone formation markers in adolescent patients with anorexia nervosa.

Evidence-Based Follow-up after Varicose Vein Surgery

Objective: To determine the optimum timing and need for outpatient follow-up of patients after varicose vein operations. Methods: Ninety-six consecutive patients undergoing varicose vein operations were enrolled. Patients completed linear analogue scales to record pain, bruising and swelling on postoperative days 1 to 10, 12, 14, 21 and 28. Return to daily activities, visits to the general practitioner (GP) and outpatient review at 6 weeks were recorded. Results: Maximum scores were on day 2 for swelling, day 4 for bruising, and days 1 and 6 for pain. Median time to return to work was 14 days (range 1-42 days). During the postoperative period 29 patients visited their GP, 24 (83%) within 2 weeks of operation. Median length of outpatient consultation at 6 weeks was 5 min. Although 57 patients found the appointment reassuring, none required further treatment. Conclusions: Outpatient follow-up after varicose vein operations cannot be justified on clinical grounds. The majority of patients who have postoperative problems develop them within the first 2 weeks, coinciding with the peaks of pain, swelling and bruising, and these problems can be dealt with in the community.