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De Oliveira L, Korkes H, Rizzo MD, Siaulys MM, Cordioli E. Magnesium sulfate in preeclampsia: Broad indications, not only in neurological symptoms. Pregnancy Hypertens 2024; 36:101126. [PMID: 38669914 DOI: 10.1016/j.preghy.2024.101126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Revised: 04/05/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024]
Abstract
The role of magnesium sulfate for treatment of eclampsia is well established. The medication proved to be superior to other anticonvulsants to reduce the incidence of recurrent convulsions among women with eclampsia. Additionally, magnesium sulfate has been indicated for women with preeclampsia with different severe features. However, despite these recommendations, many clinicians are still not confident with the use of magnesium sulfate, even in settings with high incidence of preeclampsia and unacceptable rates of maternal mortality. This review brings basic science and clinical information to endorse recommendations to encourage clinicians to use magnesium sulfate for patients with all severe features of preeclampsia, not only for women with neurological symptoms. Additionally, other benefits of magnesium sulfate in anesthesia and fetal neuroprotection are also presented. Finally, a comprehensive algorithm presents recommendations to manage patients with preeclampsia with severe features between 34 and 36+6 weeks.
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Affiliation(s)
- Leandro De Oliveira
- Hospital e Maternidade Santa Joana, Centro de Ensino, Pesquisa e Inovação, São Paulo, Brazil; Department of Gynecology & Obstetrics, Sao Paulo State University (UNESP), Medical School, Botucatu, SP, Brazil.
| | - Henri Korkes
- Hospital e Maternidade Santa Joana, Centro de Ensino, Pesquisa e Inovação, São Paulo, Brazil; Department of Obstetrics and Gynecology, Faculty of Medicine, Pontifícia Universidade Católica de São Paulo, São Paulo, SP, Brazil
| | - Marina de Rizzo
- Hospital e Maternidade Santa Joana, Centro de Ensino, Pesquisa e Inovação, São Paulo, Brazil
| | - Monica Maria Siaulys
- Hospital e Maternidade Santa Joana, Centro de Ensino, Pesquisa e Inovação, São Paulo, Brazil
| | - Eduardo Cordioli
- Hospital e Maternidade Santa Joana, Centro de Ensino, Pesquisa e Inovação, São Paulo, Brazil
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Giacometti CF, Galfano GS, Wajman DS, Cordioli E, Beck APA, Podgaec S. Internet use by pregnant women during prenatal care. Einstein (Sao Paulo) 2024; 22:eAO0447. [PMID: 38597463 DOI: 10.31744/einstein_journal/2024ao0447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 08/30/2023] [Indexed: 04/11/2024] Open
Abstract
OBJECTIVE The search for medical information on the internet is a part of people's daily lives. Exponential volumes of data are available through various media and platforms. There are several problems related to the ease of creating and accessing medical information on the internet, as evidenced by the quantity of false content and increasing anxiety due to the consumption of these data. In light of this accessibility, it is necessary to understand how people use internet-based medical information and its impact on specific populations. This prospective study aimed to analyze pregnant women's behavior when searching for health-related information on the internet, and how they were influenced by the information. METHODS Questionnaires were administered to the participants during their immediate puerperium, and their answers were tabulated. RESULTS Three hundred and two patients answered the questionnaires. We observed that internet use was frequent, and most patients discussed the findings with their physicians. However, this did not affect the delivery routes. CONCLUSION The search for health information by pregnant women is very prevalent but does not interfere with the delivery route.
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Affiliation(s)
| | | | | | | | | | - Sérgio Podgaec
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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Accorsi TAD, dos Santos GGR, Nemoto RP, Moreira FT, De Amicis K, Köhler KF, Cordioli E, Pedrotti CHS. Telemedicine and patients with heart failure: evidence and unresolved issues. Einstein (Sao Paulo) 2024; 22:eRW0393. [PMID: 38451690 PMCID: PMC10948100 DOI: 10.31744/einstein_journal/2024rw0393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Accepted: 10/26/2023] [Indexed: 03/08/2024] Open
Abstract
BACKGROUND Heart failure is the leading cause of cardiac-related hospitalizations. Limited access to reevaluations and outpatient appointments restricts the application of modern therapies. Telemedicine has become an essential resource in the healthcare system because of its countless benefits, such as higher and more frequent appointments and faster titration of medications. This narrative review aimed to demonstrate the evidence and unresolved issues related to the use of telemedicine in patients with heart failure. No studies have examined heart failure prevention; however, several studies have addressed the prevention of decompensation with positive results. Telemedicine can be used to evaluate all patients with heart failure, and many telemedicine platforms are available. Several strategies, including both noninvasive (phone calls, weight measurement, and virtual visits) and invasive (implantable pulmonary artery catheters) strategies can be implemented. Given these benefits, telemedicine is highly desirable, particularly for vulnerable groups. Although some questions remain unanswered, the development of new technologies can complement remote visits and improve patient care.
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Affiliation(s)
| | | | - Renato Paladino Nemoto
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Flavio Tocci Moreira
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karine De Amicis
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karen Francine Köhler
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Accorsi TAD, De Amicis Lima K, Köhler KF, Cordioli E, Pedrotti CHS. Assessment of suicidal ideation via telemedicine: a case report and management suggestions. Int J Emerg Med 2023; 16:84. [PMID: 37953263 PMCID: PMC10641932 DOI: 10.1186/s12245-023-00557-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 10/26/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Nowadays, we find ourselves in very unexpected and challenging circumstances facing the COVID-19 pandemic. The impact of the new coronavirus pandemic probably affected everyone's mental health, and people with pre-existing mental disorders may have an aggravated disease condition, leading to a suicide attempt. Pandemic also increased the use of direct-to-consumer telemedicine (TM) exponentially, and consequently, it was expected that cases of attempted suicide could be evaluated remotely. Some TM centers have adapted safety protocols from psychiatric guidelines for managing these patients. However, there is a lack of evidence of the effectiveness of follow-up by TM for patients at high risk for suicide, and there is no consensus on what action should be taken vis-à-vis the patient who requests immediate help remotely. CASE PRESENTATION Here, we reported a case of a TM evaluation of a patient's suicidal ideation in a direct-to-consumer telemedicine emergency center, describing the conduct taken in the face of this situation. We also discuss the importance of planning the emergency telemedicine center for situations of risk of suicide. CONCLUSIONS Telemedicine centers should be prepared for direct consumer assessment of suicidal ideation. Current management suggestions include recognizing the risk profile through institutional training and software skills and immediate referral for face-to-face assessment, encouraging continuous monitoring until the admission and active recruitment of family members or closest friends.
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Affiliation(s)
- Tarso Augusto Duenhas Accorsi
- Hospital Israelita Albert Einstein, Secretaria da Unidade de Telemedicina, Av. Albert Einstein, 627. Bloco B, 2° Andar, Sao Paulo, 05652-900, Brazil.
| | - Karine De Amicis Lima
- Hospital Israelita Albert Einstein, Secretaria da Unidade de Telemedicina, Av. Albert Einstein, 627. Bloco B, 2° Andar, Sao Paulo, 05652-900, Brazil
| | - Karen Francine Köhler
- Hospital Israelita Albert Einstein, Secretaria da Unidade de Telemedicina, Av. Albert Einstein, 627. Bloco B, 2° Andar, Sao Paulo, 05652-900, Brazil
| | - Eduardo Cordioli
- Hospital Israelita Albert Einstein, Secretaria da Unidade de Telemedicina, Av. Albert Einstein, 627. Bloco B, 2° Andar, Sao Paulo, 05652-900, Brazil
| | - Carlos Henrique Sartorato Pedrotti
- Hospital Israelita Albert Einstein, Secretaria da Unidade de Telemedicina, Av. Albert Einstein, 627. Bloco B, 2° Andar, Sao Paulo, 05652-900, Brazil
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Cordioli E, Giavina-Bianchi M, Pedrotti CHS, Podgaec S. Brazilian Medical Survey on Telemedicine since the onset of COVID-19. Einstein (Sao Paulo) 2023; 21:eAE0428. [PMID: 37729352 PMCID: PMC10501763 DOI: 10.31744/einstein_journal/2023ae0428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/23/2023] [Indexed: 09/22/2023] Open
Abstract
OBJECTIVE The primary aim of this study was to understand the difference in the use of Telemedicine by Brazilian physicians before and after the onset of COVID-19 pandemic and their intention to continue using it post the pandemic period. The secondary objective was to analyze the differences of opinion between physicians in the private and public sectors. METHODS We conducted an online medical survey through the SurveyMonkey platform in a large hospital in São Paulo, Brazil, from May to July 2022. RESULTS Three-hundred-and -two physicians responded to the survey. We found that there was a significant increase in the number of physicians who started using Telemedicine in both the public and private sectors (p<0.0001) since the onset of COVID-19 pandemic and that >50% of them intend to continue using Telemedicine in their daily practice. Most responders consider that Telemedicine is useful in screening, diagnosis and management of patients; that it facilitates the physician's daily practice; that it can maintain or even add financial gains through reducing office expenses; and that is another medium for dispensing medical care. They also believe that Telemedicine should be regulated by the Brazilian Federal Council of Medicine. There were no significant differences between the responses from private and public sector physicians. CONCLUSION Telemedicine has played a major role in healthcare since the onset of COVID-19 pandemic and most of the physicians approve its use and intend to continue using Telemedicine in their daily practice.
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Affiliation(s)
- Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Mara Giavina-Bianchi
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Sérgio Podgaec
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Paladino FV, Accorsi TAD, Gueuvoghlanian-Silva BY, de Almeida MA, Barbosa JC, de Oliveira MA, Pedrotti CHS, Amicis KD, Lottenberg CL, Cordioli E. Mobile application-based oximetry: a potential toolfor appropriate referral of patients with respiratory symptoms examined via telemedicine. Einstein (Sao Paulo) 2023; 21:eAO0025. [PMID: 36629679 PMCID: PMC9785575 DOI: 10.31744/einstein_journal/2023ao0025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 08/08/2022] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To calculate the positive likelihood ratio to determine whether telemedicine is able to optimize referral to the emergency department. METHODS Unicenter study with 182 consecutive patients admitted to Hospital Israelita Albert Einstein due to respiratory symptoms. All patients were submitted to oxygen saturation measurement using the standard method Welch Allyn finger device vital sign monitor and a 2-minute evaluation (Binah.ai mobile application). The reproducibility of oxygen saturation measurements made with both methods was investigated using interclass correlation coefficients and analysis of dispersion. Bland-Altman plots were constructed and kappa concordance coefficients used to examine data normality. Accuracy was also estimated. RESULTS Oxygen saturation measurement differences between methods were ≤2% in more than 85% of cases. The mean difference (bias) between methods was near zero (0.835; Bland-Altman analysis). Oxygen saturation measurements made using the Binah.ai mobile application had an average ability to detect patients with altered oxygen saturation levels compared to the conventional method (ROC analysis). The positive likelihood ratio of the mobile application was 6.23. CONCLUSION Mobile applications for oxygen saturation measurement are accessible user-friendly tools with moderate impact on clinical telemedicine evaluation of patients with respiratory symptoms, and may optimize referral to the emergency department.
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Affiliation(s)
- Fernanda Vieira Paladino
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | - Marcia Aparecida de Almeida
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - João Carlos Barbosa
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Miguel Almeida de Oliveira
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Karine De Amicis
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Claudio Luiz Lottenberg
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Accorsi TAD, Moreira FT, Amicis KD, Köhler KF, Cordioli E, Pedrotti CHS. Tips and tricks for the persistent hiccup management in a Telemedicine encounter. Einstein (Sao Paulo) 2022; 20:eCE0155. [PMID: 36259921 PMCID: PMC9550159 DOI: 10.31744/einstein_journal/2022ce0155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/27/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
| | - Flavio Tocci Moreira
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karine De Amicis
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Karen Francine Köhler
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazil Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Accorsi TAD, Moreira FT, Pedrotti CHS, Amicis KD, Correia RFV, Morbeck RA, Medeiros FF, de Souza JL, Cordioli E. Telemedicine diagnosis of acute respiratory tract infection patients is not inferior to face-to-face consultation: a randomized trial. Einstein (Sao Paulo) 2022; 20:eAO6800. [PMID: 35649057 PMCID: PMC9126601 DOI: 10.31744/einstein_journal/2022ao6800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 11/05/2021] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVE To analyze telemedicine diagnostic accuracy in patients with respiratory infections during COVID-19 pandemic compared to face-to-face evaluation in the emergency department. METHODS Randomized, unicentric study between September 2020 and November 2020 in patients with any respiratory symptom (exclusion criteria: age >65 years, chronic heart or lung diseases, immunosuppressed). Patients were randomized 1:1 for brief telemedicine followed by face-to-face consultation or direct face-to-face evaluation. The primary endpoint was the International Classification of Diseases code. The secondary analysis comprised length of stay, diagnostic test ordering, medical prescription, and proposed destination. RESULTS Ninety-eight patients were enrolled. The mean age was 36.3±9.7 years old, 57.1% were women, and 81.6% had diagnostic test ordered. Mean grouped by International Classification of Diseases code for upper respiratory tract infection, pharyngotonsillitis, and sinusitis showed no difference between study groups or secondary endpoints. The Telemedicine Group was representative of the population usually evaluated in this center. In the Telemedicine Group (n=48), 18.7% patients would be referred for evaluation at the emergency department. The distribution of diagnoses by telemedicine was 67.4% for upper respiratory tract infection, 2.3% for pharyngotonsillitis, and 0% for sinusitis, being statistically similar to the subsequent face-to-face assessment, respectively: 72.1%, 11.6% and 7% (Kappa 0.386 [95%CI: 0.112-0.66]; p=0.536). Telemedicine ordered COVID-19 molecular (RT-PCR) tests in 76.5% versus 79.4% in face-to-face evaluation (Kappa 0.715 [95%CI: 0.413-1]; p>0.999). CONCLUSION Diagnostic telemedicine consultation of low-risk patients with acute respiratory symptoms is not inferior to face-to-face evaluation at emergency department. Telemedicine is to be reinforced in the health care system as a strategy for the initial assessment of acute patients. ClinicalTrials.gov Identifier: NCT04806477.
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Affiliation(s)
| | - Flavio Tocci Moreira
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Karine De Amicis
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | - Renata Albaladejo Morbeck
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Fernanda Ferreira Medeiros
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - José Leão de Souza
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | - Eduardo Cordioli
- Hospital Israelita Albert EinsteinSão PauloSPBrazilHospital Israelita Albert Einstein, São Paulo, SP, Brazil.
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Accorsi TAD, Lima KDA, Silva Filho JRDO, Morbeck RA, Pedrotti CHS, Köhler KF, Racy FDCJ, Cordioli E. Telemedicine can be a feasible means of guiding untrained general practitioners to perform point-of-care ultrasound in life-threatening situations: the case of a field hospital during the COVID-19 pandemic. Radiol Bras 2022; 55:236-241. [PMID: 35983338 PMCID: PMC9380614 DOI: 10.1590/0100-3984.2021.0098] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 10/13/2021] [Indexed: 11/22/2022] Open
Abstract
Objective To evaluate the feasibility of telemedicine using a standardized multiorgan ultrasound assessment protocol to guide untrained on-site general practitioners at a field hospital during a life-threatening crisis. Materials and Methods We evaluated 11 inpatients with shock, with or without acute dyspnea, for whom general practitioners spontaneously requested remote evaluation by a specialist. Results All of the general practitioners accepted the protocol and were able to position the transducer correctly, thus obtaining key images of the internal jugular vein, lungs, and inferior vena cava when guided remotely by a telemedicine physician, who interpreted all of the findings. However, only four (36%) of the on-site general practitioners obtained the appropriate key image of the heart in the left parasternal long-axis view, and only three (27%) received an immediate interpretation of an image from the remote physician. The mean evaluation time was 22.7 ± 12 min (range, 7-42 min). Conclusion Even in life-threatening situations, untrained general practitioners may be correctly guided by telemedicine specialists to perform multiorgan point-of-care ultrasound in order to improve bedside diagnostic evaluation.
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Pedrotti CHS, Accorsi TAD, Moreira FT, Lima KDA, Köhler KF, Gaz MVB, Chiamolera M, Cunha GA, Neto AS, Morbeck RA, Cordioli E. Telemedicine medical evaluation of low-risk patients with dengue during an outbreak may be an option in reducing the need for on-site physicians. Int J Infect Dis 2022; 121:106-111. [PMID: 35504552 DOI: 10.1016/j.ijid.2022.04.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 04/11/2022] [Accepted: 04/26/2022] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To analyze the effectiveness of telemedicine consultations during an outbreak in reducing the need for face-to-face consultations at a field hospital for patients with dengue. METHODS We performed a retrospective unicentric study between April and May 2015 with 4626 patients (≥15 years old) who spontaneously sought care at an emergency field hospital (Sāo Paulo/Brazil). A nurse initially assessed all patients with dengue through rapid diagnostic testing, automated complete blood count, and risk stratification. During overcrowded situations, a video-based telemedicine consultation was provided as an option to all low-to-moderate risk patients who tested positive. The management was carried out according to current dengue guidelines. The primary end point was a referral to immediate face-to-face medical evaluation. RESULTS Of all patients suspected of dengue infection, 2003 presented positive testing, 1978 were classified as low-moderate risk, and 267 patients with dengue were evaluated by telemedicine. The mean age was 38.17 ± 13.7 years (54.6% female). Oral medications were recommended in 169 (63.3%), intravenous hydration or symptomatic drugs in 96 (36%), 252 (94.4%) were discharged after telemedicine assessment, and only 15 (5.6%) were referred to immediate face-to-face medical evaluation. No adverse events were recorded. CONCLUSION Telemedicine medical assessment of low-to-moderate risk patients with dengue previously screened by nursing triage is effective in replacing the face-to-face evaluation in a field hospital. Telemedicine may be reinforced in epidemiological outbreak scenarios as a cost-effective strategy for the initial assessment of acute patients.
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Affiliation(s)
- Carlos H S Pedrotti
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil.
| | - Tarso A D Accorsi
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | | | | | | | - Marcus V B Gaz
- Emergency Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Murilo Chiamolera
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Gustavo A Cunha
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Ary Serpa Neto
- Intensive Care Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Renata A Morbeck
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine Department, Hospital Israelita Albert Einstein, Sāo Paulo, Brazil
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Perez L, Tran K, Alvarenga-Bezerra V, Chadha D, Dotson L, Assir F, Cordioli E, Tamura Vieira Gomes M, Podgaec S, Lopes da Silva-Filho A, Ramanujam N, Moretti-Marques R. Cervical Cancer-Related Knowledge, Attitudes, Practices and Self-Screening Acceptance Among Patients, Employees, and Social Media Followers of Major Brazilian Hospital. Cancer Control 2022; 29:10732748221135441. [PMID: 36433760 PMCID: PMC9703545 DOI: 10.1177/10732748221135441] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/16/2022] [Accepted: 10/11/2022] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Brazil has a high burden of cervical cancer, even though it is preventable, traceable and treatable. Hence, this study evaluated levels of knowledge, attitudes and practices (KAP) related to cervical cancer screening and diagnosis and acceptance of self-screening techniques among women aged 24 and greater. METHODS A cross-sectional KAP survey was administered to n = 4206 women and spanned questions relating to cervical cancer, HPV, speculum, Pap test and colposcopy. Questionnaire was disseminated through a major hospital's social media platforms, intranet and gynecologic-oncology clinics. Logistic regressions evaluated associations between sociodemographic characteristics and knowledge, attitudes, and preventative behaviors against cervical cancer. Participants indicated willingness to try DNA-HPV self-sampling and cervix self-visualization (self-colposcopy). FINDINGS Participants were mostly white individuals (70.5%) with higher education and from social classes A and B. They demonstrated superior levels of KAP than described in the literature, with over 57.8% having answered 80+% of questions correctly. KAP scores were predicted by social class, educational attainment, race, history of premalignant cervical lesions and geographic location. About 80% and 63% would be willing to try DNA-HPV self-sampling and cervix self-visualization, respectively. Interest in self-screening was associated with adequate attitude (OR = 1.85) and inadequate practice (OR = .83). INTERPRETATION Adequate KAP are fundamental for the successful implementation of a self-screening program. Participants were interested in methods that provide them with greater autonomy, control and practicality. Self-screening could address barriers for under-screened women such as shame, discomfort, distance from clinics and competing commitments, enabling Brazil to reach the WHO's cervical cancer elimination goals. It could also decrease excess medical intervention in over-screened populations by promoting shared decision-making.
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Giavina-Bianchi M, Azevedo MFD, Cordioli E. Clinical Features of Acne in Primary Care Patients Assessed Through Teledermatology. J Prim Care Community Health 2022; 13:21501319221074117. [PMID: 35098785 PMCID: PMC8808038 DOI: 10.1177/21501319221074117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Introduction/Objectives: Acne is present in about 90% of teenagers and 12% to 14% of adults. Face and trunk are the most affected areas. Lesions can result in postinflammatory hyperpigmentation and scarring, leading to reduced quality of life. Asynchronous teledermatology has been increasingly used around the world, facilitating patient access to dermatologists. Our objectives were to assess: (1) clinical features of acne patients according to gender, age, severity, site of lesions, excoriation, postinflammatory hyperpigmentation (PIH), and atrophic scar (AS) and (2) how many referrals to in-person consultations with dermatologists could be avoided using asynchronous teledermatology in primary care attention? Methods: We analyzed images, demographic and clinical data of 2459 acne patients assisted by teledermatology, with the aim to confirm the diagnoses, to classify acne severity according to grades I to IV, and to search for the presence of postinflammatory hyperpigmentation, atrophic scars, and/or excoriated acne (EA). We compared the clinical and biological data, looking for associations among them. Results: Acne severity and age were associated with the most common sequels: postinflammatory hyperpigmentation (mainly on the trunk and in females, P < .0001) and atrophic scars (mainly on the face and in males, P < .0001). We also observed different frequencies according to age and sex: 13 to 24 years in males (P = .0023); and <12 (P = .0023) and 25 to 64 years old (P <.0001) for females; 68% of the patients had no need for in-person dermatologists’ referral, being kept at primary care attention with proper diagnosis and treatment. Conclusion: Clinical features of acne and its sequels differ according to gender, age, site, and severity. The new findings of PIH associated with women and AS, with men, may help offer a more personalized management to patients. Teledermatology was suitable for the majority of the acne cases in primary care.
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Affiliation(s)
| | | | - Eduardo Cordioli
- Hospital Israelita Albert Einstein, São Paulo, São Paulo, Brazil
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Ranzani O, Pereira AJ, dos Santos MC, Corrêa TD, Ferraz LJR, Cordioli E, Morbeck RA, Berwanger O, de Morais LC, Schettino G, Cavalcanti AB, Rosa RG, Biondi RS, Salluh JIF, de Azevedo LCP, Serpa Neto A, Noritomi DT. Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial. Rev Bras Ter Intensiva 2022. [PMID: 35766658 PMCID: PMC9345581 DOI: 10.5935/0103-507x.20220003-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Objective: The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care. Methods: The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia. Conclusion: According to the trial’s best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results. ClinicalTrials.gov registration: NCT03920501
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Affiliation(s)
- Otavio Ranzani
- Pulmonary Division, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brazil
- Barcelona Institute for Global Health - Barcelona, Spain
| | - Adriano José Pereira
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
- Telemedicine Department, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
- Postgraduate Program of Health Sciences, Universidade Federal de Lavras - Lavras (MG), Brazil
- Corresponding author: Adriano José Pereira Hospital Israelita Albert Einstein Avenida Albert Einstein, 700 Zip code: 05652-900 - São Paulo (SP), Brazil E-mail:
| | - Maura Cristina dos Santos
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
- Telemedicine Department, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
| | - Thiago Domingos Corrêa
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
| | | | - Eduardo Cordioli
- Telemedicine Department, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
| | | | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
| | - Lúbia Caus de Morais
- Telemedicine Department, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
| | - Guilherme Schettino
- Institute of Social Responsibility, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Research Institute, HCor-Hospital do Coração - São Paulo, (SP), Brazil
| | - Regis Goulart Rosa
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Critical Care Department, Hospital Moinhos de Vento - Porto Alegre (RS), Brazil
| | | | - Jorge Ibrain Figueira Salluh
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Instituto D’Or de Pesquisa e Ensino - Rio de Janeiro, (RJ), Brazil
| | - Luciano César Pontes de Azevedo
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Emergency Medicine Department, Universidade de São Paulo - São Paulo (SP), Brazil
- Institute for Teaching and Research, Hospital Sírio-Libanês - Sao Paulo, Sao Paulo, (SP), Brazil
| | - Ary Serpa Neto
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
- Brazilian Research in Intensive Care Network (BRICNet) - São Paulo (SP), Brazil
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University - Melbourne, Australia
| | - Danilo Teixeira Noritomi
- Department of Critical Care Medicine, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
- Telemedicine Department, Hospital Israelita Albert Einstein - São Paulo (SP), Brazil
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Ranzani O, Pereira AJ, Santos MCD, Corrêa TD, Ferraz LJR, Cordioli E, Morbeck RA, Berwanger O, Morais LCD, Schettino G, Cavalcanti AB, Rosa RG, Biondi RS, Salluh JIF, Azevedo LCPD, Serpa Neto A, Noritomi DT. Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial. Rev Bras Ter Intensiva 2022; 34:87-95. [PMID: 35766658 DOI: 10.5935/0103-507x.20220003-pt] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 11/13/2021] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE) trial aims to assess whether a complex telemedicine intervention in intensive care units, which focuses on daily multidisciplinary rounds performed by remote intensivists, will reduce intensive care unit length of stay compared to usual care. METHODS The TELESCOPE trial is a national, multicenter, controlled, open label, cluster randomized trial. The study tests the effectiveness of daily multidisciplinary rounds conducted by an intensivist through telemedicine in Brazilian intensive care units. The protocol was approved by the local Research Ethics Committee of the coordinating study center and by the local Research Ethics Committee from each of the 30 intensive care units, following Brazilian legislation. The trial is registered with ClinicalTrials. gov (NCT03920501). The primary outcome is intensive care unit length of stay, which will be analyzed accounting for the baseline period and cluster structure of the data and adjusted by prespecified covariates. Secondary exploratory outcomes included intensive care unit performance classification, in-hospital mortality, incidence of nosocomial infections, ventilator-free days at 28 days, rate of patients receiving oral or enteral feeding, rate of patients under light sedation or alert and calm, and rate of patients under normoxemia. CONCLUSION According to the trial's best practice, we report our statistical analysis prior to locking the database and beginning analyses. We anticipate that this reporting practice will prevent analysis bias and improve the interpretation of the reported results.ClinicalTrials.gov registration: NCT03920501.
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Affiliation(s)
- Otavio Ranzani
- Divisão de Pneumologia, Instituto do Coração, Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo - São Paulo (SP), Brasil.,Barcelona Institute for Global Health - Barcelona, Espanha
| | - Adriano José Pereira
- Departamento de Cuidados Críticos em Medicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Telemedicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Lavras - Lavras (MG), Brasil
| | - Maura Cristina Dos Santos
- Departamento de Cuidados Críticos em Medicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Telemedicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Thiago Domingos Corrêa
- Departamento de Cuidados Críticos em Medicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Rede Brasileira de Pesquisa em Terapia Intensiva (BRICNet) - São Paulo (SP), Brasil
| | - Leonardo Jose Rolim Ferraz
- Departamento de Cuidados Críticos em Medicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Eduardo Cordioli
- Departamento de Telemedicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | | | - Otávio Berwanger
- Organização de Pesquisa Acadêmica, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Lúbia Caus de Morais
- Departamento de Telemedicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Guilherme Schettino
- Instituto da Responsabilidade Social, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
| | - Alexandre Biasi Cavalcanti
- Rede Brasileira de Pesquisa em Terapia Intensiva (BRICNet) - São Paulo (SP), Brasil.,Instituto de Pesquisa, HCor-Hospital do Coração - São Paulo (SP), Brasil
| | - Regis Goulart Rosa
- Rede Brasileira de Pesquisa em Terapia Intensiva (BRICNet) - São Paulo (SP), Brasil.,Departamento de Cuidados Críticos, Hospital Moinhos de Vento - Porto Alegre (RS), Brasil
| | | | - Jorge Ibrain Figueira Salluh
- Rede Brasileira de Pesquisa em Terapia Intensiva (BRICNet) - São Paulo (SP), Brasil.,Instituto D'Or de Pesquisa e Ensino - Rio de Janeiro (RJ), Brasil
| | - Luciano César Pontes de Azevedo
- Rede Brasileira de Pesquisa em Terapia Intensiva (BRICNet) - São Paulo (SP), Brasil.,Departamento de Medicina de Emergência, Universidade de São Paulo - São Paulo (SP), Brasil.,Instituto de Ensino e Pesquisa, Hospital SírioLibanês - São Paulo (SP), Brasil
| | - Ary Serpa Neto
- Departamento de Cuidados Críticos em Medicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Rede Brasileira de Pesquisa em Terapia Intensiva (BRICNet) - São Paulo (SP), Brasil.,Centro de Pesquisa Australiano e Neozelandês em Terapia Intensiva, School of Public Health and Preventive Medicine, Monash University - Melbourne, Austrália
| | - Danilo Teixeira Noritomi
- Departamento de Cuidados Críticos em Medicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil.,Departamento de Telemedicina, Hospital Israelita Albert Einstein - São Paulo (SP), Brasil
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15
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Ranzani O, Pereira AJ, Santos MCD, Corrêa TD, Ferraz LJR, Cordioli E, Morbeck RA, Berwanger O, Morais LCD, Schettino G, Cavalcanti AB, Rosa RG, Biondi RS, Salluh JIF, Azevedo LCPD, Serpa Neto A, Noritomi DT, Investigators TELESCOPET. Statistical analysis of a cluster-randomized clinical trial on adult general intensive care units in Brazil: TELE-critical care verSus usual Care On ICU PErformance (TELESCOPE) trial. Rev Bras Ter Intensiva 2022. [DOI: 10.5935/0103-507x.20220003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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16
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Pedrotti CHS, Accorsi TAD, Amicis Lima KD, Filho JRDOS, Morbeck RA, Cordioli E. Cross-sectional study of the ambulance transport between healthcare facilities with medical support via telemedicine: Easy, effective, and safe tool. PLoS One 2021; 16:e0257801. [PMID: 34591876 PMCID: PMC8483335 DOI: 10.1371/journal.pone.0257801] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Accepted: 09/11/2021] [Indexed: 11/18/2022] Open
Abstract
Background Feasibility and safety of ambulance transport between healthcare facilities with medical support exclusively via telemedicine are unknown. Methods This was a retrospective study with a single telemedicine center reference for satellite emergency departments of the same hospital. The study population was all critically ill patients admitted to one of the peripheral units from November 2016 to May 2020 and who needed to be transferred to the main building. Telemedicine-assisted transportation was performed by an emergency specialist. The inclusion criteria included patients above the age of 15 and initial stabilization performed at the emergency department. Unstable, intubated, ST-elevation myocardial infarction and acute stroke patients were excluded. There was a double-check of safety conditions by the nurse and the remote doctor before the ambulance departure. The primary endpoint was the number of telemedicine-guided interventions during transport. Results 2840 patients were enrolled. The population was predominantly male (53.2%) with a median age of 60 years. Sepsis was the most prevalent diagnosis in 28% of patients, followed by acute coronary syndromes (8.5%), arrhythmia (6.7%), venous thromboembolism (6.1%), stroke (6.1%), acute abdomen (3.6%), respiratory distress (3.3%), and heart failure (2.5%). Only 22 (0.8%) patients required telemedicine-assisted support during transport. Administration of oxygen therapy and analgesics were the most common recommendations made by telemedicine emergency physicians. There were no communication problems in the telemedicine-assisted group. Conclusions Telemedicine-assisted ambulance transportation between healthcare facilities of stabilized critically ill patients may be an option instead of an onboard physician. The frequency of clinical support requests by telemedicine is minimal, and most evaluations are of low complexity and easily and safely performed by trained nurses.
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Affiliation(s)
- Carlos H. S. Pedrotti
- Telemedicine Department, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
- * E-mail:
| | - Tarso A. D. Accorsi
- Telemedicine Department, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | | | | | - Renata A. Morbeck
- Telemedicine Department, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine Department, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
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17
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Giavina-Bianchi M, Cordioli E, Dos Santos AP. Accuracy of Deep Neural Network in Triaging Common Skin Diseases of Primary Care Attention. Front Med (Lausanne) 2021; 8:670300. [PMID: 34513863 PMCID: PMC8427035 DOI: 10.3389/fmed.2021.670300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/30/2021] [Indexed: 01/02/2023] Open
Abstract
Access to dermatological care can be challenging in certain regions of the world. The triage process is usually conducted by primary care physicians; however, they may not be able to diagnose and assign the correct referral and level of priority for different dermatosis. The present research aimed to test different deep neural networks to obtain the highest level of accuracy for the following: (1) diagnosing groups of dermatoses; (2) correct referrals; and (3) the level of priority given to the referral compared to dermatologists. Using 140,446 images from a teledermatology project, previously labeled with the clinical diagnosis, and their respective referrals, namely biopsy, in-person dermatologist visits or monitoring the case via teledermatology along with the general physician, 27 different scenarios of neural networks were derived, and the algorithm accuracies in classifying different dermatosis, according to the group of the diagnosis they belong to, were calculated. The most accurate algorithm was then tested for accuracy in diagnosis, referral, and level of priority given to 6,945 cases. The GoogLeNet architecture, trained with 24,000 images and 1,000 epochs, using weight random initialization and learning rates of 10−3 was found to be the most accurate network, showing an accuracy of 89.72% for diagnosis, 96.03% for referrals and 92.54% for priority level in 6,975 image testing. Our study population, however, was confined to individuals with chronic skin conditions and, therefore, it has limited value as a triage tool because it has not been tested for acute conditions. Deep neural networks are accurate in triaging, correct referral and prioritizing common chronic skin diseases related to primary care attention. They can also help health-care systems optimize patients' access to dermatologists.
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Affiliation(s)
- Mara Giavina-Bianchi
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - André P Dos Santos
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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18
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Noritomi DT, Ranzani OT, Ferraz LJR, Dos Santos MC, Cordioli E, Albaladejo R, Serpa Neto A, Correa TD, Berwanger O, de Morais LC, Schettino G, Cavalcanti AB, Rosa RG, Biondi RS, Salluh JI, Azevedo LCP, Pereira AJ. TELE-critical Care verSus usual Care On ICU PErformance (TELESCOPE): protocol for a cluster-randomised clinical trial on adult general ICUs in Brazil. BMJ Open 2021; 11:e042302. [PMID: 34155070 PMCID: PMC8217943 DOI: 10.1136/bmjopen-2020-042302] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
INTRODUCTION Daily multidisciplinary rounds (DMRs) consist of systematic patient-centred discussions aiming to establish joint therapeutic goals for the next 24 hours of intensive care unit (ICU) care. The aim of the present study protocol is to evaluate whether an intervention consisting of guided DMRs, supported by a remote specialist and audit/feedback on care performance will reduce ICU length of stay compared with a control group. METHODS AND ANALYSIS A multicentre, controlled, cluster-randomised superiority trial including 30 ICUs in Brazil (15 intervention and 15 control), from August 2019 to June 2021. In a parallel assignment, ICUs are randomised to a complex-intervention composed by daily rounds carried out through Tele-ICU by a remote ICU physician; development of local quality indicators dashboards coupled with monthly meetings with local leadership; and dissemination of evidence-based clinical protocols versus usual care. Primary outcome is ICU length of stay. Secondary outcomes include classification of the unit according to the profiles defined by the standardised resource use and the standardised mortality rate, hospital mortality, incidence of healthcare-associated infections, ventilator-free days at 28 days, patient-days receiving oral or enteral feeding, patient-days under light sedation or alert and calm, rate of patients under normoxaemia. All adult patients admitted after the beginning of the study in each participant ICU will be enrolled. Inclusion criteria (clusters): public Brazilian ICUs with a minimum of 8 ICU beds interested/committed to participating in the study. Exclusion criteria (clusters): units with fully established DMRs by an intensivist, specialised or step-down units. ETHICS AND DISSEMINATION The study protocol was approved by the institutional review board (IRB) of the coordinator centre, and by IRBs of each enrolled hospital/ICU. Statistical analysis protocol is being prepared for submission before the end of patient's enrolment. Results will be disseminated through conferences, peer-reviewed journals and to each participating unit. TRIAL REGISTRATION NUMBER NCT03920501; Pre-results.
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Affiliation(s)
- Danilo Teixeira Noritomi
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Clinical Governance, DASA, Sao Paulo, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Otavio T Ranzani
- Pulmonary Division, Heart Institute, Hospital das Clinicas, Universidade de Sao Paulo Faculdade de Medicina Hospital das Clinicas, Sao Paulo, SP, Brazil
- ISGlobal, Barcelona Institute for Global Health, Barcelona, Catalunya, Spain
| | | | - Maura C Dos Santos
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Ary Serpa Neto
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
| | - Thiago D Correa
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
| | - Otávio Berwanger
- Academic Research Organization, Hospital Israelita Albert Einstein, Sao Paulo, São Paulo, Brazil
| | - Lubia Caus de Morais
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
| | - Guilherme Schettino
- Institute of Social Responsibility, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Alexandre Biasi Cavalcanti
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- HCor Research Institute, Sao Paulo, SP, Brazil
| | - Regis Goulart Rosa
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Intensive Care, HMV, Porto Alegre, Rio Grande do Sul, Brazil
| | - Rodrigo Santos Biondi
- Instituto de Cardiologia do Distrito Federal, Brasília, Distrito Federal, Brazil
- Hospital Brasília, Brasília, DF, Brazil
| | - Jorge If Salluh
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil, Rio de Janeiro, Brazil
| | - Luciano Cesar Pontes Azevedo
- Brazilian Research in Intensive Care Network - BRICNET, São Paulo, SP, Brazil
- Intensive Care Unit, Hospital Sírio-Libanês, São Paulo, SP, Brazil
- Emergency Medicine Department, University of Sao Paulo, Sao Paulo, São Paulo, Brazil
| | - Adriano Jose Pereira
- Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, SP, Brazil
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Postgraduate Program of Health Sciences, Universidade Federal de Lavras, Lavras, MG, Brazil
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Accorsi TAD, Brigido ARD, De Amicis K, Belfort DDSP, Habrum FC, Scarpanti FG, Magalhães IR, Silva Filho JRDO, Sampaio LPC, Lira MTSDS, Morbeck RA, Pedrotti CHS, Racy FDCJ, Cordioli E. Clinical features of a series of patients in life-threatening situations at a COVID-19 pandemic field hospital, evaluated by teleconsultation: evidence for Telemedicine expansion. Einstein (Sao Paulo) 2021; 19:eCE6370. [PMID: 34133667 PMCID: PMC8169026 DOI: 10.31744/einstein_journal/2021ce6370] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/04/2021] [Indexed: 01/08/2023] Open
Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - Fábio de Castro Jorge Racy
- Instituto Israelita de Responsabilidade Social, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
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20
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Giavina-Bianchi M, Cordioli E, Machado BS. Melanoma: implications of diagnostic failure and perspectives. Einstein (São Paulo) 2021; 19:eED6680. [PMID: 35019042 PMCID: PMC8693881 DOI: 10.31744/einstein_journal/2021ed6680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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21
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Accorsi TAD, Amicis KD, Brígido ARD, Belfort DDSP, Habrum FC, Scarpanti FG, Magalhães IR, Silva Filho JRDO, Sampaio LPC, Lira MTSDS, Morbeck RA, Pedrotti CHS, Cordioli E. Assessment of patients with acute respiratory symptoms during the COVID-19 pandemic by Telemedicine: clinical features and impact on referral. Einstein (Sao Paulo) 2020; 18:eAO6106. [PMID: 33295428 PMCID: PMC7690926 DOI: 10.31744/einstein_journal/2020ao6106] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 10/19/2020] [Indexed: 12/15/2022] Open
Abstract
Objective: To characterize variables associated with referral to the emergency department following Telemedicine consultation during the COVID-19 pandemic. Methods: Cross-sectional retrospective study conducted between March and May 2020, with a sample of 500 adult patients. The inclusion criterion was the manifestation of respiratory symptoms, regardless of type. Results: The mean age of patients was 34.7±10.5 years, and 59% were women. Most patients (62.6%) perceived their own health status as malaise and some (41.4%) self-diagnosed COVID-19. Cough (74.4%), rhinorrhea (65.6%), sore throat (38.6%) and sneezing (20.6%) were the most common infection-related symptoms. Overall, 29.4% and 16% of patients reported dyspnea and chest pain, respectively. The Roth score was calculated for a sizeable number of patients (67.6%) and was normal, moderately altered or severely altered in 83.5%, 10.7% and 5.6% of patients, respectively. The percentage of suspected COVID-19 cases was 67.6%. Of these, 75% were managed remotely and only one quarter referred for emergency assessment. Conclusion: Telemedicine assessment is associated with reclassification of patient's subjective impression, better inspection of coronavirus disease 2019 and identification of risk patients. Referral is therefore optimized to avoid inappropriate in-person assessment, and low-risk patients can be properly guided. Telemedicine should be implemented in the health care system as a cost-effective strategy for initial assessment of acute patients.
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22
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Giavina-Bianchi M, Santos AP, Cordioli E. Teledermatology reduces dermatology referrals and improves access to specialists. EClinicalMedicine 2020; 29-30:100641. [PMID: 33437950 PMCID: PMC7788431 DOI: 10.1016/j.eclinm.2020.100641] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 10/27/2020] [Accepted: 11/04/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Teledermatology may be used for triage in primary care to address skin conditions, improving access and reducing time to treat the most severe or surgical cases. We aimed to evaluate the proportion of individuals who could be assessed in primary care using teledermatology, and how this affected the waiting time for an in-person dermatologist appointment. METHODS A cross-sectional retrospective study, involving 30,976 individuals and 55,624 skin lesions, was performed from July 2017 to July 2018 We assessed the frequency of diagnoses and referrals to biopsy, to in-person dermatologists, or to primary care, and compared the waiting time for an in-person dermatologist appointment before and after the teledermatology implementation. FINDINGS 53% of the patients were managed with the primary care physician, 43% were referred to in-person dermatologists and 4% directly to biopsy, leading to a reduction of 78% in the waiting time for in-person appointments when compared to the previous period. The most frequent diseases were: melanocytic nevus, seborrheic keratosis, acne, benign neoplasms, onychomycosis, atopic dermatitis, solar lentigo, melasma, xerosis, and epidermoid cyst, with significant differences according to sex, age and referrals. The most frequent treatment prescribed was emollient. INTERPRETATION The use of teledermatology as a triage tool significantly reduced the waiting time for in-person visits, improving health care access and utilizing public resources wisely. Knowledge of sex, age, diagnoses and treatment of common skin conditions can enable public policies for the prevention and orientation of the population, as it can be used to train general physicians to address such cases. FUNDING None.
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Giavina-Bianchi M, Azevedo MFD, Sousa RM, Cordioli E. Part II: Accuracy of Teledermatology in Skin Neoplasms. Front Med (Lausanne) 2020; 7:598903. [PMID: 33330564 PMCID: PMC7732487 DOI: 10.3389/fmed.2020.598903] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/28/2020] [Indexed: 12/04/2022] Open
Abstract
Teledermatology has been proving to be of great help for delivering healthcare, especially now, during the SARS-CoV-2 pandemic. It is crucial to assess how accurate this method can be for evaluating different dermatoses. Such knowledge can contribute to the dermatologists' decision of whether to adhere to teledermatology or not. Our objective was to determine the accuracy of teledermatology in the 10 most frequent skin neoplasms in our population, comparing telediagnosis to histopathological report and in-person dermatologists' diagnosis. A retrospective cohort study was conducted in São Paulo, Brazil, where a store-and-forward teledermatology project was implemented under primary-care attention to triage surgical, more complex, or severe dermatoses. A total of 30,976 patients presenting 55,012 lesions took part in the project. Thirteen teledermatologists who participated in the project had three options to refer the patients: send them directly to biopsy, to the in-person dermatologist, or back to the general physician with the most probable diagnosis and management. In the groups referred to the in-person dermatologist and biopsy, we looked for the 10 most frequent International Statistical Classification of Diseases and Related Health Problems-10 (ICD-10) of skin neoplasms, which resulted in 289 histopathologic reports and 803 in-person dermatologists' diagnosis. We were able to compare the ICD-10 codes filled by teledermatologists, in-person dermatologists, and from histopathological reports. The proportion of complete, partial, and no agreement rates between the in-person dermatologist's, histopathologic report, and the teledermatologist's diagnosis was assessed. We also calculated Cohen's kappa, for complete and complete plus partial agreement. The mean complete agreement rate comparing telediagnosis to histopathological report was 54% (157/289; kappa = 0.087), being the highest for malign lesions; to in-person dermatologists was 61% (487/803; kappa = 0.213), highest for benign lesions. When accuracy of telediagnosis for either malign or benign lesions was evaluated, the agreement rate with histopathology was 70% (kappa = 0.529) and with in-person dermatologist, 81% (kappa = 0.582). This study supports that teledermatology for skin neoplasms has moderate accuracy. This result reassures that it can be a proper option for patient care, especially when the goal is to differentiate benign from malign lesions.
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Affiliation(s)
- Mara Giavina-Bianchi
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | | | - Raquel Machado Sousa
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Giavina-Bianchi M, Sousa R, Cordioli E. Part I: Accuracy of Teledermatology in Inflammatory Dermatoses. Front Med (Lausanne) 2020; 7:585792. [PMID: 33195344 PMCID: PMC7653494 DOI: 10.3389/fmed.2020.585792] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/30/2020] [Indexed: 12/02/2022] Open
Abstract
Teledermatology is assuming a progressively greater role as a healthcare delivery method, especially now, during this pandemic time. It is important to know how accurate this tool is for different skin diseases. Most of the studies have focused on skin neoplasms or general dermatology. Studies based on a large number of inflammatory dermatoses have not yet been performed. Such knowledge can help dermatologists to decide whether endorsing this method or not. Our objective was to determine the accuracy of teledermatology in inflammatory dermatoses in a robust number of cases. A retrospective cohort study was conducted in São Paulo, Brazil, from July 2017–18, where a store-and-forward Teledermatology project was implemented under primary-care attention to triage surgical, more complex, or severe dermatoses. A total of 30,976 patients presenting 55,012 lesions took part in the project. Thirteen participating teledermatologists had three options to refer the patients: directly to biopsy, to the in-person dermatologist or back to the general physician with most probable diagnosis and management. In the group referred to the in-person dermatologist, we looked for the 20 most frequent International Classification of Diseases and Related Health Problems- 10th revision (ICD-10) of inflammatory dermatoses, which resulted in 739 patients and 739 lesions. As patients had been triaged by teledermatology previously, we were able to compare ICD-10 codes filled both by teledermatogists and by in-person dermatologists. The proportion of complete, partial, and no agreement rates between the in-person dermatologist's and the teledermatologist's diagnoses was used for accuracy. We also calculated Cohen's kappa, a statistical measure of inter-rater agreement, for complete agreement. The mean complete agreement rate for all twenty dermatoses was 78% (31–100%) and kappa = 0.743; partial agreement 8%; and no agreement 14%, presenting variability according to the disease. Our study showed that teledermatology for inflammatory dermatoses has a high accuracy. This result reassures that it can be a proper option for patient care.
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Affiliation(s)
- Mara Giavina-Bianchi
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Raquel Sousa
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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G Bianchi M, Santos A, Cordioli E. Benefits of Teledermatology for Geriatric Patients: Population-Based Cross-Sectional Study. J Med Internet Res 2020; 22:e16700. [PMID: 32314966 PMCID: PMC7201316 DOI: 10.2196/16700] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 12/21/2019] [Accepted: 01/27/2020] [Indexed: 01/22/2023] Open
Abstract
Background Teledermatology is a health care tool that has been increasingly used around the world, mostly because dermatology has an emphasis on visual diagnosis. Many studies have shown that access to specialized care improves using teledermatology, which provides accurate diagnosis and reduces the time taken for treatment, with high patient satisfaction. As the population around the world grows old, there will be even more demand for dermatologists in years to come. It is essential to know which are the most prevalent skin conditions in the primary care population and if they can be addressed through teledermatology. Objective Our main goal was to evaluate the proportion of lesions in individuals aged 60 years and older that could be managed using teledermatology in conjunction with primary care physicians. Second, we aimed to assess the most frequent skin lesions, the most common treatments provided to patients, and the distribution and causes of referrals made by the teledermatologists. Methods This was a retrospective cohort study from July 2017 to July 2018 in São Paulo, Brazil. We included 6633 individuals aged 60 years and older who presented with 12,770 skin lesions. Teledermatologists had three options to refer patients: (1) to undergo biopsy directly, (2) to an in-person dermatologist visit, and (3) back to the primary care physician with the most probable diagnosis and treatment. Results Teledermatology managed 66.66% (8408/12614) of dermatoses with the primary care physician without the need for an in-presence visit; 27.10% (3419/12614) were referred to dermatologists, and 6.24% (787/12614) directly to biopsy. The most frequent diseases were seborrheic keratosis, solar lentigo, onychomycosis, melanocytic nevus, benign neoplasms, actinic keratosis, epidermoid cyst, xerosis, leucoderma, and wart, with significant differences between sexes. Malignant tumors increased with age and were the leading cause for biopsies, while infectious skin conditions and pigmentary disorders decreased. Emollient was the most frequent treatment prescribed, in 31.88% (909/2856) of the cases. Conclusions Teledermatology helped to treat 67% of the dermatoses of older individuals, addressing cases of minor complexity quickly and conveniently together with the primary care physician, thus optimizing dermatological appointments for the most severe, surgical, or complex diseases. Teledermatology does not aim to replace a face-to-face visit with the dermatologist; however, it might help to democratize dermatological treatment access for patients and decrease health care expenses.
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Affiliation(s)
- Mara G Bianchi
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Andre Santos
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Giavina Bianchi M, Santos AP, Cordioli E. The majority of skin lesions in pediatric primary care attention could be managed by Teledermatology. PLoS One 2019; 14:e0225479. [PMID: 31790453 PMCID: PMC6886848 DOI: 10.1371/journal.pone.0225479] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2019] [Accepted: 11/05/2019] [Indexed: 11/18/2022] Open
Abstract
Background Teledermatology is a tool that provides accurate diagnosis and has been gaining more emphasis over time. It can be used for triage in primary care attention to address skin conditions improving access and reducing time to treatment for surgical, severe or even lethal diseases. Objectives Our main goal was to evaluate the proportion of pediatric patient’s lesions that could be managed using teledermatology in primary care attention. Secondly, we wanted to assess the ten most frequent skin conditions, the most common treatments and the referrals made by the teledermatologists to biopsy, in-presence dermatologist or kept at primary care attention. Methods A cross-sectional retrospective study involving 6,879 individuals and 10,126 lesions was conducted by store-and-forward teledermatology during one year in the city of Sao Paulo, Brazil. If the photographs taken had enough quality, teledermatologist would diagnose, treat and orient each lesion (if possible), and choose one of three options for referral: direct to biopsy, in-presence dermatologist or kept at primary care attention. Results Teledermatology managed 62% of the lesions to be kept at primary care attention, 37% were referred to dermatologists and 1% to biopsy, reducing the mean waiting time for an in-presence visit in 78%. In patients 0–2 years old, lesions related to eczema and benign congenital lesions predominated. From 3–12 years old, eczema was still a major cause of complaint, as well as warts and molluscum. From 13–19 years old, acne was the most significant problem, followed by atopic dermatitis, nevi and warts. The most frequent treatment was emollient. Conclusion Teletriage addressed 63% of the lesions without the need for an in-presence visit, suggesting that teledermatology can manage common diseases and optimize dermatological appointments for the most serious, surgical or complex skin illnesses, reducing the mean waiting time for them.
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Affiliation(s)
- Mara Giavina Bianchi
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
- * E-mail:
| | - Andre Pires Santos
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Eduardo Cordioli
- Department of Telemedicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
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Ferreira LADP, Piccinato CDA, Cordioli E, Zlotnik E. Pregestational body mass index, weight gain during pregnancy and perinatal outcome: a retrospective descriptive study. Einstein (Sao Paulo) 2019; 18:eAO4851. [PMID: 31721895 PMCID: PMC6896599 DOI: 10.31744/einstein_journal/2020ao4851] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Accepted: 06/17/2019] [Indexed: 11/22/2022] Open
Abstract
Objective To analyze the pregestational body mass index and weight gain during pregnancy, and to associate data to perinatal outcomes of pregnant women from a Prenatal Care Program. Methods A retrospective study was carried out with 151 patients seen at the Healthy Gestation Program of Hospital Israelita Albert Einstein . Data were collected from a medical chart review of the patients seen between March 2015 and March 2016. Results The chance of developing gestational diabetes for obese patients in early gestation was estimated at 7.5-fold as compared to patients with low or normal body mass index. Conclusion There was a significant association between obesity in early pregnancy and the occurrence of gestational diabetes mellitus in this population.
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Abstract
Introduction Few studies have assessed the perception of teledermatologists about the utility and limitations of teledermatology, especially to diagnose a broad range of skin diseases. This study aimed to evaluate dermatologists’ confidence in teledermatology, its utility and limitations for dermatological conditions in primary care. Methods An analytical study that used a survey for dermatologists who diagnosed 30,916 patients with 55,012 lesions through teledermatology during a 1-year project in São Paulo, Brazil. Results Dermatologists found teledermatology useful for triage and diagnosis, especially for xerotic eczema, pigmentary disorders and superficial infections. Their confidence in teledermatology was statistically higher by the end of the project (p = 0.0012). Limitations included some technical issues and the impossibility to suggest how soon the patient should be assisted face-to-face by a dermatologist. The most treatable group of diseases by teledermatology was superficial infections (92%). The use of dermoscopy images would significantly increase the confidence to treat atypical naevi and malignant tumours (p < 0.0001 and p = 0.0003 respectively). Follow-ups by teledermatology or feedback from primary-care physicians would be desirable, according to the dermatologists. Discussion We found it interesting that dermatologists became increasingly confident in teledermatology after the project and how they classified teledermatology as useful for triage, diagnosis and even treatment of most types of skin conditions followed at primary care. Dermoscopy should definitely be added to the photographs, especially for malignant tumours and atypical naevi. Most of the technical limitations found could be solved with a few improvements in the software/platform.
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Affiliation(s)
| | - Andre Santos
- Telemedicine Department, Hospital Israelita Albert Einstein, Brazil
| | - Eduardo Cordioli
- Telemedicine Department, Hospital Israelita Albert Einstein, Brazil
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Figueira SF, Wolf C, D'Innocenzo M, de Carvalho JPV, Barbosa MG, Zlotnik E, Cordioli E. Economic evaluation of sFlt-1/PlGF ratio test in pre-eclampsia prediction and diagnosis in two Brazilian hospitals. Pregnancy Hypertens 2018; 13:30-36. [DOI: 10.1016/j.preghy.2018.04.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2017] [Revised: 04/06/2018] [Accepted: 04/16/2018] [Indexed: 12/21/2022]
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Raiza LCP, Bianchi PHM, Cordioli E, Santos ARC, Francisco NMJ, Funari MB, Podgaec S. Prevalence of Sonographic Signs of Deep Infiltrative Endometriosis Among Women Submitted to Routine Transvaginal Sonography. J Minim Invasive Gynecol 2016. [DOI: 10.1016/j.jmig.2016.08.075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Viola DCM, Cordioli E, Pedrotti CHS, Iervolino M, Bastos Neto ADS, Almeida LRND, Neves HSDS, Lottenberg CL. Advanced units: quality measures in urgency and emergency care. ACTA ACUST UNITED AC 2015; 12:492-8. [PMID: 25628203 PMCID: PMC4879918 DOI: 10.1590/s1679-45082014gs2894] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2013] [Accepted: 06/30/2014] [Indexed: 11/23/2022]
Abstract
Objective To evaluate, through care indicators, the quality of services rendered to patients considered urgency and emergency cases at an advanced emergency care unit. Methods We analyzed data from managerial reports of 64,891 medical visits performed in the Emergency Care Unit of the Ibirapuera Unit at Care during the period from June 1st, 2012 through May 31st, 2013. The proposed indicators for the assessment of care were rate of death in the emergency care unit; average length of stay of patients in the unit; rate of unplanned return visits; admission rate for patients screened as level 1 according to the Emergency Severity Index; rate of non-finalized medical consultations; rate of complaints; and door-to-electrocardiogram time. Results The rate of death in the emergency care unit was zero. Five of the 22 patients classified as Emergency Severity Index 1 (22.7%) arrived presenting cardiac arrest. All were treated with cardiopulmonary resuscitation and reestablishment of vital functions. The average length of stay of patients in the unit was 3 hours, 33 minutes, and 7 seconds. The rate of unscheduled return visits at the emergency care unit of the Ibirapuera unit was 13.64%. Rate of complaints was 2.8/1,000 patients seen during the period Conclusion The model of urgency and emergency care in advanced units provides an efficient and efficaious service to patients. Both critically ill patients and those considered less complex can receive proper treatment for their needs.
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Cordioli RL, Cordioli E, Negrini R, Silva E. Sepsis and pregnancy: do we know how to treat this situation? Rev Bras Ter Intensiva 2015; 25:334-44. [PMID: 24553516 PMCID: PMC4031877 DOI: 10.5935/0103-507x.20130056] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2013] [Accepted: 11/21/2013] [Indexed: 12/18/2022] Open
Abstract
Sepsis is defined as an acute inflammatory response syndrome secondary to an
infectious focus. It has a high incidence, morbidity and mortality, causing
substantial financial costs, especially due to complications such as septic shock and
multiple organ dysfunction. The pathogen toxins associated with individual
susceptibility culminate with cytokine release, which promotes a systemic
inflammatory response that can progress to multiple organ dysfunction and eventual
patient death. Specifically, sepsis incidence, morbidity and mortality are lower in pregnant women,
as this group is typically younger with fewer comorbidities having a polymicrobial
etiology resulting in sepsis. Pregnant women exhibit physiological characteristics that may confer specific
clinical presentation and laboratory patterns during the sepsis course. Thus, a
better understanding of these changes is critical for better identification and
management of these patients. The presence of a fetus also requires unique approaches
in a pregnant woman with sepsis. Sepsis treatment is based on certain guidelines that were established after major
clinical trials, which, unfortunately, all classified pregnancy as a exclusion
criteria. Thus, the treatment of sepsis in the general population has been extrapolated to the
pregnant population, with the following main goals: maintenance of tissue perfusion
with fluid replacement and vasoactive drugs (initial resuscitation), adequate
oxygenation, control of the infection source and an early start of antibiotic
therapy, corticosteroid infusion and blood transfusion when properly indicated,
prophylaxis, and specifically monitoring and maintenance of fetal heath.
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Affiliation(s)
- Ricardo Luiz Cordioli
- Corresponding author: Ricardo Luiz Cordioli, Unidade de Terapia
Intensiva do Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627/701,
5º Andar - Morumbi, Zip code: 05652-900 - São Paulo (SP), Brazil.
E-mail:
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Abstract
BACKGROUND Enthusiasts suggest that labouring in water and waterbirth increase maternal relaxation, reduce analgesia requirements and promote a midwifery model of care. Critics cite the risk of neonatal water inhalation and maternal/neonatal infection. OBJECTIVES To assess the evidence from randomised controlled trials about immersion in water during labour and waterbirth on maternal, fetal, neonatal and caregiver outcomes. METHODS SEARCH METHODS We searched the Cochrane Pregnancy and Childbirth Group's Trials Register (30 June 2011) and reference lists of retrieved studies. SELECTION CRITERIA Randomised controlled trials comparing immersion in any bath tub/pool with no immersion, or other non-pharmacological forms of pain management during labour and/or birth, in women during labour who were considered to be at low risk of complications, as defined by the researchers. DATA COLLECTION AND ANALYSIS We assessed trial eligibility and quality and extracted data independently. One review author entered data and the other checked for accuracy. MAIN RESULTS This review includes 12 trials (3,243 women): 8 related to just the first stage of labour: one to early versus late immersion in the first stage of labour; two to the first and second stages; and another to the second stage only. We identified no trials evaluating different baths/pools, or the management of third stage of labour. Results for the first stage of labour showed there was a significant reduction in the epidural/spinal/paracervical analgesia/anaesthesia rate amongst women allocated to water immersion compared to controls (478/1,254 versus 529/1,245; risk ratio (RR) 0.90; 95% confidence interval (CI) 0.82 to 0.99, six trials). There was also a reduction in duration of the first stage of labour (mean difference -32.4 minutes; 95% CI -58.7 to -6.13). There was no difference in assisted vaginal deliveries (RR 0.86; 95% CI 0.71 to 1.05, seven trials), caesarean sections (RR 1.21; 95% CI 0.87 to 1.68, 8 trials), use of oxytocin infusion (RR 0.64; 95% CI 0.32 to 1.28, 5 trials), perineal trauma or maternal infection. There were no differences for Apgar score less than 7 at 5 minutes (RR 1.58; 95% CI 0.63 to 3.93, 5 trials), neonatal unit admissions (RR 1.06; 95% CI 0.71 to 1.57, three trials), or neonatal infection rates (RR 2.00; 95% CI 0.50 to 7.94, five trials). Of the 3 trials that compared water immersion during the second stage with no immersion, one trial showed a significantly higher level of satisfaction with the birth experience (RR 0.24; 95% CI 0.07 to 0.80). A lack of data for some comparisons prevented robust conclusions. Further research is needed. AUTHORS' CONCLUSIONS Evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth. However, the studies are very variable and considerable heterogeneity was detected for some outcomes. Further research is needed.
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Simioni C, Sanchez Oliveira RDC, Moscovi T, D´Agostini Deutsch A, Cordioli E, Santos E. Twin pregnancy and congenital cytomegalovirus: Case report and review. J Matern Fetal Neonatal Med 2012; 26:622-4. [DOI: 10.3109/14767058.2012.745503] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Drummond CL, Oliveira RDCS, Bussamra LCDS, Mangueira CLP, Cordioli E, Aoki T. [Analysis of the combined first trimester screening for chromosomal abnormalities]. Rev Bras Ginecol Obstet 2011; 33:288-294. [PMID: 21877018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2011] [Accepted: 06/07/2011] [Indexed: 05/31/2023] Open
Abstract
PURPOSE to evaluate the performance of the combined first trimester screening for chromosomal abnormalities in a group of the Brazilian population. METHODS a retrospective study including pregnant women with single fetuses referred to a fetal medicine center to perform the first trimester screening that combines maternal age, nuchal translucency measurement and two maternal serum biochemical markers: free B-hCG and PAPP-A. To evaluate the performance of the test, the detection rate, specificity, negative and positive predicted values and false-positive rates were calculated, considering as high risk the cut-off value above 1 in 300. RESULTS we studied 456 patients submitted to the test. Advanced maternal age above 35 years was observed in 36.2% of cases. The incidence of chromosomal abnormalities in the study population was 2.2%. Twenty-one patients (4.6%) presented a high risk (above 1:300) by the combined test. Using this cut-off level, the detection rate of the test was 70% for all chromosomal abnormalities and 83.3% for trisomy 21, for a false-positive rate of 3.1%. CONCLUSIONS the combined first trimester screening was effective to detect chromosomal abnormalities, mainly for trisomy 21, with low false-positive rates. The combined test contributed to decreasing the indication of an invasive test if we compare to maternal age alone as a risk factor.
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Oliveira TA, da Cunha DR, Policastro A, Traina É, Gomes MT, Cordioli E. [The progesterone receptor gene polymorphism as factor of risk for the preterm delivery]. Rev Bras Ginecol Obstet 2011; 33:271-275. [PMID: 21877015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2011] [Accepted: 06/20/2011] [Indexed: 05/31/2023] Open
Abstract
PURPOSE to investigate the association between gene polymorphism of the progesterone receptor (PROGINS) and the risk of premature birth. METHODS In this case-control study, 57 women with previous premature delivery (Case Group) and 57 patients with delivery at term in the current pregnancy and no history of preterm delivery (Control Group) were selected. A 10 mL amount of peripheral blood was collected by venipuncture and genomic DNA was extracted followed by the polymerase chain reaction (PCR) under specific conditions for this polymorphism and 2% agarose gel electrophoresis. The bands were visualized with an ultraviolet light transilluminator. Genotype and allele PROGINS frequencies were compared between the two groups by the χ2 test, with the level of significance set at value p < 0.05. The Odds Ratio (OR) was also used, with 95% confidence intervals. RESULTS PROGINS genotypic frequencies were 75.4% T1/T1, 22.8% T1/T2 and 1.8% T2/T2 in the Group with Preterm Delivery and 80.7% T1/T1, 19.3% T1/T2 and 0% T2/T2 in the term Delivery Group. There were no differences between groups when genotype and allele frequencies were analyzed: p = 0.4 (OR = 0.7) and p = 0.4 (OR = 0.7). CONCLUSIONS the present study suggests that the presence of PROGINS polymorphism in our population does not constitute a risk factor for premature birth.
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Nardozza LMM, Camano L, Moron AF, Chinen PA, Torloni MR, Cordioli E, Araújo Junior E. Perinatal mortality in Rh alloimmunized patients. Eur J Obstet Gynecol Reprod Biol 2007; 132:159-62. [PMID: 16854514 DOI: 10.1016/j.ejogrb.2006.06.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2005] [Revised: 05/22/2006] [Accepted: 06/13/2006] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Evaluate and compare the perinatal mortality of Rh-negative pregnancies managed at São Paulo Federal University during a 9-year period, using either amniocentesis or middle cerebral artery peak systolic velocity. METHOD Descriptive observational study involving 291 consecutive Rh-negative pregnancies managed between January 1995 and January 2004. The perinatal mortality of 99 alloimmunized patients was compared with 192 Rh-negative unimmunized patients (control group). The perinatal mortality of patients managed with amniocenteses was compared to those managed with Doppler studies. RESULTS There were 74 patients managed with amniocenteses and 25 managed with Doppler studies. Perinatal mortality was significantly higher in the 99 Rh-negative isoimmunized patients than in the 192 unimmunized patients (12.1% versus 1%, p=0.0001) and did not differ according to the management protocol used (amniocentesis 13.5% versus cerebral Doppler 8.0%, p=0.725). Mean gestational age and mean weight at birth in pregnancies managed with amniocenteses (35.7 weeks and 2586 g) did not differ significantly from those managed with Doppler (36.3 weeks and 2647 g). CONCLUSIONS Perinatal mortality in Rh-negative alloimmunized patients remains high and does not differ whether pregnancies are managed through amniocentesis or cerebral Doppler evaluation.
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Affiliation(s)
- Luciano Marcondes Machado Nardozza
- Fetal Medicine Unit, Obstetrics Department, São Paulo Federal University-Paulista Medical School, UNIFESP-EPM, Av. Lopes de Azevedo, 888, CEP 05603-001, São Paulo, Brazil.
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Torloni MR, Cordioli E, Zamith MM, Hisaba WJ, Nardozza LMM, Santana RM, Moron AF. Reversible constriction of the fetal ductus arteriosus after maternal use of topical diclofenac and methyl salicylate. Ultrasound Obstet Gynecol 2006; 27:227-9. [PMID: 16355417 DOI: 10.1002/uog.2647] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Abstract
Asymmetrical conjoined twins or heteropagus twins are extremely rare. They are characterized by an incomplete component (parasite) that is normally smaller and dependent on the host (autosite). In cases of an epigastric heteropagus twin, the insertion occurs in the epigastrium. There are few reports of epigastric heteropagus twinning in the English-language literature. The authors report an extremely rare case of epigastric heteropagus twinning in which the parasite presented with head, thorax, and a rudimentary heart.
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40
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de Souza GN, Cordioli E, de Jesus Simões M, de Souza E, Kulay LJ, Camano L. Morphological and morphometric changes in the cervix uteri of the rat at term pregnancy induced by hyaluronidase. CLIN EXP OBSTET GYN 2004; 31:225-8. [PMID: 15491070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/01/2023]
Abstract
Intracervix injection of hyaluronidase during pregnancy has been proposed to accelerate cervix ripening. We evaluated the morphological and morphometric changes of the uterine cervix of pregnant rats, caused by the action of this enzyme. Ten female rats were equally divided between an experimental group (G II) and a control group (G I). On the 20th day of pregnancy, under light microscopy, a greater thinning of the superficial muciferous epithelium, with lamina propria rich in blood vessels and in eosinophils was found in G II. The histometric count of G II showed a smaller number of collagen fibers (average 248 vs 552 in the control group) and a greater concentration of eosinophils (average 18.20 vs 9.20 in the control group). The Student's t-test showed a significant difference in collagen fibers (p < 0.0001) and in eosinophils (p < 0.0007). The action of this enzyme caused a predominance of flaccid connective tissue, a lower concentration of collagen fibers and an increased concentration of eosinophils, confirming its utilization in cervix ripening.
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Affiliation(s)
- G Negrão de Souza
- Obstetrics Department, Federal University of São Paulo, School of Medicine, São Paulo (Brazil)
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41
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Hisaba WJ, Moron AF, Cavalheiro S, Santana RM, Passos JP, Cordioli E. Espinha bífida aberta: achados ultra-sonográficos e presença de contrações uterinas na predição da evolução motora neonatal. Rev Bras Ginecol Obstet 2003. [DOI: 10.1590/s0100-72032003000600007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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42
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Souza GND, Cordioli E, Simões MDJ, Souza ED, Kulay Júnior L, Camano L. Alterações morfológicas e na contagem de fibras colágenas induzidas pela hialuronidase no colo de ratas prenhes. Rev Bras Ginecol Obstet 2003. [DOI: 10.1590/s0100-72032003000400005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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43
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Cordioli E, Pizzi C, Martinelli M. Winter mortality in Emilia-Romagna, Italy. Int J Circumpolar Health 2000; 59:164-9. [PMID: 11209662] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
In this epidemiological study we have studied during 1997 in Emilia-Romagna (population about four million) Italy, mortality from ischaemic heart disease, hypertension, cerebrovascular and respiratory disease in 50-89 year-olds. The data were collected from "Ufficio Risorse Informative" and "servizio Meteorologico" of the Emilia-Romagna region. The results show high indices of deaths in the elderly, the highest being those of the 80-89 year-olds, during the winter with a maximum in January. There were some differences between males and females with regard to cold-related mortality of the different diseases. Comparing mortality rates of persons living in the North (Piacenza) and in the South (Rimini) of Emilia-Romagna, a consistent lower mortality was found in the people of Rimini. These results confirm the close relationship between advanced age, cold and excess mortality in Emilia-Romagna. The results suggest that at least two factors may be involved in explaining excess winter mortality: the sympathetic system changes in the elderly and the effects of cold on some haemostatic factors.
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Affiliation(s)
- E Cordioli
- Dipartimento di Medicina Interna, Cardioangiologia, Epatologia Università degli Studi di Bologna, Bologna, Italy
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44
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Keatinge WR, Donaldson GC, Bucher K, Jendritzky G, Cordioli E, Martinelli M, Katsouyanni K, Kunst AE, McDonald C, Näyhä S, Vuori I. Winter mortality in relation to climate. Int J Circumpolar Health 2000; 59:154-9. [PMID: 11209660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
We report further details of the Eurowinter survey of cold related mortalities and protective measures against cold in seven regions of Europe, and review these with other evidence on the relationship of winter mortality to climate. Data for the oldest subject group studied, aged 65-74, showed that in this vulnerable group, high levels of protection against indoor and outdoor cold at given outdoor temperatures were found mainly in countries with cold winters, and were associated with low levels of excess mortality at a given level of outdoor cold. Regions such as London that had poor protection against cold and/or high baseline mortalities had higher levels of winter excess mortality than expected for the coldness of their winters.
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45
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Keatinge WR, Donaldson GC, Cordioli E, Martinelli M, Kunst AE, Mackenbach JP, Nayha S, Vuori I. Heat related mortality in warm and cold regions of Europe: observational study. BMJ 2000; 321:670-3. [PMID: 10987770 PMCID: PMC27480 DOI: 10.1136/bmj.321.7262.670] [Citation(s) in RCA: 181] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To assess heat related mortalities in relation to climate within Europe. DESIGN Observational population study. SETTING North Finland, south Finland, Baden-Württemberg, Netherlands, London, north Italy, and Athens. SUBJECTS People aged 65-74. MAIN OUTCOME MEASURES Mortalities at temperatures above, below, and within each region's temperature band of minimum mortality. RESULTS Mortality was lowest at 14.3-17.3 degrees C in north Finland but at 22.7-25.7 degrees C in Athens. Overall the 3 degrees C minimum mortality temperature bands were significantly higher in regions with higher than lower mean summer temperatures (P=0.027). This was not due to regional differences in wind speeds, humidity, or rain. As a result, regions with hot summers did not have significantly higher annual heat related mortality per million population than cold regions at temperatures above these bands. Mean annual heat related mortalities were 304 (95% confidence interval 126 to 482) in North Finland, 445 (59 to 831) in Athens, and 40 (13 to 68) in London. Cold related mortalities were 2457 (1130 to 3786), 2533 (965 to 4101), and 3129 (2319 to 3939) respectively. CONCLUSIONS Populations in Europe have adjusted successfully to mean summer temperatures ranging from 13.5 degrees C to 24.1 degrees C, and can be expected to adjust to global warming predicted for the next half century with little sustained increase in heat related mortality. Active measures to accelerate adjustment to hot weather could minimise temporary rises in heat related mortality, and measures to maintain protection against cold in winter could permit substantial reductions in overall mortality as temperatures rise.
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Affiliation(s)
- W R Keatinge
- Medical Sciences Building, Queen Mary and Westfield College, London E1 4NS, UK.
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46
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Cordioli E, Pizzi C, Bugiardini R. Left ventricular metastasis from uterine leiomyosarcoma. Cardiologia 1999; 44:1001-3. [PMID: 10686777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/15/2023]
Abstract
Cardiac metastases are uncommon but seem to be increasing in incidence, possibly in relation to prolonged survival of cancer patients. Leiomyosarcoma metastatic to the heart is extremely rare. We report the case of a 57-year-old woman previously treated for uterine leiomyosarcoma who presented with dyspnea, electrocardiographic changes mimicking myocardial infarction, and normal enzymes. A left intraventricular mass, suspected as cardiac metastasis, was revealed by echocardiography. The patient died 1 week later. At autopsy the mass proved to be histologically a metastasis of the uterine tumor.
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Affiliation(s)
- E Cordioli
- Dipartimento di Medicina Interna, Cardioangiologia, Epatologia, Università degli Studi, Bologna
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47
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Costa GM, Pizzi C, Leone C, Borghi A, Cordioli E, Bugiardini R. Thrombosis of a mitral valve prosthesis resulting from Staphylococcus epidermidis endocarditis. Cardiologia 1999; 44:675-8. [PMID: 10476594] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
A 70-year-old man with a Duromedics mitral valve prosthesis had two episodes of infective endocarditis caused by enterococcus (1994 and 1996). Colonoscopy revealed five polyps. Surgical resection was performed and 2 days later the patient had dyspnea and fever. Because of a suspected valve thrombosis, intravenous heparin was given which resulted in hematic effusion in the Douglas' cul-de-sac. Intravenous heparin was withdrawn but the patient continued to have a worsening dyspnea, hyperthermia and hypotension. The patient was transferred to our Institution in cardiogenic shock. Acute thrombosis of the valve was diagnosed by echocardiography, and the patient died before transesophageal Doppler echocardiography was performed. Post mortem examination revealed mitral valve infective thrombosis. In patients with valvular prostheses, endocarditis is an added thromboembolic risk.
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Affiliation(s)
- G M Costa
- Servizio di Cura Intensiva Cardiologica, Università degli Studi, Bologna
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48
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Pizzi C, Costa GM, Borghi A, Premuda G, Tondini C, Magri G, Cordioli E, Bugiardini R. [Effects of reperfusion and coronary reocclusion on the variability of heart rate in patients with acute myocardial infarction]. Cardiologia 1999; 44:181-6. [PMID: 10208055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
The aim of this study was to analyze the very early (first 24 hours) effect of successful or failed thrombolytic therapy on the autonomic nervous system. Thirty consecutive patients with a first acute myocardial infarction were enrolled in the study, and admitted to the Coronary Care Unit within 6 hours of the onset of symptoms and treated with systemic thrombolytic therapy. All patients underwent 24-hour Holter monitoring in order to analyze ST segment variation. The autonomic nervous system was evaluated by frequency-domain heart rate variability: low frequency/high frequency ratio (LF/HF) was measured at the beginning of Holter monitoring (T1), 15 min after reperfusion or 1 hour from the start of thrombolytic therapy (T2) and after 24 hours (T3). Reperfusion status was assessed by a > or = 50% reduction in ST segment elevation within 90 min of thrombolytic therapy, and early CK-MB peak. Early coronary reocclusion was detected by early reduction in ST segment elevation followed by stable ST segment re-elevation. Twenty patients (66%) showed successful thrombolytic therapy (Group 1), 5 patients (17%) had no evidence of successful thrombolytic therapy (Group 2) and 5 patients (17%) showed an early reocclusion (Group 3). LF/HF ratio values at T1 were similar in the three groups (5.66 +/- 1.7 vs 5.65 +/- 1.2 vs 5.51 +/- 0.9, NS). At T2, LF/HF ratio was significantly higher in Group 1 and 3 than Group 2 patients (9.21 +/- 1.7 and 11.1 +/- 1.2 vs 5.58 +/- 1.4, respectively, p < 0.001). In Group 1 LF/HF ratio was significantly lower at T3 when compared with T1 and T2 (1.9 +/- 1 vs 5.66 +/- 1.7 and 9.21 +/- 1.7, respectively, p < 0.001). Conversely, in Group 3 LF/HF ratio at T3 was similar to values measured at T1 (5.59 +/- 1.7 vs 5.51 +/- 0.9, respectively, NS) and significantly higher than those detected in Group 1. In Group 2, LF/HF ratio resulted substantially unchanged at T3 (5.49 +/- 1.7, NS). In conclusion, 1) successful thrombolytic therapy induces early beneficial effects on the autonomic nervous system function, as shown by increased heart rate variability values, when compared with failed thrombolytic therapy; 2) however, during the early period following coronary reperfusion, a transient but dramatic increase in sympathetic activity is observed. This could trigger coronary flow instability, thus facilitating reocclusion, by activating different pathogenetic mechanisms (increased vascular tone, platelet activation, thrombogenic factor prevalence); 3) early coronary vessel reocclusion precludes favorable effects of reperfusion on sympatho-vagal balance observed after the first 24 hours.
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Affiliation(s)
- C Pizzi
- Dipartimento di Medicina Interna, Cardioangiologia ed Epatologia, Università degli Studi, Bologna
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49
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Cordioli E, Pizzi C, Tondini C. [Cardiac arrhythmia associated with malignant neuroleptic syndrome: description of 2 clinical cases]. G Ital Cardiol 1997; 27:1164-8. [PMID: 9463060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Malignant neuroleptic syndrome (alteration of consciousness, muscle rigidity and hyperthermia) is a potentially lethal condition, due also to its life-threatening complications. In particular, hypokinetic and hyperkinetic arrhythmias can be rare and severe early manifestations of this illness, and they deserve a careful approach because of their drug-refractoriness. Arrhythmias associated with the malignant neuroleptic syndrome depend on various mechanisms: neurotransmitter receptor blockades typical of neuroleptic drugs, clustered lipid droplets among the cardiac myofibrils and possible electrolytic disorder due to diaphoresis. The two cases described here presented hypokinetic and hyperkinetic (supraventricular and ventricular) arrhythmias. The arrhythmias, which failed to respond to antiarrhythmic drugs, were temporarily suppressed by DC shock, over-drive pacing and correction of electrolytic imbalance. In case 1, prolonged bromocriptine treatment was required. Complete wash-out of the causative agents resulted in lasting regression of arrhythmias. In conclusion, a correct treatment and a favourable outcome of this syndrome can be achieved only through early diagnosis.
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Affiliation(s)
- E Cordioli
- Dipartimento di Medicina Interna Cardioangiologia, Epatologia Università degli Studi, Bologna
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50
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Cordioli E, Tondini C, Pizzi C, Massarelli G. [Silent myocardial infarction in a patient treated with radiation therapy and polychemotherapy for Hodgkin's lymphoma]. Cardiologia 1997; 42:635-8. [PMID: 9289380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
A 48-year-old woman with no cardiovascular risk factors was admitted to the hospital because of acute dyspnea. At 27-year-old, she developed Hodgkin's disease, that was successfully treated with splenectomy, combined chemotherapy (nitrogen mustard, vincristine, procarbazine, prednisone-MOPP regimen) and radiotherapy (4500 rads). At 43-year-old the lymphoma relapsed and she had further chemotherapy with doxorubicin, bleomycin, vinblastina and dacarbazine. After this treatment, she had an episode of pulmonary edema, attributed to doxorubicin acute cardiotoxicity. She responded to digitalis and diuretics and was discharged with an electrocardiogram (ECG) showing left bundle branch block and a normal echocardiogram. The patient enjoyed good health for several years and 4 months before the present admission the ECG and echocardiogram were unchanged. On this admission there were signs of left ventricular failure with acute pulmonary edema, and a new soft apical murmur (3-4 Levine). The patient required endotracheal intubation and high doses of diuretics, digitalis and vasodilators. The cardiac enzymes were negative, the serial ECGs confirmed left bundle branch block, while the echocardiogram showed moderate to severe mitral regurgitation, akinesia of the interventricular septum and inferior wall with dilation of the left ventricle. A previous silent myocardial infarction was suspected. After recovery, she underwent cardiac catheterization confirming akinesia of the interventricular septum and inferior wall with moderate mitral regurgitation, while coronary angiography showed a critical ostial stenosis of the right coronary artery. In view of a dipyridamole-thallium scan negative for myocardial viability, reperfusion was not attempted. With changes in radiotherapeutic techniques, the incidence of radiation-induced heart disease (pericarditis, myocarditis, conduction abnormalities and, rarely, occlusive coronary artery disease) is declining. Nevertheless, after irradiation of the chest and mediastinum a longterm cardiological follow-up is useful in selecting patients at higher risk of radiation-induced coronary artery disease, who will eventually require coronary angiography and reperfusion intervention.
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Affiliation(s)
- E Cordioli
- Dipartimento di Medicine Interna, Cardioangiologia, Epatologia, Università degli Studi, Bologna
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