Nosocomial infections are common in patients receiving extracorporeal membrane oxygenation (ECMO), with ECMO cannula-site infections (ECMO-CSI) being the most frequent infections directly related to the ECMO run. These infections can significantly impact patient outcomes. Currently, no adult guidelines exist for the prevention, diagnosis, and/or treatment of peripheral ECMO-CSI, resulting in heterogeneity in both clinical practice and research findings. We conducted a Delphi study involving 39 international experts in ECMO management. The experts participated in four Delphi rounds to reach consensus on various aspects of ECMO-CSI complicating peripheral ECMO (central ECMO excluded), including definition, clinical suspicion, diagnostic methods, preventive measures, and treatment. Consensus was defined as ≥ 70
BACKGROUND:Cancer care faces increasing sustainability challenges due to the structural growth of health care costs, driven by longer survival, expanding treatment indications, and the rapid diffusion of high-cost technologies. In this context, policymakers have implemented prospective payment systems (PPS) as policy strategies to promote care coordination, efficiency, and resource optimization in oncology. OBJECTIVE:To evaluate the association between the implementation of PPS and key outcomes in cancer care, including health care expenditure, service utilization, quality of care, and patient survival or mortality, compared with fee-for-service (FFS) payment models. METHODS:We conducted a systematic literature following PRISMA guidelines. Eligible studies, published between 2000 and 2024, assessed PPS mechanisms in adult cancer patient populations, mostly using cohort and case-control studies. We synthesized evidence across four predefined domains: health expenditures, service utilization, quality of care, and survival or mortality. RESULTS:Across included studies, findings were heterogeneous and context dependent. Nine studies evaluated health expenditures, of which 90 % reported reductions. Among six studies assessing service utilization, 66.7 % found no significant variation. Eleven studies examined quality outcomes; 54.5 % reported improvements. For survival, 57.1 % of seven studies showed favourable results. CONCLUSION:Our review synthesizes the evidence on the implementation of PPS applied to cancer care compared with FFS models. PPS are consistently associated with cost containment, while evidence regarding utilization, quality, and survival remains mixed and, in some cases, inconclusive. Our findings underscore the potential of PPS as a policy instrument to improve financial sustainability in oncology, while also highlighting the need for careful design, implementation, and monitoring to mitigate unintended risks.
Importance:The efficacy and safety of guideline-recommended treatments for heart failure (HF) are uncertain in patients with Chagas disease. Objective:To evaluate the efficacy and safety of the angiotensin receptor-neprilysin inhibitor sacubitril/valsartan in patients with HF with reduced ejection fraction due to Chagas disease. Design, Setting, and Participants:From December 10, 2019, through September 13, 2023, patients with HF, confirmed diagnosis of Chagas disease, left ventricular ejection fraction of 40% or less, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) of 600 pg/mL or greater (or B-type natriuretic peptide [BNP] ≥150 pg/mL) or 400 pg/mL or greater (or BNP ≥100 pg/mL) if hospitalized for HF within the previous 12 months were screened at 83 sites in Argentina, Brazil, Colombia, and Mexico. Statistical analysis was conducted between May and July 2025. Interventions:Patients were randomized to receive sacubitril/valsartan (target dose, 200 mg twice daily) or enalapril (target dose, 10 mg twice daily), in addition to standard therapy. Main Outcomes and Measures:The primary end point was a hierarchical composite outcome tested, in order, of death from cardiovascular causes, hospitalization for HF, or relative change in NT-proBNP from baseline to 12 weeks. The primary analysis was done using a win ratio approach. Results:Overall, 462 participants were randomized to receive sacubitril/valsartan and 460 to receive enalapril (mean [SD] age, 64.2 [10.8] years; 387 [42.0%] were female). Over a median (IQR) follow-up of 25.2 (18.4-33.2) months, cardiovascular death occurred in 110 patients (23.8% [18.3% wins in the hierarchical comparison]) in the sacubitril/valsartan group and 117 patients (25.4% [17.5% wins]) in the enalapril group. A total of 102 patients (22.1% [7.7% wins]) in the sacubitril/valsartan group and 111 (24.1% [6.9% wins]) in the enalapril group experienced a first hospitalization for HF. Patients in the sacubitril/valsartan group had a median (IQR) decrease in NT-proBNP of 30.6% (-54.3% to -0.9%) at 12 weeks, leading to 22.5% wins, while those in the enalapril group had a 5.5% (-31.9% to 37.5%) decrease (7.2% wins). The resulting stratified win ratio was 1.52 (95% CI, 1.28-1.82; P < .001) for sacubitril/valsartan compared with enalapril. Conclusions and Relevance:In patients with HF with reduced ejection fraction due to Chagas disease, there was no significant difference in clinical outcomes between sacubitril/valsartan and enalapril, but there was a greater reduction in NT-proBNP at 12 weeks in patients in the sacubitril/valsartan group. Trial Registration:ClinicalTrials.gov Identifier: NCT04023227.
ABSTRACT Background Chronic Chagas cardiomyopathy (CCC) exhibits high arrhythmic risk despite preserved systolic function, challenging LVEF‐based stratification. Methods We performed a cross‐sectional analysis of 146 heart failure patients (75 CCC, 71 Ischemic Cardiomyopathy [IC]) with comparable age, LVEF, and NT‐proBNP. Results CCC patients had a higher arrhythmic burden and NSVT prevalence (RR 4.37, 95% CI 1.67–11.39). NSVT prevalence in CCC was similar regardless of LVEF (p = 0.707). Conventional heart failure severity markers, including worse global and regional strain, were associated with NSVT in IC but not in CCC, where atrial fibrillation (p = 0.002) and ventricular aneurysms (p = 0.033) were the primary associated variables. Conclusions Arrhythmic vulnerability in CCC appears decoupled from LVEF, suggesting that complementary substrate‐based markers may improve risk stratification in this population.
INTRODUCTION:Urinary tract infection (UTI) is the second most common cause of infection globally, following respiratory system infections. The aim is to evaluate the effectiveness of an optimization strategy in the diagnosis of UTIs through the patient's clinical condition and laboratory tests, with the purpose of reducing unnecessary urine culture processing, reducing antibiotic treatment of asymptomatic bacteriuria, and improving the diagnostic accuracy of UTIs. METHODS:A quasi-experimental study was conducted in a high-complexity hospital's emergency department from January to September 2024. Adult patients with suspected UTIs were included. The intervention, implemented in April, consisted of a protocol created by the Antimicrobial Stewardship Program for diagnostic accuracy of UTIs. Data on sociodemographic, clinical, laboratory, and cost-related variables were analyzed. RESULTS:A total of 1,376 urine cultures were included. The intervention showed a statistically significant (p < 0.001) decrease in the processing of urine culture in the intervention and postintervention group, with 71% and 84% less urine cultures processed than the preintervention group, respectively. No differences were found (p = 0.384) in readmission due to UTI within the next 30 days or in mortality (p = 0.488). The intervention reduced the number of urine cultures collected, leading to an 84.05% decrease in costs compared to the preintervention period. CONCLUSION:The implementation of an optimized urine culture protocol that incorporates clinical conditions and laboratory tests can lead to a significant reduction in costs and waste, while also promoting better optimization of available resources.
