RESUMO
BACKGROUND: Long-term symptoms following severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection are a major concern, yet their prevalence is poorly understood. METHODS: We conducted a prospective cohort study comparing adults with SARS-CoV-2 infection (coronavirus disease-positive [COVID+]) with adults who tested negative (COVID-), enrolled within 28 days of a Food and Drug Administration (FDA)-approved SARS-CoV-2 test result for active symptoms. Sociodemographic characteristics, symptoms of SARS-CoV-2 infection (assessed with the Centers for Disease Control and Prevention [CDC] Person Under Investigation Symptom List), and symptoms of post-infectious syndromes (ie, fatigue, sleep quality, muscle/joint pains, unrefreshing sleep, and dizziness/fainting, assessed with CDC Short Symptom Screener for myalgic encephalomyelitis/chronic fatigue syndrome) were assessed at baseline and 3 months via electronic surveys sent via text or email. RESULTS: Among the first 1000 participants, 722 were COVID+ and 278 were COVID-. Mean age was 41.5 (SD 15.2); 66.3% were female, 13.4% were Black, and 15.3% were Hispanic. At baseline, SARS-CoV-2 symptoms were more common in the COVID+ group than the COVID- group. At 3 months, SARS-CoV-2 symptoms declined in both groups, although were more prevalent in the COVID+ group: upper respiratory symptoms/head/eyes/ears/nose/throat (HEENT; 37.3% vs 20.9%), constitutional (28.8% vs 19.4%), musculoskeletal (19.5% vs 14.7%), pulmonary (17.6% vs 12.2%), cardiovascular (10.0% vs 7.2%), and gastrointestinal (8.7% vs 8.3%); only 50.2% and 73.3% reported no symptoms at all. Symptoms of post-infectious syndromes were similarly prevalent among the COVID+ and COVID- groups at 3 months. CONCLUSIONS: Approximately half of COVID+ participants, as compared with one-quarter of COVID- participants, had at least 1 SARS-CoV-2 symptom at 3 months, highlighting the need for future work to distinguish long COVID. CLINICAL TRIALS REGISTRATION: NCT04610515.
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COVID-19 , Envio de Mensagens de Texto , Adulto , Feminino , Humanos , Masculino , COVID-19/diagnóstico , COVID-19/epidemiologia , Síndrome de COVID-19 Pós-Aguda , Estudos Prospectivos , SARS-CoV-2RESUMO
The COVID-19 pandemic has disproportionately affected Hispanic or Latino, non-Hispanic Black (Black), non-Hispanic American Indian or Alaska Native (AI/AN), and non-Hispanic Native Hawaiian or Other Pacific Islander (NH/PI) populations in the United States. These populations have experienced higher rates of infection and mortality compared with the non-Hispanic White (White) population (1-5) and greater excess mortality (i.e., the percentage increase in the number of persons who have died relative to the expected number of deaths for a given place and time) (6). A limitation of existing research on excess mortality among racial/ethnic minority groups has been the lack of adjustment for age and population change over time. This study assessed excess mortality incidence rates (IRs) (e.g., the number of excess deaths per 100,000 person-years) in the United States during December 29, 2019-January 2, 2021, by race/ethnicity and age group using data from the National Vital Statistics System. Among all assessed racial/ethnic groups (non-Hispanic Asian [Asian], AI/AN, Black, Hispanic, NH/PI, and White populations), excess mortality IRs were higher among persons aged ≥65 years (426.4 to 1033.5 excess deaths per 100,000 person-years) than among those aged 25-64 years (30.2 to 221.1) and those aged <25 years (-2.9 to 14.1). Among persons aged <65 years, Black and AI/AN populations had the highest excess mortality IRs. Among adults aged ≥65 years, Black and Hispanic persons experienced the highest excess mortality IRs of >1,000 excess deaths per 100,000 person-years. These findings could help guide more tailored public health messaging and mitigation efforts to reduce disparities in mortality associated with the COVID-19 pandemic in the United States,* by identifying the racial/ethnic groups and age groups with the highest excess mortality rates.
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COVID-19/mortalidade , Disparidades nos Níveis de Saúde , Mortalidade/tendências , Adulto , Distribuição por Idade , Idoso , COVID-19/etnologia , Etnicidade/estatística & dados numéricos , Humanos , Pessoa de Meia-Idade , Grupos Raciais/estatística & dados numéricos , Estados Unidos/epidemiologia , Adulto JovemRESUMO
OBJECTIVE: Although timely administration of antibiotics has an established benefit in serious bacterial infection, the majority of studies evaluating antibiotic delay focus only on the first dose. Recent evidence suggests that delays in redosing may also be associated with worse clinical outcome. In light of the increasing burden of boarding in Emergency Departments (ED) and subsequent need to redose antibiotic in the ED, we examined the association between delayed second antibiotic dose administration and mortality among patients admitted from the ED with a broad array of infections and characterized risk factors associated with delayed second dose administration. METHODS: We performed a retrospective cohort study of patients admitted through five EDs in a single healthcare system from 1/2018 through 12/2018. Our study included all patients, aged 18 years or older, who received two intravenous antibiotic doses within a 30-h period, with the first dose administered in the ED. Patients with end stage renal disease, cirrhosis and extremes of weight were excluded due to a lack of consensus on antibiotic dosing intervals for these populations. Delay was defined as administration of the second dose at a time-point greater than 125% of the recommended interval. The primary outcome was in-hospital mortality. RESULTS: A total of 5605 second antibiotic doses, occurring during 4904 visits, met study criteria. Delayed administration of the second dose occurred during 21.1% of visits. After adjustment for patient characteristics, delayed second dose administration was associated with increased odds of in-hospital mortality (OR 1.50, 95%CI 1.05-2.13). Regarding risk factors for delay, every one-hour increase in allowable compliance time was associated with a 18% decrease in odds of delay (OR 0.82 95%CI 0.75-0.88). Other risk factors for delay included ED boarding more than 4 h (OR 1.47, 95%CI 1.27-1.71) or a high acuity presentation as defined by emergency severity index (ESI) (OR 1.54, 95%CI 1.30-1.81 for ESI 1-2 versus 3-5). CONCLUSIONS: Delays in second antibiotic dose administration were frequent in the ED and early hospital course, and were associated with increased odds of in-hospital mortality. Several risk factors associated with delays in second dose administration, including ED boarding, were identified.
Assuntos
Antibacterianos/administração & dosagem , Infecções Bacterianas/tratamento farmacológico , Administração Intravenosa , Antibacterianos/uso terapêutico , Infecções Bacterianas/mortalidade , Esquema de Medicação , Serviço Hospitalar de Emergência/estatística & dados numéricos , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Fatores de Risco , Fatores de TempoRESUMO
BACKGROUND: To estimate, prior to finalization of claims, the national monthly numbers of admissions and rates of 30-day readmissions and post-discharge observation-stays for Medicare fee-for-service beneficiaries hospitalized with acute myocardial infarction (AMI), heart failure (HF), or pneumonia. METHODS: The centers for Medicare & Medicaid Services (CMS) Integrated Data Repository, including the Medicare beneficiary enrollment database, was accessed in June 2015, February 2017, and February 2018. We evaluated patterns of delay in Medicare claims accrual, and used incomplete, non-final claims data to develop and validate models for real-time estimation of admissions, readmissions, and observation stays. RESULTS: These real-time reporting models accurately estimate, within 2 months from admission, the monthly numbers of admissions, 30-day readmission and observation-stay rates for patients with AMI, HF, or pneumonia. CONCLUSIONS: This work will allow CMS to track the impact of policy decisions in real time and enable hospitals to better monitor their performance nationally.
Assuntos
Insuficiência Cardíaca/terapia , Tempo de Internação/estatística & dados numéricos , Medicare/estatística & dados numéricos , Infarto do Miocárdio/terapia , Admissão do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Pneumonia/terapia , Idoso , Humanos , Revisão da Utilização de Seguros , Observação , Fatores de Tempo , Estados UnidosRESUMO
BACKGROUND: Efforts to decrease hospitalization costs could increase post-acute care costs. This effect could undermine initiatives to reduce overall episode costs and have implications for the design of health care under alternative payment models. METHODS: Among Medicare fee-for-service beneficiaries aged ≥65 years hospitalized with acute myocardial infarction (AMI) between July 2010 and June 2013 in the Premier Healthcare Database, we studied the association of in-hospital and post-acute care resource utilization and outcomes by in-hospital cost tertiles. RESULTS: Among patients with AMI at 326 hospitals, the median (range) of each hospital's mean per-patient in-hospital risk-standardized cost (RSC) for the low, medium, and high cost tertiles were $16,257 ($13,097-$17,648), $18,544 ($17,663-$19,875), and $21,831 ($19,923-$31,296), respectively. There was no difference in the median (IQR) of risk-standardized post-acute payments across cost-tertiles: $5014 (4295-6051), $4980 (4349-5931) and $4922 (4056-5457) for the low (n = 90), medium (n = 98), and high (n = 86) in-hospital RSC tertiles (p = 0.21), respectively. In-hospital and 30-day mortality rates did not differ significantly across the in-hospital RSC tertiles; however, 30-day readmission rates were higher at hospitals with higher in-hospital RSCs: median = 17.5, 17.8, and 18.0% at low, medium, and high in-hospital RSC tertiles, respectively (p = 0.005 for test of trend across tertiles). CONCLUSIONS: In our study of patients hospitalized with AMI, greater resource utilization during the hospitalization was not associated with meaningful differences in costs or mortality during the post-acute period. These findings suggest that it may be possible for higher cost hospitals to improve efficiency in care without increasing post-acute care utilization or worsening outcomes.
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Economia Hospitalar/estatística & dados numéricos , Gastos em Saúde/estatística & dados numéricos , Hospitalização/economia , Medicare/economia , Infarto do Miocárdio/terapia , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Idoso , Estudos Transversais , Planos de Pagamento por Serviço Prestado , Recursos em Saúde/estatística & dados numéricos , Humanos , Infarto do Miocárdio/economia , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Estados UnidosRESUMO
BACKGROUND: The current acute kidney injury (AKI) risk prediction model for patients undergoing percutaneous coronary intervention (PCI) from the American College of Cardiology (ACC) National Cardiovascular Data Registry (NCDR) employed regression techniques. This study aimed to evaluate whether models using machine learning techniques could significantly improve AKI risk prediction after PCI. METHODS AND FINDINGS: We used the same cohort and candidate variables used to develop the current NCDR CathPCI Registry AKI model, including 947,091 patients who underwent PCI procedures between June 1, 2009, and June 30, 2011. The mean age of these patients was 64.8 years, and 32.8% were women, with a total of 69,826 (7.4%) AKI events. We replicated the current AKI model as the baseline model and compared it with a series of new models. Temporal validation was performed using data from 970,869 patients undergoing PCIs between July 1, 2016, and March 31, 2017, with a mean age of 65.7 years; 31.9% were women, and 72,954 (7.5%) had AKI events. Each model was derived by implementing one of two strategies for preprocessing candidate variables (preselecting and transforming candidate variables or using all candidate variables in their original forms), one of three variable-selection methods (stepwise backward selection, lasso regularization, or permutation-based selection), and one of two methods to model the relationship between variables and outcome (logistic regression or gradient descent boosting). The cohort was divided into different training (70%) and test (30%) sets using 100 different random splits, and the performance of the models was evaluated internally in the test sets. The best model, according to the internal evaluation, was derived by using all available candidate variables in their original form, permutation-based variable selection, and gradient descent boosting. Compared with the baseline model that uses 11 variables, the best model used 13 variables and achieved a significantly better area under the receiver operating characteristic curve (AUC) of 0.752 (95% confidence interval [CI] 0.749-0.754) versus 0.711 (95% CI 0.708-0.714), a significantly better Brier score of 0.0617 (95% CI 0.0615-0.0618) versus 0.0636 (95% CI 0.0634-0.0638), and a better calibration slope of observed versus predicted rate of 1.008 (95% CI 0.988-1.028) versus 1.036 (95% CI 1.015-1.056). The best model also had a significantly wider predictive range (25.3% versus 21.6%, p < 0.001) and was more accurate in stratifying AKI risk for patients. Evaluated on a more contemporary CathPCI cohort (July 1, 2015-March 31, 2017), the best model consistently achieved significantly better performance than the baseline model in AUC (0.785 versus 0.753), Brier score (0.0610 versus 0.0627), calibration slope (1.003 versus 1.062), and predictive range (29.4% versus 26.2%). The current study does not address implementation for risk calculation at the point of care, and potential challenges include the availability and accessibility of the predictors. CONCLUSIONS: Machine learning techniques and data-driven approaches resulted in improved prediction of AKI risk after PCI. The results support the potential of these techniques for improving risk prediction models and identification of patients who may benefit from risk-mitigation strategies.
Assuntos
Injúria Renal Aguda/etiologia , Mineração de Dados/métodos , Técnicas de Apoio para a Decisão , Aprendizado de Máquina , Intervenção Coronária Percutânea/efeitos adversos , Injúria Renal Aguda/diagnóstico , Injúria Renal Aguda/prevenção & controle , Idoso , Tomada de Decisão Clínica , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de Proteção , Sistema de Registros , Reprodutibilidade dos Testes , Estudos Retrospectivos , Medição de Risco , Fatores de Risco , Fatores de Tempo , Resultado do TratamentoRESUMO
PURPOSE: To estimate medical device utilization needed to detect safety differences among implantable cardioverter defibrillators (ICDs) generator models and compare these estimates to utilization in practice. METHODS: We conducted repeated sample size estimates to calculate the medical device utilization needed, systematically varying device-specific safety event rate ratios and significance levels while maintaining 80% power, testing 3 average adverse event rates (3.9, 6.1, and 12.6 events per 100 person-years) estimated from the American College of Cardiology's 2006 to 2010 National Cardiovascular Data Registry of ICDs. We then compared with actual medical device utilization. RESULTS: At significance level 0.05 and 80% power, 34% or fewer ICD models accrued sufficient utilization in practice to detect safety differences for rate ratios <1.15 and an average event rate of 12.6 events per 100 person-years. For average event rates of 3.9 and 12.6 events per 100 person-years, 30% and 50% of ICD models, respectively, accrued sufficient utilization for a rate ratio of 1.25, whereas 52% and 67% for a rate ratio of 1.50. Because actual ICD utilization was not uniformly distributed across ICD models, the proportion of individuals receiving any ICD that accrued sufficient utilization in practice was 0% to 21%, 32% to 70%, and 67% to 84% for rate ratios of 1.05, 1.15, and 1.25, respectively, for the range of 3 average adverse event rates. CONCLUSIONS: Small safety differences among ICD generator models are unlikely to be detected through routine surveillance given current ICD utilization in practice, but large safety differences can be detected for most patients at anticipated average adverse event rates.
Assuntos
Bases de Dados Factuais/estatística & dados numéricos , Desfibriladores Implantáveis/estatística & dados numéricos , Vigilância de Produtos Comercializados/estatística & dados numéricos , Falha de Prótese , Sistema de Registros/estatística & dados numéricos , Procedimentos Cirúrgicos Cardíacos/instrumentação , Procedimentos Cirúrgicos Cardíacos/estatística & dados numéricos , Interpretação Estatística de Dados , Morte Súbita Cardíaca , Desfibriladores Implantáveis/efeitos adversos , Insuficiência Cardíaca/cirurgia , Humanos , Prevenção Primária , Vigilância de Produtos Comercializados/métodos , Implantação de Prótese/instrumentação , Implantação de Prótese/estatística & dados numéricos , Tamanho da Amostra , Estados UnidosRESUMO
OBJECTIVES: To characterize hospital phenotypes by their combined utilization pattern of percutaneous coronary interventions (PCI), coronary artery bypass grafting (CABG) procedures, and intensive care unit (ICU) admissions for patients hospitalized for acute myocardial infarction (AMI). RESEARCH DESIGN: Using the Premier Analytical Database, we identified 129,138 hospitalizations for AMI from 246 hospitals with the capacity for performing open-heart surgery during 2010-2013. We calculated year-specific, risk-standardized estimates of PCI procedure rates, CABG procedure rates, and ICU admission rates for each hospital, adjusting for patient clinical characteristics and within-hospital correlation of patients. We used a mixture modeling approach to identify groups of hospitals (ie, hospital phenotypes) that exhibit distinct longitudinal patterns of risk-standardized PCI, CABG, and ICU admission rates. RESULTS: We identified 3 distinct phenotypes among the 246 hospitals: (1) high PCI-low CABG-high ICU admission (39.2% of the hospitals), (2) high PCI-low CABG-low ICU admission (30.5%), and (3) low PCI-high CABG-moderate ICU admission (30.4%). Hospitals in the high PCI-low CABG-high ICU admission phenotype had significantly higher risk-standardized in-hospital costs and 30-day risk-standardized payment yet similar risk-standardized mortality and readmission rates compared with hospitals in the low PCI-high CABG-moderate ICU admission phenotype. Hospitals in these phenotypes differed by geographic region. CONCLUSIONS: Hospitals differ in how they manage patients hospitalized for AMI. Their distinctive practice patterns suggest that some hospital phenotypes may be more successful in producing good outcomes at lower cost.
Assuntos
Hospitais/estatística & dados numéricos , Infarto do Miocárdio/terapia , Doença Aguda , Idoso , Ponte de Artéria Coronária/estatística & dados numéricos , Custos Hospitalares/estatística & dados numéricos , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Infarto do Miocárdio/economia , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/estatística & dados numéricosRESUMO
BACKGROUND: The number of percutaneous coronary interventions (PCI) in China has increased more than 20-fold over the last decade. Consequently, there is a need for national-level information to characterize PCI indications and long-term patient outcomes, including health status, to understand and improve evolving practice patterns. OBJECTIVES: This nationwide prospective study of patients receiving PCI is to: (1) measure long-term clinical outcomes (including death, acute myocardial infarction [AMI], and/or revascularization), patient-reported outcomes (PROs), cardiovascular risk factor control and adherence to medications for secondary prevention; (2) determine patient- and hospital-level factors associated with care process and outcomes; and (3) assess the appropriateness of PCI procedures. METHODS: The China Patient-centered Evaluative Assessment of Cardiac Events (PEACE) Prospective Study of PCI has enrolled 5,000 consecutive patients during 2012-2014 from 34 diverse hospitals across China undergoing PCI for any indication. We abstracted details of patient's medical history, treatments, and in-hospital outcomes from medical charts, and conducted baseline, 1-, 6-, and 12-month interviews to characterize patient demographics, risk factors, clinical presentation, healthcare utilization, and health status using validated PRO measures. The primary outcome, a composite measure of death, AMI and/or revascularization, as well as PROs, medication adherence and cardiovascular risk factor control, was assessed throughout the 12-month follow-up. Blood and urine samples were collected at baseline and 12 months and stored for future analyses. To validate reports of coronary anatomy, 2,000 angiograms are randomly selected and read by two independent core laboratories. Hospital characteristics regarding their facilities, processes and organizational characteristics are assessed by site surveys. CONCLUSION: China PEACE Prospective Study of PCI will be the first study to generate novel, high-quality, comprehensive national data on patients' socio-demographic, clinical, treatment, and metabolic/genetic factors, and importantly, their long-term outcomes following PCI, including health status. This will build the foundation for PCI performance improvement efforts in China. © 2016 The Authors. Catheterization and Cardiovascular Interventions. Published by Wiley Periodicals, Inc.
Assuntos
Infarto do Miocárdio/etiologia , Medidas de Resultados Relatados pelo Paciente , Assistência Centrada no Paciente , Intervenção Coronária Percutânea/efeitos adversos , China , Protocolos Clínicos , Angiografia Coronária , Nível de Saúde , Disparidades em Assistência à Saúde , Humanos , Adesão à Medicação , Infarto do Miocárdio/diagnóstico , Infarto do Miocárdio/mortalidade , Intervenção Coronária Percutânea/mortalidade , Valor Preditivo dos Testes , Estudos Prospectivos , Projetos de Pesquisa , Medição de Risco , Fatores de Risco , Prevenção Secundária/métodos , Fatores de Tempo , Resultado do TratamentoRESUMO
BACKGROUND: The treatment for patients with acute myocardial infarction (AMI) was transformed by the introduction of intensive care units (ICUs), yet we know little about how contemporary hospitals use this resource-intensive setting and whether higher use is associated with better outcomes. METHODS: We identified 114,136 adult hospitalizations for AMI from 307 hospitals in the 2009 to 2010 Premier database using codes from the International Classification of Diseases, Ninth Revision, Clinical Modification. Hospitals were stratified into quartiles by rates of ICU admission for AMI patients. Across quartiles, we examined in-hospital risk-standardized mortality rates and usage rates of critical care therapies for these patients. RESULTS: Rates of ICU admission for AMI patients varied markedly among hospitals (median 48%, Q1-Q4 20%-71%, range 0%-98%), and there was no association with in-hospital risk-standardized mortality rates (6% all quartiles, P = .7). However, hospitals admitting more AMI patients to the ICU were more likely to use critical care therapies overall (mechanical ventilation [from Q1 with lowest rate of ICU use to Q4 with highest rate 13%-16%], vasopressors/inotropes [17%-21%], intra-aortic balloon pumps [4%-7%], and pulmonary artery catheters [4%-5%]; P for trend < .05 in all comparisons). CONCLUSIONS: Rates of ICU admission for patients with AMI vary substantially across hospitals and were not associated with differences in mortality, but were associated with greater use of critical care therapies. These findings suggest uncertainty about the appropriate use of this resource-intensive setting and a need to optimize ICU triage for patients who will truly benefit.
Assuntos
Infarto Miocárdico de Parede Anterior , Unidades de Cuidados Coronarianos , Admissão do Paciente/normas , Adulto , Idoso , Idoso de 80 Anos ou mais , Infarto Miocárdico de Parede Anterior/diagnóstico , Infarto Miocárdico de Parede Anterior/economia , Infarto Miocárdico de Parede Anterior/terapia , Unidades de Cuidados Coronarianos/economia , Unidades de Cuidados Coronarianos/métodos , Unidades de Cuidados Coronarianos/estatística & dados numéricos , Alocação de Recursos para a Atenção à Saúde/estatística & dados numéricos , Mortalidade Hospitalar , Humanos , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Melhoria de Qualidade , Estudos Retrospectivos , Medição de Risco , Triagem/organização & administração , Triagem/normas , Estados UnidosRESUMO
BACKGROUND: The present study aimed to assess the role of C3435T polymorphism in drug-resistance in epilepsy by a meta-analysis. MATERIAL AND METHODS: Databases were obtained from the Cochrane Library, MEDLINE, EMBASE, PubMed, Science Direct database, CNKI, and Wanfang up to October 2014. All the case-control association studies evaluating the role of ABCB1 C3435T in pharmacoresistance to anti-epileptic drug (AED) were identified. RevMan 5.0 software was utilized to perform quantitative analyses in an allele model (C vs. T) and a genotype model (CC vs. CT+TT). RESULTS: From the 189 potential studies, we included 28 articles for the meta-analysis, including 30 independent case-control studies involving 4124 drug-resistant epileptic patients and 4480 epileptic patients for whom drug treatment was effective. We excluded 164 studies because of duplication, lack of genotype data, and non-clinical research. We found that C3435T polymorphism was not significantly associated with drug resistance in epilepsy, either in allele model (C vs. T: OR=1.07; 95%CI: 0.95-1.19) or in genotype model (CC vs. CT+TT: OR=1.05; 95%CI: 0.89-1.24, P=0.55). Subgroup analyses suggested that in Caucasian populations there are significant differences between resistance group (NR) and control group (R) in both allele model (C vs. T: OR=1.09; 95%CI: 1.00-1.18, P=0.05) and genotype model (CC vs. CT+TT: OR=1.20; 95%CI: 1.04-1.40, P=0.01). However, we did not find this association in Asian populations. CONCLUSIONS: We conclude that the ABCB1 C3435T polymorphism may be a genetic marker for drug resistance in epilepsy in Caucasian populations.
Assuntos
Resistência a Medicamentos/genética , Epilepsia/tratamento farmacológico , Epilepsia/genética , Predisposição Genética para Doença , Polimorfismo de Nucleotídeo Único/genética , Subfamília B de Transportador de Cassetes de Ligação de ATP/genética , Humanos , Viés de Publicação , População BrancaRESUMO
BACKGROUND: Despite increasing attention on reducing relatively costly hospital practices while maintaining the quality of care, few studies have examined how hospitals use the intensive care unit (ICU), a high-cost setting, for patients admitted with heart failure (HF). We characterized hospital patterns of ICU admission for patients with HF and determined their association with the use of ICU-level therapies and patient outcomes. METHODS AND RESULTS: We identified 166 224 HF discharges from 341 hospitals in the 2009-2010 Premier Perspective database. We excluded hospitals with <25 HF admissions, patients <18 years old, and transfers. We defined ICU as including medical ICU, coronary ICU, and surgical ICU. We calculated the percent of patients admitted directly to an ICU. We compared hospitals in the top quartile (high ICU admission) with the remaining quartiles. The median percentage of ICU admission was 10% (interquartile range, 6%-16%; range, 0%-88%). In top-quartile hospitals, treatments requiring an ICU were used less often; the percentage of ICU days receiving mechanical ventilation was 6% for the top quartile versus 15% for the others; noninvasive positive pressure ventilation, 8% versus 19%; vasopressors and/or inotropes, 9% versus 16%; vasodilators, 6% versus 12%; and any of these interventions, 26% versus 51%. Overall HF in-hospital risk-standardized mortality was similar (3.4% versus 3.5%; P=0.2). CONCLUSIONS: ICU admission rates for HF varied markedly across hospitals and lacked association with in-hospital risk-standardized mortality. Greater ICU use correlated with fewer patients receiving ICU interventions. Judicious ICU use could reduce resource consumption without diminishing patient outcomes.
Assuntos
Bases de Dados Factuais/tendências , Insuficiência Cardíaca/terapia , Hospitais/tendências , Unidades de Terapia Intensiva/tendências , Admissão do Paciente/tendências , Estudos de Coortes , Estudos Transversais , Feminino , Insuficiência Cardíaca/economia , Insuficiência Cardíaca/mortalidade , Mortalidade Hospitalar/tendências , Humanos , Unidades de Terapia Intensiva/economia , Masculino , Admissão do Paciente/economia , Estados Unidos/epidemiologiaRESUMO
BACKGROUND/AIMS: In this study, a subpopulation of stem-like cells in human high grade serous ovarian carcinomas (ovarian cancer stem cells; OCSCs) were isolated and characterized. METHODS: Primary high-grade serous ovarian carcinoma (HGSC) fresh biopsies were cultured under serum-free conditions to produce floating spheres. Sphere formation assay, including self-renewal, differentiation potential, chemo-resistance, and tumorigenicity were determined in vitro or in vivo. RESULTS: OCSCs overexpressed stem cell genes (Oct-4, Nanog, Sox-2, Bmi-1, Nestin, CD133, CD44, CD24, ALDH1, CD117, and ABCG2). Immunostaining of spheres showed overexpressed Oct-4, Nanog, and Sox-2. These isolated tumor cells expanded as spheroid colonies for more than 30 passages. In contrast, adherent cells expressed high levels of CA125 and CK7. Flow cytometry analysis showed increased CSC markers (CD44, CD24, CD117, CD133, ABCG2, and ALDH1) in the spheroid cell population. OCSCs displayed higher chemoresistance to cisplatin or paclitaxel compared to adherent cells. Moreover, subcutaneous injection of 1 × 104 sphere-forming cells into NOD/SCID mice gave rise to new tumors similar to the original human tumors and could be passaged in mice. CONCLUSION: These results revealed that HGSCs are created and propagated by a small number of undifferentiated tumorigenic cells, and therapeutic targeting of these cells could be beneficial for treatment of HGSCs.
Assuntos
Separação Celular/métodos , Neoplasias Císticas, Mucinosas e Serosas/patologia , Células-Tronco Neoplásicas/patologia , Neoplasias Ovarianas/patologia , Animais , Biomarcadores Tumorais/metabolismo , Carcinogênese/patologia , Adesão Celular , Autorrenovação Celular , Resistencia a Medicamentos Antineoplásicos , Feminino , Regulação Neoplásica da Expressão Gênica , Humanos , Imunofenotipagem , Camundongos SCID , Pessoa de Meia-Idade , Gradação de Tumores , Neoplasias Císticas, Mucinosas e Serosas/genética , Neoplasias Ovarianas/genética , Células-Tronco Pluripotentes/metabolismo , Reação em Cadeia da Polimerase em Tempo Real , Esferoides Celulares/patologiaRESUMO
BACKGROUND: The Centers for Medicare & Medicaid Services publicly reports risk-standardized mortality rates (RSMRs) within 30-days of admission and, in 2013, risk-standardized unplanned readmission rates (RSRRs) within 30-days of discharge for patients hospitalized with acute myocardial infarction (AMI), heart failure (HF), and pneumonia. Current publicly reported data do not focus on variation in national results or annual changes. OBJECTIVE: Describe U.S. hospital performance on AMI, HF, and pneumonia mortality and updated readmission measures to provide perspective on national performance variation. DESIGN: To identify recent changes and variation in national hospital-level mortality and readmission for AMI, HF, and pneumonia, we performed cross-sectional panel analyses of national hospital performance on publicly reported measures. PARTICIPANTS: Fee-for-service Medicare and Veterans Health Administration beneficiaries, 65 years or older, hospitalized with principal discharge diagnoses of AMI, HF, or pneumonia between July 2009 and June 2012. RSMRs/RSRRs were calculated using hierarchical logistic models risk-adjusted for age, sex, comorbidities, and patients' clustering among hospitals. RESULTS: Median (range) RSMRs for AMI, HF, and pneumonia were 15.1% (9.4-21.0%), 11.3% (6.4-17.9%), and 11.4% (6.5-24.5%), respectively. Median (range) RSRRs for AMI, HF, and pneumonia were 18.2% (14.4-24.3%), 22.9% (17.1-30.7%), and 17.5% (13.6-24.0%), respectively. Median RSMRs declined for AMI (15.5% in 2009-2010, 15.4% in 2010-2011, 14.7% in 2011-2012) and remained similar for HF (11.5% in 2009-2010, 11.9% in 2010-2011, 11.7% in 2011-2012) and pneumonia (11.8% in 2009-2010, 11.9% in 2010-2011, 11.6% in 2011-2012). Median hospital-level RSRRs declined: AMI (18.5% in 2009-2010, 18.5% in 2010-2011, 17.7% in 2011-2012), HF (23.3% in 2009-2010, 23.1% in 2010-2011, 22.5% in 2011-2012), and pneumonia (17.7% in 2009-2010, 17.6% in 2010-2011, 17.3% in 2011-2012). CONCLUSIONS: We report the first national unplanned readmission results demonstrating declining rates for all three conditions between 2009-2012. Simultaneously, AMI mortality continued to decline, pneumonia mortality was stable, and HF mortality experienced a small increase.
Assuntos
Insuficiência Cardíaca/mortalidade , Infarto do Miocárdio/mortalidade , Avaliação de Resultados em Cuidados de Saúde/tendências , Readmissão do Paciente/tendências , Pneumonia/mortalidade , Idoso , Idoso de 80 Anos ou mais , Estudos de Coortes , Estudos Transversais , Feminino , Insuficiência Cardíaca/terapia , Hospitalização/tendências , Humanos , Masculino , Mortalidade/tendências , Infarto do Miocárdio/terapia , Pneumonia/terapia , Medição de Risco , Estados Unidos/epidemiologiaRESUMO
For meeting the real-time fault diagnosis and the optimization monitoring requirements of the polymerization kettle in the polyvinyl chloride resin (PVC) production process, a fault diagnosis strategy based on the self-organizing map (SOM) neural network is proposed. Firstly, a mapping between the polymerization process data and the fault pattern is established by analyzing the production technology of polymerization kettle equipment. The particle swarm optimization (PSO) algorithm with a new dynamical adjustment method of inertial weights is adopted to optimize the structural parameters of SOM neural network. The fault pattern classification of the polymerization kettle equipment is to realize the nonlinear mapping from symptom set to fault set according to the given symptom set. Finally, the simulation experiments of fault diagnosis are conducted by combining with the industrial on-site historical data of the polymerization kettle and the simulation results show that the proposed PSO-SOM fault diagnosis strategy is effective.
Assuntos
Algoritmos , Redes Neurais de Computação , PolimerizaçãoRESUMO
For meeting the forecasting target of key technology indicators in the flotation process, a BP neural network soft-sensor model based on features extraction of flotation froth images and optimized by shuffled cuckoo search algorithm is proposed. Based on the digital image processing technique, the color features in HSI color space, the visual features based on the gray level cooccurrence matrix, and the shape characteristics based on the geometric theory of flotation froth images are extracted, respectively, as the input variables of the proposed soft-sensor model. Then the isometric mapping method is used to reduce the input dimension, the network size, and learning time of BP neural network. Finally, a shuffled cuckoo search algorithm is adopted to optimize the BP neural network soft-sensor model. Simulation results show that the model has better generalization results and prediction accuracy.
Assuntos
Algoritmos , Redes Neurais de Computação , Tensoativos/químicaRESUMO
INTRODUCTION: To investigate the utility of frozen section of uterine curetting in excluding the possibility of ectopic pregnancy (EP). MATERIALS AND METHODS: A retrospective analysis of 715 curetting records in the present hospital from July 1999 to May 2009 was obtained. All specimens were processed routinely with frozen section and paraffin section. RESULTS: Of 715 cases, frozen section analyses were discordant in 33 cases (4.6%), including 32 cases under-diagnosed, and one case over-diagnosed, compared with the final diagnoses. Frozen section had a sensitivity of 92.6%, specificity of 99.6%, and frozen section accuracy rate of 95.4%. CONCLUSIONS: Frozen section is a useful and rapid method to differentiate EP from intrauterine pregnancy.
Assuntos
Gravidez Ectópica/diagnóstico , Adulto , Curetagem , Feminino , Secções Congeladas , Humanos , Pessoa de Meia-Idade , Inclusão em Parafina , Gravidez , Gravidez Ectópica/patologia , Sensibilidade e Especificidade , Útero/patologia , Adulto JovemRESUMO
BACKGROUND: The digital transformation of medical data enables health systems to leverage real-world data from electronic health records to gain actionable insights for improving hypertension care. METHODS AND RESULTS: We performed a serial cross-sectional analysis of outpatients of a large regional health system from 2010 to 2021. Hypertension was defined by systolic blood pressure ≥140 mm Hg, diastolic blood pressure ≥90 mm Hg, or recorded treatment with antihypertension medications. We evaluated 4 methods of using blood pressure measurements in the electronic health record to define hypertension. The primary outcomes were age-adjusted prevalence rates and age-adjusted control rates. Hypertension prevalence varied depending on the definition used, ranging from 36.5% to 50.9% initially and increasing over time by ≈5%, regardless of the definition used. Control rates ranged from 61.2% to 71.3% initially, increased during 2018 to 2019, and decreased during 2020 to 2021. The proportion of patients with a hypertension diagnosis ranged from 45.5% to 60.2% initially and improved during the study period. Non-Hispanic Black patients represented 25% of our regional population and consistently had higher prevalence rates, higher mean systolic and diastolic blood pressure, and lower control rates compared with other racial and ethnic groups. CONCLUSIONS: In a large regional health system, we leveraged the electronic health record to provide real-world insights. The findings largely reflected national trends but showed distinctive regional demographics and findings, with prevalence increasing, one-quarter of the patients not controlled, and marked disparities. This approach could be emulated by regional health systems seeking to improve hypertension care.