Your browser doesn't support javascript.
Mostrar: 20 | 50 | 100
Resultados 1 - 20 de 444
Filtrar
1.
J Surg Res ; 250: 112-118, 2020 Feb 06.
Artigo em Inglês | MEDLINE | ID: mdl-32044507

RESUMO

BACKGROUND: The benefits of the Affordable Care Act (ACA) for trauma patients have been well established. However, the ACA's impact on penetrating trauma patients (PTPs), a population that is historically young and uninsured, has not been defined. We hypothesized that PTPs in the post-ACA era would have better outcomes. MATERIAL AND METHODS: The National Trauma Data Bank (NTDB) was queried for all PTPs from 2009 (pre-ACA) and 2011-2014 (post-ACA). Subset analysis was performed in patients aged 19-25 y, as this group was eligible for the ACA's dependent care provision (DCP). RESULTS: There were 9,714,471 patients in the study, with 2,053,501 (21.1%) pre-ACA and 7,660,970 (78.9%) post-ACA. When compared to pre-ACA, patients in the post-ACA cohort were more likely to have commercial/private insurance, less likely to have Medicaid, and more likely to be uninsured. On logistic regression, the pre-ACA era was associated with mortality (HR: 1.02, 95% CI: 1.01-1.04, P = 0.004). Being uninsured was associated with mortality (HR: 1.89, 95% CI: 1.87-1.92, P < 0.001). On subset analysis of the DCP age group, post-ACA patients were more likely to be uninsured (24.1% versus 17.6%; P < 0.001). In addition, for the DCP age group, pre-ACA era was not associated with mortality (HR: 1.03, 95% CI: 0.99-1.06, P = 0.20). CONCLUSIONS: Although the ACA provided a survival benefit to PTPs overall, it did not increase insurance coverage for this population. In addition, the DCP of the ACA did not improve insurance access for PTP in the eligible age group. Further efforts are needed to extend insurance access to this population.

2.
Plant Physiol ; 2020 Feb 20.
Artigo em Inglês | MEDLINE | ID: mdl-32079734

RESUMO

The corrinoid B12 is synthesised only by prokaryotes yet is widely required by eukaryotes as an enzyme cofactor. Microalgae have evolved B12 dependence on multiple occasions and we previously demonstrated that experimental evolution of the non-B12-requiring alga Chlamydomonas reinhardtii in media supplemented with B12 generated a B12-dependent mutant (hereafter metE7). This clone provides a unique opportunity to study the physiology of a nascent B12 auxotroph. Our analyses demonstrate that B12 deprivation of metE7 disrupts C1 metabolism, causes an accumulation of starch and triacylglycerides, and leads to a decrease in photosynthetic pigments, proteins, and free amino acids. B12 deprivation also caused a substantial increase in reactive oxygen species (ROS), which preceded rapid cell death. Surprisingly, survival could be improved without compromising growth by simultaneously depriving the cells of nitrogen, suggesting a type of cross protection. Significantly, we found further improvements in survival under B12 limitation and an increase in B12use efficiency after metE7 underwent a further period of experimental evolution, this time in coculture with a B12-producing bacterium. Therefore, although an early B12-dependent alga would likely be poorly adapted to coping with B12 deprivation, association with B12-producers can ensure long-term survival whilst also providing a suitable environment to evolve mechanisms to better tolerate B12 limitation.

3.
Annu Rev Plant Biol ; 2020 Feb 19.
Artigo em Inglês | MEDLINE | ID: mdl-32075407

RESUMO

Research in the past decade has uncovered new and surprising information about the pathways of starch synthesis and degradation. This includes the discovery of previously unsuspected protein families required for both processes and for the long-sought mechanism of initiation of starch granules. There is also growing recognition of the central role of leaf starch turnover in making carbon available for growth across the day-night cycle. Sophisticated systems-level control mechanisms involving the circadian clock set rates of nighttime starch mobilization that maintain a steady supply of carbon until dawn and modulate partitioning of photosynthate into starch in the light, optimizing the fraction of assimilated carbon that can be used for growth. These discoveries also uncover complexities: Results from experiments with Arabidopsis leaves in conventional controlled environments are not necessarily applicable to other organs or species or to growth in natural, fluctuating environments. Expected final online publication date for the Annual Review of Plant Biology, Volume 71 is April 29, 2020. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

4.
World J Surg ; 2020 Jan 02.
Artigo em Inglês | MEDLINE | ID: mdl-31897695

RESUMO

INTRODUCTION: The reported rate of postoperative bile leak is variable between 3 and 33%. Recent data would suggest a minimally invasive approach to liver surgery has decreased this incidence. METHODS: This multi-institutional case-control study utilized databases from three high-volume surgeons. All consecutive open and minimally invasive liver resection cases were analyzed in a propensity score-adjusted multivariable regression. A p value < 0.05 was considered significant. RESULTS: In 1388 consecutive liver resections, the average age was 56.9 ± 14.0 years, 730 (52.59%) were male gender, and 599 (43.16%) underwent minimally invasive liver resection. Thirty-nine (2.81%) in the series were identified with post-resection bile duct leaks. Leaks were associated with major resections and increased blood loss (p < 0.05). Propensity score-adjusted multivariable regression identified minimally invasive liver resection significantly and independently reduced the odds of bile duct leak (OR 0.48, p = 0.046) even controlling for BMI, ASA, cirrhosis, major resection, and resection year. CONCLUSIONS: Our data suggest the incidence of bile leaks in a large-volume center series is far less than previously reported and that a minimally invasive approach to liver resection reduces the incidence of postoperative bile leak.

5.
Sci Rep ; 10(1): 588, 2020 Jan 17.
Artigo em Inglês | MEDLINE | ID: mdl-31953418

RESUMO

For canid species, scent marking plays a critical role in territoriality, social dynamics, and reproduction. However, due in part to human dependence on vision as our primary sensory modality, research on olfactory communication is hampered by a lack of tractable methods. In this study, we leverage a powerful biologging approach, using accelerometers in concert with GPS loggers to monitor and describe scent-marking events in time and space. We performed a validation experiment with domestic dogs, monitoring them by video concurrently with the novel biologging approach. We attached an accelerometer to the pelvis of 31 dogs (19 males and 12 females), detecting raised-leg and squat posture urinations by monitoring the change in device orientation. We then deployed this technique to describe the scent marking activity of 3 guardian dogs as they defend livestock from coyote depredation in California, providing an example use-case for the technique. During validation, the algorithm correctly classified 92% of accelerometer readings. High performance was partly due to the conspicuous signatures of archetypal raised-leg postures in the accelerometer data. Accuracy did not vary with the weight, age, and sex of the dogs, resulting in a method that is broadly applicable across canid species' morphologies. We also used models trained on each individual to detect scent marking of others to emulate the use of captive surrogates for model training. We observed no relationship between the similarity in body weight between the dog pairs and the overall accuracy of predictions, although models performed best when trained and tested on the same individual. We discuss how existing methods in the field of movement ecology can be extended to use this exciting new data type. This paper represents an important first step in opening new avenues of research by leveraging the power of modern-technologies and machine-learning to this field.

6.
Philos Trans R Soc Lond B Biol Sci ; 375(1794): 20190120, 2020 Mar 16.
Artigo em Inglês | MEDLINE | ID: mdl-31983344

RESUMO

There is growing awareness that 'nature-based solutions' (NbS) can help to protect us from climate change impacts while slowing further warming, supporting biodiversity and securing ecosystem services. However, the potential of NbS to provide the intended benefits has not been rigorously assessed. There are concerns over their reliability and cost-effectiveness compared to engineered alternatives, and their resilience to climate change. Trade-offs can arise if climate mitigation policy encourages NbS with low biodiversity value, such as afforestation with non-native monocultures. This can result in maladaptation, especially in a rapidly changing world where biodiversity-based resilience and multi-functional landscapes are key. Here, we highlight the rise of NbS in climate policy-focusing on their potential for climate change adaptation as well as mitigation-and discuss barriers to their evidence-based implementation. We outline the major financial and governance challenges to implementing NbS at scale, highlighting avenues for further research. As climate policy turns increasingly towards greenhouse gas removal approaches such as afforestation, we stress the urgent need for natural and social scientists to engage with policy makers. They must ensure that NbS can achieve their potential to tackle both the climate and biodiversity crisis while also contributing to sustainable development. This will require systemic change in the way we conduct research and run our institutions. This article is part of the theme issue 'Climate change and ecosystems: threats, opportunities and solutions'.

8.
Plant Physiol ; 182(2): 870-881, 2020 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-31694903

RESUMO

Starch granules contain two Glc polymers, amylopectin and amylose. Amylose makes up approximately 10% to 30% (w/w) of all natural starches thus far examined, but mutants of crop and model plants that produce amylose-free starch are generally indistinguishable from their wild-type counterparts with respect to growth, starch content, and granule morphology. Since the function and adaptive significance of amylose are unknown, we asked whether there is natural genetic variation in amylose synthesis within a wild, uncultivated species. We examined polymorphisms among the 1,135 sequenced accessions of Arabidopsis (Arabidopsis thaliana) in GRANULE-BOUND STARCH SYNTHASE (GBSS), encoding the enzyme responsible for amylose synthesis. We identified 18 accessions that are predicted to have polymorphisms in GBSS that affect protein function, and five of these accessions produced starch with no or extremely low amylose (< 0.5% [w/w]). Eight further accessions had amylose contents that were significantly lower or higher than that of Col-0 (9% [w/w]), ranging from 5% to 12% (w/w). We examined the effect of the polymorphisms on GBSS function and uncovered three mechanisms by which GBSS sequence variation led to different amylose contents: (1) altered GBSS abundance, (2) altered GBSS activity, and (3) altered affinity of GBSS for binding PROTEIN TARGETING TO STARCH1-a protein that targets GBSS to starch granules. These findings demonstrate that amylose in leaves is not essential for the viability of some naturally occurring Arabidopsis genotypes, at least over short timescales and under some environmental conditions and open an opportunity to explore the adaptive significance of amylose.

9.
J Surg Res ; 245: 636-642, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31525629

RESUMO

BACKGROUND: Bystanders play a significant role in the immediate management of life-threatening hemorrhage. The Stop the Bleed (STB) program was designed to train lay rescuers (LRs) to identify and control life-threatening bleeding. The aim of this study was to evaluate the efficacy of STB training for rescuers from different backgrounds. We hypothesized that STB training would be appropriate to increase skills and knowledge of bleeding control techniques for all providers, regardless of level of medical training. STUDY DESIGN: Course participants anonymously self-reported confidence in six major areas. A five-point Likert scale was used to quantitate participant's self-reported performance. Results were stratified into medical rescuers (MR) and LRs. Students' ability to perform STB skills were objectively assessed using an internally validated 15-point objective assessment tool. Data were pooled and analyzed using Student's t-test and chi-Squared test with P < 0.05 considered significant. Results are presented as average with standard deviation (SD) unless otherwise stated. RESULTS: A total of 1974 participants were included in the study. Precourse confidence was lowest for both groups in management of active severe bleeding and ability to pack a bleeding wound. Postcourse confidence improved significantly for both groups in all 6 core areas measured (P < 0.001). The most significant increases were reported in the two previous areas of lowest precourse confidence-management of active severe bleeding-LRs 2.0 (SD 1.2) versus 4.2 (SD 0.9) and MRs 2.6 (SD 1.4) versus 4.6 (SD 0.6), P < 0.001-and ability to pack a bleeding wound-LR 2.1 (SD 1.3) versus 4.4 (SD 0.8) and MR 2.7 (SD 1.3) versus 4.7 (SD 0.05), P < 0.001. Objective assessment of LR skills at the end of the course demonstrated combined 99.3% proficiency on postcourse objective assessments. CONCLUSIONS: This study provides quantitative evidence that Stop the Bleed training is effective, with both LRs and MRs demonstrating improved confidence and skill proficiency after a 1-h course. Future program development should focus on building a pool of instructors, continued training of LRs, and determining how often skills should be recertified.


Assuntos
Competência Clínica , Medicina de Emergência/educação , Conhecimentos, Atitudes e Prática em Saúde , Hemorragia/prevenção & controle , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Criança , Avaliação Educacional , Feminino , Técnicas Hemostáticas , Humanos , Masculino , Pessoa de Meia-Idade , Estudantes de Medicina , Adulto Jovem
10.
BMJ Glob Health ; 4(6): e001833, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31798993

RESUMO

Introduction: While there is substantial evidence for the benefits of exercise-based rehabilitation in the prevention and management of non-communicable disease (NCD) in high-resource settings, it is not evident that these programmes can be effectively implemented in a low-resource setting (LRS). Correspondingly, it is unclear if similar benefits can be obtained. The objective of this scoping review was to summarise existing studies evaluating exercise-based rehabilitation, rehabilitation intervention characteristics and outcomes conducted in an LRS for patients with one (or more) of the major NCDs. Methods: The following databases were searched from inception until October 2018: PubMed/Medline, Embase, CINAHL, Cochrane Library, PsycINFO and trial registries. Studies on exercise-based rehabilitation for patients with cardiovascular disease, diabetes, cancer or chronic respiratory disease conducted in an LRS were included. Data were extracted with respect to study design (eg, type, patient sample, context), rehabilitation characteristics (eg, delivery model, programme adaptations) and included outcome measures. Results: The search yielded 5930 unique citations of which 60 unique studies were included. Study populations included patients with cardiovascular disease (48.3%), diabetes (28.3%), respiratory disease (21.7%) and cancer (1.7%). Adaptations included transition to predominant patient-driven home-based rehabilitation, training of non-conventional health workers, integration of rehabilitation in community health centres, or triage based on contextual or patient factors. Uptake of adapted rehabilitation models was 54%, retention 78% and adherence 89%. The majority of the outcome measures included were related to body function (65.7%). Conclusions: The scope of evidence suggests that adapted exercise-based rehabilitation programmes can be implemented in LRS. However, this scope of evidence originated largely from lower middle-income, urban settings and has mostly been conducted in an academic context which may hamper extrapolation of evidence to other LRS. Cost-benefits, impact on activity limitations and participation restrictions, and subsequent mortality and morbidity are grossly understudied.

11.
Trauma Surg Acute Care Open ; 4(1): e000351, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31799416

RESUMO

Introduction: Gunshot wounds to the brain (GSWB) confer high lethality and uncertain recovery. It is unclear which patients benefit from aggressive resuscitation, and furthermore whether patients with GSWB undergoing cardiopulmonary resuscitation (CPR) have potential for survival or organ donation. Therefore, we sought to determine the rates of survival and organ donation, as well as identify factors associated with both outcomes in patients with GSWB undergoing CPR. Methods: We performed a retrospective, multicenter study at 25 US trauma centers including dates between June 1, 2011 and December 31, 2017. Patients were included if they suffered isolated GSWB and required CPR at a referring hospital, in the field, or in the trauma resuscitation room. Patients were excluded for significant torso or extremity injuries, or if pregnant. Binomial regression models were used to determine predictors of survival/organ donation. Results: 825 patients met study criteria; the majority were male (87.6%) with a mean age of 36.5 years. Most (67%) underwent CPR in the field and 2.1% (n=17) survived to discharge. Of the non-survivors, 17.5% (n=141) were considered eligible donors, with a donation rate of 58.9% (n=83) in this group. Regression models found several predictors of survival. Hormone replacement was predictive of both survival and organ donation. Conclusion: We found that GSWB requiring CPR during trauma resuscitation was associated with a 2.1% survival rate and overall organ donation rate of 10.3%. Several factors appear to be favorably associated with survival, although predictions are uncertain due to the low number of survivors in this patient population. Hormone replacement was predictive of both survival and organ donation. These results are a starting point for determining appropriate treatment algorithms for this devastating clinical condition. Level of evidence: Level II.

12.
J Emerg Med ; 2019 Dec 03.
Artigo em Inglês | MEDLINE | ID: mdl-31810831

RESUMO

BACKGROUND: Older adults presenting to the emergency department (ED) represent a highly vulnerable patient population with complex conditions and multiple comorbidities. The introduction of a Geriatric and Palliative (GAP)-ED partnership may be an effective strategy to avoid unneeded admissions and improve outcomes for this population. OBJECTIVES: The primary objective was to decrease 30-day revisit and hospitalization rates in this population through identifying patients that could be safely sent home with connection to community resources. Secondary outcomes included achieving high patient and family satisfaction scores assessed through follow-up interviews. METHODS: The GAP-ED intervention included the placement of a Specialist in the ED to coordinate care for older adults presenting to the ED who were likely to be discharged home. Independent t-tests and chi-squared tests were used to assess for changes in outcomes between the intervention group and a blocked matched historical usual-care group. RESULTS: There was no significant difference in 30-day ED revisits between the two groups, but there was a statistically significant reduction in hospital admissions from these 30-day revisits. Patient and family satisfaction with the presence of the GAP-ED Specialist was high. CONCLUSION: The implementation of a GAP-ED partnership and use of a GAP-ED Specialist is an effective means of reducing hospitalization in older adults revisiting the ED.

13.
Int J Biometeorol ; 2019 Dec 13.
Artigo em Inglês | MEDLINE | ID: mdl-31834494

RESUMO

Phenological variation in spring leafing between and within species can determine plant responses to warmer winter and spring temperatures in the short term. Methods are needed for monitoring canopy development that can be replicated on a large-scale, while retaining fine-scale resolution at the level of individual trees. Citizen science has the potential to provide this, but a range of approaches exist in terms of the phenophase recorded (e.g. budburst or leaf expansion), how the phenophase is characterised (first events or intensity monitoring) and the portion of tree crown assessed and observation frequency. A comparison of spring budburst and leaf expansion of four tree species (Fraxinus excelsior, Fagus sylvatica, Quercus robur and Acer pseudoplatanus) was monitored in one woodland using (1) counts of expanded leaves on three crown sections, (2) percentage estimates of expanded leaves across the whole crown and (3) a greenness index from photography. Logistic growth models were applied to make comparisons. First-event dates were found to be misleading due to high variation in leaf development rates within and between species. Percentage estimates and counts produced similar estimates of leaf expansion timing and rate. The greenness index produced similar estimates of timing, but not rate, and was compromised by practicalities of photographing individual crowns in closed-canopy woodland. Citizen scientists could collect data across the period of spring leafing, with visual counts and/or estimates made every 3-4 days, subject to tests of reliability in pilot citizen science studies.

16.
Am Surg ; 85(9): 973-977, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638509

RESUMO

Failure to rescue (FTR), defined as death after a major complication in surgical patients, is being used to measure outcomes for quality improvement. Major complications frequently occur in patients undergoing damage control laparotomy (DCL). No previous FTR studies have looked specifically into DCL patients. The aim of this study was to examine risk factors of FTR and identify potential areas for targeted quality improvement in DCL patients. A 10-year retrospective review of all consecutive adult trauma patients who underwent DCL at a Level I trauma center was performed. Demographic and clinical variables were examined for association with FTR. Multivariate regression analysis was performed to identify risk factors of FTR in DCL patients. A total of 199 DCL patients were analyzed. Overall DCL mortality observed was 11.1 per cent (n = 22/199) and overall FTR for the cohort was n = 16/199. FTR represented 72 per cent (n = 16/22) of the total mortality. The significantly increased risk of FTR was associated with older age (P = 0.027), lower initial Glasgow Coma Scale score (P = 0.037), more units of packed red blood cells (P = 0.028), and respiratory complications (P = 0.035). Renal and infectious complications did not significantly increase the risk of FTR in this population. FTR is an important benchmark of quality for trauma patients. This study elucidates potential initial characteristics and complications related to FTR in DCL patients. Efforts in achieving zero death from FTR can potentially improve overall mortality in this subset of patients. Future quality interventions to help minimize FTR should target these specific areas.


Assuntos
Falha da Terapia de Resgate , Laparotomia/efeitos adversos , Laparotomia/normas , Melhoria de Qualidade , Ferimentos e Lesões/cirurgia , Adulto , Fatores Etários , Transfusão de Eritrócitos , Feminino , Escala de Coma de Glasgow , Humanos , Masculino , Complicações Pós-Operatórias , Transtornos Respiratórios , Estudos Retrospectivos , Fatores de Risco , Centros de Traumatologia/normas , Estados Unidos
17.
Am Surg ; 85(9): 992-997, 2019 Sep 01.
Artigo em Inglês | MEDLINE | ID: mdl-31638512

RESUMO

Ventilator-associated pneumonia (VAP) affects up to 30 per cent of ICU patients and has been associated with increased morbidity and mortality. We identified factors associated with prolonged latency of VAP and evaluated its effects on survival and additional outcomes. We also determined the sensitivity of various clinical definitions of VAP, including the Centers for Disease Control and Prevention (CDC) 2013 criteria. We hypothesized that the CDC 2013 criteria would have poor sensitivity. We collected data on 102 subjects who developed VAP between 2012 and 2017. We conducted a Kaplan-Meier survival analysis with Cox proportional hazards regression and generalized linear models/ANOVA to look at predictor variables along with multivariate models for each outcome. White patients, nonsurgical patients, patients with renal failure, altered mental status, increased FiO2, and increased positive end-expiratory pressure had worse survival. Trauma patients, patients with positive sputum cultures, and patients with suspected pneumonia had better survival. Sensitivity of the CDC 2013 criteria was only 44.1 per cent. Our results emphasize the importance of having a high index of suspicion for VAP in ventilator-dependent patients. The 2013 CDC criteria failed to detect 55.9 per cent of confirmed VAP cases. These results are concerning because undetected VAP can have devastating consequences for patients.


Assuntos
Pneumonia Associada à Ventilação Mecânica/diagnóstico , Pneumonia Associada à Ventilação Mecânica/mortalidade , Adulto , Idoso , Cuidados Críticos , Feminino , Humanos , Estimativa de Kaplan-Meier , Tempo de Internação , Modelos Lineares , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Modelos de Riscos Proporcionais , Estudos Retrospectivos , Fatores de Risco , Sensibilidade e Especificidade , Fatores de Tempo
18.
J Trauma Acute Care Surg ; 87(5): 1070-1076, 2019 Nov.
Artigo em Inglês | MEDLINE | ID: mdl-31658237

RESUMO

BACKGROUND: Ischemia/reperfusion injury (IRI) has been shown to cause endothelial glycocalyx (EG) damage.Whether the hypoxic/ischemic insult or the oxidative and inflammatory stress of reperfusion plays a greater part in glycocalyx damage is not known. Furthermore, the mechanisms by which IRI causes EG damage have not been fully elucidated. The aims of this study were to determine if hypoxia alone or hypoxia/reoxygenation (H/R) caused greater damage to the glycocalyx, and if this damage was mediated by reactive oxygen species (ROS) and Ca signaling. METHODS: Human umbilical vein endothelial cells were cultured to confluence and exposed to either normoxia (30 minutes), hypoxia (2% O2 for 30 minutes), or H/R (30 minutes hypoxia followed by 30 minutes normoxia). Some cells were pretreated with ROS scavengers TEMPOL, MitoTEMPOL, Febuxostat, or Apocynin, or with the Ca chelator BAPTA or Ca channel blockers 2-aminoethoxydiphenyl borate, A967079, Pyr3, or ML204. Intracellular ROS was quantified for all groups. Endothelial glycocalyx was measured using fluorescently tagged wheat germ agglutinin and imaged with fluorescence microscopy. RESULTS: Glycocalyx thickness was decreased in both hypoxia and H/R groups, with the decrease being greater in the H/R group. TEMPOL, MitoTEMPOL, BAPTA, and 2-aminoethoxydiphenyl borate prevented loss of glycocalyx in H/R. The ROS levels were likewise elevated compared with normoxia in both groups, but were increased in the H/R group compared with hypoxia alone. BAPTA did not prevent ROS production in either group. CONCLUSION: In our cellular model for shock, we demonstrate that although hypoxia alone is sufficient to produce glycocalyx loss, H/R causes a greater decrease in glycocalyx thickness. Under both conditions damage is dependent on ROS and Ca signaling. Notably, we found that ROS are generated upstream of Ca, but that ROS-mediated damage to the glycocalyx is dependent on Ca.

19.
Br J Nurs ; 28(17): S16-S22, 2019 Sep 26.
Artigo em Inglês | MEDLINE | ID: mdl-31556737

RESUMO

Postoperative complications following curative lung cancer surgery are well recognised, but there is limited data on 30-day readmission rates. The UK Thoracic Surgery Group conducted a multicentre review over a 3-month period to assess readmission rates. Overall readmission among the 268 patients who had undergone primary lung cancer surgery was 30 (11%); 14/30 of readmissions occurred within 7 days of discharge, with 13/30 patients readmitted to a hospital that had not performed the surgery. The causes of readmission were mainly pulmonary related (16/30). Readmission was associated with being discharged with a pleural drain 11/30 (P<0.01), having two or more postoperative complications 11/30 (P<0.01) and a patient's readiness for discharge 9/30 (P=0.001). There was a trend toward an association with smoking 13/30 (P=0.18). The authors suggest that a greater focus on patients presenting with characteristics associated with readmission, and incorporating a patient's readiness for discharge, may reduce readmission, although more studies are needed.


Assuntos
Neoplasias Pulmonares/cirurgia , Alta do Paciente/estatística & dados numéricos , Readmissão do Paciente/estatística & dados numéricos , Complicações Pós-Operatórias/terapia , Humanos , Complicações Pós-Operatórias/epidemiologia , Fatores de Tempo , Reino Unido/epidemiologia
20.
Med Decis Making ; 39(7): 857-866, 2019 10.
Artigo em Inglês | MEDLINE | ID: mdl-31556806

RESUMO

Diagnostic tests are expensive and time-consuming to develop. Early economic evaluation using decision modeling can reduce commercial risk by providing early evidence on cost-effectiveness. The National Institute for Health Research Diagnostic Evidence Co-operatives (DECs) was established to catalyze evidence generation for diagnostic tests by collaborating with commercial developers; DEC researchers have consequently made extensive use of early modeling. The aim of this article is to summarize the experiences of the DECs using early modeling for diagnostics. We draw on 8 case studies to illustrate the methods, highlight methodological strengths and weaknesses particular to diagnostics, and provide advice. The case studies covered diagnosis, screening, and treatment stratification. Treatment effectiveness was a crucial determinant of cost-effectiveness in all cases, but robust evidence to inform this parameter was sparse. This risked limiting the usability of the results, although characterization of this uncertainty in turn highlighted the value of further evidence generation. Researchers evaluating early models must be aware of the importance of treatment effect evidence when reviewing the cost-effectiveness of diagnostics. Researchers planning to develop an early model of a test should also 1) consult widely with clinicians to ensure the model reflects real-world patient care; 2) develop comprehensive models that can be updated as the technology develops, rather than taking a "quick and dirty" approach that may risk producing misleading results; and 3) use flexible methods of reviewing evidence and evaluating model results, to fit the needs of multiple decision makers. Decision models can provide vital information for developers at an early stage, although limited evidence mean researchers should proceed with caution.

SELEÇÃO DE REFERÊNCIAS
DETALHE DA PESQUISA