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1.
BMJ Open ; 11(10): e055219, 2021 10 01.
Artículo en Inglés | MEDLINE | ID: mdl-34598995

RESUMEN

INTRODUCTION: Hyperthyroidism is a common condition affecting up to 3% of the UK population. Treatment improves symptoms and reduces the risk of atrial fibrillation and stroke that contribute to increased mortality. The most common symptom is weight loss, which is reversed during treatment. However, the weight regain may be excessive, contributing to increased risk of obesity. Current treatment options include antithyroid drugs, radioiodine and thyroidectomy. Whether there are differences in either weight change or the long-term cardiometabolic risk between the three treatments is unclear. METHODS AND ANALYSIS: The study will establish the natural history of weight change in hyperthyroidism, investigate the risk of obesity and risks of cardiometabolic conditions and death relative to the treatment. The data on patients diagnosed with hyperthyroidism between 1 January 1996 and 31 December 2015 will come from Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office of National Statistics Death Registry. The weight changes will be modelled using a flexible joint modelling, accounting for mortality. Obesity prevalence in the general population will be sourced from Health Survey for England and compared with the post-treatment prevalence of obesity in patients with hyperthyroidism. The incidence and time-to-event of major adverse cardiovascular events, other cardiometabolic outcomes and mortality will be compared between the treatments using the inverse propensity weighting model. Incidence rate ratios of outcomes will be modelled with Poisson regression. Time to event will be analysed using Cox proportional hazards model. A competing risks approach will be adopted to estimate comparative incidences to allow for the impact of mortality. ETHICS AND DISSEMINATION: The study will bring new knowledge on the risk of developing obesity, cardiometabolic morbidity and mortality following treatment for hyperthyroidism to inform clinical practice and public health policies. The results will be disseminated via open-access peer-reviewed publications and directly to the patients and public groups (Independent Scientific Advisory Committee protocol approval #20_000185).


Asunto(s)
Hipertiroidismo , Accidente Cerebrovascular , Estudios de Cohortes , Humanos , Hipertiroidismo/epidemiología , Radioisótopos de Yodo , Reino Unido/epidemiología
2.
Artículo en Inglés | MEDLINE | ID: mdl-34196882

RESUMEN

Information about the occurrence of polybrominated diphenyl ethers (PBDEs) in indoor dusts from various industrial sectors in Southeast Asia is still scarce. In this study, concentrations and congener-specific profiles of PBDEs were determined in indoor dusts from industrial factories, offices, and houses in northern Vietnam. Levels of Σ8PBDEs were higher in the office dusts (median 270; range 230-300 ng/g) and factory dusts (170; 89-510 ng/g) than in the house dusts (61; 25-140 ng/g). BDE-209 was the most dominant congener, accounting for 27-98% (average 62%) of Σ8PBDEs, suggesting the abundance of products treated with deca-BDE mixtures. Residential, commercial, and industrial activities in the studied locations of this survey were not significant sources of PBDEs as compared to those of informal waste processing activities in Vietnam. Relatively low PBDE concentrations detected in our dust samples partially reflect effectiveness of the global PBDE phase-out. Human exposure and health risk associated with dust-bound PBDEs were estimated, indicating acceptable levels of risk (i.e., neurobehavioral effects). The contributions of workplace dusts in total daily intake doses of PBDEs via dust ingestion were more important for local workers in informal recycling areas than factory workers and general population, raising the need of appropriate labor protection measures.

3.
HPB (Oxford) ; 23(11): 1732-1743, 2021 Nov.
Artículo en Inglés | MEDLINE | ID: mdl-33975800

RESUMEN

BACKGROUND: Gallstone related pathology (GRP) accounts for a significant proportion of general surgery admissions. The aim of this study is to investigate if seasonal variation for GRP admissions exist in England allowing improved resource allocation and planning. METHODS: This multicentre retrospective cohort study included only emergency adult (≥18 years old) admissions to acute secondary care with ICD-10 codes associated with gallstones between 01/01/2010 to 31/12/2019 in England using Hospital Episode Statistics data. Seasons were defined according to United Kingdom Met Office. RESULTS: A total of 396 879 GRP related admissions were recorded during the specified period, accounting for 1.44% of all emergency admissions. Our study suggests a significant seasonal peak in Summer (n = 102 620) based cumulative admissions per season and a linear regression model (p < 0.001), followed by Autumn (n = 102 267), then Spring (n = 97 807) and finally Winter (n = 94 185). Spectral analysis confirmed there is seasonality in the emergency GRP admissions every 12 months. A forecasting model was shown to be reliable; all observed admissions for 2019 were within the 95% prediction intervals for each month for the proportion of emergency GRP admissions. CONCLUSION: Resource allocation towards the Summer months to target seasonal peaks in GRP should be considered.

4.
Multimedia | Recursos Multimedia | ID: multimedia-8577

RESUMEN

00:02:09 TJ Hello to everyone watching us on a number of WHO platforms. It's December 21st. My name is Tarik and I welcome you to our regular COVID-19 press conference from WHO headquarters here in Geneva. I will just introduce you briefly to our speakers today here. We have in the room Dr Tedros, WHO Director-General, Dr Maria Van Kerkhove, Technical Lead for COVID-19, and Dr Bruce Aylward, Senior Advisor to the DirectorGeneral. We also have online with us Dr Soumya Swaminathan, WHO Chief Scientist. We have Mr Derek Walton who is our legal counsel. We also have Dr Mike Ryan, the Executive Director of the Health Emergency Programme and we have Dr Mariangela Simao, who is Assistant Director-General for Access to Medicine. We also have a special guest whom Dr Tedros will introduce in a second. Before I give the floor to Dr Tedros just to remind you we will have simultaneous interpretation in six UN languages plus Portuguese and Hindi. I would like to thank our interpreters who are here with us. Once we start the question-and-answer session you can ask a question in those languages. With this I'll give the floor to Dr Tedros for his opening remarks. 00:03:44 TAG Thank you. Thank you, Tarik. Good morning, good afternoon and good evening. In the past few days there have been reports of new variants of the COVID-19 virus in South Africa and the United Kingdom. Viruses mutate over time. That's natural and expected. The UK has reported that this new variant transmits more easily but there is no evidence so far that it's more likely to cause severe disease or mortality. WHO is working with scientists to understand how these genetic changes affect how the virus behaves. The bottom line is that we need to suppress transmission of all SARS-CoV-2 viruses as quickly as we can. The more we allow it to spread the more opportunity it has to change. I cannot stress enough to all governments and all people how important it is to take the necessary precautions to limit transmission. This year has been difficult for all of us but for health workers it has never been harder. At this festive time of year for so many the best gift for health workers is for leaders and citizens to take precautions that ease the pressure on health systems. 00:05:14 Safe and effective vaccines give us hope but they're not an excuse for people to let down their guard and put themselves and their loved ones at risk. Now is the time to double down on the public health basics that have seen many countries suppress the virus effectively. There are a number of groups that continue to push a narrative that this virus only affects the old and that with vaccines on the horizon we can relax. COVID-19 affects children and adults in a variety of ways and it can attack every system in the body. A growing number of people suffer with long-term consequences of the virus. This includes neurological complications for children and adults which are still being researched. Vaccines are offering hope for some but I'm deeply concerned that vaccine nationalism will deprive the world's poorest and most vulnerable people of these life-saving tools. Now is the time for political commitment to be translated into action. Pledges and promises will not protect anyone unless they are realised. Last week we announced that the COVAX facility, which is backed by 190 countries and economies, has secured access to nearly two billion doses of promising vaccine candidates. 00:06:56 In early 2021 US$4.6 billion in additional funding will be needed to purchase COVID-19 vaccine for at least 20% of the population of all low and lower-middle-income countries. This will ensure health workers and those at highest risk of severe disease are vaccinated, which is the fastest way to stabilise health systems and economies and stimulate a truly global recovery. The 100/100 initiative of WHO, UNICEF and the World Bank aims to support 100 countries to conduct rapid readiness assessments and develop country-specific plans within 100 days for vaccines and other COVID-19 tools. 89 countries have already completed the assessments and our teams are working around the clock to ensure that governments and health systems are ready for global vaccine roll-out. WHO has also released a new training course for health workers on COVID-19 vaccination which is available at openwho.org 00:08:10 Vaccines will help to end the pandemic but the effects of COVID19 will continue to be felt for many years to come. The pandemic has exploited and exacerbated the vulnerabilities and inequalities of our world but it has also shown that in the face of an unprecedented crisis we can come together in new ways to confront it. Every crisis is an opportunity to question the way we do things and to find new ways of doing them. For 30 years our colleagues at the United Nations Development Programme or UNDP have published a Human Development Report, an annual snapshot of the state of global development. UNDP has long been a critical partner to WHO, working closely on a host of health and development issues together to solve problems on the ground so that people get the services they need. The latest addition of the Human Development Report published last week takes an in-depth look at the COVID-19 pandemic and what it might mean for the future of development and humanity. To talk more about the report I'm pleased to be joined by my bother, Achim Steiner, the administrator of UNDP. Achim, thank you for your partnership and thank you so much for joining us today. The floor is yours. 00:09:54 AS Thank you very much, dear Tedros. Thank you for the very kind invitation to join you for today's briefing at another very sobering and dramatic point in this pandemic. It is an honour to be part of this press conference today to mark the launch of what you just referred to, the 2020 human development report. These unprecedented times require us to come together to seek solutions to our shared problems and that includes us as UN agencies. COVID-19 is a dramatic health crisis and we have just been reminded of it again in the words that you have shared with us. But we also come together today because it has triggered a social and economic, a development crisis that we have not seen in our lifetimes. Not only has the virus taken the lives of more than 1.6 million people; it has destroyed livelihoods, crippled health systems, locked hundreds of millions of children out of classrooms and is costing the world's economies more than $9 trillion over two years according to the IMF and the equivalent of up to four million jobs according to our sister agency, the ILO. 00:11:08 UNDP projects that for the first time in 30 years global human development progress is going backwards. UNDP has calculated that by the end of the decade one billion people could be living in extreme poverty. A quarter of those, 250 million, could be people pushed into poverty as a consequence of the pandemic. As the human development report makes clear COVID-19 is the latest in a string of consequences resulting from the evergrowing pressures we put on the planet in the name of progress. This is the reality of the Anthropocene, the age of humans, as we refer to it, and in it humanity is in a certain way waging a war against itself. For 30 years UNDP has released the Human Development Index, ranking countries in the world by how they expand people's freedom and opportunities, by measuring health, education and income. But this year we decided that we needed to try something new and long overdue. We included an experimental index to gauge human progress by accounting for per capital national carbon dioxide emissions and per capita material footprint. 00:12:22 The result shows that no country is successful in advancing humanity without extracting a heavy toll on nature and our planet. Yes, there are countries successful in a lighter planetary imprint and yes, there are countries with prosperous populations but not one nation is doing both. Achieving this balance is the next frontier of human development, as the report is called, and as it sets out very critically also, inequality is central and is a barrier to that mission because inequality is both a cause and a consequence of planetary imbalances and it stands in the way of solutions. While the pandemic has undoubtedly touched us all its impact is being felt differently depending on who you are, where you live and how much money or power you have. Existing and growing inequalities have meant that around the world those that already have the least have been hurt the most and in its simplest we have all realised that it is extremely expensive to be poor in a pandemic whether you are a household or a country. 00:13:31 Poor people, women, marginalised people, day labourers and those in unstable employment or in the informal sector have all faced disproportional hardship. For instance evidence from a number of countries also indicates that the pandemic is erasing decades of progress in women's labour force participation. But the report is very much focused on also stating that it doesn't have to be this way. The first test of our willingness to transform will be the delivery, as Dr Tedros just referred to, of COVID-19 vaccines to the world's population. The COVID-19 pandemic is exposing and exacerbating fragmentation and long-standing gaps in public health and deepening chronic inequities. The delivery of the COVID-19 vaccine must be equitable otherwise we risk entrenching the very inequalities which are harming the health of people and the health of the planet and are going to give rise to more social and economic tensions. Without delivery of COVID vaccines that are equitable, efficient and trusted we will undermine the recovery from COVID-19 and not only lose even more lives; we have to be reminded that none of us is safe unless we are all safe. The scientists who have brought us effective COVID-19 vaccine candidates in record time have shown what is possible through collaboration and innovation. We must now be equally bold in taking the baton to deliver the vaccine to the people of all high and low, middle-income and least developing countries. 00:15:03 This is the ultimate stress for planetary health; delivering the largest public health intervention of a lifetime and driving in a concurrent way the recovery in an inclusive and green direction. An undertaking of this magnitude [unclear] requires us all to work together in unprecedented ways. UNDP is privileged and continues to be committed to playing its part in the whole UN family system response but guided in particular also by WHO's leadership while working in partnership with our sister agencies, GAVI, the Global Fund and others through the ACT Accelerator, the SDG3 global action plan and beyond. Thank you so much, Tedros, for inviting me to join you today because together with the world's people we can defeat this virus and most importantly come out of this deep, dark valley that the world finds itself in right now. Part of that story will be a different development pathway into the future and that's what the Human Development Report 2020 has tried to address itself to. Back to you. Thank you. 00:16:13 TAG Thank you. Thank you, Achim, and I hope you will stay with us to respond to questions from journalists who have joined today. Tarik, back to you. TJ Thank you very much, Dr Tedros, and thank you, Mr Steiner, for these very important declarations you have made. We will now open the floor to questions from journalists who are with us online. We have a big number of questions today so let's try to be short with one question per person in the language that you prefer most. Let's start with Shoko Koyama from Japanese NHK. Shoko. SH Hello, Tarik. Can you hear me? TJ Yes. SH Thank you so much for taking my question. Regarding the mutation of the virus which Dr Tedros just mentioned, can you please elaborate on what WHO knows so far, in which countries apart from the UK the same variant has been identified and also if there is a link between this variant and the variant identified in South Africa? Thank you. 00:17:28 MK Thank you, Shoko, for the question. It's a very timely one today. Yes, there has been a variant under investigation, as the UK is calling it, that has been reported from the UK. This variant is SARS-CoV-2 virus and it has a number of mutations and it was identified through genomic sequencing that is carried out across the country. The variant under investigation was reported to WHO on 14th December following detailed analyses that the UK had done in the south-east of England looking at their epidemiologic surveillance data and their laboratory data, noting an increase in transmission at the end of November/December while interventions were in place. They did some phylogenetic analyses and they identified this variant. They're calling it the B117 lineage which includes this mutation at the N501Y site. There's a lot of work that's ongoing in the United Kingdom and we're very grateful for working across Public Health England, different academic institutions and modelling groups, different labs that are looking at three different things. 00:18:38 They're looking at transmission and this variance and if there're any differences in this virus' ability to transmit. They're looking at the disease that this variant causes in terms of clinical presentation and severity and they're looking at the body's antibody response following infection with this variant. What we understand so far from the data that's been reported by the UK is that they have reported an increase in transmission of this variant but I want to put that into context because what they have told us is that they're looking at an increase in the reproduction number, which is the number of people that one infected individual transmits to another, an increase of about 0.4 so it's an increase moving from 1.1 to 1.5 so there is an increase in transmission that they're looking at. They're trying to determine how much of that is associated with the variant itself as well as behavioural differences in individuals that this variant has infected so they're still working through that right now. In terms of disease, in terms of severity the information that we have so far is that there isn't a change in the clinical presentation or severity from this variant but again the work is still underway, that they're looking at including patients who are hospitalised with this variant as opposed to the other viruses circulating. 00:20:02 The studies around the antibody response are currently underway. As we speak here today the scientists in the lab are working on these types of studies and looking at the antibody response and we expect results from those studies in the coming days and coming weeks. So we're really grateful for colleagues working with us directly. They have informed us with more detailed analysis through our virus evolution working group which was established to specifically look at mutations and specifically look at what are the studies that are needed to understand what these mutations mean and any potential implications. And they have informed us through their modelling network where they've looked at trends in surveillance activities and surveillance data. The data is coming in in real time and the UK is making information available as quickly as possible, they're reporting it to us as well and we will make updated information available as quickly as possible. 00:21:00 The UK has informed us that they don't believe there's an impact on the vaccine so that's good news but again there's a lot of information coming out and there're a lot of studies that are ongoing. One more point; your second point about South Africa. At the same time there was another variant that was identified in South Africa and it has one of the same mutations, this 501Y mutation but it's a different variant. They've arisen at the same time so it sounds as if they're linked but this is actually a separate variant. South Africans are also working with us through our virus evolution working group and they have presented to us some preliminary results from the studies that they're doing. They're currently growing the virus in South Africa so that more studies can be done, similar to the studies that I just mentioned about the UK. So it does sound confusing that they're the same virus but these are actually different variants. I do want to say a big thank you to all over the world for people who are doing full genome sequencing and making these sequences available to other researchers and scientists and on publicly available platforms like GISAID. This really helps us to monitor these natural changes that happen in the virus so we need that to continue. 00:22:24 We are hopeful that more sequencing capacity can increase across the globe and it has significantly increased during this pandemic but we still need more so thank you to all of you who are out there who are doing these sequences and sharing those through publicly available sites. TJ Thank you very much, Dr Van Kerkhove. I think many of the journalists who are online wanted to ask questions precisely about this. Dr Ryan maybe would like to add something. Dr Ryan, please. MR Yes, can you hear me, Tarik? TJ Very well. Please. MR I think Maria says it all but I think it's important maybe just to re-emphasise a couple of things. There's zero evidence at this point that there's any increase in severity associated with this disease. Clearly work is ongoing to look at transmission and the increased rates of transmission and how much of that is attributable to this particular variant. 00:23:26 We've seen many variants emerge over the last number of months and some have been successful; some have not been as successful at establishing themselves as part of the driving force of COVID. What no variant has done yet is establish itself as having any higher level of severity or evading our diagnostics or hiding from vaccines or the effectiveness of vaccines and it remains to be seen with any new variant. That's why it's so important that we continue the work. We're very grateful to the countries for their transparency, for their scientific openness and co-operation. We need to continue to do this but it's very important. Countries are now acting on a precautionary principle. They're taking the highest amount of precaution and therefore many countries put in place some precautionary travel restrictions while they looked at the risk assessment around this virus. That is prudent but it's also important that everyone recognise that this happens, these variants occur, science and health authorities and government are looking at that very carefully, they're taking care of citizens by being extremely cautious about any new variant and examining the potential impacts. 00:24:35 But at this stage we don't have evidence that this virus will change the severity, the diagnostics or the value of the vaccines going forward so I think as we enter the holiday period, as the DG said, we need to stop all SARS-CoV variants, we need to stop all SARS-CoV transmission. We know how to do this, we know how to suppress transmission, we know how to protect ourselves and how to protect others. It's the same rules with this virus, any variant of this virus and we must focus on what we can do and what we do know rather than what we don't know. Science will find the answer to what we don't know, governments will take the appropriate precautions. In the meantime people, individuals and communities need to get on with the business of stopping the transmission of this virus. Thank you. TJ Many thanks, Dr Ryan. I think it was very important to answer these questions because many journalists probably would like to hear more about this. Let's see if we have follow-ups on this or some other issues. Let's go to Azerbaijan, to our friend, Kamran. Kamran, the floor is yours. 00:25:50 KA Do you hear me? TJ Yes, please go ahead. KA Hello. Yesterday we got new information about the mutation of the coronavirus and we want to know about the situation for the South Caucasus region, for Azerbaijan. How much danger is there for our people, for the Caucasus region and for Azerbaijan? Because at this time we have a four-digit number infected every day and it's a very bad situation for our health system. What will the new version of this virus do to the South Caucasus region and especially to Azerbaijan? Thank you for your attention. MK Thank you for the question. I'll begin and maybe others want to come in but I think it's worth noting that we're still learning about this variant identified in the UK as well as any changes that are happening in the virus. The SARS-CoV-2 virus in any form is a dangerous virus and the activities that we take ourselves to minimise our own exposure are applicable for any SARS-CoV-2 virus that is circulating including the new variant that has been identified in the UK. 00:27:07 The measures that are in place, the public health measures that are necessary to bring transmission under control include the comprehensive approach that you've heard us talking about and it's worth emphasising this again; as the Director-General has said repeatedly, we need to double down because we have these tools at hand. This includes the public health measures about active case finding, knowing where the virus is so that we have strategic testing in our countries so that we know where the virus is and who is infected and who is not. Making sure that test results come back quickly so that we know what public health actions need to take place in terms of making sure we have good clinical care, we have contact tracing, cluster investigations, we have supported quarantine of contacts. 00:27:52 Then all of us need to make sure that we do everything that we can to minimise our exposure. We have the holidays coming up across many, many countries, across many different religions. We need to make sure that we as individuals do what we can to minimise our exposure. We say, know your risk, lower your risk and there are things that you can do at an individual level. This is physical distancing, this wearing a mask, this is washing your hands, making sure that when you do wear a mask you have clean hands, you put your mask on appropriately, you take the mask off appropriately, you wash your hands, you practise respiratory etiquette, you avoid crowded spaces, you keep your distance, you make sure that you try to avoid enclosed, crowded spaces especially with poor ventilation, open a window if you're indoors. So there're lots of individual-level measures that you can take and as individuals, as communities we can all help each other out; make sure that while we are physically separated we remain socially connected. As we come up to the end of 2020 it's a difficult period for many people whether we have a pandemic or not. It's really important that we reach out and help each other and we touch base with each other; just make a phone call. So everything that we can do now for this variant as well as the SARS-CoV-2 viruses that are circulating still remains true. We need to do everything we can to prevent as many infections as we can because this is a dangerous virus, not only for older individuals, as the DG also said today; it's for everyone. 00:29:22 We are learning about the long-term effects of long COVID for individuals. There's so much that we're still learning about this particular virus so do what you can to keep yourself safe. TJ Thank you very much, Dr Van Kerkhove. Let's go to... I would assume it's Mexico; Claudia Luna Palencia from Vertigo Politico and TV Azteca. Claudia, if you can hear us please unmute yourself. Do we have Claudia online? If not let's go to Imogen from the BBC. Imogen. Imogen, if you hear us please unmute yourself. IM The unmute permission comes up a bit late. Hello. I know you've said a bit about this new variant. I'm just wondering if you're able to give any more precise detail. We've heard a lot about how this is up to 70% more infectious than other strains, the strains that were already circulating. Can you give us any detail about what evidence you've seen that suggests that and what countries should do about it apart from what you've already said, the usual stuff we know works; wash hands and distance? 00:31:06 MK Thanks, Imogen. I will begin and maybe others want to come in but I am going to repeat what I just said because I think it's worth hammering in. In terms of the reports from the UK about an up to 70% increase, that information comes from different types of analyses that UK colleagues are working on. They've looked at their surveillance data across the country, looking at data that's coming in from testing at different sites in south-east England but also across the country; across all of the UK. They're also looking at phylogenetic analysis, looking at the sequences and doing detailed analysis, making estimates of the reproduction number, of the generation time, etc, to look at differences between this circulating virus and other wild-type viruses. So they look at people who are sequenced and not all people across the UK are sequenced so it's a subset of the population. But having said that, the 70% increase is an increase of a reproduction number of about 0.4 so it's an increase from 1.1 reproduction number to 1.5. 00:32:15 This is in the presence of interventions that are in place across the UK so what they're doing now is more analysis of this as more surveillance data and more sequence data comes in. They're always refining these estimates so these estimates may slightly change and that's to be expected. But what they're trying to also do is look at what is associated with this variant and what is associated with people's behaviour in terms of the interventions and applying and complying with the interventions that are in place. It could be the variant, a combination of the behavioural factors and both so that's what they're looking at right now. We expect more analyses and results from our colleagues in the UK over the coming days, coming weeks as they continue to look at this. They're also doing some epidemiologic investigations of individuals with this variant compared to those without this variant. 00:33:08 They're doing detailed studies of patients in hospitals to look at the clinical course and severity but again we have no indication that there's a change in disease presentation or mortality so that's good news. Then there're more studies of the neutralisation but again I come back to what we need to do; we need to do it all. The combination of factors is what works. With a reproduction number of 1.5 that means that one individual can infect more than one person. That means an epidemic will grow but it means that we just need to work hard at making sure we don't give this virus an opportunity to do so. So especially as we see the upcoming holidays and many people wanting to spend time together we need to think about how we minimise our exposure, we minimise the opportunity for us to pass the virus to others. We want everyone to have a safe holiday this year. It may not be exactly how we anticipated spending it but it doesn't mean that we can't celebrate it in our own way but it's do it all and it's the individual-level measures, it's complying with national guidance, it's being patient as the vaccines and vaccination come online. We just really need to hang in tight. 00:34:18 TJ Thank you, Maria. Dr Mike Ryan. MR Thanks, Imogen, and thank you, Maria. I think, as Maria said, with the work being done by the UK, the very responsible work just looking at what is the combination potentially of the virus and also just the difficulty of the measures at this time of year in any given country; what's driving transmission and then we'll sort that out. But if we even look at their estimates with the new estimate of around 1.5 that just put the bar up a little bit. In some senses it means we have to work harder. Even if the virus has become a little bit more efficient in spreading the virus can be stopped. The R0 is around 1.5. That means the virus can be stopped and we've had R0s much higher than 1.5 at different points in this pandemic and we have got it under control. So this situation is not in that sense out of control but it cannot be left to its own devices, either personal behaviour or the virus itself. As we learn more about the virus we'll learn more about how it may replace other strains and that, as I said, has happened before. 00:35:31 But we're not talking about a reproductive number like measles which is somewhere between 12 and 18 or mumps or chicken pox, ten to 12. We're talking about 1.5. The virus may have become slightly more efficient in transmission. That can have a big impact on numbers when we have so many people being infected but it means the virus can be contained, the virus can be suppressed and it is exactly the same interventions, exactly the same behaviours done with more intensity and more completeness that we need to focus on right now. TJ Thank you very much, Dr Ryan. I see there is huge interest in this particular issue and it is important to answer. Let's see what the next question will be. It's Christian Ulrich from German news agency, DPA. Christian. CH Thank you very much for taking my question. Can you explain, Maria or maybe Mike, what more transmissible means in layman's terms. Does that mean the virus flies over more than 1.5m or does it mean that there's more virus in a person so the person standing next to that person is infected in five minutes rather than ten minutes before? Just try and make it more understandable for laymen, people who wonder what is different now from what was happening three weeks ago. 00:37:17 There was also a question that hasn't been answered; how many countries have actually reported cases of this new variant so far? Thank you. MK Thank you for this question. It's a great question and I very much appreciate the way that you ask it because we sometimes forget how complicated a lot of this is and we use a lot of terms that may just not translate very well to everybody. What we mean when it transmits more; the data that we have from the UK - and I'm reporting what they are telling us through he detailed monitoring analysis - is that when you have somebody that is infected, what we estimate is, if I were infected how many other people would I infect. If I can infect more than one person and then that person infects more than one person an epidemic can grow. We call that the reproduction number. In the beginning of an outbreak everyone is susceptible and so there aren't interventions in place yet; they're starting to come online and so we look at that first reproduction number. 00:38:24 Right now we have a lot of interventions in place across the world and that same number of how many people do I infect, one person to another person; what does that number look like with those interventions in place? Ideally you want that number to be below one because then the outbreak will die out. In the situation in the UK the reproduction number, this number has increased from 1.1 meaning if I were infected I would infect 1.1 person, just over one person. That's important because it means it grows; it'll grow at a certain rate. If I infect 1.5 people - I know that doesn't make sense because you can only infect a full person but it means I can infect more people - that is a concern, when the reproduction number increases. What we want to see happen is when you have interventions in place it reduces. How it transmits; we don't have any indication that it's changed how it spreads. It's a respiratory pathogen so it spreads between me and you through these particles in the air. Some are big, called droplets, some are small, called aerosols but mainly what is happening is that the virus spreads between people who are in close contact with another. That's still the same. 00:39:37 There are detailed epi investigations that are underway. We will let you know if anything in that space changes but the virus likes people who are in close contact with one another. So when we say there are things that you need to do with your physical distancing, wearing a mask, washing your hands all of that remains true in terms of protecting yourself and preventing the ability to spread to somebody else. I hope that was a little bit more clear but maybe others want to come in; I'm sure Mike will want come in on that. In terms of the international spread we are learning of countries that are doing sequencing, that are looking for individuals with this particular variant and there are a few countries that have reported single cases of this variant. The sequences are being uploaded into GISAID and other online platforms so again we're grateful for that. We understand Australia had one case, Iceland, Italy, the Netherlands and Denmark, each with single cases with the exception of Denmark and I think the cases are around ten. I may be wrong on that; I don't have the latest updated information but countries are looking and that's the current information that we have at the moment. 00:40:54 TJ Dr Ryan. MR I think Maria explains it very well. In the end when viruses change their genetic sequences in effect they're just changing a sequence of instructions that are used to build proteins. It's like a programme and I think many of you will know programmes are a set of instructions. I liken it sometimes... Most of you women out there will know that if you give the same set of flat-pack instructions for furniture to men you'll end up with many slightly different version for furniture at the end based on their interpretation of those instructions and I think it's very much the same in this case. The instructions can change slightly and the outcome can change slightly. That's very important because if the proteins change because of the slight changes in instruction the shape of the protein can change. The spike protein on the SARS-CoV-2 virus is very variable because of that and therefore it can either fit very well into the receptors on human cells or not so well and it's a pure chance thing. 00:42:00 Some mutations result in that protein being able to bind a little better; some result in it not being able to bind so well. If it binds a little better, a little bit more successfully, a little bit more tightly then the virus finds it easier to get into the cell, it's easier to infect a cell and the person can be infected more easily so that can change either the ease with which a person can be infected or the viral loads that they may have ultimately with the same exposure. So in that sense it is very much linked to those instructions, the success of the virus in the human body and then, as Maria said, the types of transmission don't necessarily change but if you increase the number of people who are infected in the community then obviously the rate of infection can then increase when more people are successfully infected with the virus. But again - we're talking hypothetically here - we've seen the estimate of a small increase in the reproductive number from the UK. It remains to be seen how much of that is due to the specific genetic change in the new variant; I suspect some. 00:43:05 As I said - Maria has laid it out - we're just going to have to keep working hard, keep doing it all and dealing with this SARS-CoV-2 variant as we have dealt with all the previous ones. TJ Thank you, Dr Ryan and Dr Van Kerkhove, for these additional in-depth explanations. Let's see if we have more questions on this or we may have some other questions. Let's turn to Georgia and we have Katelan Kardava from TV Georgia. KA Hello. Can you hear me? TJ Yes. Please go ahead. KA Thank you very much. Good evening. The European Medicine Agency recommended the Pfizer COVID-19 vaccine today. It's great news and a historic day and achievement. We want to know and would like to know what are the procedures, when AHW will recommend a vaccine. Also I have a question for Dr Ryan; how would you assess the situation in Georgia right now? The regional director for Europe is in Tblisi. 00:44:17 TJ Thank you very much. I will call on Mariangela Simao, our Assistant Director-General. Mariangela. MS Yes, thank you. Thank you for the question. Can you hear me, Tarik? TJ Yes, very well. If you turn on the camera as well we could see you but we can hear you very well. MS I'm on the iPhone so I don't know how to turn on the camera. Just to say that it's very welcome news that the EMA has issued a conditional market authorisation for the Pfizer vaccine. WHO is finalising the emergency use listing of this same vaccine, the Pfizer vaccine. We received the dossiers and we are working together with the EMA and it's likely that before the end of this month we will also have an emergency use listing by WHO for this vaccine. Then we do have the WHO's advisory group on immunisation also assessing the recommendations of how this vaccine should be used at country level. This is some parallel work that's going on as we speak so we will have the WHO emergency use listing which allows for a quicker registration of this vaccine in many countries where WHO works with bilateral agreements. 00:45:45 We also have the advisory group working on the policy recommendations for the use of the Pfizer vaccine. I'll stop here. Thank you. TJ Thank you very much. I don't know if Dr Swaminathan would like to add something to this. SS Yes, maybe very briefly just to say that we look forward to the SAGE recommendations, which is the policy for how this vaccine should be used and the details of which groups and the schedule and so on. We're expecting that to happen in the first week of January for the Pfizer vaccine. Hopefully we're going to look at the Moderna dossier as well soon after that. We do hope that through the COVAX facility we will be able to start rolling out the Pfizer vaccine in a limited set of countries in late January/early February to vaccinate healthcare workers in those countries who are at highest risk for getting the infection and also to protect the health system from being overburdened and collapsing. This will allow us to first of all have a public health impact by protecting this high-risk group but also to be a learning for us to then rapidly be able to scale out vaccines to the remainder of the COVAX facility countries. 00:47:22 So we're really looking forward to that and we're doing everything possible to try to roll this out as quickly as possible, hopefully in the coming weeks. Thank you. TJ Thank you very much, Dr Swaminathan and Dr Simao. We will move now to Shane from CCTV. Shane. SH Hi, Tarik. Thank you. Can you hear me? TJ Yes. SH Thank you, Tarik. My question is again about the mutation identified in the UK. Will this mutation make the testing harder and will this mutation have any effects on the therapeutics? Beside that for the countries, for the pandemic what will this mutation bring to the whole global pandemic and what specific suggestions might you offer to countries to deal with this mutation? 00:48:20 One last piece of information I wanted to verify; Dr Maria Van Kerkhove said at the beginning of the briefing that the mutation was reported to WHO on December 14th but we saw some reports saying this mutation was among some mutations that were identified in England in September. Could you confirm when we found this mutation or did we find it in September but we only identified its transmissibility to be higher this month? Could you verify that? Thank you. MK Thank you for the question. I'll take the last part of the question first. As I was explaining in the first answer, the colleagues in the UK are monitoring sequences all the time and they conduct full-genome sequencing of a proportion of the cases across the country. They were alerted to an increase in transmission in south-east England towards the end of November, early December, around that time. They can provide more specific details of their detailed analysis. In doing so they had the question of why are we seeing increased transmission if we have interventions in place. They were looking at the characteristics of the cases and they were looking at the sequences and they identified this variant under investigation, this B117 lineage. 00:49:42 When they did back-tracing and retrospective analyses of cases in south-east England they saw some of these cases had this variant in September so that was looking retrospectively. When they were doing more detailed analysis they had phylogenetic analysis, they reported to WHO through the IHR mechanism on 14th December where they outlined this variant under investigation, they outlined all of the different mutations that were there on 14th. Then we followed up with an number of teleconferences with our European office but also with ECDC and colleagues in the UK to get more details on the analysis that they currently still carrying out and that's where that retrospective identification of those cases in September came from. But the transmissibility; those reports came late last week in terms of the analyses that were done looking at this increase in transmission that they reported. I hope that that's clear. 00:50:43 They are looking at... Because some of the mutations are in the spike protein they are looking at the diagnostics that are currently available and that are in use. Most of the tests that are out look at multiple targets within the genome, within the sequences themselves and so it will not affect diagnostic tests that have multiple targets. There are some tests, very few tests that are out there that only look at a single target. Those tests may be impacted by being able to detect this particular variant but, as I said, most of the tests that are out there use multiple gene targets and so that is good news. But they're still evaluating right now, they're really looking at all of the tests that are in use in the UK and they will be reporting to us on the efficacy of the tests that are there. I don't have any information on the therapeutics but that is also being looked at. As I said, they're looking at the hospitalisations but we don't have any indication that the therapeutics will be altered by this. Soumya may have more information on this but, as I said, the studies are underway and they haven't reported any impact on therapeutics for patients with this variant versus other SARS-CoV2 viruses. 00:52:00 TJ Dr Ryan. MR Thanks, Tarik; thanks, Maria. Again I think we have to remain very balanced here. This is probably the first time where we've been able to use real-time genetic sequence to track the movement of a disease around this planet and it does mean that we're picking up new variants all the time. Their significance when they're picked up, at the moment they're picked up is not known because we just find them and then we have to find what they're doing within populations. We look forward to see what's happening; we look backwards to see if this has existed before and how many people it's affected. It's an incredible detective story, a scientific detective story and what's wonderful is that countries like the UK and like South Africa are looking, they're monitoring, they're taking it deadly seriously and then they're looking for those variants and then seeing in the real world what those variants are doing, whether they're having an impact or not having an impact. 00:52:56 So this is an era of new tools. We're getting used to how to use those tools and it's really important as we use those tools that we are very cautious then and very measured in how we communicate with the media and with you, the public, so that we're communicating important information but at the same time that we're not overplaying that information in a way that scares people too much. We have to find a balance. It's very important to have that transparency. It's very important to tell the public the way it is but it's also important to get across that this is a normal part of virus evolution and being able to track a virus this closely, this carefully, this scientifically in real time is a real, positive development for global public health. Those countries doing this kind of surveillance should be commended but it does bring with it some moments when we gasp at the emergence of new strains and then we have to track those strains over time. But the message overall is a positive message of knowing and learning how this virus moves and works and then finding ways to combat its spread. 00:54:02 What's good is the measures we currently have in place are the correct measures. We need to continue to do what we've been doing. We may just have to do it with a little more intensity and for a little longer to make sure we can bring this virus under control. TJ Many thanks, Dr Ryan. We have time for one or two more questions. Dr Simao mentioned a SAGE meeting at the end of January and we will have a press briefing following that meeting so stay tuned for the outcome of the SAGE meeting. Let's take a question from Pamela Falk from CBS. Pamela. PA Hi. Thank you, Tarik, and thank you, Chris. My question is for Dr Van Kerkhove and Dr Ryan or Dr Tedros. You talk about the research that continues to be done for the B11 variant or the variant in the UK and you have said that there's no evidence that there's a negative impact on the vaccine or you believe there isn't or the UK believes there isn't. How do you know, can you explain how you know, have you tested the vaccine on this variant, how do you know that the current vaccines that are available are applicable and will work with the new variant? Thank you so much. 00:55:42 MR I could start there, Maria, if you don't mind because I think we can at this point bring Dr Soumya in. This is being tested. You don't know, first of all, when you start but it's usually, vaccines are able to cover quite a broad range of changes in any given virus in terms of the protein. But it does need to be checked and it is currently being checked in a number of labs. I think we have Soumya there. I saw Bruce there so I think we have Bruce but I think we have Soumya online and I know this is a very high priority for the RD blueprint and for COVAX right now and the work is underway. Soumya. SS Thank you, Mike. As you said, I think this is a very important issue because a lot of the hope now is on the vaccines making first an impact on the acute phase of the epidemic by reducing deaths, by protecting the most high-risk and vulnerable groups and by protecting our health systems and then ultimately really making an impact on the pandemic itself by creating that population immunity. All viruses mutate, some more rapidly than others. We have one example, the influenza virus which mutates quite rapidly and requires every year the vaccine strain to be reviewed and revised based on the circulating influenza strains prevalent that year. 00:57:14 So that's one example of a viral vaccine that's updated every year with the current information. The SARS-CoV-2 virus is mutating at a much slower rate than the influenza virus and so far even though we've seen a number of changes, a number of mutations none has made a significant impact on either the susceptibility of the virus to any of the currently used therapeutics, drugs or the vaccines under development and one hopes that that will continue to be the case. But this is why we have to continuously monitor what's happening to this virus. This is why the sequencing is important and the research. That's why we have all of these expert groups that are looking at what's happening with... Maria mentioned the virus evolution working group. There are now laboratories across the world that have set up experiments, the assays to culture this new variant of the virus and test both convalescent plasma, serum from people who've recovered from natural infection, as well as those who've been vaccinated. 00:58:27 We have serum taken from those individuals and then in the laboratory you can actually see whether this virus is being killed or neutralised by these antibodies from people who've got the vaccine and from people who've recovered from the disease and that will tell us. There are also experiments that are being done; the companies that are running vaccine trials like Pfizer and Moderna and so on are going to follow up individuals who are in those trials to see if any of them get infected with SARS-CoV-2 and develop disease and if they do they're going to sequence that strain to see if that's a variant or it's an escaped mutant. Those kind of studies in the coming weeks and months are going to give us a lot of information about how this virus is going to behave especially when it's put under pressure with more and more people getting vaccinated. This is again something that viruses do naturally to escape and to survive; they mutate so that they can continue to spread. 00:59:34 That's why it's really important, again going back to what Mike and Maria said; the focus now has to be on bringing transmission down and controlling it and getting it as low as possible because the more viruses you have in circulation the more chances of mutation and the more such variants that can arise. The bottom line here is keep the virus transmission low, keep circulation low, don't allow it to get out of control and spread in the population. That way we'll also keep the mutations down. TJ Thank you very much, Dr Swaminathan. We have lots of questions in line but unfortunately we won't be able to take all of them so let's try to take one or two max. Corinne from Bloomberg. Corinne. CO Hi. Thanks for taking my question. It's a very short one. As vaccines are being rolled out across the US, UK, China and are soon going to start across the rest of Europe as well, you mentioned the WHO's dashboard tracking these inoculations. Since we're seeing so many vaccinations already do you have a better idea of when that might go live and what kind of data you'll be able to collect? 01:01:05 TJ I don't know if Dr Swaminathan can answer that. If not we are happy to look back for information. Dr Soumya. SS I could just say that the WHO does track immunisation coverage in countries across the world. We do this in partnership with UNICEF and other partners. This is something we do on an annual basis but this is for childhood vaccinations and we produce a report every year on coverage and on challenges. For the new virus vaccine for COVID-19 we actually plan to have a much more real-time dashboard and this is now being set up. Hopefully it's going to be updated on a monthly basis where we'll be able to track coverage across the world in different countries. A lot will depend of course on the data that's provided to us by countries. We're setting up the systems now and the indicators that are going to go into the dashboard but, yes, that should be up and running some time early next year. Thank you. TJ Thank you very much, Dr Swaminathan. We will of course keep everyone informed about the new dashboard. MR Tarik. TJ Dr Ryan, please. 01:02:22 MR Just to supplement Soumya because adding in vaccine data is very important. We've been tracking multiple data points on this epidemic since the very beginning. Epidemiologic data, activity data, impact data, a lot of social data; a lot of information that's been on our country platforms and been out there. Countries themselves have built their own dashboards to track this disease so it's really important that we now continue in and do the necessary tracking for this virus. As Soumya said, for a lot of routine immunisation is a yearly process, a monthly process but we do real-time tracking and we have done and do for yellow fever, for meningitis, for cholera and for Ebola. For epidemic diseases we are in a position to be able to do realtime daily tracking of vaccines as they're used at country level. The task here though is much bigger because usually we're dealing with one, two, three, maybe four or five countries in which we're doing mass campaigns. This is hundreds of countries potentially at the same time so the need to be able to track this carefully is very important both to look at how the vaccine has been used, to look for side-effects, to see how effective the vaccine is in the real world; all of those matters are very, very important. 01:03:37 But we'll be adding the tracking system for vaccination to a vast system for tracking all kinds of other interventions that WHO and partners are currently using to support our member states. TJ Thank you very much, Dr Ryan. We will conclude our press briefing with this. I understand our guest administrator, Achim Steiner, is still online so maybe I will give the floor to Dr Tedros. TAG Achim, if you're online and you'd like to say closing words you're welcome. AS Thank you, Tedros. Very briefly clearly today's focus, given that it is the WHO press conference and everything that is happening in the last 24, 48 hours, it's just very good to be here with you and I just want to add one reminder; as you lead us and as the world tries to contain the virus our ability to do so is also premised on being able to recognise that for hundreds of millions of people to do the right thing is extremely challenging. Less than half the world's population has social protections when in many developing countries 70 to 80% of people live in the informal sector. A lock-down and ability to contain the virus is directly relatable to the ability of people to survive this and this literally means the ability to have food and income. 01:05:14 That is why as we in the development programme of the UN look for instance at temporary basic income, something that enriches a nation through furloughs, unemployment benefits, social safety and the crisis response is being provided. Let us not forget that for literally hundreds of millions of people there is as of now nothing and our ability to fight this virus through technology and science and innovation is equally premised on our ability to be societies in which we do not forget that there are many who rely on other to be able to do what's called on from us. In that spirit, Dr Tedros, dear colleagues, we join today in looking forward to both containing the virus and making the vaccine something that becomes accessible to everyone. In the meantime we must not forget that people need to survive not just the virus but in fact poverty and the inability to be able to cope with this economic reality. Thank you so much for having me be able to join you today. Back to you. 01:06:21 TJ Thank you so much, Achim. We were hoping that we would have more questions on the report but because of the developing story of the new strain I think questions were focused on that. But I would like to join my colleague, Mike Ryan, in appreciating South Africa and the UK for their strong surveillance and that's why the new strain was detected. I would like to use this opportunity to remind other countries to strengthen their surveillance. Mutation happens, it's natural. The most important thing is to detect it as early as possible and, as Mike said, all the measures we're taking, the tools we have actually work for the new strain too so the most important thing is to really be implementing all the measures that we know globally. Having said that, I would like to thank the media who've joined today and also on behalf of my colleagues here, on behalf of WHO we wish all Christians around the world Merry Christmas and a Happy New Year. Thank you so much. 01:07:53


Asunto(s)
Betacoronavirus/genética , Infecciones por Coronavirus/genética , Neumonía Viral/genética , Pandemias/prevención & control , Américas/epidemiología , Mutación/genética , ADN Viral/genética , Personal de Salud , Consorcios de Salud , Monitoreo Epidemiológico , Vulnerabilidad Social , Betacoronavirus/inmunología , Infecciones por Coronavirus/inmunología , Neumonía Viral/inmunología , Vacunas Virales/provisión & distribución
5.
Br J Gen Pract ; 71(705): e296-e302, 2021 04.
Artículo en Inglés | MEDLINE | ID: mdl-33753350

RESUMEN

BACKGROUND: In 2011, National Institute for Health and Care Excellence (NICE) guidelines recommended the routine use of out-of-office blood pressure (BP) monitoring for the diagnosis of hypertension. These changes were predicted to reduce unnecessary treatment costs and workload associated with misdiagnosis. AIM: To assess the impact of guideline change on rates of hypertension-related consultation in general practice. DESIGN AND SETTING: A retrospective open cohort study in adults registered with English general practices contributing to the Clinical Practice Research Datalink between 1 April 2006 and 31 March 2017. METHOD: The primary outcome was the rate of face-to-face, telephone, and home visit consultations related to hypertension with a GP or nurse. Age- and sex-standardised rates were analysed using interrupted time-series analysis. RESULTS: In 3 937 191 adults (median follow-up 4.2 years) there were 12 253 836 hypertension-related consultations. The rate of hypertension-related consultation was 71.0 per 100 person-years (95% confidence interval [CI] = 67.8 to 74.2) in April 2006, which remained flat before 2011. The introduction of the NICE hypertension guideline in 2011 was associated with a change in yearly trend (change in trend -3.60 per 100 person-years, 95% CI = -5.12 to -2.09). The rate of consultation subsequently decreased to 59.2 per 100 person-years (95% CI = 56.5 to 61.8) in March 2017. These changes occurred around the time of diagnosis, and persisted when accounting for wider trends in all consultations. CONCLUSION: Hypertension-related workload has declined in the last decade, in association with guideline changes. This is due to changes in workload at the time of diagnosis, rather than reductions in misdiagnosis.


Asunto(s)
Hipertensión , Carga de Trabajo , Adulto , Estudios de Cohortes , Humanos , Hipertensión/diagnóstico , Hipertensión/epidemiología , Análisis de Series de Tiempo Interrumpido , Atención Primaria de Salud , Estudios Retrospectivos
6.
Int J Occup Med Environ Health ; 34(3): 363-372, 2021 Jun 28.
Artículo en Inglés | MEDLINE | ID: mdl-33399135

RESUMEN

OBJECTIVES: According to the Organization for Economic Cooperation and Development (OECD) data, 13% of deaths recorded in the European Union in 2010 were related to coronary heart disease. The Polish Central Statistical Office data show that cardiovascular mortality in 2014 was at the level of 100.1/100 000 general population. The aim of the study was to assess the current burden of deaths due to acute myocardial infarction (AMI) with the assessment of temporal and spatial variability in the Silesian Voivodeship, Poland. MATERIAL AND METHODS: Depersonalized data obtained from the Silesian Voivodeship Branch of the National Health Fund of Poland, based in Katowice, were used as the study material. The death rate due to acute or subsequent myocardial infarction in each of the subregions of the Silesian Voivodeship was standardized to the European Standard Population 2013. The analyses of the annual AMI death rate for 2009-2014 were performed and assigned to all the subregions of the Silesian Voivodeship, according to the patients' domicile. RESULTS: In this study, 37.7% of the patients (N = 20 806) were females, and 30 142 healthcare services were granted to them, accounting for 36.64% of all services provided to all patients. The average patient's age during the service provision was 66±12 years, with women being about 6.5 years older than men (70±12 years vs. 64±11 years, respectively). The standardized death rate (SDR) values in each of the 8 subregions of the Silesian Voivodeship were analyzed. In 2009-2014, a substantial decrease in the SDR was noted in 7 of them, except for the Sosnowiec subregion in which an increase in the average annual SDR value was observed. Moreover, its values were the highest in the whole Silesian Voivodeship. CONCLUSIONS: The obtained results confirmed the spatial variability of mortality due to AMI in the study region. The worst situation was observed in the Sosnowiec subregion in which the number of specific deaths continuously increased, probably due to the limited availability of cardiological and invasive cardiology treatments or adverse health conditions. Int J Occup Med Environ Health. 2021;34(3):363-72.


Asunto(s)
Infarto del Miocardio , Anciano , Femenino , Humanos , Masculino , Persona de Mediana Edad , Polonia/epidemiología
7.
J Pediatr Orthop B ; 30(4): 393-398, 2021 Jul 01.
Artículo en Inglés | MEDLINE | ID: mdl-32694425

RESUMEN

This study investigates determinants of pediatric orthopedic surgery patients' parent or guardian (caregiver) satisfaction with the physician in an outpatient office setting. This was a cross-sectional survey study of 200 English-speaking caregivers of pediatric patients that checked into the pediatric orthopedic clinic at the authors' institution from 1 March 2017 to 1 November 2018. Questionnaires given in clinic include the Newest Vital Sign and The Literacy in Musculoskeletal Problems survey to measure general and musculoskeletal health literacy, respectively, demographic information, expected/estimated wait time, Consultation and Relational Empathy Measure, and Consumer Assessment of Healthcare Providers and Systems Clinician and Group. After multivariate regression, only perceived physician empathy as measured by the Consultation and Relational Empathy Measure score was significantly correlated with caregiver satisfaction (P < 0.0001), accounting for 56% of the variability of caregiver satisfaction scores. The odds of a satisfaction score of at least 9 out of 10 were 21% higher for every unit increase of the Consultation and Relational Empathy Measure score [odds ratio = 1.21 (P < 0.0001)]. After logistic regression, the caregiver's gender was also correlated with patient satisfaction and the odds of a patient satisfaction score ≥9 for males was less than 1/4th that of females [odds ratio = 0.16 (P = 0.040)]. The most important determinant of caregiver satisfaction with the physician in an outpatient pediatric orthopedic setting is perceived physician empathy. This accounts for the majority of the caregiver's satisfaction. This is the first study to determine this relationship in pediatric orthopedic surgery.

8.
Med J Malaysia ; 75(5): 467-471, 2020 09.
Artículo en Inglés | MEDLINE | ID: mdl-32918411

RESUMEN

INTRODUCTION: Patients undergoing emergency general surgery (EGS) are at risk for death and complications. Information on the burden of EGS is critical for developing strategies to improve the outcomes. METHODS: In this retrospective cohort study, medical records of all general surgical operations in a public hospital were reviewed for the period 1st January 2017 to 31st December 2017. Data on patient demographics, operative workload, case mix, time of surgery and outcomes were analysed. RESULTS: Of the 2960 general surgical operations that were performed in 2017, 1720 (58.1%) of the procedures were performed as emergencies. The mean age for the patients undergoing emergency general surgical procedures was 37.9 years (Standard Deviation, ±21.0), with male preponderance (57.5%). Appendicitis was the most frequent diagnosis for the emergency procedures (43%) followed by infections of the skin and soft tissues (31.6%). Disorders of the colon and rectum ranked as the third most common condition, accounting for 6.7% of the emergency procedures. Majority of emergency surgery (59.3%) took place after office hours and on weekends. Post-operative deaths and admissions to critical care facilities increased during EGS when compared to elective surgery, p<0.01. CONCLUSIONS: EGS constitutes a major part of the workload of general surgeons and it is associated significant risk for death and post-operative complications. The burden of EGS must be recognised and patient care systems must evolve to make surgery safe and efficient.


Asunto(s)
Servicio de Urgencia en Hospital , Cirugía General , Hospitales Públicos , Adolescente , Adulto , Atención Posterior , Anciano , Anciano de 80 o más Años , Niño , Preescolar , Femenino , Cirugía General/clasificación , Cirugía General/estadística & datos numéricos , Humanos , Lactante , Malasia/epidemiología , Masculino , Auditoría Médica , Persona de Mediana Edad , Evaluación de Resultado en la Atención de Salud , Complicaciones Posoperatorias/epidemiología , Estudios Retrospectivos , Adulto Joven
9.
Anesth Analg ; 131(4): 1070-1079, 2020 10.
Artículo en Inglés | MEDLINE | ID: mdl-32925326

RESUMEN

BACKGROUND: We report hospitalization patterns from 2000 to 2016 for young children (ages 0-5 years old) in California who underwent 1 of the 20 most common inpatient procedures that required general anesthesia and evaluate the estimated probability of treatment at a tertiary care children's hospital (CH) by year. METHODS: We hypothesized that children ≤5 years old increasingly undergo care at tertiary care CHs for common inpatient surgeries or other procedures that require general anesthesia. Data from the California Office of Statewide Health Planning and Development dataset were used to determine procedure, patient age, year of procedure, and hospital name. Hospitals were designated as either tertiary care CHs, children's units within general hospitals (CUGHs), or general hospitals (GHs) based on the California Children's Services Provider List. A tertiary care CH was defined using the California Children's Services definition as a referral hospital that provides comprehensive, multidisciplinary, regionalized pediatric care to children from birth up to 21 years of age with a full range of medical and surgical care for severely ill children. We report the unadjusted percentage of patients treated at each hospital type and, after controlling for patient covariates and comorbidities, the estimated probability of undergoing care at a tertiary care CH from 2000 to 2016. RESULTS: There were 172,318 treatment episodes from 2000 to 2016. The estimated probability of undergoing care at a tertiary care CH increased from 63.4% (95% confidence interval [CI], 62.4%-64.4%) in 2000 to 78.3% (95% CI, 77.3%-79.4%) in 2016. CONCLUSIONS: Children ≤5 years old undergoing common inpatient procedures that require general anesthesia increasingly receive care at tertiary care CHs in California.


Asunto(s)
Cirugía General/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Pacientes Internos , Pediatría/estadística & datos numéricos , Anestesia General , California , Preescolar , Comorbilidad , Bases de Datos Factuales , Demografía , Femenino , Hospitales/clasificación , Hospitales/estadística & datos numéricos , Hospitales Generales/estadística & datos numéricos , Humanos , Lactante , Recién Nacido , Masculino , Procedimientos Quirúrgicos Operativos/estadística & datos numéricos , Centros de Atención Terciaria/estadística & datos numéricos
10.
J Manag Care Spec Pharm ; 26(9): 1153-1161, 2020 Sep.
Artículo en Inglés | MEDLINE | ID: mdl-32857655

RESUMEN

BACKGROUND: Adults with cerebral palsy (CP) have increased risk for developing various secondary chronic diseases, especially when they have other neurodevelopmental disabilities (NDDs). Multiple medications are likely prescribed to manage the greater morbidity-related burden for adults with CP; however, because health care delivery and care coordination is suboptimal for this population, adults with CP may have an increased risk for polypharmacy. To date, very little is known about the prescribing practices and extent of polypharmacy for adults with CP. OBJECTIVE: To determine the prevalence and adjusted odds of polypharmacy among adults with CP only and those with CP+NDDs, compared with adults without CP. METHODS: Data from 2017 Optum Clinformatics Data Mart, a U.S. private administrative database, was used for this retrospective cohort study. Diagnosis codes were used to identify adults (aged ≥ 18 years) with CP, NDDs (e.g., intellectual disabilities, epilepsy, and autism spectrum disorders), and 24 relevant morbidities. Polypharmacy was examined as 0-4 versus ≥ 5, 0-9 versus ≥ 10, and 0-14 versus ≥ 15 medications. Logistic regression estimated the OR and 95% CI of polypharmacy before and after adjusting for age, sex, region of residence, and multimorbidity (as 0, 1, 2, 3, 4-5, and ≥ 6 morbidities). Exploratory analyses were conducted to compare polypharmacy among young (18-40 years) and middle-aged (41-64 years) adults with CP only and CP + NDDs with elderly (≥ 65 years) adults without CP. RESULTS: Adults with CP only (n = 5,603) and CP + NDDs (n = 2,474) had higher unadjusted prevalence and adjusted OR for each polypharmacy definition compared with adults without CP (n = 9.0 million; e.g., ≥ 5 medications: adjusted OR for CP only = 1.38, 95% CI = 1.30-1.47; CP + NDDs: OR = 2.42, 95% CI = 2.20-2.67). Adults with CP+NDDs had higher unadjusted prevalence and adjusted OR of each polypharmacy definition compared with CP only. Compared with elderly without CP, the unadjusted prevalence of polypharmacy was lower for young adults with CP only (e.g., ≥ 5 medications: 60.2%, 43.8%), similar for young adults with CP+NDDs (e.g., ≥ 15 medications: 10.9%, 12.5%), and elevated for middle-aged CP only and CP + NDDs (e.g., ≥ 10 medications: 28.7%, 34.3%, 41.7%). CONCLUSIONS: Privately insured adults with CP only and CP + NDDs have an elevated prevalence of polypharmacy compared with adults without CP, even after accounting for multimorbidity. Importantly, adults aged 18-40 years with CP have a similar (CP + NDDs) prevalence of polypharmacy compared with the general geriatric population, with the prevalence increasing further for CP by middle age. DISCLOSURES: Whitney was supported by the University of Michigan Office of Health Equity and Inclusion Diversity Fund and the American Academy of Cerebral Palsy and Developmental Medicine. These funding sources had no role in the design or conduct of the study; collection, management, analysis, or interpretation of the data; preparation, review, or approval of the manuscript; or the decision to submit the manuscript for publication. The other authors have no conflicts of interest to disclose.


Asunto(s)
Parálisis Cerebral/tratamiento farmacológico , Seguro de Salud , Polifarmacia , Adolescente , Adulto , Factores de Edad , Anciano , Parálisis Cerebral/economía , Estudios de Cohortes , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Prevalencia , Estudios Retrospectivos , Adulto Joven
11.
Preprint en Inglés | medRxiv | ID: ppmedrxiv-20141986

RESUMEN

IntroductionNovel coronavirus 2019 (COVID-19) has propagated a global pandemic with significant health, economic and social costs. Emerging emergence has suggested that several factors may be associated with increased risk from severe outcomes or death from COVID-19. Clinical risk prediction tools have significant potential to generate individualised assessment of risk and may be useful for population stratification and other use cases. Methods and analysisWe will use a prospective open cohort study of routinely collected data from 1205 general practices in England in the QResearch database. The primary outcome is COVID-19 mortality (in or out-of-hospital) defined as confirmed or suspected COVID-19 mentioned on the death certificate, or death occurring in a person with SARS-CoV-2 infection between 24th January and 30th April 2020. Our primary outcome in adults is COVID-19 mortality (including out of hospital and in hospital deaths). We will also examine COVID-19 hospitalisation in children. Time-to-event models will be developed in the training data to derive separate risk equations in adults (19-100 years) for males and females for evaluation of risk of each outcome within the 3-month follow-up period (24th January to 30th April 2020), accounting for competing risks. Predictors considered will include age, sex, ethnicity, deprivation, smoking status, alcohol intake, body mass index, pre-existing medical co-morbidities, and concurrent medication. Measures of performance (prediction errors, calibration and discrimination) will be determined in the test data for men and women separately and by ten-year age group. For children, descriptive statistics will be undertaken if there are currently too few serious events to allow development of a risk model. The final model will be externally evaluated in (a) geographically separate practices and (b) other relevant datasets as they become available. Ethics and disseminationThe project has ethical approval and the results will be submitted for publication in a peer-reviewed journal. Strengths and limitations of the studyO_LIThe individual-level linkage of general practice, Public Health England testing, Hospital Episode Statistics and Office of National Statistics death register datasets enable a robust and accurate ascertainment of outcomes C_LIO_LIThe models will be trained and evaluated in population-representative datasets of millions of individuals C_LIO_LIShielding for clinically extremely vulnerable was advised and in place during the study period, therefore risk predictions influenced by the presence of some shielding conditions may require careful consideration C_LI

12.
Clin Orthop Relat Res ; 478(6): 1319-1329, 2020 06.
Artículo en Inglés | MEDLINE | ID: mdl-32097128

RESUMEN

BACKGROUND: Depression symptoms are prevalent in the general population, and as many as one in eight patients seeing a hand surgeon may have undiagnosed major depression. It is not clear to what degree lower mood is the consequence or cause of greater symptoms and limitations. If depressive symptoms are a consequence of functional limitations, they might be expected to improve when pathophysiology and impairment are ameliorated. Because surgical treatment is often disease-modifying or salvage, surgery might have a greater impact than nonoperative treatment, which is more often palliative (symptom relieving) than disease-modifying. QUESTIONS/PURPOSES: (1) For which hand or wrist conditions are depression symptoms lower after operative compared with nonoperative treatment? (2) Among the subset of patients with the highest depression scores, are depression symptoms lower after operative treatment compared with nonoperative treatment? (3) Among the subset of patients who had nonoperative treatment, are depression symptoms lower after a corticosteroid injection compared with no specific biomedical intervention? METHODS: At an academic orthopaedic department, 4452 patients had a new office visit for carpal tunnel syndrome, benign neoplasm, primary hand osteoarthritis, de Quervain's tendinopathy, or trigger digit. We analyzed the 1652 patients (37%) who had a return visit at least 3 months later for the same diagnosis. Patients completed the Patient-reported Outcomes Measurement Information System (PROMIS) Depression computerized adaptive test at every office visit (higher scores indicate more depression symptoms) and PROMIS Pain Interference (higher scores indicates greater hindrance in daily life owing to pain). Patients with a return visit were more likely to have surgical treatment and had greater Pain Interference scores at the first visit. Thirteen percent of patients (221 of 1652) had incomplete or missing scores at the initial visit and 33% (550 of 1652) had incomplete or missing scores at the final return visit. We used multiple imputations to account for missing or incomplete data (imputations = 50). In a multivariable linear regression analysis, we compared the mean change in Depression scores between patients treated operatively and those treated nonoperatively, accounting for PROMIS Pain Interference scores at the first visit, age, gender diagnosis, provider, and treatment duration. A post-hoc power analysis demonstrated that the smallest patient cohort (benign lump, n = 176) provided 99% power (α = 0.05) with eight predictor variables to detect a change of 2 points in the PROMIS Depression score (minimally important difference = 3.5). RESULTS: After controlling for potentially confounding variables such as pain interference and age, only carpal tunnel release was associated with a slightly greater decrease in depression symptoms compared with nonoperative treatment (regression coefficient [RC] = -3 [95% confidence interval -6 to -1]; p = 0.006). In patients with the highest PROMIS Depression scores for each diagnosis, operative treatment was not associated with an improvement in depression symptoms (carpal tunnel release: RC = 5 [95% CI -7 to 16]; p = 0.44). Moreover, a corticosteroid injection was not associated with fewer depression symptoms than no biomedical treatment (carpal tunnel release: RC = -3 [95% CI -8 to 3]; p = 0.36). CONCLUSIONS: Given that operative treatment of hand pathology is not generally associated with a decrease in depression symptoms, our results support treating comorbid depression as a separate illness rather than as a secondary effect of pain or physical limitations. LEVEL OF EVIDENCE: Level II, therapeutic study.


Asunto(s)
Corticoesteroides/administración & dosificación , Afecto , Depresión/psicología , Mano/cirugía , Enfermedades Musculoesqueléticas/terapia , Procedimientos Ortopédicos , Muñeca/cirugía , Adulto , Anciano , Bases de Datos Factuales , Depresión/diagnóstico , Femenino , Mano/fisiopatología , Humanos , Inyecciones , Masculino , Salud Mental , Persona de Mediana Edad , Enfermedades Musculoesqueléticas/diagnóstico , Enfermedades Musculoesqueléticas/fisiopatología , Medición de Resultados Informados por el Paciente , Recuperación de la Función , Estudios Retrospectivos , Resultado del Tratamiento , Muñeca/fisiopatología
13.
Pediatrics ; 145(3)2020 03.
Artículo en Inglés | MEDLINE | ID: mdl-32060140

RESUMEN

BACKGROUND: Hepatitis C virus (HCV) prevalence doubled among pregnant women from 2009 to 2014, reaching 3.4 per 1000 births nationwide. Infants exposed to HCV may acquire HCV by vertical transmission. National guidelines recommend that infants exposed to HCV be tested; however, it is unclear if these recommendations are being followed. Our objectives were to determine if infants exposed to HCV were tested and to determine hospital- and patient-level factors associated with differences in testing. METHODS: In this retrospective cohort study of infants exposed to HCV who were enrolled in the Tennessee Medicaid program, we used vital statistics-linked administrative data for infants born between January 1, 2005, and December 31, 2014. Infants were followed until 2 years old. Multilevel logistic regression was used to assess the association of HCV testing and hospital- and patient-level characteristics. RESULTS: Only 23% of 4072 infants exposed to HCV were tested. Infants whose mothers were white versus African American (96.6% vs 3.1%; P <.001), used tobacco (78% vs 70%; P <.001), and had HIV (1.3% vs 0.4%; P = .002) were more likely to be tested. Infants exposed to HCV who had a higher median of well-child visits (7 vs 6; P <.001) were more likely to be tested. After accounting for maternal and infant characteristics and health care use patterns, African American infants were less likely to undergo general testing (adjusted odds ratio 0.32; 95% confidence interval, 0.13-0.78). CONCLUSIONS: Testing occurred in <1 in 4 infants exposed to HCV and less frequently among African American infants. Public health systems need to be bolstered to ensure that infants exposed to HCV are tested for seroconversion.


Asunto(s)
Hepatitis C/diagnóstico , Hepatitis C/transmisión , Transmisión Vertical de Enfermedad Infecciosa , Tamizaje Neonatal , Complicaciones Infecciosas del Embarazo/epidemiología , Adulto , Afroamericanos/estadística & datos numéricos , Preescolar , Estudios de Cohortes , Grupo de Ascendencia Continental Europea/estadística & datos numéricos , Femenino , Infecciones por VIH/epidemiología , Humanos , Lactante , Recién Nacido , Masculino , Intercambio Materno-Fetal , Medicaid , Visita a Consultorio Médico/estadística & datos numéricos , Embarazo , Estudios Retrospectivos , Fumar/epidemiología , Tennessee/epidemiología , Estados Unidos , Adulto Joven
14.
J Surg Educ ; 76(6): e173-e181, 2019.
Artículo en Inglés | MEDLINE | ID: mdl-31466894

RESUMEN

OBJECTIVE: Surgical graduate medical education (GME) programs add both significant cost and complexity to the mission of teaching hospitals. While expenses tied directly to surgical training programs are well tracked, overall cost-benefit accounting has not been performed. In this study, we attempt to better define the costs and benefits of maintaining surgical GME programs within a large integrated health system. DESIGN: We examined the costs, in 2018 US dollars, associated with the surgical training programs within a single health system. Total health system expenses were calculated using actual and estimated direct GME expenses (salary, benefits, supplies, overhead, and teaching expenses) as well as indirect medical education (IME) expenses. IME expenses for each training program were estimated by using both Medicare percentages and the Medicare Payment Advisor Commission study. The projected cost to replace surgical trainees with advanced practitioners or hospitalists was obtained through interviews with program directors and administrators and was validated by our system's business office. SETTING: A physician lead, integrated, rural health system consisting of 8 hospitals, a medical school and a health insurance company. PARTICIPANTS: GME surgical training programs within a single health system's department of surgery. RESULTS: Our health system's department of surgery supports 8 surgical GME programs (2 general surgery residencies along with residencies in otolaryngology, ophthalmology, oral-maxillofacial surgery, urology, pediatric dentistry, and vascular surgery), encompassing 89 trainees. Trainees work an average of 64.4 hours per week. Total health system cost per resident ranged from $249,657 to $516,783 based on specialty as well as method of calculating IME expenses. After averaging program costs and excluding IME and overhead expenses, we estimated the average annual cost per trainee to be $84,171. We projected that replacing our surgical trainees would require hiring 145 additional advanced practitioners at a cost of $166,500 each per year, or 97 hospitalists at a cost of $346,500 each per year. Excluding overhead, teaching and IME expenses, these replacements would cost the health system an estimated additional $16,651,281 or $26,119,281 per year, respectively. CONCLUSIONS: Surgical education is an integral part of our health system and ending surgical GME programs would require large expansion of human resources and significant additional fiscal capital.


Asunto(s)
Prestación Integrada de Atención de Salud/economía , Educación de Postgrado en Medicina/economía , Cirugía General/educación , Servicios de Salud Rural/economía , Adulto , Femenino , Humanos , Internado y Residencia , Masculino , Medicare/economía , Pennsylvania , Estados Unidos
15.
Fam Med ; 51(9): 737-741, 2019 Oct 04.
Artículo en Inglés | MEDLINE | ID: mdl-31465109

RESUMEN

BACKGROUND AND OBJECTIVES: Few studies address the impact of physician attire on ratings of personality characteristics in the presence of varied physician demographic characteristics (gender, racial/ethnic background). Even fewer have examined the boundaries of acceptable physician attire, given recent loosening of societal standards of dress. METHODS: Using an online survey methodology, adult participants (N=505; 45% medical professionals) were recruited. Participants rated target photos depicting a male and female individual from three ethnic/racial categories each dressed in business casual (with and without a white coat) or in professional attire (with and without a white coat) on a number of personality characteristics. General willingness to have physicians wear certain apparel items was also queried, as was the importance/acceptability of specific clothing items and appearance choices. Responses were analyzed by gender, age, ethnicity, and profession of respondent. RESULTS: Both business casual and professional attire were rated highly. A name tag had the highest ratings for importance of wear. The results for wearing a white coat were not as consistent as earlier studies as physicians were perceived as warmer and kinder when not wearing a lab coat, particularly with professional attire. However, female Caucasian physicians were rated most positively when wearing a lab coat. Consistent with previous studies, attire that was too casual (jeans, t-shirts) was rated negatively. CONCLUSIONS: The current study supports the notion that rules of attire are changing, even in the physician's office. Name tags were perceived to be crucial in medical settings, and casual clothing should be avoided. Despite often being considered a defining component of a physician's "uniform," the white lab coat may not be a universal positive and perhaps even a negative for some physicians.


Asunto(s)
Vestuario , Demografía , Prioridad del Paciente/psicología , Médicos Mujeres/psicología , Médicos/psicología , Adulto , Femenino , Humanos , Masculino , Persona de Mediana Edad , Encuestas y Cuestionarios
16.
Int J Med Inform ; 127: 134-140, 2019 07.
Artículo en Inglés | MEDLINE | ID: mdl-31128825

RESUMEN

OBJECTIVE: As digital technologies for health continue to develop, the ability to provide primary care services to patients with new symptoms will grow. In Sweden, two providers of digital primary care have expanded rapidly over the past years giving rise to a heated debate with clear policy implications. The purpose of the study is to present a descriptive review of digital primary care as currently under development in Sweden. METHODS: Descriptive analysis of national coverage data on the utilization of digital care by sex, age, place of residence, socioeconomic status, and most common diagnoses. The data are compared with samples of corresponding data on traditional, office-based primary care, out-of-hours care, and on non-emergency telephone consultations to obtain a comparative analysis of digital care. RESULTS: Digital primary care in Sweden has increased rapidly over the past two years. Currently, more than 30,000 digital consultations are made per month, equivalent to around two percent of all physician-led primary care. Digital care differs in some ways to that of traditional care as users are generally younger and seek for different conditions compared with office-based primary care. Digital care is also similar to traditional care as utilization is higher in metropolitan areas compared with rural areas. Similar to general health care use, there is a negative correlation between use of digital care and socioeconomic status. User profiles by age and sex of digital care are also similar to those of out-of-hours care and non-emergency telephone medical consultations. CONCLUSIONS: By providing a detailed description of the development of digital primary care the study contributes to a growing understanding of the contributions that digital technologies can make to health care. Based on current trends digital primary care is likely to continue to increase in frequency over the coming years. As technologies develop and the public becomes more familiar to interacting with medical providers over the Internet also the scope of digital care is likely to expand. As the provision of digital primary care expands across Europe and beyond, policy makers will need to develop regulating capacities to ensure its safe, effective and equitable integration into existing health systems.


Asunto(s)
Atención Primaria de Salud , Demografía , Europa (Continente) , Atención Primaria de Salud/economía , Derivación y Consulta , Factores Socioeconómicos , Suecia , Teléfono
17.
Arthroscopy ; 35(5): 1576-1581, 2019 05.
Artículo en Inglés | MEDLINE | ID: mdl-30926191

RESUMEN

PURPOSE: To analyze the individual costs associated with anterior crucial ligament reconstruction (ACLR), accounting for patient demographics, perioperative decision making, and location of the surgical procedure (hospital vs ambulatory surgery center), utilizing a cost-minimization analysis in a large national database. METHODS: Univariate analysis and multiple linear regression were performed to determine which patient and surgical variables were the largest cost drivers for ACLR in the United States according to the State Ambulatory Surgery and Services Database. RESULTS: The average cost for ACLR (n = 14,713) was $24,707 (standard deviation, $15,644). When patient variables were considered, younger age (P < .001), male sex (P < .001), Hispanic ethnicity (P < .001), number of chronic medical conditions (P < .001), Medicare insurance (P < .001), and quartile of household income (P < .001) were all associated with higher costs after ACLR. For operative variables, time spent in the operating room (P < .001), meniscal repair (P < .001), and use of general anesthesia alone (P < .001) were all associated with higher costs for ACLR. There was no significant difference between cost of surgery performed at a private surgery center and cost at a hospital-owned center. In the multivariate regression, the 3 variables with the greatest influence on cost of ACLR were use of isolated general anesthesia (associated with an increase of $2,049), Hispanic ethnicity ($1,828), and >1 chronic medical condition ($1,749). Male sex, time in operating room, and older age also significantly increased ACLR cost. CONCLUSIONS: The greatest contributor to cost of ACLR was the use of general anesthesia alone. Time spent in the operating room increased ACLR cost by $108 per minute. Patient factors included greater age, male sex, Hispanic ethnicity, number of chronic medical conditions, Medicare insurance, and annual income. Meniscal repair and regional nerve block did not significantly affect cost as determined by multivariate regression.


Asunto(s)
Lesiones del Ligamento Cruzado Anterior/cirugía , Reconstrucción del Ligamento Cruzado Anterior/economía , Costos de la Atención en Salud/estadística & datos numéricos , Adolescente , Adulto , Anciano , Procedimientos Quirúrgicos Ambulatorios/economía , Anestesia General/economía , Lesiones del Ligamento Cruzado Anterior/economía , Reconstrucción del Ligamento Cruzado Anterior/métodos , Costos y Análisis de Costo/métodos , Femenino , Investigación sobre Servicios de Salud/métodos , Humanos , Periodo Intraoperatorio , Masculino , Medicare , Factores Socioeconómicos , Estados Unidos , Adulto Joven
18.
BMJ Open ; 9(1): e023010, 2019 01 25.
Artículo en Inglés | MEDLINE | ID: mdl-30782692

RESUMEN

OBJECTIVE: To calculate standardised mortality ratios (SMRs) for a cohort of homeless people in the Dublin region over a 5-year period and to examine leading causes of death. SETTING: Homeless services reporting deaths from homeless persons in their care across the Dublin Homeless Region. METHODS: Death data among people who experience homelessness was acquired from the Dublin Region Homeless Executive (2011-2015) and validated from both death certificates and records from the Dublin Coroner's Office. PARTICIPANTS: Two hundred and nine deaths were recorded; of these 201 were verified (n=156 males, 77.6%). Deaths that could not be verified by certificate or coroners record were excluded from the study. RESULTS: SMRs were 3-10 times higher in homeless men and 6-10 times higher in homeless women compared with the general population. Drug and alcohol-related deaths were the leading cause of death, accounting for 38.4% of deaths in homeless individuals. These were followed by circulatory (20%) and respiratory causes (13%). CONCLUSION: Mortality rates among homeless persons are exceptionally high. Services and programmes, particularly housing and those targeting overdose and alcoholism, are urgently needed to prevent premature mortality in this vulnerable population.


Asunto(s)
Causas de Muerte/tendencias , Personas sin Hogar/estadística & datos numéricos , Mortalidad , Adolescente , Adulto , Anciano , Alcoholismo/mortalidad , Sobredosis de Droga/mortalidad , Femenino , Vivienda , Humanos , Irlanda/epidemiología , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto Joven
19.
BMC Womens Health ; 18(1): 180, 2018 11 09.
Artículo en Inglés | MEDLINE | ID: mdl-30413199

RESUMEN

BACKGROUND: To combine results from a randomized controlled study (RCT) and an observational study (OS) to evaluate discontinuation rate of a levonorgestrel-containing intrauterine contraceptive device (LNG IUD) in a real-life setting. METHODS: We included 253 parous and nulliparous women aged 21-40 years from our own phase II RCT. A total of 1607 women of all ages (including adolescents, < 20 years) were recruited from an OS. We applied the cross design synthesis (CDS) method recommended by the United States General Accounting Office. This method combines the different strengths of RCTs and OSs into one single estimate. RESULTS: Combined continuation rates for parous vs nulliparous women could be estimated more precisely as well as overall continuation rates after one (86.6%) and two years (78.5%), irrespective of age and parity. CONCLUSION: Cross design synthesis allowed more precise estimation of continuation rates of an intrauterine device.


Asunto(s)
Anticonceptivos Femeninos/uso terapéutico , Estudios Transversales , Dispositivos Intrauterinos Medicados , Levonorgestrel/uso terapéutico , Cumplimiento de la Medicación/estadística & datos numéricos , Paridad , Ensayos Clínicos Controlados Aleatorios como Asunto , Adolescente , Adulto , Femenino , Humanos , Embarazo , Adulto Joven
20.
Aust N Z J Public Health ; 42(6): 582-587, 2018 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-30151870

RESUMEN

OBJECTIVE: To determine: 1) the mean, median and range of fees for initial and subsequent private outpatient consultations with a general paediatrician in Australia; 2) any variation in fees and bulk billing rates between states/territories; and 3) volume of outpatient general paediatric specialist consultations relative to child population. METHODS: Analysis of Medicare claims data from the years 2011 and 2014 for initial consultations (items 110 and 132), subsequent consultations (items 116 and 133), and autism or pervasive developmental disorder (PDD) initial consultation (item 135) with a general paediatrician. RESULTS: Fees for initial and subsequent general paediatric outpatient consultations varied within, and between, states and territories. Fees increased slightly from 2011 to 2014, after accounting for inflation. The volume of consultations relative to child population varied markedly across states and territories, as did bulk billing rates. Use of item codes for patients with multiple morbidities (132 and 133) increased significantly from 2011 to 2014. Autism/PDD consultation service use (item 135) and fees remained relatively stable. CONCLUSIONS: There was variation in service use, fees and bulk billing within, and between, states and territories, and across time and consultation types. Implications for public health: Future studies should assess the impact of such variation on access to paediatric services and the relationship, if any, to variation in state investment in public paediatric outpatient services.


Asunto(s)
Medicina Familiar y Comunitaria/economía , Honorarios y Precios/estadística & datos numéricos , Visita a Consultorio Médico/economía , Pacientes Ambulatorios/estadística & datos numéricos , Pediatría , Australia , Femenino , Costos de la Atención en Salud , Humanos , Masculino , Programas Nacionales de Salud/economía , Visita a Consultorio Médico/estadística & datos numéricos
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