RESUMO
Rapid and seemingly effortless word recognition is a virtually unquestioned characteristic of skilled reading, yet the definition and operationalization of the concept of cognitive effort have proven elusive. We investigated the cognitive effort involved in oral and silent word reading using pupillometry among adults (Experiment 1, N = 30; Experiment 2, N = 20) and fourth through sixth graders (Experiment 3, N = 30; Experiment 4, N = 18). We compared multiple pupillary measures (mean, peak, and peak latency) for reading familiar words (real words) and unfamiliar letter strings (pseudowords) varying in length. Converging with the behavioral data for accuracy and response times, pupillary responses demonstrated a greater degree of cognitive effort for pseudowords compared with real words and stronger length effects for pseudowords than for real words. These findings open up new possibilities for studying the issue of effort and effortlessness in the field of word recognition and other fields of skill learning.
Assuntos
Reconhecimento Visual de Modelos , Leitura , Adulto , Humanos , Aprendizagem , Tempo de ReaçãoRESUMO
We evaluated the impact of the prescription of evidence-based medical therapy (EBMT) including aspirin (ASA), beta-blockers (BB), ACE-inhibitors or angiotensin receptor blockade (ACE/ARB), and statins prior to discharge after peripheral vascular intervention (PVI) on long-term medication utilization in a large multi-specialty, multicenter quality improvement collaborative. Among patients undergoing coronary revascularization, use of the component medications of EBMT at hospital discharge is a major predictor of long-term utilization. Predictors of EBMT use after PVI are largely unknown. A total of 10,169 patients undergoing PVI between 1 January 2008 and 31 December 2011 were included. Post-PVI discharge and 6-month medication utilization in patients without contra-indications to ASA, BB, ACE/ARB, and statins were compared. ASA was prescribed at discharge to 9345 (92%) patients, BB to 7012 (69%), ACE/ARB to 6424 (63%), and statins to 8342 (82%), and all four component drugs of EBMT in 3953 (39%). Compared with patients not discharged on the appropriate medications, post-procedural use was associated (all p<0.001) with reported 6-month use: ASA (84.5% vs 39.2%), BB (82.5% vs 11.1%), ACE/ARB (78.2% vs 11.8%), statins (84.6% vs 21.8%). Multivariable analysis revealed that prescription of EBMT at the time of discharge remained strongly associated with use at 6 months for each of the individual component drugs as well as for the combination of all four EBMT medications. In conclusion, prescription of the component medications of EBMT at the time of PVI is associated with excellent utilization at 6 months, while failure to prescribe EBMT at discharge is associated with low use of these medications 6 months later. These data suggest that the time of a PVI is a therapeutic window in which to prescribe EBMT in this high-risk cohort and represents an opportunity for quality improvement.
Assuntos
Fármacos Cardiovasculares/uso terapêutico , Medicina Baseada em Evidências , Alta do Paciente , Doença Arterial Periférica/tratamento farmacológico , Padrões de Prática Médica , Prescrições de Medicamentos , Revisão de Uso de Medicamentos , Medicina Baseada em Evidências/normas , Feminino , Humanos , Modelos Lineares , Modelos Logísticos , Masculino , Análise Multivariada , Razão de Chances , Doença Arterial Periférica/diagnóstico , Doença Arterial Periférica/fisiopatologia , Padrões de Prática Médica/normas , Melhoria de Qualidade , Indicadores de Qualidade em Assistência à Saúde , Sistema de Registros , Fatores de TempoRESUMO
The aim of this study was to examine self-teaching in the context of English as a foreign language literacy acquisition. Three groups comprising 88 sixth-grade children participated. The first group consisted of Russian-Hebrew-speaking bilinguals who had acquired basic reading skills in Russian as their first language (L1) and literacy and who were literate in Hebrew as a second language. The second group consisted of Russian-Hebrew-speaking bilinguals who had not learned to read in their native Russian but had acquired Hebrew as their first literate language. The third group consisted of Hebrew-speaking monolingual children who were literate in Hebrew. This design facilitated examining the effect of biliteracy and bilingualism on basic English reading skills. We hypothesized that due to the proximity between the Russian and English orthographies as opposed to the Hebrew-English "distance," the Russian-Hebrew-speaking biliterate group who acquired basic reading and spelling skills in L1 Russian would have superior self-teaching in English as opposed to the two other groups. The standard two-session self-teaching paradigm was employed with naming (speed and accuracy) and orthographic choice as posttest measures of orthographic learning. Results showed that after 4 years of English instruction, all three groups showed evidence of self-teaching on naming speed and orthographic recognition. The Russian-Hebrew-speaking biliterate group, moreover, showed a partial advantage over the comparison groups for initial decoding of target pseudowords and clear-cut superiority for measures of later orthographic learning, thereby showing self-teaching while supporting the script dependence hypothesis.
Assuntos
Desenvolvimento da Linguagem , Aprendizagem/fisiologia , Multilinguismo , Leitura , Análise de Variância , Criança , Comparação Transcultural , Feminino , Humanos , Israel/etnologia , Masculino , Federação Russa/etnologia , SimbolismoRESUMO
BACKGROUND: The role of vascular closure devices (VCDs) in patients having percutaneous coronary intervention (PCI) is controversial, and recommendations for use vary. OBJECTIVE: To examine the use of and outcomes associated with VCDs in real-world practice. DESIGN: Observational cohort study. SETTING: 32 hospitals in Michigan that participate in a large multicenter quality improvement collaborative. PATIENTS: Consecutive patients having emergent and nonemergent PCI from 2007 to 2009. MEASUREMENTS: Vascular complications and the need for transfusion. RESULTS: Of the 85 048 PCIs performed during the study that met the inclusion criteria, 28 528 (37%) procedures used VCDs. In propensity score-matched analysis, VCDs were associated with reductions in vascular complications (odds ratio [OR], 0.78 [95% CI, 0.67 to 0.90]; P = 0.001) and postprocedure transfusions (OR, 0.85 [CI, 0.74 to 0.96]; P = 0.011). These findings were consistent across many prespecified subgroups except for patients with a body mass index (BMI) less than 25 kg/m2 and those treated with platelet glycoprotein (GP) IIb/IIIa inhibitors, in whom the benefit of VCDs over manual closure was attenuated. When the specific subtypes of vascular complications were evaluated, VCDs were associated with fewer hematomas (OR, 0.69 [CI, 0.58 to 0.83]; P < 0.001) or pseudoaneurysms (OR, 0.54 [CI, 0.38 to 0.76]; P < 0.001) but an increase in the odds of retroperitoneal bleeding (OR, 1.57 [CI, 1.12 to 2.20]; P = 0.009). LIMITATION: Unmeasured confounding cannot be excluded despite the study having measured and balanced many confounders. CONCLUSION: Vascular closure devices were associated with a significant reduction in vascular complications and need for transfusion in this large cohort of patients having transfemoral PCI. This benefit was lost in patients receiving GP IIb/IIIa inhibitors and those with normal or lean BMI and was counterbalanced by a small increase in the more serious risk for retroperitoneal bleeding.
Assuntos
Intervenção Coronária Percutânea/instrumentação , Hemorragia Pós-Operatória/prevenção & controle , Técnicas de Fechamento de Ferimentos , Idoso , Falso Aneurisma/etiologia , Falso Aneurisma/prevenção & controle , Transfusão de Sangue , Índice de Massa Corporal , Feminino , Artéria Femoral , Hematoma/etiologia , Hematoma/prevenção & controle , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Complexo Glicoproteico GPIIb-IIIa de Plaquetas/antagonistas & inibidores , Hemorragia Pós-Operatória/etiologia , Espaço Retroperitoneal , Fatores de Risco , Técnicas de Fechamento de Ferimentos/efeitos adversosRESUMO
Peripheral letter recognition is fundamentally limited not by the visibility of letters but by the spacing between them, i.e., 'crowding'. Crowding imposes a significant constraint on reading, however, the interplay between crowding and reading is not fully understood. Using a letter recognition task in varying display conditions, we investigated the effects of lexicality (words versus pseudowords), visual hemifield, and transitional letter probability (bigram/trigram frequency) among skilled readers (N = 14. and N = 13) in Hebrew - a script read from right to left. We observed two language-universal effects: a lexicality effect and a right hemifield (left hemisphere) advantage, as well as a strong language-specific effect - a left bigram advantage stemming from the right-to-left reading direction of Hebrew. The latter finding suggests that transitional probabilities are essential for parafoveal letter recognition. The results reveal that script-specific contextual information such as letter combination probabilities is used to accurately identify crowded letters.
Assuntos
Idioma , Reconhecimento Visual de Modelos , Humanos , Reconhecimento Psicológico , LeituraRESUMO
Behavioral differences in speed and accuracy between reading familiar and unfamiliar words are well-established in the empirical literature. However, these standard measures of skill proficiency are limited in their ability to capture the moment-to-moment processing involved in visual word recognition. In the present study, the effect of word familiarity was initially investigated using an eye blink rate among adults and children. The probability of eye blinking was higher for familiar (real) words than for unfamiliar (pseudo)words. This counterintuitive pattern of results suggests that the processing of unfamiliar (pseudo)words is more demanding and perhaps less rewarding than the processing of familiar (real) words, as previously observed in both behavioral and pupillometry data. Our findings suggest that the measurement of eye blinks might shed new light on the cognitive processes involved in visual word recognition and other domains of human cognition.
RESUMO
OBJECTIVE: To assess relationships between safety culture and complications within 30 days of bariatric surgery. BACKGROUND: Safety culture refers to the quality of teamwork, coordination, and communication, as well as responses to error in health care settings. Although safety culture is thought to be an important determinant of surgical outcomes, few studies have examined this empirically. METHODS: We surveyed staff from 22 Michigan hospitals participating in a statewide bariatric surgery collaborative. Each safety culture survey item was rated on a 1 to 5 Likert scale with lower scores representing better patient safety culture. These data were linked to clinical registry data for 24,117 bariatric surgery patients between 2007 and 2010. We used negative binomial regression to calculate incidence rates and incidence rate ratios measuring the increase in hospitals' rate of complications per unit increase in safety culture (individual items as well as hospital and operating room-specific subscales), controlling for patient risk factors, procedure mix, and bariatric procedure volume. RESULTS: All 22 hospitals participated in this study, submitting safety culture ratings from 53 surgeons, 102 nurses, and 29 operating room administrators. Rates of serious complications were significantly lower among hospitals receiving an overall safety rating of excellent from nurses (1.5%), compared with those receiving a very good (2.6%) or acceptable (4.6%) rating (P = <0.0001). Surgeons' overall safety ratings were also associated with rates of serious complications (2.1% excellent, 2.6% very good, 4.7% acceptable, P = 0.011). Nurses' ratings of the hospital-specific subscale (P = 0.002) and surgeons' ratings of the operating room-specific subscale (P = 0.045) were also associated with rates of serious complications. Of the individual items, those related to coordination and communication between hospital units were the most strongly associated with rates of complications. Operating room administrator ratings of safety culture were not related to rates of complications for any of the domains of safety culture studied. CONCLUSIONS: Safety culture is associated with rates of serious surgical complications in bariatric surgery. Although nurses provide better information about hospital safety culture, surgeons are better judges of safety culture in the operating room. Interventions targeting safety culture, particularly coordination and communication, seem to be important for quality improvement.
Assuntos
Cirurgia Bariátrica/efeitos adversos , Salas Cirúrgicas/organização & administração , Comunicação , Pesquisa sobre Serviços de Saúde , Humanos , Michigan , Enfermagem de Centro Cirúrgico , Salas Cirúrgicas/normas , Cultura Organizacional , Equipe de Assistência ao Paciente , Complicações Pós-Operatórias/epidemiologia , Complicações Pós-Operatórias/prevenção & controle , Melhoria de QualidadeRESUMO
OBJECTIVE: To evaluate the comparative effectiveness of sleeve gastrectomy (SG), laparoscopic gastric bypass (RYGB), and laparoscopic adjustable gastric banding (LAGB) procedures. BACKGROUND: Citing limitations of published studies, payers have been reluctant to provide routine coverage for SG for the treatment of morbid obesity. METHODS: Using data from an externally audited, statewide clinical registry, we matched 2949 SG patients with equal numbers of RYGB and LAGB patients on 23 baseline characteristics. Outcomes assessed included complications occurring within 30 days, and weight loss, quality of life, and comorbidity remission at 1, 2, and 3 years after bariatric surgery. RESULTS: Matching resulted in cohorts of SG, RYGB, and LAGB patients that were well balanced on baseline characteristics. Overall complication rates among patients undergoing SG (6.3%) were significantly lower than for RYGB (10.0%, P < 0.0001) but higher than for LAGB (2.4%, P < 0.0001). Serious complication rates were similar for SG (2.4%) and RYGB (2.5%, P = 0.736) but higher than for LAGB (1.0%, P < 0.0001). Excess body weight loss at 1 year was 13% lower for SG (60%) than for RYGB (69%, P < 0.0001), but was 77% higher for SG than for LAGB (34%, P < 0.0001). SG was similarly closer to RYGB than LAGB with regard to remission of obesity-related comorbidities. CONCLUSIONS: With better weight loss than LAGB and lower complication rates than RYGB, SG is a reasonable choice for the treatment of morbid obesity and should be covered by both public and private payers.
Assuntos
Pesquisa Comparativa da Efetividade , Gastrectomia , Derivação Gástrica , Gastroplastia , Laparoscopia , Obesidade Mórbida/cirurgia , Feminino , Seguimentos , Gastrectomia/métodos , Gastroplastia/métodos , Humanos , Modelos Logísticos , Masculino , Michigan , Pessoa de Meia-Idade , Análise Multivariada , Complicações Pós-Operatórias/epidemiologia , Pontuação de Propensão , Qualidade de Vida , Sistema de Registros , Resultado do Tratamento , Redução de PesoRESUMO
BACKGROUND: The aim of this study was to examine if racial disparities exist in the treatment and outcomes of patients undergoing contemporary percutaneous coronary intervention (PCI). METHODS: We examined the association between race, process of care, and outcomes of patients undergoing PCI between January 1, 2010, and December 31, 2011, and enrolled in the Blue Cross Blue Shield of Michigan Cardiovascular Consortium. We used propensity matching to compare the outcome of black and white patients. RESULTS: The study cohort comprised 65,175 patients, of whom 6,873 (10.5%) were black and 55,789 (85.6%) were white. Black patients were more likely to be younger, be female, have more comorbidities, and be uninsured. Overall, black patients were less likely to receive prasugrel (10.0% vs 14.5%, P < .001) and drug-eluting stents (62.5% vs 67.7%, P < .001), largely related to lower use of these therapies in hospitals treating a higher proportion of black patients. No differences were seen between white and black patients with regard to inhospital mortality (odds ratio 1.34, 95% CI 0.82-2.2, P = .24), contrast-induced nephropathy (OR 1.06, 95% CI 0.81-1.40, P = .67), and need for transfusion (OR 1.27, 95% CI 0.98-1.64, P = .06). White race was associated with increased odds of heart failure (OR 1.48, 95% CI 1.05-2.08, P = .024) and vascular complications (OR 1.40, 95% CI 1.03-1.90, P = .032). CONCLUSIONS: Compared with white patients, black patients undergoing PCI have a greater burden of comorbidities but, after adjusting for these differences, have similar inhospital survival and lower odds of vascular complications and heart failure after PCI.
Assuntos
Negro ou Afro-Americano , Planos de Seguro Blue Cross Blue Shield , Doença da Artéria Coronariana/etnologia , Doença da Artéria Coronariana/cirurgia , Intervenção Coronária Percutânea/métodos , Sistema de Registros , População Branca , Idoso , Doença da Artéria Coronariana/economia , Feminino , Seguimentos , Humanos , Masculino , Michigan/epidemiologia , Pessoa de Meia-Idade , Morbidade/tendências , Avaliação de Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/economia , Pontuação de Propensão , Grupos Raciais , Estudos Retrospectivos , Taxa de Sobrevida/tendênciasRESUMO
BACKGROUND: Percutaneous coronary intervention (PCI) for stable coronary artery disease (CAD) is not superior to optimal medical therapy. It remains unclear if patients who receive PCI for stable CAD are receiving appropriate medical therapy. METHODS: We evaluated the medical management of 60,386 patients who underwent PCI for stable CAD between 2004 and 2009. We excluded patients with contraindications to aspirin, clopidogrel, statins, or ß-blockers (BBs). We defined essential medical therapy of stable CAD as treatment with aspirin, statin, and BB before PCI and treatment with aspirin, clopidogrel, and statin after PCI. RESULTS: Essential medical therapy was used in 53.0% of patients before PCI and 82.1% at discharge. Aspirin was used in 94.8% patients before PCI and 98.3% of after PCI. Statins were used in 69.5% of patients before PCI and 84.5% after PCI. ß-Blockers were used in 72.8% of patients before PCI. Clopidogrel was used in 97.3% of patients after PCI. Patients with a history of myocardial infarction or revascularization before PCI had better medical therapy compared with patients without such a history (62.8% vs 34.3% [P < .001] before PCI and 83.6% vs 79.1% [P < .001] after PCI). After adjusting for confounders and clustering, women (odds ratio 0.74, 95% CI 0.71-0.78) and patients on dialysis (odds ratio 0.68, 95% CI 0.57-0.80) were less likely to receive a statin at discharge. CONCLUSIONS: Medical therapy remains underused before and after PCI for stable CAD. Women are less likely to receive statin therapy. There are significant opportunities to optimize medical therapy in patients with stable CAD.
Assuntos
Antagonistas Adrenérgicos beta/uso terapêutico , Corantes/uso terapêutico , Doença da Artéria Coronariana/terapia , Intervenção Coronária Percutânea , Inibidores da Agregação Plaquetária/uso terapêutico , Cuidados Pós-Operatórios/métodos , Cuidados Pré-Operatórios/métodos , Idoso , Aspirina/uso terapêutico , Clopidogrel , Angiografia Coronária , Doença da Artéria Coronariana/diagnóstico por imagem , Quimioterapia Combinada , Eletrocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Índice de Gravidade de Doença , Ticlopidina/análogos & derivados , Ticlopidina/uso terapêutico , Resultado do TratamentoRESUMO
BACKGROUND: Teaching hospitals have superior outcomes for major medical conditions including cardiovascular disease compared to non-teaching hospitals. This may not be applicable to invasive cardiac procedures given a potential increase in complications due to trainee participation. METHODS: We assessed the impact of hospital teaching status on the outcome of 89,048 patients who underwent percutaneous coronary intervention (PCI). Teaching hospitals were defined as trainee involvement in greater than 50% of PCIs conducted at that hospital and corresponded to teaching status granted by national accreditation agencies. Unadjusted and risk adjusted analyses were used to determine differences in process of care, morbidity and mortality. RESULTS: Of 89,048 patients studied, 30,870 received their PCI at teaching hospitals and 58,178 at non-teaching hospitals. Risk-adjusted analysis showed no significant difference in death, in-hospital myocardial infarction, contrast induced nephropathy or gastrointestinal bleeding between teaching and non-teaching hospitals. PCI at teaching hospitals was associated with a lower rate of emergency coronary artery bypass grafting (OR, 0.63; 95% CI, 0.49-0.83; P = .0009) and an increased rate of vascular complications (OR, 1.33; 95% CI, 1.21-1.46; P < .0001). CONCLUSIONS: General outcomes of patients undergoing PCI are similar across hospital types. However, PCI at teaching hospitals is associated with increased risk of vascular complications and reduced risk of emergency coronary artery bypass grafting compared to non-teaching hospitals.
Assuntos
Doença da Artéria Coronariana/cirurgia , Hospitais de Ensino/estatística & dados numéricos , Hospitais/estatística & dados numéricos , Intervenção Coronária Percutânea/métodos , Complicações Pós-Operatórias/epidemiologia , Idoso , Idoso de 80 Anos ou mais , Feminino , Mortalidade Hospitalar , Humanos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Intervenção Coronária Percutânea/efeitos adversos , Estudos Prospectivos , Medição de Risco , Fatores de Risco , Resultado do TratamentoRESUMO
BACKGROUND: The patient-centered medical home (PCMH) has been recognized as a strategy to redesign and improve the delivery of primary health care. Collaboration between Blue Cross Blue Shield of Michigan (BCBSM) and 39 Physician Organizations in Michigan laid the foundation for a state-wide medical home program. OBJECTIVE: The objective of the study was to describe a unique methodology developed and implemented by BCBSM to designate primary care physician practices as medical homes. METHODS: Since 2009, practices were designated annually as medical homes on the basis of (1) implementation of PCMH-related capabilities, and (2) performance on quality-of-care and health resource utilization measures. An overall score for each practice was calculated. Practices were ranked relative to each other, with the top portion of the continuum representing an achievable level of performance. RESULTS: The number of practices designated as medical homes more than tripled since the program's inception: 302 (1283 physicians) in 2009, 513 (1876 physicians) in 2010, 772 (2547 physicians) in 2011, and 994 (3028 physicians) in 2012. Designated practices reported implementing more than double the PCMH capabilities of nondesignated practices, yet all practices increased their number of implemented capabilities during the 4 years. DISCUSSION: This program represents the largest state-based PCMH program in the United States. Over the 4-year period, 1130 unique practices have received designation, representing 3469 unique physicians. An estimated 1.4 million BCBSM members in Michigan received care from these practices. This program will continue to develop, drawing on changes in the health system landscape, collaboration with the physician community, and knowledge gained from PCMH evaluations.
Assuntos
Planos de Seguro Blue Cross Blue Shield/organização & administração , Assistência Centrada no Paciente/organização & administração , Atenção Primária à Saúde/organização & administração , Qualidade da Assistência à Saúde/organização & administração , Planos de Seguro Blue Cross Blue Shield/economia , Custos e Análise de Custo , Humanos , Michigan , Assistência Centrada no Paciente/economia , Atenção Primária à Saúde/economiaRESUMO
Previous studies examining the link between visual word recognition and eye movements have shown that eye movements reflect the time-course of cognitive processes involved in reading. Whereas most studies have been undertaken in Western European languages written in the Roman alphabet, the present developmental study investigates a non-European language-Hebrew, which is written in a non-alphabetic (abjadic) script. We compared the eye-movements of children in Grades 4 to 6 (N = 30) and university students (N = 30) reading familiar real words and unfamiliar (pseudo)words of 3 letters and 5 letters in length. Using linear mixed models, we focused on the effects of word familiarity, word length, and age group. Our results highlight both universal aspects of word reading (developmental and familiarity (lexicality) effects) as well as language-specific word length effect which appears to be related to the unique morphological and orthographic features of the Semitic abjad.
RESUMO
OBJECTIVE: We sought to identify risk factors for venous thromboembolism (VTE) among patients undergoing bariatric surgery in Michigan. BACKGROUND: VTE remains a major source of morbidity and mortality after bariatric surgery. It is unclear which factors should be used to identify patients at high risk for VTE. METHODS: The Michigan Bariatric Surgery Collaborative maintains a prospective clinical registry of bariatric surgery patients. For this study, we identified all patients undergoing primary bariatric surgery between June 2006 and April 2011 and determined rates of VTE. Potential risk factors for VTE were analyzed using a hierarchical logistic regression model, accounting for clustering of patients within hospitals. Significant risk factors were used to develop a risk calculator for development of VTE after bariatric surgery. RESULTS: Among 27,818 patients who underwent bariatric surgery during the study period, 93 patients (0.33%) experienced a VTE complication, including 51 patents with pulmonary embolism. There were 8 associated deaths. Significant risk factors included previous history of VTE (OR 4.15, CI 2.42-7.08); male gender (OR 2.08, CI 1.36-3.19); operative time more than 3 hours (OR 1.86, CI 1.07-3.24); BMI category (per 10 units) (OR 1.37, CI 1.06-1.75); age category (per 10 years) (OR 1.25, CI 1.03-1.51); and procedure type (reference adjustable gastric band): duodenal switch (OR 9.45, CI 2.50-35.97); open gastric bypass (OR 6.48, CI 2.17-19.41); laparoscopic gastric bypass (OR 3.97, CI 1.77-8.91); and sleeve gastrectomy (OR 3.50, CI 1.30-9.34). Nearly 97% of patients had a predicted VTE risk less than 1%. CONCLUSIONS: In this population-based study, overall VTE rates were low among patients undergoing bariatric surgery. The use of an empirically based risk calculator will allow for the development of a risk-stratified approach to VTE prophylaxis.
Assuntos
Cirurgia Bariátrica/efeitos adversos , Sistema de Registros , Tromboembolia Venosa/etiologia , Adulto , Pesquisas sobre Atenção à Saúde , Humanos , Modelos Logísticos , Michigan , Pessoa de Meia-Idade , Risco Ajustado , Medição de Risco , Fatores de RiscoRESUMO
BACKGROUND: The traditional definition of contrast-induced nephropathy (CIN) has been an absolute rise of serum creatinine (Cr) of ≥0.5 mg/dL, although most recent clinical trials have included a ≥25% increase from baseline Cr. The clinical implication of this definition change remains unknown. METHODS AND RESULTS: We compared the association of the two definitions with risk of death or need for dialysis among 58,957 patients undergoing percutaneous coronary intervention in 2007 to 2008 in a large collaborative registry. Patients with a preexisting history of renal failure requiring dialysis were excluded. Contrast-induced nephropathy as defined by a rise in Cr ≥0.5 mg/dL (CIN(Traditional)) developed in 1,601, whereas CIN defined either as Cr ≥0.5 mg/dL or ≥25% increase in baseline Cr (CIN(New)) developed in 4,308 patients. Patients meeting the definition of CIN(New) but not CIN(Traditional) were classified as CIN(Incremental) (n = 2,707). Compared with CIN(New), CIN(Traditional) was more commonly seen in patients with abnormal renal function, which was more likely to develop in patients with normal renal function at baseline. Compared with CIN(Incremental), patients meeting the definition of CIN(Traditional) were more likely to die (16.7% vs 1.7%) and require in-hospital dialysis (9.8% vs 0%). CONCLUSIONS: Our data suggest that the traditional definition of CIN (a rise in Cr of ≥0.5 mg/dL) in patients undergoing PCI is superior to ≥25% increase in Cr at identifying patients at greater risk for adverse renal and cardiac events.
Assuntos
Injúria Renal Aguda/induzido quimicamente , Injúria Renal Aguda/classificação , Angioplastia Coronária com Balão/efeitos adversos , Meios de Contraste/efeitos adversos , Creatinina/normas , Mortalidade Hospitalar/tendências , Injúria Renal Aguda/mortalidade , Idoso , Idoso de 80 Anos ou mais , Angioplastia Coronária com Balão/métodos , Planos de Seguro Blue Cross Blue Shield/normas , Congressos como Assunto , Creatinina/sangue , Bases de Dados Factuais , Relação Dose-Resposta a Droga , Feminino , Seguimentos , Taxa de Filtração Glomerular , Humanos , Masculino , Pessoa de Meia-Idade , Guias de Prática Clínica como Assunto , Estudos Retrospectivos , Medição de Risco , Taxa de SobrevidaRESUMO
BACKGROUND: Coronary computed tomography angiography (CCTA) is an emerging noninvasive anatomical method for evaluation of patients with suspected coronary artery disease (CAD). Multicenter clinical registries are key to efforts to establish the role of CCTA in CAD diagnosis and management. The Advanced Cardiovascular Imaging Consortium (ACIC) is a statewide, multicenter collaborative quality initiative with the intent to establish quality and appropriate use of CCTA in Michigan. METHODS: The ACIC is sponsored by the Blue Cross Blue Shield of Michigan/Blue Care Network, and its 47 sites include imaging centers that offer CCTA and meet established structure and process standards for participation. Patients enrolled include those with suspected ischemia with or without known CAD, and individuals across the entire spectrum of CAD risk. Patient demographics, history, CCTA scan-related data and findings, and 90-day follow-up data are entered prospectively into a centralized database with strict validation tools and processes. Collaborative quality initiatives include radiation dose reduction and appropriate CCTA use by education and feedback to participating sites and referring physicians. CONCLUSIONS: Across a wide range of institutions, the ACIC permits evaluation of "real-world" utilization and effectiveness of CCTA and examines an alternative, nontraditional approach to utilization management wherein physicians and payers collaborate to address the growing problem of cardiac imaging overutilization.
Assuntos
Planos de Seguro Blue Cross Blue Shield/estatística & dados numéricos , Doenças Cardiovasculares/diagnóstico , Angiografia Coronária/estatística & dados numéricos , Doença da Artéria Coronariana/diagnóstico por imagem , Melhoria de Qualidade/organização & administração , Tomografia Computadorizada por Raios X/estatística & dados numéricos , Angiografia Coronária/economia , Humanos , Michigan , Estudos Prospectivos , Tomografia Computadorizada por Raios X/economiaRESUMO
Venous thromboembolism (VTE) carries significant morbidity and mortality and affects a large portion of hospitalized patients. VTE prophylaxis is rated by the Agency for Healthcare Research and Quality as the most effective of 79 patient safety practices it assessed in 2001. Since 1997, Blue Cross Blue Shield of Michigan/Blue Care Network (BCBSM/BCN) have partnered with Michigan hospitals and providers in statewide registry-based collaborative quality improvement initiatives (CQI) aimed at improving the safety and quality of surgical and medical care; many of these collaborative have a particular focus on VTE prevention. The CQIs are uniquely structured to catalyze hospitals and practitioners to become self-optimizing. In this review, we describe the model BCBSM/BCN and participating Michigan hospitals have developed to improve the prevention and diagnosis of VTE for patients in the state of Michigan.
Assuntos
Comportamento Cooperativo , Clínicos Gerais/normas , Hospitais/normas , Seguradoras/normas , Melhoria de Qualidade/normas , Tromboembolia Venosa/terapia , Humanos , Michigan/epidemiologia , Garantia da Qualidade dos Cuidados de Saúde/normas , Tromboembolia Venosa/diagnóstico , Tromboembolia Venosa/epidemiologiaRESUMO
I argue that the study of variability rather than invariance should head the reading research agenda, and that strong claims of orthographic "optimality" are unwarranted. I also expand briefly on Frost's assertion that an efficient orthography must represent sound and meaning, by considering writing systems as dual-purpose devices that must provide decipherability for novice readers and automatizability for the expert.
Assuntos
Encéfalo/fisiologia , Modelos Neurológicos , Leitura , Reconhecimento Psicológico/fisiologia , Semântica , HumanosRESUMO
Throughout the history of modern psychology, the neural basis of cognitive performance, and particularly its efficiency, has been assumed to be an essential determinant of developmental and individual differences in a wide range of human behaviors. Here, we examine one aspect of cognitive efficiency-cognitive effort, using pupillometry to examine differences in word reading among adults (N = 34) and children (N = 34). The developmental analyses confirmed that children invested more effort in reading than adults, as indicated by larger and sustained pupillary responses. The within-age (individual difference) analyses comparing faster (N = 10) and slower (N = 10) performers revealed that in both age groups, the faster readers demonstrated accelerated pupillary responses compared to slower readers, although both groups invested a similar overall degree of cognitive effort. These findings have the potential to open up new avenues of research in the study of skill growth in word recognition and many other domains of skill learning.
Assuntos
Individualidade , Leitura , Adulto , Criança , Cognição/fisiologia , Humanos , AprendizagemRESUMO
The purpose of the current study was to examine whether morphological awareness measured before children are taught to read (Kindergarten in Israel) predicts reading accuracy and fluency in the middle of first grade, at the very beginning of the process of learning to read pointed Hebrew - a highly transparent orthography, and whether this contribution remains after controlling for phonemic awareness. In a longitudinal design, 680 Hebrew-speaking children were administered morphological and phonemic awareness measures at the end of the preschool year (before they were taught to read) then followed up into first grade when reading was tested in mid-year. The results indicated that even at this early point in learning to read a transparent orthography, preschool morphological awareness contributes significantly to both reading accuracy and reading fluency, even after partialling out age, non-verbal general ability, and phonemic awareness. The current results extend the Functional Opacity argument (Share, 2008) which proposes that at the initial stages of reading acquisition, when children still have incomplete mastery of some aspects of the spelling-sound system, non-phonological sources of information about word identity such as morphology can assist in the decoding process. The practical implications of these results with regard to early reading instruction are discussed.