Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy

ObjectivesTo describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered “low-value”, and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations.MethodsWe analyzed 2002–2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression.ResultsFrom 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: ?3.1%; 95%CI ?4.7, ?1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: ?2.2%; 95%CI ?3.0, ?1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: ?0.6%; 95%CI ?2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI ?1.9, 2.0]; ?0.9% [95%CI ?3.1, 1.3]; and ?1.2% [95%CI ?5.3, 2.9], respectively).ConclusionsBefore and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.     

The incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception in children: A retrospective analysis

Background

There is a lack of studies addressing the occurrence of negative intraoperative findings (that is the absence of intussusception) after an unsuccessful hydrostatic reduction of an ileocolic intussusception. The aim of this study is to determine the incidence of negative intraoperative findings after unsuccessful hydrostatic reduction of ileocolic intussusception.

Pro-equity immunization and health systems strengthening strategies in select Gavi-supported countries

BackgroundAchieving universal immunization coverage and reaching every child with life-saving vaccines will require the implementation of pro-equity immunization strategies, especially in poorer countries. Gavi-supported countries continue to implement and report strategies that aim to address implementation challenges and improve equity. This paper summarizes the first mapping of these strategies from country reports.MethodsThirteen Gavi-supported countries were purposively selected with emphasis on Gavi’s priority countries. Following a scoping of different documents submitted to Gavi by countries, 47 Gavi Joint Appraisals (JAs) for the period 2016–2019 from the 13 selected countries were included in the mapping. We used a consolidated framework synthesized from 16 different equity and health systems frameworks, which incorporated UNICEF’s coverage and equity assessment approach – an adaptation of the Tanahashi model. Using search terms, the mapping was conducted using a combination of manual search and the MAXQDA qualitative analysis tool. Pro-equity strategies meeting the inclusion criteria were identified and compiled in an Excel database, and then populated on a tableau visualization dashboard.ResultsIn total, 258 pro-equity strategies were implemented by the 13 sampled Gavi-supported countries between 2016 and 2019. The framework determinants of social norms, utilization, and management and coordination accounted for more than three-quarters of all pro-equity strategies implemented in these countries. The median number of strategies reported per country was 17. Afghanistan, Nigeria, and Uganda reported the highest number of strategies that we considered as pro-equity.ConclusionFindings from this mapping can be useful in addressing equity gaps, reaching partially immunized, and ‘zero-dose’ vaccinated children, and valuable resource for countries planning to implement pro-equity strategies, especially as immunization stakeholders reimagine immunization delivery in light of COVID-19, and as Gavi finalizes its fifth organizational strategy. Future efforts should seek to identify pro-equity strategies being implemented across additional countries, and to assess the extent to which these strategies have improved immunization coverage and equity.     

Avoidable hospitalisation for diabetes mellitus among immigrants and natives: Results from the Italian Network for Longitudinal Metropolitan Studies

Background and aimsItaly has experienced a relevant increase in migration inflow over the last 20 years. Although the Italian Health Service is widely accessible, immigrants can face many barriers that limit their use of health services. Diabetes mellitus (DM) has a different prevalence across ethnic groups, but studies focusing on DM care among immigrants in Europe are scarce. This study aimed to compare the rates of avoidable hospitalisation (AH) between native and immigrant adults in Italy.Methods and resultsA multi-centre open cohort study including all 18- to 64-year-old residents in Turin, Venice, Reggio-Emilia, Modena, Bologna and Rome between 01/01/2001 and 31/12/2013–14 was conducted. Italian citizens were compared with immigrants from high migratory pressure countries who were further divided by their area of origin. We calculated age-, sex- and calendar year-adjusted rate ratios (RRs) and 95% confidence intervals (95% CIs) of AH for DM by citizenship using negative binomial regression models. The RRs were summarized using a random effects meta-analysis. The results showed higher AH rates among immigrant males (RR: 1.63, 95% CI: 1.16–2.23), whereas no significant difference was found for females (RR: 1.14, 95% CI: 0.65–1.99). Immigrants from Asia and Africa showed a higher risk than Italians, whereas those from Central-Eastern Europe and Central-Southern America did not show any increased risk.ConclusionAdult male immigrants were at higher risk of experiencing AH for DM than Italians, with differences by area of origin, suggesting that they may experience lower access to and lower quality of primary care for DM. These services should be improved to reduce disparities.     

The effect of different statistical approaches on image quality data obtained from radiological examinations

IntroductionSelection of optimal image acquisition protocols in medical imaging remains a grey area, the superimposed use of the Likert scale in radiological image quality evaluations creates an additional challenge for the statistical analysis of image quality data.Using a simulation study, we have trialled a novel approach to analysing radiological image quality Likert scale data.MethodsA simulation study was undertaken where simulated datasets were generated based on the distribution of Likert scale values according to varying image acquisition protocols from a real dataset. Simulated Likert scale values were pooled in four different ways; the mean, median, mode and the summation of patient Likert scale values of which the total was assigned a categorical Likert scale value. Estimates of bias, MAPE and RMSPE were then calculated for all four pooling approaches to determine which method most accurately represented an expert's opinion.ResultsWhen compared to an expert's opinion, the method of summation and categorisation of Likert scale values was most accurate 49 times out of the 114 (43.0%) tests. The mean 28 times out of 114 (24.6%), the median 23 times out of 114 (20.2%) and the mode 17 times out of 114 (14.9%).ConclusionWe conclude that our method of summation and categorisation of Likert scale values is most often the best representation of the simulated data compared to the expert's opinion.Implications for practiceThere is scope to reproduce this simulation study with multiple observers to reflect clinical reality more accurately with the dynamic nature of multiple observers. This also prompts future investigation into other anatomical areas, to see if the same methods produce similar results.     

“以学生为中心”理念指导下的《医学统计学》教学综合改革与探索

目的 针对医学生学习《医学统计学》普遍存在的焦虑情绪和消极态度,进行综合性教学改革和实践,以改善《医学统计学》的教学效果。 方法 提升教师的教育理论水平,坚持立德树人和以学生为中心的理念,针对医学生普遍存在的统计学焦虑问题开展实证研究,遵循“实践-理论-实践”的认知规律,帮助学生克服学习障碍,并以研究结果指导教学实践和教学改革,开展了《医学统计学》课程教学“理念提升-改革实践-效果评价”三位一体的综合性教学改革。 结果 通过改革,教师的教育理论水平和教学技能得以全面提高,学生的学习兴趣和创新意识增强。学生对待统计学的态度越来越积极,统计学焦虑程度有所缓解,课程成绩有了明显提升,改善了教学效果,更好地达成了教学目标。 结论 本次改革是将“以学生为中心”的理念落实到教学实践中的成功尝试,为医学统计学教学改革提供了新思路和新方向。     

基于网络平台的中医统计学混合教学模式探索与实践

目的:在中医统计学教学过程中构建混合式教学框架并探索其应用效果。方法:构建高度契合中医类专业医学统计学教学的混合教学框架。选取河北中医学院9个专业2252名学生作为研究对象,课程结束对教学效果进行评估。结果:学生对统计学基本方法的理解及课程的学习热情均有提高。结论:混合教学模式可显著提高中医院校医学统计学教学效果。     

On-line computer estimation of carbon dioxide response curves

Anesthesiologists are concerned with the effect of various anesthetics on a patient's central nervous ventilatory control. The most widely accepted method of determining the effect of a drug is to compare carbon dioxide response curves ( e/PetCO₂, where e = minute ventilation [in L/min] andPetCO₂ = end-tidal carbon dioxide [in mm Hg]) measured before and after administration of the drug. Additional information concerning neuromechanical control can be obtained by also including a measure of the airway occlusion pressure (generally measured 100 ms after occlusion, i.e., P₁₀₀).To facilitate these measurements we have developed a portable, computer-controlled data acquisition system. It includes an Apple II+ computer and measures e,PetCO₂, and P₁₀₀. Each subject rebreathes exhaled carbon dioxide through a two-way breathing valve attached to a 9-liter reservoir, which is initially filled with 5% carbon dioxide and balance oxygen. Exhaled carbon dioxide concentrations are measured with an infrared medical gas analyzer on samples taken through a catheter connected at the mouthpiece. The exhaled flow is measured with a pneumotachograph in conjunction with a differential pressure transducer, and P₁₀₀ is determined with a Validyne MP45 pressure transducer.