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1.
本文目的是介绍一种能很好地拟合具有间断点资料的方法。当资料中具有明确的间断点或整个资料包含多段不同变化趋势的曲线类型时,为了提高曲线回归模型对资料的拟合优度,需要充分发挥"节点"的作用。可基于两种不同视角来利用"节点":其一,人为设定不同数目的节点,利用样条变换方法拟合分段多项式曲线;其二,在客观存在的节点上,求曲线的一阶乃至四阶导数,并据此构建曲线回归模型。得到的结论是:后者的拟合效果优于前者。  相似文献   
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《Value in health》2020,23(8):1027-1033
ObjectivesIn many countries, future unrelated medical costs occurring during life-years gained are excluded from economic evaluation, and benefits of unrelated medical care are implicitly included, leading to life-extending interventions being disproportionately favored over quality of life-improving interventions. This article provides a standardized framework for the inclusion of future unrelated medical costs and demonstrates how this framework can be applied in England and Wales.MethodsData sources are combined to construct estimates of per-capita National Health Service spending by age, sex, and time to death, and a framework is developed for adjusting these estimates for costs of related diseases. Using survival curves from 3 empirical examples illustrates how our estimates for unrelated National Health Service spending can be used to include unrelated medical costs in cost-effectiveness analysis and the impact depending on age, life-years gained, and baseline costs of the target group.ResultsOur results show that including future unrelated medical costs is feasible and standardizable. Empirical examples show that this inclusion leads to an increase in the ICER of between 7% and 13%.ConclusionsThis article contributes to the methodology debate over unrelated costs and how to systematically include them in economic evaluation. Results show that it is both important and possible to include future unrelated medical costs.  相似文献   
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IntroductionThe purpose of this national study was to audit the weight-bearing practice of orthopaedic services in the National Health Service (NHS) in the treatment of operatively and non-operatively treated ankle fractures.MethodsA multicentre prospective two-week audit of all adult ankle fractures was conducted between July 3rd 2017 and July 17th 2017. Fractures were classified using the AO/OTA classification. Fractures fixed with syndesmosis screws or unstable fractures (>1 malleolus fractured or talar shift present) treated conservatively were excluded. No outcome data were collected. In line with NICE (The National Institute for Health and Care Excellence) criteria, “early” weight-bearing was defined as unrestricted weight-bearing on the affected leg within 3 weeks of injury or surgery and “delayed” weight-bearing as unrestricted weight-bearing permitted after 3 weeks.Results251 collaborators from 81 NHS hospitals collected data: 531 patients were managed non-operatively and 276 operatively. The mean age was 52.6 years and 50.5 respectively. 81% of non-operatively managed patients were instructed for early weight-bearing as recommended by NICE. In contrast, only 21% of operatively managed patients were instructed for early weight-bearing.DiscussionThe majority of patients with uni-malleolar ankle fractures which are managed non-operatively are treated in accordance with NICE guidance. There is notable variability amongst and within NHS hospitals in the weight-bearing instructions given to patients with operatively managed ankle fractures.ConclusionThis study demonstrates community equipoise and suggests that the randomized study to determine the most effective strategy for postoperative weight-bearing in ankle fractures described in the NICE research recommendation is feasible.  相似文献   
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Background

10–25% of childhood burns arise from maltreatment.

Aim

To derive and validate a clinical prediction tool to assist the recognition of suspected maltreatment.

Methods

Prospectively collected data from 1327 children with burns were analyzed using logistic regression. Regression coefficients for variables associated with ‘referral for child maltreatment investigation’ (112 cases) in multivariable analyses were converted to integers to derive the BuRN-Tool, scoring each child on a continuous scale. A cut-off score for referral was established from receiver operating curve analysis and optimal sensitivity and specificity values. We validated the BuRN-Tool on 787 prospectively collected novel cases.

Results

Variables associated with referral were: age <5 years, known to social care, concerning explanation, full thickness burn, uncommon body location, bilateral pattern and supervision concern. We established 3 as cut-off score, resulting in a sensitivity and specificity for scalds of 87.5% (95% CI:61.7–98.4) and 81.5% (95% CI:77.1–85.4) respectively and for non-scalds sensitivity was 82.4% (95%CI:65.5–93.2) and specificity 78.7% (95% CI:73.9–82.9) when applied to validation data. Area under the curve was 0.87 (95% CI:0.83–0.90) for scalds and 0.85 (95% CI:0.81–0.88) for non-scalds.

Conclusion

The BuRN-Tool is a potential adjunct to clinical decision-making, predicting which children warrant investigation for child maltreatment. The score is simple and easy to complete in an emergency department setting.  相似文献   
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《The surgeon》2021,19(6):e526-e535
IntroductionDiabetic peripheral neuropathy leads to foot deformity, soft tissues damage, and gait imbalance, all of which can increase the mechanical stress imposed on the foot and give rise to Charcot neuroarthropathy. The current International Working Group of the Diabetic Foot International Guidelines on offloading focus on managing neuropathic foot ulcers related to pressure: only 2 of their 9 recommendations deal with surgical interventions. We assess the role of surgical techniques in off-loading to heal and possibly prevent diabetic foot ulceration.MethodsWe systematically analysed published data from January 2000 to November 2020 to assess methods of surgical offloading and associated outcomes for the surgical reconstruction. We tried to identify healing, remission-rates, return to ambulation, complications and limitations.ResultsFive discrete categories of surgical offloading are used in recalcitrant ulcers: 1. Lesser toe tenotomies; 2. Metatarsal head resection ± Achilles tendon release; 3. Hallux procedures; 4. Bony off-loading procedures in the form of exostectomy; and 5. Complex surgical foot reconstruction. Adjuvant modalities including surgically placed antibiotic delivery systems show promise, but further studies are required to clarify their role and effect on systemic antibiotic requirements.Conclusions and implicationsSurgery is important to mechanically stabilise and harmonise the foot for long term off-loading and foot-protection. Surgery should not be reserved for recalcitrant cases only, but extended to ulcer prevention and remission. Further comparative studies will benefit surgical decision making to avoid recurrence and define time point when surgical off-loading could protect against irretrievable tissue loss/re-ulceration.  相似文献   
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It has been demonstrated that embryo transfer during IVF treatment can be performed competently and successfully by nurses (Barber et al., 1996). The present study has examined the success of nurses in training using the standardized protocol of this Unit. Initially, three nurses (two experienced (training completed) and one inexperienced (training ongoing)) each performed 80 transfers, which were standardized to three embryos replaced per transfer. The study aimed to establish whether a standardized procedure was undertaken by the nurses and to assess the influence of one inexperienced nurse performing the procedure. A further study (study 2) was performed to assess the influence of three inexperienced nurses against three experienced nurses undertaking the same procedures. In study 1, the pregnancy rates were 27.5%, 38.8% and 40.0% and there was no significant difference in the clinical pregnancy rates. In study 2, the pregnancy rates were 18.7%, 20.0% and 20.0% for the inexperienced nurses, and 26.3%, 30.0% and 32.5% for the experienced nurses. There was no significant difference in the clinical pregnancy rates within the inexperienced group or the experienced group. When the results of the three inexperienced nurses were grouped and were compared with those of the three experienced nurses, the pregnancy rates were 19.5% and 29.5%, respectively (P < 0.02). It has been shown that good clinical pregnancy rates can be achieved when nurses perform embryo transfer. There is no significant effect on clinical results when one nurse is in training; however, because of the expected learning curve, when three nurses train together a more significant effect is observed.  相似文献   
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