Development of explicit criteria for prioritization of hip and knee replacement

RATIONALE AND AIMS: Among the problems to the publicly funded national health services are the waiting lists. Patients who need elective surgery generally have long waiting times before treatment. We aimed to develop a new prioritization tool for primary hip and knee replacement. METHODS: Criteria were developed using a modified Delphi panel process. We convened a panel of nine members who scored the scenarios created by the research team and by patient focus groups. We studied the level of agreement among the panelists and the contribution of the variables to the ratings of the panel using linear and logistic regression models. The priority scores of the variables and their levels were synthesized using the optimal scaling and standard linear regression methods. RESULTS: Seven variables, pain on motion, walking functional limitations, abnormal findings on physical examination, pain at rest, other functional limitations, social role, and other pathologies that could improve with joint replacement, were considered to create the different scenarios. The panel scored 192 scenarios. The disagreement among the panelists was very low (1%) with an intra-class correlation coefficient of 0.72. Of the 192 scenarios, 45.8% were scored as urgent, 35.4% as preferred and 18.8% as ordinary. The variables that contributed most to the scores were pain on motion and walking functional limitations. When optimal scaling and regression techniques were applied, similar results were obtained. CONCLUSION: This tool can evaluate and prioritize patients on a waiting list for hip or knee replacement. We also provide a simple and easy way to use an algorithm to estimate the treatment priority for individual patients.     

Oxidative DNA damage induced by Ochratoxin A in the HK-2 human kidney cell line: evidence of the relationship with cytotoxicity

Ochratoxin A (OTA) is a mycotoxin produced by species of the genera Aspergillus and Penicillium. The kidneys are the target organ of this mycotoxin and it is considered a potent renal carcinogen in male rats. The mechanisms of its genotoxicity and carcinogenicity have been studied thoroughly, but controversial results have been published. The aim of this study was to evaluate the ability of OTA to produce single-strand DNA breaks and oxidative DNA damage in the human renal proximal tubular epithelial cell line (HK-2), due to the fact that there is no study on human kidney cells as the toxic target. In addition, we attempted to determine if biotransformation processes mediate OTA genotoxicity. Therefore, single-cell gel electrophoresis assay (comet assay) was performed after 3h- and 6h-treatments using different OTA concentrations, both cytotoxic and non-cytotoxic, in order to be able to distinguish a genotoxic effect of the mycotoxin from an indirect effect derived from its general cellular toxicity. No effect was shown where no cytotoxicity was found, both in the presence and in the absence of metabolic activation (10% rat liver S9-mix). However, oxidative DNA damage was shown at cytotoxic concentrations when formamidopyrimidine DNA glycosylase (FPG) and endonucleaseIII (EndoIII) were introduced in the assay with or without metabolic activation. Furthermore, at these concentrations, an elevation of reactive oxygen species was measured and pre-incubation with N-acetyl-L-cysteine was able to produce a slight protective effect on OTA-induced oxidative DNA damage as well as cytotoxicity. These data suggest that OTA is not acting as a direct genotoxic carcinogen and that oxidative stress is implicated in the genotoxicity and cytotoxicity observed in these human renal cells.     

Declining length of hospital stay for pneumonia and postdischarge outcomes

Objective

This study was designed to assess 8-year trends in the duration of hospitalization for community-acquired pneumonia and to evaluate the impact of declining length of stay on postdischarge short-term readmission and mortality.

Methods

We conducted a prospective observational cohort study of 1886 patients with community-acquired pneumonia who were discharged from a single hospital between March 1, 2000, and June 30, 2007. The main outcomes measured were all-cause mortality and hospital readmission during the 30-day period after discharge. Regression models were used to identify risk factors associated with hospital length of stay and the adjusted associations between length of stay and mortality and readmission.

Results

Factors associated with a longer hospital stay included the number of comorbid conditions, high risk classification on the Pneumonia Severity Index, bilateral or multilobe radiographic involvement, and treatment failure. Patients treated with an appropriate antibiotic were less likely to have an increased length of stay. The mean length of stay was significantly shorter during the 2006 to 2007 period (3.6 days) than during the 2000 to 2001 period (5.6 days, P <.001). Despite the reduction in length of stay, there were no significant differences in the likelihood of death or readmission at 30 days between the 2 time periods. Adjusted multivariate analysis showed that patients with hospital stays less than 3 days did not have significant increases in postdischarge outcomes.

Conclusion

The marked decreased in the length of stay for patients hospitalized with community-acquired pneumonia since 2000 has not been accompanied by an increase in short-term mortality or hospital readmission.     

Epigenomic Evaluation of Cholangiocyte Transforming Growth Factor-β Signaling Identifies a Selective Role for Histone 3 Lysine 9 Acetylation in Biliary Fibrosis

1. Download : Download high-res image (154KB)
2. Download : Download full-size image