Using a Decision Support Algorithm for Referrals to Post-Acute Care

Objectives

Although hospital clinicians strive to effectively refer patients who require post-acute care (PAC), their discharge planning processes often vary greatly, and typically are not evidence-based.

基于DEMATEL的非计划性拔管风险因素分析

目的应用决策试验与评价实验室方法(DEMATEL)确定非计划性拔管的关键风险因素,为临床管道管理提供决策依据。方法对49例非计划性拔管不良事件,由管道护理小组现场认证确定19项风险因素;选取35名专家进行2轮函询,以函询结果构建风险因素的直接影响矩阵,运用DEMATEL软件计算综合影响度(Tr)、被影响度(Tc)、中心度(Mi)和原因度(Ri)。结果专家积极性为100%,权威程度0.857,协调系数0.297(P0.05);19项风险因素的Tr为0~2.535,Tc为0~2.321,Mi为0.653~3.891,Ri0的风险因素有10个,Ri0的风险因素有9个。结论基于DEMATEL分析影响非计划性拔管的风险因素,其主要风险因素有操作方法、固定方法、肢体约束、健康教育及高危人群评估,其中操作方法为最关键因素。     

Development of an inhalation unit risk factor for hexavalent chromium

A unit risk factor (URF) was developed for hexavalent chromium (CrVI). The URF is based on excess lung cancer mortality in two key epidemiological studies of chromate production workers. The Crump et al. (2003) study concerns the Painesville, OH worker cohort, while Gibb et al. (2000) regards the Baltimore, MD cohort. A supporting assessment was also performed for a cohort from four low-dose chromate plants (Leverkusen and Uerdingen, Germany, Corpus Christi, TX, Castle Hayne, NC). For the Crump et al. (2003) study, grouped observed and expected number of lung cancer mortalities along with cumulative CrVI exposures were used to obtain the maximum likelihood estimate and asymptotic variance of the slope (β) for the linear multiplicative relative risk model using Poisson regression modeling. For the Gibb et al. (2000) study, Cox proportional hazards modeling was performed with optimal exposure lag and adjusting for the effect of covariates (e.g., smoking) to estimate β values. Life-table analyses were used to develop URFs for each of the two key studies, as well as for supporting and related studies. The two key study URFs were combined using weighting factors relevant to confidence to derive the final URF for CrVI of 2.3E-03 per μg CrVI/m³.     

Pile sorting innovations: Exploring gender norms,power and equity in sub-Saharan Africa

Abstract

Understanding gender norms, power and equity is important for developing successful sexual and reproductive health interventions. However, little attention has been given to how to capture the gender ideals and imbalances that inform these relationships in low resource settings. Pile sorting exercises were conducted in four gender-segregated focus groups in Ethiopia and Kenya. Each group received cards illustrated with a man, woman and man and woman together and cards labelled with duties and decisions. Participants discussed and decided together whether men, women or both performed each duty and decision and assigned the cards accordingly. Participants then reflected on and physically manipulated the piles to challenge gender norms, investigate role flexibility and identify agents of social change. Data collected included photographs of the pile sorts and recordings of the discussions. Conducting pile sorting within focus group discussions enabled comparative analyses of gender norms, while enriching data by focusing discussions and encouraging consensus building. Innovative applications facilitated participants' abilities to engage abstract concepts, reflecting on issues of gender norms, power and equity.     

Compellingness: assessing the practical relevance of clinical research results

While the critical appraisal of clinical research has generally focused on aspects of study design and statistical analysis, other features of clinical studies appear to be more important to clinicians for assessing the value of a particular study in the care of particular patients. These features relate to the quality of the knowledge derived from the research, the value of the results to the care of individual patients, and the responsibility of clinicians to be stewards of limited resources. Twelve features of clinical research studies that affect how compelling individual clinicians find the results are proposed and examined here. By better understanding what makes clinical research compelling enough to alter or reinforce clinical practice, clinical researchers can design future studies to better serve the needs of clinicians and patients.     

Clinical and histological changes associated with corticosteroid therapy in IgG4-related tubulointerstitial nephritis

Abstract

Objectives This study aimed to investigate the clinicopathological changes induced by corticosteroid therapy in immunoglobulin (Ig)G4-related tubulointerstitial nephritis (TIN).

Methods We studied six IgG4-related TIN patients receiving renal biopsies before and after corticosteroid therapy. Their clinical data and histological findings were evaluated before and after therapy.

Results Elevated serum creatinine levels rapidly improved after corticosteroid therapy except for two patients, in whom it persisted. Abnormal radiological findings improved in all patients, although focal cortical atrophy persisted in three. Histologically, TIN-like dense lymphoplasmacytic infiltration, interstitial fibrosis, IgG4-positive plasma cell, CD4+CD25+ T cell, and Foxp3+ cell infiltration were characteristic before therapy. After therapy, the area with cell infiltration decreased and regional fibrosis became evident in the renal interstitium. The number of IgG4-positive plasma cells and Foxp3+ cells significantly diminished even in the early stage of therapy, whereas low to moderate numbers of CD4+ and CD8+ T cells still infiltrated where inflammation persisted in the later stage.

Conclusions Our study shows that persistent renal insufficiency associated with macroscopic atrophy and microscopic fibrosis is not so rare in IgG4-related TIN. Pathologically, the behavior of regulatory T cells during the clinical course is quite similar to that of IgG4-positive plasma cells, and the behavior pattern of those cells is distinctive.     

Physiological basis of preoperative cardiopulmonary exercise testing

The use of cardiopulmonary exercise testing (CPET) is gaining popularity as a preoperative functional assessment tool and a useful adjunct to risk stratification before surgery. Determination of the integrated response of multiple body systems (including the cardiorespiratory and peripheral oxygen delivery systems) to exercise stress, adds important prognostic value to pre-surgical assessment, shared-decision making and postoperative management of the surgical patient. Thorough CPET interpretation is complex but may be assisted by an understanding of basic exercise physiology and its application to the preoperative context.