Assessing feasibility and acceptability of study procedures : getting ready for implementation of national stroke guidelines in out-patient health care

BACKGROUND: Even though Swedish national guidelines for stroke care (SNGSC) have been accessible for nearly a decade access to stroke rehabilitation in out-patient health care vary considerably. In order to aid future interventions studies for implementation of SNGSC, this study assessed the feasibility and acceptability of study procedures including analysis of the context in out-patient health care settings. METHODS: The feasibility and acceptability of recruitment, observations and interviews with managers, staff and patients were assessed, as well as the feasibility of surveying health care records. RESULTS: To identify patients from the the hospitals was feasible but not from out-patient care where a need to relieve clinical staff of the recruitment process was identified. Assessing adherence to guidelines and standardized evaluations of patient outcomes through health care records was found to be feasible and suitable assessment tools to evaluate patient outcome were identified. Interviews were found to be a feasible and acceptable tool to survey the context of the health care setting. CONCLUSION: In this feasibility study a variety of qualitative and quantitative data collection procedures and measures were tested. The results indicate what can be used as a set of feasible and acceptable data collection procedures and suitable measures for studying implementation of stroke guidelines in an out-patient health care context.

Impacto clínico e econômico da redefinição dos critérios diagnósticos de infarto do miocárdio

Introdução: Estudos sobre implicações clínicas da nova definição de infarto do miocárdio (IAM), incorporando novos marcadores de lesão miocárdica, são escassos na literatura. A prevalência de IAM e das suas complicações são diretamente dependentes do critério diagnóstico utilizado. Objetivo: Avaliar o impacto diagnóstico, prognóstico e econômico da nova definição de IAM proposta pela AHA/ ESC usando troponina T (TnT) como marcador de lesão cardíaca. Métodos: Um total de 740 pacientes com dor torácica admitidos na Emergência do Hospital de Clínicas de Porto Alegre no período de julho/ 1999 a janeiro/ 2002 foram incluídos no estudo. Creatina quinase total (CK), CK-MB atividade e TnT foram dosados em uma amostra de 363 pacientes, representativa de toda a coorte. Para redefinição de IAM foram utilizados como ponto de corte valores pico de TnT > 0,2 mg/dl. Os desfechos avaliados foram classificados como eventos cardíacos maiores (angina recorrente, insuficiência cardíaca congestiva, choque cardiogênico e óbito) e como procedimentos de revascularização. Também foram avaliados o manejo prescrito, os custos e o faturamento hospitalar. Resultados: Nos 363 pacientes com marcadores dosados, foram diagnosticados 59 casos de IAM (16%) pelos critérios clássicos; enquanto 40 pacientes (11%) tiveram o diagnóstico de IAM pelo critério redefinido, o que corresponde a um incremento de 71% na incidência. Pacientes com IAM redefinido eram significativamente mais idosos e do sexo masculino, apresentaram mais dor atípica e diabetes mellitus. Na análise multivariada, pacientes com infarto redefinido tiveram um risco 5,1 [IC 95% 1,0-28] vezes maior para óbito hospitalar e 3,4 [IC 95% 1,1-10] vezes maior para eventos combinados em relação aqueles sem IAM. O manejo dos casos de IAM redefinido foi semelhante ao manejo daqueles com IAM tradicional, exceto pelos procedimentos de revascularização que foram menos freqüentes (25% vs. 51%, P < 0,001). O grupo com IAM redefinido permaneceu mais tempo internado e foi submetido a procedimentos mais tardiamente. Do ponto de vista institucional, o uso dos novos critérios para IAM poderia resultar em um aumento de 9% (mais R$ 2.756,00 por grupo de 100 pacientes avaliados) no faturamento baseado em diagnóstico segundo a tabela do SUS. Conclusões: O novo diagnóstico de IAM acrescenta um número expressivo de indivíduos com infarto aos serviços de emergência. A incorporação deste critério é importante na medida que estes pacientes têm um prognóstico semelhante aos demais casos tradicionalmente diagnosticados. Como a identificação destes casos poderia resultar em um manejo mais qualificado e eficiente destes pacientes, esforços deveriam ser adotados para reforçar a adoção da redefinição de IAM.

Uma comparação entre os custos atuais, custos por pacote e reembolso hospitalar para o procedimento de revascularização miocárdica

In Brazil, the supplemental healthcare system is going through a transition period from the traditional Fee-for-service reimbursement system to the Package reimbursement system, similar to the American model known as the Diagnoses Related Groups (DRG) system. Although the Package concept is nothing new to the hospital environment, it is still seldom used since this system calls for a level of control and analytical knowledge of hospital costs that are poorly developed in Brazilian institutions. This study focuses on determining how much the reimbursement for a Myocardial Revascularization Package actually covers of the current costs for patients submitted to this procedure. A prospective analysis method for determining the cost per patient has been developed and 13 patients were individually followed-up during all their hospitalization period. The expenses with intensive care unit and in-patient clinical care, as well as the type of admittance - whether elective or emergency - were determined for each patient. Additionally, all the resources and materials for the surgical procedure were included, comprising specialized personnel, surgical fees, procedures and tests, biomedical equipment, and all the materials and medication used during the hospital stay. Based on this data, the current total costs were calculated and compared to the reimbursement for the Package previously agreed upon by the institution and the healthcare carriers. The study found an average cost of BR$ 8,826 for a Myocardial Revascularization surgical procedure, while the respective reimbursement for the Package is of BR$ 7,476. Therefore, the reimbursement does not cover the current costs of the procedure.

Sequential cost-reimbursement rules

This paper studies cost-sharing rules under dynamic adverse selection. We present a typical principal-agent model with two periods, set up in Laffont and Tirole's (1986) canonical regulation environment. At first, when the contract is signed, the firm has prior uncertainty about its efficiency parameter. In the second period, the firm learns its efficiency and chooses the level of cost-reducing effort. The optimal mechanism sequentially screens the firm's types and achieves a higher level of welfare than its static counterpart. The contract is indirectly implemented by a sequence of transfers, consisting of a fixed advance payment based on the reported cost estimate, and an ex-post compensation linear in cost performance.

Co-ordination failure, moral hazard and sovereign bankruptcy procedures

We study a model of sovereign debt crisis that combines problems of creditor coordination and debtor moral hazard. Solving the sovereign debtor's incentives leads to excessive 'rollover failure' by creditors when sovereign default occurs. We discuss how the incidence of crises might be reduced by international sovereign bankruptcy procedures and relate this to the current debate on revising international financial architecture. Paper prepared for Bank of England Conference on "The Role of the Official and Private Sectors in Resolving International Financial Crises", London, and for the Latin American Meeting of the Econometric Society, Sao Paolo, Brazil. (Preliminary draft circulated for comments, please do not cite without reference to the authors).

Modified value stream mapping of airport check-in procedures

In June 2014 Brazil hosted the FIFA World Cup and in August 2016 Rio de Janeiro hosts the Summer Olympics. These two seminal sporting events will draw tens of thousands of air travelers through Brazil’s airports, airports that are currently in the midst of a national modernization program to address years of infrastructure neglect and insufficient capacity. Raising Brazil’s major airports up to the standards air travelers experience at major airports elsewhere in the world is more than just a case of building or remodeling facilities, processes must also be examined and reworked to enhance traveler experience and satisfaction. This research paper examines the key interface between airports and airline passengers—airport check-in procedures—according to how much value and waste there is associated with them. In particular, the paper makes use of a value stream mapping construct for services proposed by Martins, Cantanhede, and Jardim (2010). The uniqueness of this construct is that it attributes each activity with a certain percentage and magnitude of value or waste which can then be ordered and prioritized for improvement. Working against a fairly commonly expressed notion in Brazil that Brazil’s airports are inferior to the airports of economically advanced countries, the paper examines Rio’s two major airports, Galeão International and Santos Dumont in comparison to Washington D.C.’s Washington National and Dulles International airports. The paper seeks to accomplish three goals: - Determine whether there are differences in airport passenger check-in procedures between U.S. and Brazilian airports in terms of passenger value - Present options for Brazilian government or private sector authorities to consider adopting or implementing at Brazilian airports to maximize passenger value - Validate the Martins et al. construct for use in evaluating the airport check-in procedures Observations and analysis proved surprising in that all airports and service providers follow essentially the same check-in processes but execute them differently yet still result in similar overall performance in terms of value and waste. Although only a few activities are categorized as completely wasteful (and therefore removed in the revised value stream map of check-in activities), the weighting and categorization of individual activities according to their value (or waste) presents decision-makers a means to prioritize possible corrective actions. Various overall recommendations are presented based on this analysis. Most importantly, this paper demonstrates the viability of using the construct developed by Martins et al to examine airport operations, as well as its applicability to the study of other service industry processes.

The effects of macromolecular and serum supplements and oxygen tension during bovine in vitro procedures on kinetics of oocyte maturation and embryo development

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Optimising tetrazolium test procedures to evaluate the physiological potential of peanut seeds

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Growth optimization procedures for the phytopathogen Xylella fastidiosa

For the first time, growth curves are shown for the phytopathogen Xylella fastidiosa on traditional growth media such as PW (periwinkle wilt), BCYE (buffered charcoal yeast extract), and on new ones such as GYE (glutamate yeast extract) and PYE (phosphate yeast extract) that were developed in this work. The optimal growth conditions on solid and liquid media as well as their measurements are presented, by using total protein content and turbidity determinations. The results demonstrated that yeast extract provided sufficient nutrients for X. fastidiosa, since the cells grew well on PYE medium.

Effect of lactation length adjustment procedures on genetic parameter estimates for buffalo milk yield

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Antipanic procedures reduce the strychnine-facilitated wild running of rats

Wild running (WR) behavior of rats seen in response to intense acoustic stimulation of audiogenic seizure-paradigm is very similar to the panic flight and can be facilitated by subconvulsive doses of strychnine. The present work aimed to test whether antipanic procedures, such as dorsal periaqueductal gray (dPAG) lesion and imipramine treatments, affect the strychnine-facilitated WR. In study 1, six Wistar male adult rats with electrolytic lesion of dPAG had their WR completely blocked, whereas it was facilitated in 50% of sham-lesioned control rats by a dose of 0.5 mg/kg of strychnine administered intraperitoneal. This effect was not reproduced with a higher strychnine dose (1.0 mg/kg). In study 2, the effects of imipramine were investigated by testing 36 rats under a dose of strychnine that induces WR in 50% of subjects. They were assigned into three experimental groups: imipramine treatments of 5.0 and 10.0 mg/kg, and infusions of saline. All these treatments were subchronical with three intraperitoneal injections within 24h. Imipramine (10.0mg/kg) reduced the incidence of WR in comparison to the saline results. It is concluded that strychnine-facilitated WR is reduced by antipanic procedures and, therefore, can be viewed as a manifestation closely related to panic. (C) 2003 Elsevier B.V. B.V. All rights reserved.

Patient perceptions about anesthesia and anesthesiologists before and after surgical procedures

Fundação de Amparo à Pesquisa do Estado de São Paulo (FAPESP)

Surgical procedures used for post-traumatic neurogenic bladder in a cat: report case

Um gato de um ano de idade, macho, castrado, sem raça definida, foi encaminhado ao Hospital Veterinário Escola para avaliação de retenção urinária associada à subluxação nas vértebras T12-T13, que foi causada por um acidente automobilístico. Realizou-se a denervação do esfíncter uretral, por transecção dos nervos pudendo e hipogástrico, para permitir o esvaziamento da bexiga, porém três meses após a cirurgia inicial o animal apresentou recorrência da retenção urinária. Esfincterotomia endoscópica uretral foi então realizada, resultando em incontinência urinária por quatro meses.

Evaluating the knowledge of sports participants regarding dental emergency procedures

Dental trauma is a common consequence of sports practice to which emergency treatment is critical. The purpose of this study was to evaluate the knowledge of sports participants about dental trauma procedures, particularly tooth avulsion. A specific questionnaire concerning concepts, experiences and behaviors after dental trauma and the use of mouthguard was standardized and validated with 80 people. The validated questionnaire was then distributed to 310 sports participants. The results showed that 28.4% had experienced a kind of dental trauma; 42.6% would look for a dentist for treatment; 51.7% reimplanted or would reimplant the avulsed tooth; 6.5% would maintain the avulsed tooth in milk. Although 47.4% of the participants were aware of the possibility of accidents during sports practice, only 13.9% reported to use a mouthguard. This study showed an overall lack of knowledge of sportsmen and sportswomen with regards to tooth avulsion, thus reinforcing the need for educational campaigns to improve the immediate emergency treatment of tooth avulsion.