Measures to prevent surgical site infections: what surgeons (should) do.

BACKGROUND: The present study was designed to evaluate surgeons' strategies and adherence to preventive measures against surgical site infections (SSIs). MATERIALS AND METHODS: All surgeons participating in a prospective Swiss multicentric surveillance program for SSIs received a questionnaire developed from the 2008 National (United Kingdom) Institute for Health and Clinical Excellence (NICE) clinical guidelines on prevention and treatment of SSIs. We focused on perioperative management and surgical technique in hernia surgery, cholecystectomy, appendectomy, and colon surgery (COL). RESULTS: Forty-five of 50 surgeons contacted (90%) responded. Smoking cessation and nutritional screening are regularly propagated by 1/3 and 1/2 of surgeons, respectively. Thirty-eight percent practice bowel preparation before COL. Preoperative hair removal is routinely (90%) performed in the operating room with electric clippers. About 50% administer antibiotic prophylaxis within 30 min before incision. Intra-abdominal drains are common after COL (43%). Two thirds of respondents apply nonocclusive wound dressings that are manipulated after hand disinfection (87%). Dressings are usually changed on postoperative day (POD) 2 (75%), and wounds remain undressed on POD 2-3 or 4-5 (36% each). CONCLUSIONS: Surgeons' strategies to prevent SSIs still differ widely. The adherence to the current NICE guidelines is low for many procedures regardless of the available level of evidence. Further research should provide convincing data in order to justify standardization of perioperative management.

Do Objective Measures of Blood Alcohol Concentrations Make More Sense than Self-reports in Emergency Department Studies?

Purpose: Concerns about self-reports have led to calls for objective measures of blood alcohol concentration (BAC). The present study compared objective measures with self-reports. Methods: BAC from breath or blood samples were obtained from 272 randomly sampled injured patients who were admitted to a Swiss emergency department (ED). Self-reports were compared a) between those providing and refusing a BAC test, and b) to estimated peak BAC (EPBAC) values based on BACs using the Widmark formula. Results: Those providing BACs were significantly (P < 0.05) younger, more often male, and less often reported alcohol consumption before injury, but consumed higher quantities when drinking. Eighty-eight percent of those with BAC measures gave consistent reports (positive or negative). Significantly more patients reported consumption with negative BAC measures (N = 29) than vice versa (N = 3). Duration of consumption and times between injury and BAC measurement predicted EPBAC better than did the objective BAC measure. Conclusions: There is little evidence that patients who provide objective BAC measures deliberately conceal consumption. ED studies must rely on self-reports, eg, take the time period between injury and ED admission into account. Clearly, objective measures are of clinical relevance, eg, to provide optimal treatment in the ED. However, they may be less relevant to establishing effects in an epidemiologic sense, such as estimating risk relationships. In this respect, efforts to increase the validity and reliability of self-reports should be preferred over the collection of additional objective measures.

Assurance vieillesse des personnes non salariées. Professions agricoles . [Mise à jour au 30 novembre 1956.]

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Assurance vieillesse des personnes non salariées. Professions artisanales . [1re partie : lois et décrets relatifs aux dispositions communes aux personnes non salariées. 2e partie : arrêtés, décrets et loi relatifs aux dispositions spéciales aux professions artisanales. Edition mise à jour au 30 septembre 1956.]

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Assurance vieillesse des personnes non salariées. Professions industrielles et commerciales . [1re partie : lois et décrets relatifs aux dispositions communes aux personnes non salariées. 2e partie : arrêtés et décrets relatifs aux dispositions spéciales aux professions industrielles et commerciales. Edition mise à jour au 15 octobre 1956.]

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Assurance vieillesse des personnes non salariées. Professions libérales . [1re partie : lois et décrets relatifs aux dispositions communes aux personnes non salariées. 2e partie : arrêtés et décrets relatifs aux dispositions spéciales aux professions libérales. Edition mise à jour au 15 octobre 1956.]

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Description des possibilités et difficultés d'utilisation des dossiers de l'assurance invalidité à des fins de recherche en pédiatrie.

Afin que la base de données de l'assurance invalidite (AI) soit utilisable à des fins de recherche, il serait nécessaire de restructurer le mode de récolte de données; unifier les définitions de l'impotence et de l'invalidité utilisées à l'AI avec celles de l'Organisation mondiale de la sante (OMS); employer les codes de la classification internationale des maladies (CIM); organiser le système de telle manière qu'il soit possible d'obtenir des listes d'assurés par année de naissance, par année d'entrée à l'AI, par diagnostic et par année d'âge.

Treatment intensification and risk factor control: toward more clinically relevant quality measures.

BACKGROUND: Intensification of pharmacotherapy in persons with poorly controlled chronic conditions has been proposed as a clinically meaningful process measure of quality. OBJECTIVE: To validate measures of treatment intensification by evaluating their associations with subsequent control in hypertension, hyperlipidemia, and diabetes mellitus across 35 medical facility populations in Kaiser Permanente, Northern California. DESIGN: Hierarchical analyses of associations of improvements in facility-level treatment intensification rates from 2001 to 2003 with patient-level risk factor levels at the end of 2003. PATIENTS: Members (515,072 and 626,130; age >20 years) with hypertension, hyperlipidemia, and/or diabetes mellitus in 2001 and 2003, respectively. MEASUREMENTS: Treatment intensification for each risk factor defined as an increase in number of drug classes prescribed, of dosage for at least 1 drug, or switching to a drug from another class within 3 months of observed poor risk factor control. RESULTS: Facility-level improvements in treatment intensification rates between 2001 and 2003 were strongly associated with greater likelihood of being in control at the end of 2003 (P < or = 0.05 for each risk factor) after adjustment for patient- and facility-level covariates. Compared with facility rankings based solely on control, addition of percentages of poorly controlled patients who received treatment intensification changed 2003 rankings substantially: 14%, 51%, and 29% of the facilities changed ranks by 5 or more positions for hypertension, hyperlipidemia, and diabetes, respectively. CONCLUSIONS: Treatment intensification is tightly linked to improved control. Thus, it deserves consideration as a process measure for motivating quality improvement and possibly for measuring clinical performance.

Clinically relevant quality measures for risk factor control in primary care: a retrospective cohort study.

BACKGROUND: Assessment of the proportion of patients with well controlled cardiovascular risk factors underestimates the proportion of patients receiving high quality of care. Evaluating whether physicians respond appropriately to poor risk factor control gives a different picture of quality of care. We assessed physician response to control cardiovascular risk factors, as well as markers of potential overtreatment in Switzerland, a country with universal healthcare coverage but without systematic quality monitoring, annual report cards on quality of care or financial incentives to improve quality. METHODS: We performed a retrospective cohort study of 1002 randomly selected patients aged 50-80 years from four university primary care settings in Switzerland. For hypertension, dyslipidemia and diabetes mellitus, we first measured proportions in control, then assessed therapy modifications among those in poor control. "Appropriate clinical action" was defined as a therapy modification or return to control without therapy modification within 12 months among patients with baseline poor control. Potential overtreatment of these conditions was defined as intensive treatment among low-risk patients with optimal target values. RESULTS: 20% of patients with hypertension, 41% with dyslipidemia and 36% with diabetes mellitus were in control at baseline. When appropriate clinical action in response to poor control was integrated into measuring quality of care, 52 to 55% had appropriate quality of care. Over 12 months, therapy of 61% of patients with baseline poor control was modified for hypertension, 33% for dyslipidemia, and 85% for diabetes mellitus. Increases in number of drug classes (28-51%) and in drug doses (10-61%) were the most common therapy modifications. Patients with target organ damage and higher baseline values were more likely to have appropriate clinical action. We found low rates of potential overtreatment with 2% for hypertension, 3% for diabetes mellitus and 3-6% for dyslipidemia. CONCLUSIONS: In primary care, evaluating whether physicians respond appropriately to poor risk factor control, in addition to assessing proportions in control, provide a broader view of the quality of care than relying solely on measures of proportions in control. Such measures could be more clinically relevant and acceptable to physicians than simply reporting levels of control.

Empirical Tests of Asset Pricing Models in Finnish Stock Market

Tämän tutkielman tavoitteena on selvittää mitkä riskitekijät vaikuttavat osakkeiden tuottoihin. Arvopapereina käytetään kuutta portfoliota, jotka ovat jaoteltu markkina-arvon mukaan. Aikaperiodi on vuoden 1987 alusta vuoden 2004 loppuun. Malleina käytetään pääomamarkkinoiden hinnoittelumallia, arbitraasihinnoitteluteoriaa sekä kulutuspohjaista pääomamarkkinoiden hinnoittelumallia. Riskifaktoreina kahteen ensimmäiseen malliin käytetään markkinariskiä sekä makrotaloudellisia riskitekijöitä. Kulutuspohjaiseen pääomamarkkinoiden hinnoinoittelumallissa keskitytään estimoimaan kuluttajien riskitottumuksia sekä diskonttaustekijää, jolla kuluttaja arvostavat tulevaisuuden kulutusta. Tämä työ esittelee momenttiteorian, jolla pystymme estimoimaan lineaarisia sekä epälineaarisia yhtälöitä. Käytämme tätä menetelmää testaamissamme malleissa. Yhteenvetona tuloksista voidaan sanoa, että markkinabeeta onedelleen tärkein riskitekijä, mutta löydämme myös tukea makrotaloudellisille riskitekijöille. Kulutuspohjainen mallimme toimii melko hyvin antaen teoreettisesti hyväksyttäviä arvoja.