Economics of dialysis dependence following renal replacement therapy for critically ill acute kidney injury patients.

BACKGROUND: The obective of this study was to perform a cost-effectiveness analysis comparing intermittent with continuous renal replacement therapy (IRRT versus CRRT) as initial therapy for acute kidney injury (AKI) in the intensive care unit (ICU). METHODS: Assuming some patients would potentially be eligible for either modality, we modeled life year gained, the quality-adjusted life years (QALYs) and healthcare costs for a cohort of 1000 IRRT patients and a cohort of 1000 CRRT patients. We used a 1-year, 5-year and a lifetime horizon. A Markov model with two health states for AKI survivors was designed: dialysis dependence and dialysis independence. We applied Weibull regression from published estimates to fit survival curves for CRRT and IRRT patients and to fit the proportion of dialysis dependence among CRRT and IRRT survivors. We then applied a risk ratio reported in a large retrospective cohort study to the fitted CRRT estimates in order to determine the proportion of dialysis dependence for IRRT survivors. We conducted sensitivity analyses based on a range of differences for daily implementation cost between CRRT and IRRT (base case: CRRT day $632 more expensive than IRRT day; range from $200 to $1000) and a range of risk ratios for dialysis dependence for CRRT as compared with IRRT (from 0.65 to 0.95; base case: 0.80). RESULTS: Continuous renal replacement therapy was associated with a marginally greater gain in QALY as compared with IRRT (1.093 versus 1.078). Despite higher upfront costs for CRRT in the ICU ($4046 for CRRT versus $1423 for IRRT in average), the 5-year total cost including the cost of dialysis dependence was lower for CRRT ($37 780 for CRRT versus $39 448 for IRRT on average). The base case incremental cost-effectiveness analysis showed that CRRT dominated IRRT. This dominance was confirmed by extensive sensitivity analysis. CONCLUSIONS: Initial CRRT is cost-effective compared with initial IRRT by reducing the rate of long-term dialysis dependence among critically ill AKI survivors.

Retinal pigment epithelium protein of 65 kDA gene-linked retinal degeneration is not modulated by chicken acidic leucine-rich epidermal growth factor-like domain containing brain protein/Neuroglycan C/ chondroitin sulfate proteoglycan 5.

PURPOSE: To analyze in vivo the function of chicken acidic leucine-rich epidermal growth factor-like domain containing brain protein/Neuroglycan C (gene symbol: Cspg5) during retinal degeneration in the Rpe65⁻/⁻ mouse model of Leber congenital amaurosis. METHODS: We resorted to mice with targeted deletions in the Cspg5 and retinal pigment epithelium protein of 65 kDa (Rpe65) genes (Cspg5⁻/⁻/Rpe65⁻/⁻). Cone degeneration was assessed with cone-specific peanut agglutinin staining. Transcriptional expression of rhodopsin (Rho), S-opsin (Opn1sw), M-opsin (Opn1mw), rod transducin α subunit (Gnat1), and cone transducin α subunit (Gnat2) genes was assessed with quantitative PCR from 2 weeks to 12 months. The retinal pigment epithelium (RPE) was analyzed at P14 with immunodetection of the retinol-binding protein membrane receptor Stra6. RESULTS: No differences in the progression of retinal degeneration were observed between the Rpe65⁻/⁻ and Cspg5⁻/⁻/Rpe65⁻/⁻ mice. No retinal phenotype was detected in the late postnatal and adult Cspg5⁻/⁻ mice, when compared to the wild-type mice. CONCLUSIONS: Despite the previously reported upregulation of Cspg5 during retinal degeneration in Rpe65⁻/⁻ mice, no protective effect or any involvement of Cspg5 in disease progression was identified.

Iowa Crop and Weather Report, November 25, 2012, Vol. 12. no. 39

Report produced by the The Department of Agriculture and Land Stewardship, Climatology Bureau. Iowa Secretary of Agriculture Bill Northey today commented on the Iowa Crops and Weather report released by the USDA National Agricultural Statistical Service. The report is released weekly from April through October.

Los límites de la obligatoriedad escolar en Buenos Aires, 1884-1915

En este artículo pretendemos enriquecer el marco explicativo que inquiere en las razones del hiato entre el trazado ideal y la constitución efectiva del sistema público de instrucción en Argentina en el periodo que va desde la sanción de la Ley 1.420 hasta la entrada en la década de 1910. Nos interesará dejar asentado que tal distancia no dependió únicamente de las limitaciones materiales con las que se enfrentaron las autoridades escolares, o de las decisiones de los padres con respecto de la asistencia de sus hijos a la escuela, sino que la misma estuvo enraizada en un elemento más profundo, del orden de las representaciones, que desde muy temprano funcionó como un impedimento para la realización de la vocación educativa pretendidamente ecuménica de las élites argentinas. De hecho, las posturas educativas universalistas convivieron con ostras que rechazaban la posibilidad e incluso la conveniencia de que todos los niños se educaran en escuelas comunes, aparente contradicción que atravesó los discursos y las prácticas de casi todos los miembros de las élites, incluyendo los de los adalides de la "educación popular". A través del análisis y de la puesta en relación de la ley de Educación común (Ley n.1.420/1884) y la Ley de Reglamentación del Trabajo de Mujeres y Niños (Ley n.5.291/1907), exploraremos cómo se fueran estableciendo los criterios que desde temprano determinaron que "niños" podrían convertirse en alumnos, y cuáles no.

Violência intrafamiliar e intimidação entre colegas no ensino fundamental

Esta pesquisa teve como principal objetivo investigar a associação entre intimidação entre pares e violência intrafamiliar. Participaram do estudo 239 estudantes, com idades entre 11 e 15 anos, sendo que 34,7% eram meninos e 65,3%, meninas. Construiu-se um questionário baseado em outros instrumentos que continha: questões sobre variáveis sociodemográficas; itens que investigavam a exposição dos estudantes à violência interparental e questões que mediam a violência física e psicológica cometida por mães e pais contra os participantes. O envolvimento em bullying foi avaliado por meio de 26 itens, desenvolvidos especialmente para os propósitos do estudo, baseados em uma versão modificada do questionário de Olweus. Foram encontradas associações entre violência doméstica e bullying, com peculiaridades de acordo com o sexo dos participantes. Estar exposto à violência interparental esteve associado com ser alvo/autor de bullying na escola, especialmente para as meninas, mas não com ser vítima de intimidação. A violência parental direta, por sua vez, aumentou a probabilidade de os meninos relatarem envolvimento em bullying como vítima e também a chance de ser vítima-agressora. Entre as meninas, sofrer violência por parte dos pais mostrou-se um fator associado somente com atuar em intimidação como alvo/autor.

Impact of medical practice guidelines on the assessment of patients with acute coronary syndrome without persistent ST segment elevation.

OBJECTIVE: To assess the impact of introducing clinical practice guidelines on acute coronary syndrome without persistent ST segment elevation (ACS) on patient initial assessment. DESIGN: Prospective before-after evaluation over a 3-month period. SETTING: The emergency ward of a tertiary teaching hospital. PATIENTS: All consecutive patients with ACS evaluated in the emergency ward over the two 3-month periods. INTERVENTION: Implementation of the practice guidelines, and the addition of a cardiology consultant to the emergency team. MAIN OUTCOME MEASURES: Diagnosis, electrocardiogram interpretation, and risk stratification after the initial evaluation. RESULTS: The clinical characteristics of the 328 and 364 patients evaluated in the emergency ward for suspicion of ACS before and after guideline implementation were similar. Significantly more patients were classified as suffering from atypical chest pain (39.6% versus 47.0%; P = 0.006) after guideline implementation. Guidelines availability was associated with significantly more formal diagnoses (79.9% versus 92.9%; P < 0.0001) and risk stratification (53.7% versus 65.4%, P < 0.0001) at the end of initial assessment. CONCLUSION: Guidelines implementation, along with availability of a cardiology consultant in the emergency room had a positive impact on initial assessment of patients evaluated for suspicion of ACS. It led to increased confidence in diagnosis and stratification by risk, which are the first steps in initiating effective treatment for this common condition.

La construcción de la innovación educativa en el marco de un proyecto de investigación : el caso del School + y la investigación-acción

School +: Más que un sistema informático para construir la escuela del mañana és un projecte d'investigació i desenvolupament l'objectiu central del qual és reflexionar sobre l'educació escolar actual i contribuir a crear una nova organització d'aquests espais d'ensenyament i aprenentatge tenint en compte els desitjos i les necessitats dels seus actors principals: professorat, estudiants, pares i mares, en el context d'una societat en canvi continu. Està finançat per la Unió Europeu i entre els seus socis hi ha quatre universitats, quatre escoles secundàries i una empresa mitjana, tots de diferents punts d'Europa. En aquest article es presenten alguns dels resultats més rellevants obtinguts a partir dels principals estudis portats a terme fins ara. També mostra la complexitat que comporta tractar de portar a terme millores en el context d'un projecte integrat per persones, ja siguin estudiants, docents o investigadors, l'aproximació del qual al que és «innovar » no és idèntica, així com tampoc ho són les condicions en què desenvolupen la seva activitat.

Validation of two echocardiographic indexes to improve the diagnosis of complex coarctations.

OBJECTIVES: Coarctation of the aorta is one of the most common congenital heart defects. Its diagnosis may be difficult in the presence of a patent ductus arteriosus, of other complex defects or of a poor echocardiographic window. We sought to demonstrate that the carotid-subclavian artery index (CSA index) and the isthmus-descending aorta ratio (I/D ratio), two recently described echocardiographic indexes, are effective in detection of isolated and complex aortic coarctations in children younger and older than 3 months of age. The CSA index is the ratio of the distal aortic arch diameter to the distance between the left carotid artery and the left subclavian artery. It is highly suggestive of a coarctation when it is <1.5. The I/D ratio defined as the diameter of the isthmus to the diameter of the descending aorta, suggests an aortic coarctation when it is less than 0.64. METHODS: This is a retrospective cohort study in a tertiary care children's hospital. Review of all echocardiograms in children aged 0-18 years with a diagnosis of coarctation seen at the author's institution between 1996 and 2006. An age- and sex-matched control group without coarctation was constituted. Offline echocardiographic measurements of the aortic arch were performed in order to calculate the CSA index and I/D ratio. RESULTS: Sixty-eight patients were included in the coarctation group, 24 in the control group. Patients with coarctation had a significantly lower CSA index (0.84+/-0.39 vs 2.65+/-0.82, p<0.0001) and I/D ratio (0.58+/-0.18 vs 0.98+/-0.19, p<0.0001) than patients in the control group. Associated cardiac defects and age of the child did not significantly alter the CSA index or the I/D ratio. CONCLUSIONS: A CSA index less than 1.5 is highly suggestive of coarctation independent of age and of the presence of other cardiac defects. I/D ratio alone is less specific than CSA alone at any age and for any associated cardiac lesion. The association of both indexes improves sensitivity and permits diagnosis of coarctation in all patients based solely on a bedside echocardiographic measurement.

Impact of tight glycemic control on cerebral glucose metabolism after severe brain injury: a microdialysis study.

OBJECTIVES: To analyze the effect of tight glycemic control with the use of intensive insulin therapy on cerebral glucose metabolism in patients with severe brain injury. DESIGN: Retrospective analysis of a prospective observational cohort. SETTING: University hospital neurologic intensive care unit. PATIENTS: Twenty patients (median age 59 yrs) monitored with cerebral microdialysis as part of their clinical care. INTERVENTIONS: Intensive insulin therapy (systemic glucose target: 4.4-6.7 mmol/L [80-120 mg/dL]). MEASUREMENTS AND MAIN RESULTS: Brain tissue markers of glucose metabolism (cerebral microdialysis glucose and lactate/pyruvate ratio) and systemic glucose were collected hourly. Systemic glucose levels were categorized as within the target "tight" (4.4-6.7 mmol/L [80-120 mg/dL]) vs. "intermediate" (6.8-10.0 mmol/L [121-180 mg/dL]) range. Brain energy crisis was defined as a cerebral microdialysis glucose <0.7 mmol/L with a lactate/pyruvate ratio >40. We analyzed 2131 cerebral microdialysis samples: tight systemic glucose levels were associated with a greater prevalence of low cerebral microdialysis glucose (65% vs. 36%, p < 0.01) and brain energy crisis (25% vs.17%, p < 0.01) than intermediate levels. Using multivariable analysis, and adjusting for intracranial pressure and cerebral perfusion pressure, systemic glucose concentration (adjusted odds ratio 1.23, 95% confidence interval [CI] 1.10-1.37, for each 1 mmol/L decrease, p < 0.001) and insulin dose (adjusted odds ratio 1.10, 95% CI 1.04-1.17, for each 1 U/hr increase, p = 0.02) independently predicted brain energy crisis. Cerebral microdialysis glucose was lower in nonsurvivors than in survivors (0.46 +/- 0.23 vs. 1.04 +/- 0.56 mmol/L, p < 0.05). Brain energy crisis was associated with increased mortality at hospital discharge (adjusted odds ratio 7.36, 95% CI 1.37-39.51, p = 0.02). CONCLUSIONS: In patients with severe brain injury, tight systemic glucose control is associated with reduced cerebral extracellular glucose availability and increased prevalence of brain energy crisis, which in turn correlates with increased mortality. Intensive insulin therapy may impair cerebral glucose metabolism after severe brain injury.