Measuring potentially avoidable hospital readmissions.

The objectives of this study were to develop a computerized method to screen for potentially avoidable hospital readmissions using routinely collected data and a prediction model to adjust rates for case mix. We studied hospital information system data of a random sample of 3,474 inpatients discharged alive in 1997 from a university hospital and medical records of those (1,115) readmitted within 1 year. The gold standard was set on the basis of the hospital data and medical records: all readmissions were classified as foreseen readmissions, unforeseen readmissions for a new affection, or unforeseen readmissions for a previously known affection. The latter category was submitted to a systematic medical record review to identify the main cause of readmission. Potentially avoidable readmissions were defined as a subgroup of unforeseen readmissions for a previously known affection occurring within an appropriate interval, set to maximize the chance of detecting avoidable readmissions. The computerized screening algorithm was strictly based on routine statistics: diagnosis and procedures coding and admission mode. The prediction was based on a Poisson regression model. There were 454 (13.1%) unforeseen readmissions for a previously known affection within 1 year. Fifty-nine readmissions (1.7%) were judged avoidable, most of them occurring within 1 month, which was the interval used to define potentially avoidable readmissions (n = 174, 5.0%). The intra-sample sensitivity and specificity of the screening algorithm both reached approximately 96%. Higher risk for potentially avoidable readmission was associated with previous hospitalizations, high comorbidity index, and long length of stay; lower risk was associated with surgery and delivery. The model offers satisfactory predictive performance and a good medical plausibility. The proposed measure could be used as an indicator of inpatient care outcome. However, the instrument should be validated using other sets of data from various hospitals.

Is chemotherapy necessary for premenopausal women with lower-risk node-positive, endocrine responsive breast cancer? 10-year update of International Breast Cancer Study Group Trial 11-93.

INTRODUCTION: International Breast Cancer Study Group (IBCSG) Trial 11-93 is the largest trial evaluating the role of the addition of chemotherapy to ovarian function suppression/ablation (OFS) and tamoxifen in premenopausal patients with endocrine-responsive early breast cancer. METHODS: IBCSG Trial 11-93 is a randomized trial comparing four cycles of adjuvant chemotherapy (AC: doxorubicin or epirubicin, plus cyclophosphamide) added to OFS and 5 years of tamoxifen versus OFS and tamoxifen without chemotherapy in premenopausal patients with node-positive, endocrine-responsive early breast cancer. There were 174 patients randomized from May 1993 to November 1998. The trial was closed before the target accrual was reached due to low accrual rate. RESULTS: Patients randomized tended to have lower risk node-positive disease and the median age was 45. After 10 years median follow up, there remains no difference between the two randomized treatment groups for disease-free (hazard ratio=1.02 (0.57-1.83); P=0.94) or overall survival (hazard ratio=0.97 (0.44-2.16); P=0.94). CONCLUSION: This trial, although small, offers no evidence that AC chemotherapy provides additional disease control for premenopausal patients with lower-risk node-positive endocrine-responsive breast cancer who receive adequate adjuvant endocrine therapy. A large trial is needed to determine whether chemotherapy adds benefit to endocrine therapy for this population.

Nitrogênio e potássio via água de irrigação nas características de produção da bananeira 'Grand Naine'

O objetivo deste trabalho foi avaliar o efeito do nitrogênio e do potássio, aplicados via água de irrigação por microaspersão, sobre as características de produção da bananeira, cv. Grand Naine. O delineamento utilizado foi o de blocos casualizados, com quatro repetições. Os tratamentos consistiram de 30, 180, 300, 420 e 570 kg ha-1 ano-1 de N e de 55, 330, 550, 770 e 1.045 kg ha-1 ano-1 de K2O, e testemunha, sem adubação, totalizando onze tratamentos, de acordo com o modelo da matriz experimental de Plan Puebla III. Foram avaliadas as características: massa média de fruto, massa média de cacho e produtividade, referentes ao primeiro e segundo ciclos de produção. No primeiro e segundo ciclos, a massa média de fruto, a massa média de cacho e a produtividade foram influenciadas apenas pelas doses de potássio. Os maiores valores de massa média de fruto (253,47 g), massa média de cacho (28 kg) e produtividade (55,42 t ha-1), no primeiro ciclo, foram obtidos com a aplicação de 938,31, 665,38 e 665,27 kg ha-1 de K2O, respectivamente. No segundo ciclo, os maiores valores em relação à massa média de fruto (174, 22 g), massa média de cacho (32,04 kg) e produtividade (60,08 t ha-1) foram alcançados com a aplicação de 725,50, 907,50 e 933,33 kg ha-1 de K2O, respectivamente. Não houve resposta das características avaliadas ao nitrogênio.

Is it appropriate to index glomerular filtration rate for body surface area

Purpose: Obesity is an established independent risk factor for chronic kidney disease. Thus, measurement of glomerular filtration rate (GFR) is important in this population. Traditionally, GFR has been indexed for body surface area (BSA), but this indexation may not be appropriate in obese individuals. Therefore, the objective of the study was to compare absolute GFR with GFR indexed for BSA and with GFR indexed for height. Methods and materials: The study was conducted in 66 families from the Seychelles islands that included several members with hypertension. GFR and effective renal plasma flow (ERPF) were measured using inulin and PAH clearances, respectively. Antihypertensive treatment, if used, was withheld 2 weeks before conducting the clearances. Participants with diabetes mellitus were excluded from the analysis. BSA was calculated using the Dubois formula. We assessed trend across BMI categories using a non parametric test. Results: Participants included 174 women and 127 men. The prevalence of hypertension was 61%, of which 68% were treated. The table shows that absolute GFR, GFR indexed for height, ERPF, filtration fraction were significantly higher across BMI categories. When GFR was indexed for BSA, the association between GFR and BMI categories was lost. Conclusion: Indexing GFR for BSA in overweight and obese individuals leads to a substantial underestimation of GFR. Filtration fraction, which does not depend on BSA, is higher in obese individuals, which suggests glomerular hyperfiltration. Indexing GFR for BSA therefore would mask the underlying glomerular hyperfiltration. As the number of nephrons does not increase with weight gain, absolute GFR represents a better marker of single nephron GFR and is more appropriate.

Digital forensic osteology--possibilities in cooperation with the Virtopsy project.

The present study was carried out to check whether classic osteometric parameters can be determined from the 3D reconstructions of MSCT (multislice computed tomography) scans acquired in the context of the Virtopsy project. To this end, four isolated and macerated skulls were examined by six examiners. First the skulls were conventionally (manually) measured using 32 internationally accepted linear measurements. Then the skulls were scanned by the use of MSCT with slice thicknesses of 1.25 mm and 0.63 mm, and the 33 measurements were virtually determined on the digital 3D reconstructions of the skulls. The results of the traditional and the digital measurements were compared for each examiner to figure out variations. Furthermore, several parameters were measured on the cranium and postcranium during an autopsy and compared to the values that had been measured on a 3D reconstruction from a previously acquired postmortem MSCT scan. The results indicate that equivalent osteometric values can be obtained from digital 3D reconstructions from MSCT scans using a slice thickness of 1.25 mm, and from conventional manual examinations. The measurements taken from a corpse during an autopsy could also be validated with the methods used for the digital 3D reconstructions in the context of the Virtopsy project. Future aims are the assessment and biostatistical evaluation in respect to sex, age and stature of all data sets stored in the Virtopsy project so far, as well as of future data sets. Furthermore, a definition of new parameters, only measurable with the aid of MSCT data would be conceivable.

Rehabilitación del Parque Recreativo Cariari : propuesta de actividades de educación ambiental

El proyecto de rehabilitación del "Parque Recreativo Cariari" se enmarca en el proyecto más amplio "Proyecto Limón Ciudad Puerto". Se ubica en la zona más desfavorecida de Costa Rica, a nivel social y de infraestructuras. Nuestra labor en el proyecto de rehabilitación, se centra en la preparación de la propuesta de actividades de educación ambiental, aprovechando los recursos biológicos y geológicos del parque, así como las infraestructuras que incluirá una vez rehabilitado. Para la realización del proyecto fue necesaria una gran revisión bibliográfica, una serie de encuestas y reuniones con escuelas, profesores y la responsable del Ministerio de Educación Pública en la región. También se contactó con personal especializado con materias claves para los talleres. Además se acordó con universidades nacionales la realización de prácticas de sus estudiantes de los sectores de turismo ecológico y administración. Así, el resultado, son los 18 talleres, y la preparación de un hormiguero y un mariposario abierto, que se implementarán durante la rehabilitación del parque. De llevarse a cabo correctamente, se espera que transmitan a sus participantes la importancia ambiental de la zona, implicándolos en la conservación de esta. A nivel general, se espera que el parque sea vía de escape y ayude al progreso social y mejora de la calidad de vida de Limón.

Recueil d'actes intéressant la sénéchaussée de Beaucaire, de saint Louis à Philippe de Valois ; poème sur le comput .

Contient au f. 23 un poème sur le comput : L'escriptura mostra per ver, Que Dieus dona sen e saber [...]. Récolé le 8 mai 1877.

PPARβ/δ attenuates palmitate-induced endoplasmic reticulum stress and induces autophagic markers in human cardiac cells.

BACKGROUND: Chronic endoplasmic reticulum (ER) stress contributes to the apoptotic cell death in the myocardium, thereby playing a critical role in the development of cardiomyopathy. ER stress has been reported to be induced after high-fat diet feeding in mice and also after saturated fatty acid treatment in vitro. Therefore, since several studies have shown that peroxisome proliferator-activated receptor (PPAR)β/δ inhibits ER stress, the main goal of this study consisted in investigating whether activation of this nuclear receptor was able to prevent lipid-induced ER stress in cardiac cells. METHODS AND RESULTS: Wild-type and transgenic mice with reduced PPARβ/δ expression were fed a standard diet or a high-fat diet for two months. For in vitro studies, a cardiomyocyte cell line of human origin, AC16, was treated with palmitate and the PPARβ/δ agonist GW501516. Our results demonstrate that palmitate induced ER stress in AC16 cells, a fact which was prevented after PPARβ/δ activation with GW501516. Interestingly, the effect of GW501516 on ER stress occurred in an AMPK-independent manner. The most striking result of this study is that GW501516 treatment also upregulated the protein levels of beclin 1 and LC3II, two well-known markers of autophagy. In accordance with this, feeding on a high-fat diet or suppression of PPARβ/δ in knockout mice induced ER stress in the heart. Moreover, PPARβ/δ knockout mice also displayed a reduction in autophagic markers. CONCLUSION: Our data indicate that PPARβ/δ activation might be useful to prevent the harmful effects of ER stress induced by saturated fatty acids in the heart by inducing autophagy.

Short-term stability of testosterone and epitestosterone conjugates in urine samples: quantification by liquid chromatography-linear ion trap mass spectrometry.

A simple method using liquid chromatography-linear ion trap mass spectrometry for simultaneous determination of testosterone glucuronide (TG), testosterone sulfate (TS), epitestosterone glucuronide (EG) and epitestosterone sulfate (ES) in urine samples was developed. For validation purposes, a urine containing no detectable amount of TG, TS and EG was selected and fortified with steroid conjugate standards. Quantification was performed using deuterated testosterone conjugates to correct for ion suppression/enhancement during ESI. Assay validation was performed in terms of lower limit of detection (1-3ng/mL), recovery (89-101%), intraday precision (2.0-6.8%), interday precision (3.4-9.6%) and accuracy (101-103%). Application of the method to short-term stability testing of urine samples at temperature ranging from 4 to 37 degrees C during a time-storage of a week lead to the conclusion that addition of sodium azide (10mg/mL) is required for preservation of the analytes.

Quelle organisation des soins pour le patient polymorbide? [How should we organize health care for multimorbidity patients?].

Polymorbidity affects an increasing number of patients of all ages as demonstrated by a recent epidemiological study and represents a real challenge for the organization of health care. Appropriate management of polymorbid patients requires an interdisciplinary approach associating generalist and specialist physicians, but also nurses, other health professionals and social workers. An improvement in transition care between the community and the hospital is necessary in both directions. Prioritizing the treatment objectives is essential to allow patient adherence and avoid cumulative drug interactions and adverse effects. Those objectives are difficult to attain in the context of our present health care organization. This paper attempts to identify the difficulties involved in caring for polymorbid patients and propose ways to improve it.

Measuring Party Positions and Issue Salience from Media Coverage: Introducing and Cross-Validating New Indicators

Recent studies have started to use media data to measure party positions and issue salience. The aim of this article is to compare and cross-validate this alternative approach with the more commonly used party manifestos, expert judgments and mass surveys. To this purpose, we present two methods to generate indicators of party positions and issue salience from media coverage: the core sentence approach and political claims analysis. Our cross-validation shows that with regard to party positions, indicators derived from the media converge with traditionally used measurements from party manifestos, mass surveys and expert judgments, but that salience indicators measure different underlying constructs. We conclude with a discussion of specific research questions for which media data offer potential advantages over more established methods.

Navigator-gated and real-time motion corrected free-breathing MR Imaging of myocardial late enhancement.

PURPOSE: A new magnetic resonance imaging approach for detection of myocardial late enhancement during free-breathing was developed. METHODS AND RESULTS: For suppression of respiratory motion artifacts, a prospective navigator technology including real-time motion correction and a local navigator restore was implemented. Subject specific inversion times were defined from images with incrementally increased inversion times acquired during a single dynamic scout navigator-gated and real-time motion corrected free-breathing scan. Subsequently, MR-imaging of myocardial late enhancement was performed with navigator-gated and real-time motion corrected adjacent short axis and long axis (two, three and four chamber) views. This alternative approach was investigated in 7 patients with history of myocardial infarction 12 min after i. v. administration of 0.2 mmol/kg body weight gadolinium-DTPA. CONCLUSION: With the presented navigator-gated and real-time motion corrected sequence for MR-imaging of myocardial late enhancement data can be completely acquired during free-breathing. Time constraints of a breath-hold technique are abolished and optimized patient specific inversion time is ensured.