Hospital volume and patient outcomes in pulmonary embolism.

BACKGROUND: In numerous high-risk medical and surgical conditions, a greater volume of patients undergoing treatment in a given setting or facility is associated with better survival. For patients with pulmonary embolism, the relation between the number of patients treated in a hospital (volume) and patient outcome is unknown. METHODS: We studied discharge records from 186 acute care hospitals in Pennsylvania for a total of 15 531 patients for whom the primary diagnosis was pulmonary embolism. The study outcomes were all-cause mortality in hospital and within 30 days after presentation for pulmonary embolism and the length of hospital stay. We used logistic models to study the association between hospital volume and 30-day mortality and discrete survival models to study the association between in-hospital mortality and time to hospital discharge. RESULTS: The median annual hospital volume for pulmonary embolism was 20 patients (interquartile range 10-42). Overall in-hospital mortality was 6.0%, whereas 30-day mortality was 9.3%. In multivariable analysis, very-high-volume hospitals (> or = 42 cases per year) had a significantly lower odds of in-hospital death (odds ratio [OR] 0.71, 95% confidence interval [CI] 0.51-0.99) and of 30-day death (OR 0.71, 95% CI 0.54-0.92) than very-low-volume hospitals (< 10 cases per year). Although patients in the very-high-volume hospitals had a slightly longer length of stay than those in the very-low-volume hospitals (mean difference 0.7 days), there was no association between volume and length of stay. INTERPRETATION: In hospitals with a high volume of cases, pulmonary embolism was associated with lower short-term mortality. Further research is required to determine the causes of the relation between volume and outcome for patients with pulmonary embolism.

Les troubles alimentaires atypiques : recherche qualitative auprès d'adolescentes suivies dans un groupe thérapeutique

RESUMELes troubles des conduites alimentaires atypiques (TCAA) représentent une catégorie diagnostique émergente, relativement peu décrite. Ils regroupent des tableaux cliniques ne satisfaisant pas entièrement aux critères des troubles alimentaires typiques anorexie et boulimie. Désignés par le terme de EDNOS' dans le DSM-IV2 (American Psychiatrie Association, 1994), ils sont appelés troubles atypiques dans la CIM-103 (World Health Organization, 1993).Les TCAA représentent la majorité des demandes dans les consultations pour troubles alimentaires, concernent une grande proportion de la population non-consultante et constituent un enjeu de santé publique prioritaire.Cette étude se penche sur le parcours de 24 jeunes filles présentant de tels troubles, qui ont été suivies dans le cadre d'un groupe thérapeutique à l'UMSA (Unité Multidisciplinaire de Santé des Adolescents, CHUV, Lausanne). Elle a pour but de mieux connaître ces troubles alimentaires atypiques.Deux axes de questions de recherche organisent ce travail: le premier, orienté autour du trouble alimentaire atypique, de sa définition (avec les questions de classification diagnostique) et de son évolution (avec les questions de passages d'une catégorie à une autre), le second autour du groupe thérapeutique, de son utilité et de ses indications.1. Résultats cliniquesLes résultats de l'analyse thématique décrivent un trouble important, qui induit une souffrance plus intense que ne tendraient à le laisser penser la relative banalité de la présentation clinique en comparaison des troubles typiques ainsi que la catégorisation en tant que troubles résiduels. Des moyens compensatoires -qui visent au maintien d'un poids stable en dépit des crises alimentaires ainsi qu'à la perte de poids, soit par des méthodes non-purgatives (restrictions massives, diètes, jeûnes, pratique du sport à outrance), soit par des méthodes purgatives (vomissements auto-induits, usage de laxatifs, diurétiques) - sont présents chez 15 participantes, sous forme de vomissements chez 6 d'entre elles. Seize participantes ont présenté des troubles des menstruations. Des difficultés de la lignée anxio-dépressive sont relevées chez la moitié des participantes, alliées à un perfectionnisme important. L'estime de soi apparaît globalement basse, excessivement influencée par l'insatisfaction attachée au poids et aux formes corporelles. L'analyse fait clairement apparaître le lien complexe unissant les attitudes face à l'alimentation et le désir de maigrir aux crises de frénésie alimentaire. Les crises permettent aux patientes de moduler leurs émotions, tant .positives que négatives. Le vécu de la maladie et des préoccupations pour le corps et l'alimentation semble généralisable. et «transcatégorique», bien que les troubles alimentaires de l'ordre de l'anorexie atypique restrictive, du fait de l'absence de crises de frénésie, semblent appartenir à un registre différent des troubles avec perte de contrôle sur l'alimentation et crises, notamment en termes d'implications dans la vie quotidienne.Lorsque les participantes sont revues (au minimum un an après la sortie du groupe thérapeutique), 15 d'entre elles sont indemnes de tout symptôme, 5 présentent encore un TCAA type boulimie atypique, et 4 ont parfois des crises résiduelles. Des préoccupations pour l'alimentation et le poids subsistent. Le pronostic d'évolution n'apparaît lié ni à la durée de participation au groupe, ni uniquement à la catégorie diagnostique ou aux seuls éléments de co-morbidité, mais davantage à un investissement rapidement positif du groupe, ainsi qu'à la qualité des prises en charge parallèles en présence d'éléments de co-morbidité importants ou d'antécédents d'autres troubles alimentaires.Notre collectif atteste de passages d'une catégorie de trouble à une autre (anorexie puis boulimie, comme décrit dans la littérature) et de changements d'intensité (trouble typique puis atypique) au cours de la maladie, confirmant un continuum possible, tant entre les troubles typiques, qu'entre les troubles typiques et atypiques. Néanmoins, la multiplicité des parcours possibles dans la maladie, ainsi que l'existence de formes stables, sans passages d'une catégorie à une autre, incite à la prudence et ne permet pas de confirmer en tout point l'hypothèse de la nature dimensionnelle (même nature, intensité différente) des troubles alimentaires.Le trouble atypique représente parfois une étape dans l'évolution à partir d'un trouble typique, pouvant être envisagé comme moment sur le chemin de la guérison, ce qui pose la question des critères de guérison.2. Nature des troubles alimentaires atypiquesDu collectif émergent 4 catégories diagnostiques de troubles alimentaires atypiques: hyperphagie boulimique, boulimie atypique non-purgative, boulimie atypique purgative et anorexie atypique restrictive. Le tableau clinique.de l'hyperphagie boulimique comporte des crises de boulimie, mais peu de préoccupations concernant le poids et les formes corporelles en compá= raison des 3 autres catégories, et pas de moyens de compensation des crises, ce qui induit fréquemment un surpoids voire une obésité pour les patientes concernées. Les moyens de compensation des crises de boulimie demeurent non-purgatives (jeûne, sport) dans la boulimie atypique non-purgative, alors que vomissements et usage de laxatifs suite aux crises caractérisent la boulimie atypique purgative. Le tableau clinique de l'anorexie atypique restrictive ne présente ni crises de boulimie ni moyens de compensation purgatifs type vomissements. Ces catégories sont retrouvées dans la littérature.Nos résultats rejoignent la littérature actuelle qui envisage la nécessité d'une reclassification des troubles alimentaires en vue du DSM-V. Dans l'intervalle, adopter la classification de la CIM et parler d'anorexie atypique, de -type restrictif ou avec crises, de boulimie atypique, purgative ou non, et y ajouter l'hyperphagie boulimique, rendrait mieux compte de la réalité clinique des troubles alimentaires atypiques que ne le fait la classe des EDNOS du DSM, peu différenciée, mêlant des tableaux très divers et au final insatisfaisante.3. Utilité et indication du groupeLe groupe recèle un fort pouvoir thérapeutique pour les patientes qui s'y impliquent. L'étayage sur les autres émerge comme facteur thérapeutique principal, ainsi que le décrit la littérature. Cette prise en charge thérapeutique convient particulièrement à des patientes présentant un trouble alimentaire sur le versant boulimique, comprenant l'hyperphagie boulimique, la boulimie atypique, purgative ou non, ainsi que certaines boulimies de moyenne gravité. Les patientes du collectif qui présentent des difficultés de l'ordre de l'anorexie atypique restrictive bénéficient moins du groupe que les participantes qui expérimentent des pertes de contrôle sur la nourriture.4. ImplicationsL'intensité de la souffrance, la complexité des tableaux symptomatiques, la diversité des parcours et les multiples répercussions sur la vie sociale démontrent l'importance de repérer et prendre en charge ces troubles alimentaires qui demeurent souvent banalisés. Dans cette perspective, la formation au dépistage, à l'évaluation et à la prise en charge des divers intervenants confrontés à ces troubles représente un enjeu majeur. .Enfin, dénoncer les pressions socioculturelles à la minceur et le dictat des régimes, promouvoir une notion de bien-être et une bonne estime de soi qui ne soient pas liées à l'apparence contribuera à prévenir les troubles alimentaires atypiques.

Ombres et lumières de l'accès public a la défibrillation [Public access defibrillation]

La stratégie d'accès public à la défibrillation (APD) comprend l'installation de défibrillateurs automatiques externes (DAE) dans les lieux publics et l'entraînement de sauveteurs non professionnels à la réanimation cardio pulmonaire et à la défibrillation (RCP-D). Cette approche est recommandée pour le traitement des arrêts cardiaques (ACR) dans les lieux publics. Beaucoup d'études d'observation, mais peu d'études randomisées s'intéressant à cette approche ont été publiées. Cet article résume les différentes approches proposées dans le cadre d'APD. A notre avis, l'installation de DAE dans des lieux publics ou le choix d'une stratégie alternative doivent être précédés d'une étude de la démographie locale des ACR et de l'entraînement du plus grand nombre possible de laïcs à la reconnaissance des signes précurseurs d'ACR et au massage cardiaque externe. Placement of automated external defibrillators (AED) in public facilities and training of the lay persons in basic life support-defibrillation (BLS-D) was recommended by the American Heart Association for the treatment of out-of-hospital cardiac arrest (OHCA). Immediate use of AED result in increase of survival to hospital discharge. Many observation and much less randomized trials describe clinical efficacy of this approach. However, "negative" trials have also been published and some recent data suggest that public access defibrillation (PAD) will have a minimal impact on population survival. In this article various PAD strategies were briefly reviewed. In our opinion installation of AED in public places should be based on the long-term study of local OHCA demography and preceded by widespread BLS training of lay population.

Instrumentação na medida da pressão arterial: aspectos históricos, conceituais e fontes de erro

A medida indireta da pressão arterial é um dos procedimentos mais executados pelos enfermeiros de todo o mundo, segundo o Conselho Internacional de Enfermeiras. 0 trabalho discute os principais aspectos polêmicos do instrumental utilizado para a medida indireta da pressão arterial que são causa significativa de erros de medida, a partir da análise da literatura e das recomendações da American Heart Association.

Effect of iron supplementation on fatigue in nonanemic menstruating women with low ferritin: a randomized controlled trial.

BACKGROUND: The true benefit of iron supplementation for nonanemic menstruating women with fatigue is unknown. We studied the effect of oral iron therapy on fatigue and quality of life, as well as on hemoglobin, ferritin and soluble transferrin receptor levels, in nonanemic iron-deficient women with unexplained fatigue. METHODS: We performed a multicentre, parallel, randomized controlled, closed-label, observer-blinded trial. We recruited from the practices of 44 primary care physicians in France from March to July 2006. We randomly assigned 198 women aged 18-53 years who complained of fatigue and who had a ferritin level of less than 50 ug/L and hemoglobin greater than 12.0 g/dL to receive either oral ferrous sulfate (80 mg of elemental iron daily; n = 102) or placebo (n = 96) for 12 weeks. The primary outcome was fatigue as measured on the Current and Past Psychological Scale. Biological markers were measured at 6 and 12 weeks. RESULTS: The mean score on the Current and Past Psychological Scale for fatigue decreased by 47.7% in the iron group and by 28.8% in the placebo group (difference -18.9%, 95% CI -34.5 to -3.2; p = 0.02), but there were no significant effects on quality of life (p = 0.2), depression (p = 0.97) or anxiety (p = 0.5). Compared with placebo, iron supplementation increased hemoglobin (0.32 g/dL; p = 0.002) and ferritin (11.4 μg/L; p < 0.001) and decreased soluble transferrin receptor (-0.54 mg/L; p < 0.001) at 12 weeks. INTERPRETATION: Iron supplementation should be considered for women with unexplained fatigue who have ferritin levels below 50 μg/L. We suggest assessing the efficiency using blood markers after six weeks of treatment. Trial registration no. EudraCT 2006-000478-56.

Subclinical thyroid dysfunction and the risk of heart failure events: an individual participant data analysis from 6 prospective cohorts.

BACKGROUND: American College of Cardiology/American Heart Association guidelines for the diagnosis and management of heart failure recommend investigating exacerbating conditions such as thyroid dysfunction, but without specifying the impact of different thyroid-stimulation hormone (TSH) levels. Limited prospective data exist on the association between subclinical thyroid dysfunction and heart failure events. METHODS AND RESULTS: We performed a pooled analysis of individual participant data using all available prospective cohorts with thyroid function tests and subsequent follow-up of heart failure events. Individual data on 25 390 participants with 216 248 person-years of follow-up were supplied from 6 prospective cohorts in the United States and Europe. Euthyroidism was defined as TSH of 0.45 to 4.49 mIU/L, subclinical hypothyroidism as TSH of 4.5 to 19.9 mIU/L, and subclinical hyperthyroidism as TSH <0.45 mIU/L, the last two with normal free thyroxine levels. Among 25 390 participants, 2068 (8.1%) had subclinical hypothyroidism and 648 (2.6%) had subclinical hyperthyroidism. In age- and sex-adjusted analyses, risks of heart failure events were increased with both higher and lower TSH levels (P for quadratic pattern <0.01); the hazard ratio was 1.01 (95% confidence interval, 0.81-1.26) for TSH of 4.5 to 6.9 mIU/L, 1.65 (95% confidence interval, 0.84-3.23) for TSH of 7.0 to 9.9 mIU/L, 1.86 (95% confidence interval, 1.27-2.72) for TSH of 10.0 to 19.9 mIU/L (P for trend <0.01) and 1.31 (95% confidence interval, 0.88-1.95) for TSH of 0.10 to 0.44 mIU/L and 1.94 (95% confidence interval, 1.01-3.72) for TSH <0.10 mIU/L (P for trend=0.047). Risks remained similar after adjustment for cardiovascular risk factors. CONCLUSION: Risks of heart failure events were increased with both higher and lower TSH levels, particularly for TSH ≥10 and <0.10 mIU/L.

Improving blood pressure control through pharmacist interventions: a meta-analysis of randomized controlled trials.

BACKGROUND: Control of blood pressure (BP) remains a major challenge in primary care. Innovative interventions to improve BP control are therefore needed. By updating and combining data from 2 previous systematic reviews, we assess the effect of pharmacist interventions on BP and identify potential determinants of heterogeneity. METHODS AND RESULTS: Randomized controlled trials (RCTs) assessing the effect of pharmacist interventions on BP among outpatients with or without diabetes were identified from MEDLINE, EMBASE, CINAHL, and CENTRAL databases. Weighted mean differences in BP were estimated using random effect models. Prediction intervals (PI) were computed to better express uncertainties in the effect estimates. Thirty-nine RCTs were included with 14 224 patients. Pharmacist interventions mainly included patient education, feedback to physician, and medication management. Compared with usual care, pharmacist interventions showed greater reduction in systolic BP (-7.6 mm Hg, 95% CI: -9.0 to -6.3; I(2)=67%) and diastolic BP (-3.9 mm Hg, 95% CI: -5.1 to -2.8; I(2)=83%). The 95% PI ranged from -13.9 to -1.4 mm Hg for systolic BP and from -9.9 to +2.0 mm Hg for diastolic BP. The effect tended to be larger if the intervention was led by the pharmacist and was done at least monthly. CONCLUSIONS: Pharmacist interventions - alone or in collaboration with other healthcare professionals - improved BP management. Nevertheless, pharmacist interventions had differential effects on BP, from very large to modest or no effect; and determinants of heterogeneity could not be identified. Determining the most efficient, cost-effective, and least time-consuming intervention should be addressed with further research.

A semantic model of selective dissemination of information for digital libraries

In this paper we present the theoretical and methodologicalfoundations for the development of a multi-agentSelective Dissemination of Information (SDI) servicemodel that applies Semantic Web technologies for specializeddigital libraries. These technologies make possibleachieving more efficient information management,improving agent–user communication processes, andfacilitating accurate access to relevant resources. Othertools used are fuzzy linguistic modelling techniques(which make possible easing the interaction betweenusers and system) and natural language processing(NLP) techniques for semiautomatic thesaurus generation.Also, RSS feeds are used as “current awareness bulletins”to generate personalized bibliographic alerts.

Cross National Contact Strategies

Using paradata gathered from the 11-nation Survey of Health, Ageing and Retirement in Europe (SHARE), this paper examines the impact of the first contact attempt and the first contact properties, respectively, on contact and response efficiency using logistic multilevel models. We find that despite the different sample frames and interviewer compensation structure between countries, there are no considerable country effects with respect to making contact, once interviewer effects are controlled. Moreover, results point to an increased efficiency associated with evenings especially on Sundays, at least on the very first contact attempt. For attempts that result in initial contact, Saturday afternoons are most likely to eventually lead to completed interviews, followed by initial contact on weekdays during the daytime. We hypothesize that this may be due to the SHARE sample being composed of people aged 50 and over.

A theory of optimal random crackdowns

An incentives based theory of policing is developed which can explain the phenomenon of random “crackdowns,” i.e., intermittent periods of high interdiction/surveillance. For a variety of police objective functions, random crackdowns can be part of the optimal monitoring strategy. We demonstrate support for implications of the crackdown theory using traffic data gathered by the Belgian Police Department and use the model to estimate the deterrence effectof additional resources spent on speeding interdiction.

Importância De Informação Contabilística Na Determinação Da Matéria Colectavél, Caso Polar Lda.

Resumo Com o objectivo de modernizar o sistema contabilístico de Cabo-Verde foi introduzido em Janeiro de 2009, em substituição do Plano Nacional de Contabilidade (PNC), um novo sistema de normalização contabilística através do Decreto-Lei n.º 5/2008, de 5 de Fevereiro. O novo normativo por se tratar de um modelo de normalização assente mais em princípios do que em regras explicitas, faz com que os dirigentes das empresas elaborem as suas demonstrações financeiras de acordo com as necessidades de gestão e consequentemente independente das regras fiscais. Contudo, a determinação da matéria colectável é feita com base nas informações contabilísticas produzidas, de acordo com SNCRF, pelos dirigentes das empresas. O que se pretende com o presente trabalho é analisar a importância das informações contabilísticas ou demonstrações financeiras, elaboradas no âmbito do SNCRF, na determinação da matéria colectável de um contribuinte de verificação pela administração fiscal. A metodologia utilizada para a concretização desta pesquisa tendo em conta os objectivos traçados foram exploratória e a descritiva, através do qual conseguiu-se descrever aspectos teóricos relacionado ao termo contabilidade e fiscalidade, realizou-se ainda um caso prático na Agência Polar, com o fim de se conhecer na prática os procedimentos inerentes a determinação da matéria colectável e qual o papel da informação contabilística nesse processo. Com intuito de responder o problema da pesquisa optou-se por análise de processos da Polar, em arquivo nas repartições de finanças, referente ao ano 2009 e 2010. Para as citações bibliográficas foi utilizado American Psychological Association (APA

Ética na Administração Pública em Cabo Verde. O Papel do Tribunail de Contas de Cabo Verde como Autarquia do Estado para Accountability

Actualmente, na nossa sociedade apresenta desafios, está continuamente em busca de padrões éticos para uma melhoria da sociedade, é um padrão de grande importância para crescimento e desenvolvimento da Administração Publica cabo-verdiana (APCV). A gestão da coisa Pública é um dos fundamentos de” boa governação”. De acordo com os dados da pesquisa, a ética na APCV é um dos padrões que pouco se poem em pratica. Neste sentido o presente trabalho visa analisar” Ética na Administração Publica”, tendo como estudo de caso o Tribunal de Contas de Cabo Verde (TCCV). Para alcançar o objectivo deste trabalho, fez-se uma pesquisa bibliográfica sobre a ética na Administração Publica e sobre teorias relacionadas com a ética nas organizações. Utilizou-se o método inquisitivo baseado em questionários com perguntas abertas e fechadas para obter as percepçoes dos dirigentes públicos. O tratamento de dados foi feito recorrendo o Software SPSS versão 17 e Excel. Portanto na realização deste estudo foi utilizado o modelo American Psychological Association (APA) no que refere as citações e referências bibliográficas. Os resultados do estudo demonstraram que a ética é um dos instrumentos de extrema relevância para gestão da coisa pública.

Robust response transformations based on optimal prediction

Nonlinear regression problems can often be reduced to linearity by transforming the response variable (e.g., using the Box-Cox family of transformations). The classic estimates of the parameter defining the transformation as well as of the regression coefficients are based on the maximum likelihood criterion, assuming homoscedastic normal errors for the transformed response. These estimates are nonrobust in the presence of outliers and can be inconsistent when the errors are nonnormal or heteroscedastic. This article proposes new robust estimates that are consistent and asymptotically normal for any unimodal and homoscedastic error distribution. For this purpose, a robust version of conditional expectation is introduced for which the prediction mean squared error is replaced with an M scale. This concept is then used to develop a nonparametric criterion to estimate the transformation parameter as well as the regression coefficients. A finite sample estimate of this criterion based on a robust version of smearing is also proposed. Monte Carlo experiments show that the new estimates compare favorably with respect to the available competitors.

Abnormal Lung Function and Risk for Heart Failure in the Elderly: The Health, Aging, and Body Composition Study

Background: Chronic obstructive pulmonary disease (COPD) has been associated with increased risk for heart failure (HF). The impact of subclinical abnormal spirometric findings on HF risk among older adults without history of COPD is not well elucidated. Methods: We evaluated 2125 participants (age 73.6±2.9 years; 50.5% men; 62.3% white; 45.6/9.4% past/current smokers; body mass index [BMI] 27.2±4.6 kg/m2) without prevalent COPD or HF who underwent baseline spirometry in the Health ABC Study. Abnormal lung function was defined either as forced vital capacity (FVC) below lower limit of normal (LLN) or forced expiratory volume in 1st sec (FEV1) to FVC ratio below LLN. Results: On follow-up (median, 9.4 years), 68 of 350 (19.4%) participants with abnormal lung function developed HF, as compared to 172 of 1775 (9.7%) participants with normal lung function (hazard ratio [HR], 2.31; 95% confidence interval [CI], 1.74 -3.06; P<.001). This increased risk persisted after adjusting for all other independent predictors of HF in the Health ABC Study, BMI, incident coronary events, and several inflammatory markers (HR, 1.82; 95% CI, 1.30 -2.54; P<.001), and remained constant over time. Baseline FVC and FEV1 had a linear association with HF risk (Figure). In adjusted models, HF risk increased by 21% (95% CI, 10 -36%) per 10% decrease in FVC and 18% (95% CI, 10 -28%) per 10% decrease in FEV1 (both P<.001); this association persisted among participants with normal lung function at baseline. Findings were consistent across sex, race, and smoking status. Conclusions: Subclinical abnormal spirometric findings are prevalent among older adults and are independently associated with risk for incident HF.

Feasibility of a knowledge translation CME program: courriels Cochrane.

INTRODUCTION: Systematic literature reviews provide best evidence, but are underused by clinicians. Thus, integrating Cochrane reviews into continuing medical education (CME) is challenging. We designed a pilot CME program where summaries of Cochrane reviews (Courriels Cochrane) were disseminated by e-mail. Program participants automatically received CME credit for each Courriel Cochrane they rated. The feasibility of this program is reported (delivery, participation, and participant evaluation). METHOD: We recruited French-speaking physicians through the Canadian Medical Association. Program delivery and participation were documented. Participants rated the informational value of Courriels Cochrane using the Information Assessment Method (IAM), which documented their reflective learning (relevance, cognitive impact, use for a patient, expected health benefits). IAM responses were aggregated and analyzed. RESULTS: The program was delivered as planned. Thirty Courriels Cochrane were delivered to 985 physicians, and 127 (12.9%) completed at least one IAM questionnaire. Out of 1109 Courriels Cochrane ratings, 973 (87.7%) conta-ined 1 or more types of positive cognitive impact, while 835 (75.3%) were clinically relevant. Participants reported the use of information for a patient and expected health benefits in 595 (53.7%) and 569 (51.3%) ratings, respectively. DISCUSSION: Program delivery required partnering with 5 organizations. Participants valued Courriels Cochrane. IAM ratings documented their reflective learning. The aggregation of IAM ratings documented 3 levels of CME outcomes: participation, learning, and performance. This evaluation study demonstrates the feasibility of the Courriels Cochrane as an approach to further disseminate Cochrane systematic literature reviews to clinicians and document self-reported knowledge translation associated with Cochrane reviews.