Toward a standard approach to measurement and reporting of perioperative mortality rate as a global indicator for surgery

INTRODUCTION: The proportion of patients who die during or after surgery, otherwise known as the perioperative mortality rate (POMR), is a credible indicator of the safety and quality of operative care. Its accuracy and usefulness as a metric, however, particularly one that enables valid comparisons over time or between jurisdictions, has been limited by lack of a standardized approach to measurement and calculation, poor understanding of when in relation to surgery it is best measured, and whether risk-adjustment is needed. Our aim was to evaluate the value of POMR as a global surgery metric by addressing these issues using 4, large, mixed, surgical datasets that represent high-, middle-, and low-income countries. METHODS: We obtained data from the New Zealand National Minimum Dataset, the Geelong Hospital patient management system in Australia, and purpose-built surgical databases in Pietermaritzburg, South Africa, and Port Moresby, Papua New Guinea. For each site, we calculated the POMR overall as well as for nonemergency and emergency admissions. We assessed the effect of admission episodes and procedures as the denominator and the difference between in-hospital POMR and POMR, including postdischarge deaths up to 30 days. To determine the need for risk-adjustment for age and admission urgency, we used univariate and multivariate logistic regression to assess the effect on relative POMR for each site. RESULTS: A total of 1,362,635 patient admissions involving 1,514,242 procedures were included. More than 60% of admissions in Pietermaritzburg and Port Moresby were emergencies, compared with less than 30% in New Zealand and Geelong. Also, Pietermaritzburg and Port Moresby had much younger patient populations (P < .001). A total of 8,655 deaths were recorded within 30 days, and 8-20% of in-hospital deaths occurred on the same day as the first operation. In-hospital POMR ranged approximately 9-fold, from 0.38 per 100 admissions in New Zealand to 3.44 per 100 admissions in Pietermaritzburg. In New Zealand, in-hospital 30-day POMR underestimated total 30-day POMR by approximately one third. The difference in POMR if procedures were used instead of admission episodes ranged from 7 to 70%, although this difference was less when central line and pacemaker insertions were excluded. Age older than 65 years and emergency admission had large, independent effects on POMR but relatively little effect in multivariate analysis on the relative odds of in-hospital death at each site. CONCLUSION: It is possible to collect POMR in countries at all level of development. Although age and admission urgency are strong, independent associations with POMR, a substantial amount of its variance is site-specific and may reflect the safety of operative and anesthetic facilities and processes. Risk-adjustment is desirable but not essential for monitoring system performance. POMR varies depending on the choice of denominator, and in-hospital deaths appear to underestimate 30-day mortality by up to one third. Standardized approaches to reporting and analysis will strengthen the validity of POMR as the principal indicator of the safety of surgery and anesthesia care.

Beyond standard practice: the adaptation by design coastal communities’ workshop

The fastest regional population growth in Victoria in recent years has been in coastal areas close to Melbourne, more specifically the coastal parts of the greater Geelong region and the Great Ocean Road Coastal Region. Migration to these non-metropolitan coastal areas by city dwellers result in coastal sprawl. This coastal sprawl has devastating effects on the natural coastal environment including biodiversity and habitat loss, damage to wetlands, loss of indigenous vegetation and the introduction of developments that have no respect for ‘sense of place’, that are detrimental to the place character of these, often historical, coastal towns. Adding to these threats is the impacts of climate change and sea level rise. This paper identifies possible planning and design options reflecting community views on how to address this problem, specifically recording the outcomes of the coastal town of Port Campbell. Through a participative research process, workshops were conducted along this coast to identify the adaptation options proposed by the community members. This paper reflects the research outcomes of the Coastal Climate Change and Great Ocean Road Region research project, where an innovative Adaptation by Design Workshop process captured the views of the communities in this region and recommended future planning and design options that considered principles of sustainable design as part of adaptive planning and resilient design, thereby pushing the process of coastal planning beyond the current standard practice.

A prospective observational study of prevalence and outcomes of patients with Gold Standard Framework criteria in a tertiary regional Australian Hospital

OBJECTIVES: Report the use of an objective tool, UK Gold Standards Framework (GSF) criteria, to describe the prevalence, recognition and outcomes of patients with palliative care needs in an Australian acute health setting. The rationale for this is to enable hospital doctors to identify patients who should have a patient-centred discussion about goals of care in hospital.

DESIGN: Prospective, observational, cohort study.

PARTICIPANTS: Adult in-patients during two separate 24 h periods.

MAIN OUTCOME MEASURES: Prevalence of in-patients with GSF criteria, documentation of treatment limitations, hospital and 1 year survival, admission and discharge destination and multivariate regression analysis of factors associated with the presence of hospital treatment limitations and 1 year survival.

RESULTS: Of 626 in-patients reviewed, 171 (27.3%) had at least one GSF criterion, with documentation of a treatment limitation discussion in 60 (30.5%) of those patients who had GSF criteria. Hospital mortality was 9.9%, 1 year mortality 50.3% and 3-year mortality 70.2% in patients with GSF criteria. One-year mortality was highest in patients with GSF cancer (73%), renal failure (67%) and heart failure (60%) criteria. Multivariate analysis revealed age, hospital length of stay and presence of the GSF chronic obstructive pulmonary disease criteria were independently associated with the likelihood of an in-hospital treatment limitation. Non-survivors at 3 years were more likely to have a GSF cancer (25% vs 6%, p=0.004), neurological (10% vs 3%, p=0.04), or frailty (45% vs 3%, p=0.04) criteria. After multivariate logistic regression GSF cancer criteria, renal failure criteria and the presence of two or more GSF clinical criteria were independently associated with increased risk of death at 3 years. Patients returning home to live reduced from 69% (preadmission) to 27% after discharge.

CONCLUSIONS: The use of an objective clinical tool identifies a high prevalence of patients with palliative care needs in the acute tertiary Australian hospital setting, with a high 1 year mortality and poor return to independence in this population. The low rate of documentation of discussions about treatment limitations in this population suggests palliative care needs are not recognised and discussed in the majority of patients.

TRIAL REGISTRATION NUMBER: 11/121.

Subtyping based on readiness and confidence: the identification of help-seeking profiles for gamblers accessing web-based counselling

BACKGROUND AND AIMS: Problem gamblers are not a homogeneous group and recent data suggest that subtyping can improve treatment outcomes. This study administered three readiness rulers and aimed to identify subtypes of gamblers accessing a national web-based counselling service based on these rulers. METHODS: Participants were 1204 gamblers (99.4% problem gamblers) who accessed a single session of web-based counselling in Australia. Measures included three readiness rulers (importance, readiness and confidence to resist an urge to gamble), demographics and the Problem Gambling Severity Index (PGSI). RESULTS: Gamblers reported high importance of change [mean = 9.2, standard deviation (SD) = 1.51] and readiness to change (mean = 8.86, SD = 1.84), but lower confidence to resist an urge to gamble (mean = 3.93, SD = 2.44) compared with importance and readiness. The statistical fit indices of a latent class analysis identified a four-class model. Subtype 1 was characterized by a very high readiness to change and very low confidence to resist an urge to gamble (n = 662, 55.0%) and subtype 2 reported high readiness and low confidence (n = 358, 29.7%). Subtype 3 reported moderate ratings on all three rulers (n = 139, 11.6%) and subtype 4 reported high importance of change but low readiness and confidence (n = 45, 3.7%). A multinomial logistic regression indicated that subtypes differed by gender (P < 0.001), age (P = 0.01), gambling activity (P < 0.05), preferred mode of gambling (P < 0.001) and PGSI score (P < 0.001). CONCLUSIONS: Problem gamblers in Australia who seek web-based counselling comprise four distinct subgroups based on self-reported levels of readiness to change, confidence to resist the urge to gamble and importance of change.

Discharge communication from inpatient care: an audit of written medical discharge summary procedure against the new National Health Service Standard for clinical handover

OBJECTIVE: To audit written medical discharge summary procedure and practice against Standard Six (clinical handover) of the Australian National Safety and Quality Health Service Standards at a major regional Victorian health service. METHODS: Department heads were invited to complete a questionnaire about departmental discharge summary practices. RESULTS: Twenty-seven (82%) department heads completed the questionnaire. Seven (26%) departments had a documented discharge summary procedure. Fourteen (52%) departments monitored discharge summary completion and 13 (48%) departments monitored the timeliness of completion. Seven (26%) departments informed the patient of the content of the discharge summary and six (22%) departments provided the patient with a copy. Seven (26%) departments provided training for staff members on how to complete discharge summaries. Completing discharge summaries was usually delegated to the medical intern. CONCLUSIONS: The introduction of the National Service Standards prompted an organisation-wide audit of discharge summary practices against the external criterion. There was substantial variation in the organisation's practices. The Standards and the current audit results highlight an opportunity for the organisation to enhance and standardise discharge summary practices and improve communication with general practice.

Verification Of The Standard Vector Data Model For Interoperability Of River-Geospatial Information

Recently, two international standard organizations, ISO and OGC, have done the work of standardization for GIS. Current standardization work for providing interoperability among GIS DB focuses on the design of open interfaces. But, this work has not considered procedures and methods for designing river geospatial data. Eventually, river geospatial data has its own model. When we share the data by open interface among heterogeneous GIS DB, differences between models result in the loss of information. In this study a plan was suggested both to respond to these changes in the information envirnment and to provide a future Smart River-based river information service by understanding the current state of river geospatial data model, improving, redesigning the database. Therefore, primary and foreign key, which can distinguish attribute information and entity linkages, were redefined to increase the usability. Database construction of attribute information and entity relationship diagram have been newly redefined to redesign linkages among tables from the perspective of a river standard database. In addition, this study was undertaken to expand the current supplier-oriented operating system to a demand-oriented operating system by establishing an efficient management of river-related information and a utilization system, capable of adapting to the changes of a river management paradigm.

Study of the audio coding algorithm of the MPEG-4 AAC standard and comparison among implementations of modules of the algorithm

Audio coding is used to compress digital audio signals, thereby reducing the amount of bits needed to transmit or to store an audio signal. This is useful when network bandwidth or storage capacity is very limited. Audio compression algorithms are based on an encoding and decoding process. In the encoding step, the uncompressed audio signal is transformed into a coded representation, thereby compressing the audio signal. Thereafter, the coded audio signal eventually needs to be restored (e.g. for playing back) through decoding of the coded audio signal. The decoder receives the bitstream and reconverts it into an uncompressed signal. ISO-MPEG is a standard for high-quality, low bit-rate video and audio coding. The audio part of the standard is composed by algorithms for high-quality low-bit-rate audio coding, i.e. algorithms that reduce the original bit-rate, while guaranteeing high quality of the audio signal. The audio coding algorithms consists of MPEG-1 (with three different layers), MPEG-2, MPEG-2 AAC, and MPEG-4. This work presents a study of the MPEG-4 AAC audio coding algorithm. Besides, it presents the implementation of the AAC algorithm on different platforms, and comparisons among implementations. The implementations are in C language, in Assembly of Intel Pentium, in C-language using DSP processor, and in HDL. Since each implementation has its own application niche, each one is valid as a final solution. Moreover, another purpose of this work is the comparison among these implementations, considering estimated costs, execution time, and advantages and disadvantages of each one.

Influência da punção lombar traumática e da quimioterapia intratecal na sobrevida de pacientes pediátricos com leucemia linfocítica aguda

Introdução e Objetivos: O sistema nervoso central (SNC) é o um sítio freqüente de recaída na criança com leucemia linfocítica aguda (LLA). Existe evidência de que a punção lombar traumática (PLT) pode representar um risco adicional de recaída no SNC quando ocorre inoculação de blastos no liqüido céfalorraquidiano (LCR). Este estudo tem por objetivo determinar se a ocorrência da PLT ao diagnóstico afeta o prognóstico de pacientes com essa patologia. Material e Métodos: Setenta e sete pacientes com diagnóstico de LLA, tratados entre 1992 a 2002, foram incluídos na análise. Quimioterapia intratecal (QIT) foi instilada imediatamente após a PL inicial (precoce), ou na segunda PL (tardia), realizada no período de 24 a 48 horas após a realização da PL inicial. Foi feita análise da influência da PLT e do momento (precoce x tardia) de administração da QIT em relação a recaída no SNC. Resultados: Entre os 19 pacientes que apresentaram PLT ao diagnóstico e receberam QIT tardia, seis tiveram recaída isolada no SNC e dois recaída combinada em SNC e medula óssea (MO). Entre os nove pacientes que tiveram PLT e receberam QIT precoce, somente um apresentou recaída combinada em SNC e MO (P=0,20); não houve, portanto, influência estatisticamente significativa da PLT na sobrevida livre de eventos (SLE) (55% para QIT precoce x 49% para QIT tardia) (P=0,37). Entretanto, em análise estratificada, de acordo com grupos de risco, observamos que para pacientes de baixo ou médio risco o OR foi de 0,8 quando recebiam QIT tardia (P=0,99) e 0,17 quando recebiam QIT precoce (P=0,47). Por outro lado, entre pacientes de alto risco o OR para recaída foi de 21,0 para aqueles que recebiam QIT tardia (P=0,09) e 1,5 para o grupo que recebia Q IT precoce (P=0,99). Conclusão: Os resultados do presente estudo são sugestivos de que a ocorrência da PLT tem uma influência adversa no prognóstico de pacientes com LLA de alto risco de recaída. Como estes resultados são decorrentes de um estudo retrospectivo, recomenda-se que sejam confirmados em estudos prospectivos randomizados.

Regime político e participação do legislativo na determinação da taxa de câmbio de países que conviveram com elevada inflação e persistentes déficits em transações correntes: os casos de Argentina, Bolívia, Brasil, México e Peru entre 1970 e 1989

O objetivo deste artigo é verificar a influência de variáveis políticas na determinação da taxa de câmbio em quatro países latino-americanos que conviveram com elevada inflação e déficit em Transações Correntes nas décadas de setenta e oitenta. Estudos empíricos já haviam demonstrado a influência das eleições. Nenhum, porém, havia incorporado a estrutura de decisão do Executivo e Legislativo neste processo. Só foi possível incorporar o regime político (Autoritário/Democrático) e a divisão de poder no Legislativo de todos os países num modelo standard de taxa de câmbio porque utilizamos a técnica de painel. Obtivemos os seguintes resultados: países classificados como Autoritários apresentaram uma taxa de câmbio mais valorizada e Legislativos mais fragmentados apresentaram uma taxa de câmbio mais desvalorizada. Vimos este último resultado com desconfiança uma vez que, entre os países da amostra, o regime Autoritário era, em alguns casos, uma ditadura militar e o Legislativo pouco intervia nas decisões. Interagimos o regime político com fragmentação e percebemos que o efeito da classificação do regime predomina. No caso, se existir um regime Autoritário, o câmbio resultante da interação ainda será valorizado. A divisão de poder no Legislativo apenas provoca uma redução no impacto da valorização.

Determinação de indicadores de qualidade para avaliação do processo de gestão de pequenas e médias empresas do setor de construção civil habitacional

A escolha do tema ficou circunscrita ao subsetor de construção habitacional, que é caracterizado pela presença de pequenas e médias empresas. A consolidação de grandes empresas neste ramo de atividades tende a ocorrer sobretudo em conjunturas onde através da intervenção estatal são definidos programas habitacionais de grande escala que requerem das empresas participantes de maior volume de capital e o acesso a tecnologias mais sofisticadas. A importância da pequena empresa neste ramo de atividades pode ser notada atraves da experiência dos países da Comunidade Econômica Europeia, que em 1985 de um total de mais de um milhão de empresas de construção, 90% tinham até 10 empregados. Igual situação se verifica nos Estados Unidos da América onde conforme dados de 1965, também 90 % das 875.000 empresas então existentes no país empregavam menos de 10 pessoas (ONU, 1987). De uma maneira geral a importância do tema fica evidente quando se analisa o peso do setor da construção civil na economia nacional, que se situa em torno de 5% do PIB nos países industrializados, enquanto que nos países de industrialização recente, este percentual pode atingir o índice de 7% (PNU, op.cit.). Tal constatação evidencia que a indústria da construção representa o principal item na composição dos investimentos (formação bruta de capital fixo) das contas nacionais de diversos países, apresentando uma participação relativa quase sempre superior a 55% nos países industrializados e 60% nos países de industrialização recente (ONU, op.cit.). No Brasil tal importância se confirma pelo valor adicionado do setor habitacional correspondente a 2,2% do PIB, e numa visão mais abrangente, dentro dos contornos da indústria da construção civil como um todo, representando cerca de 7,3% do PIB (FIBGE, 1988). Quanto a questão da mão-de-obra, em que pese a ausência de dados no Brasil, e bastante visível sua larga influência na economia atuando como um ramo de atividades multiplicador de alocação de pessoal, principalmente a nível de utilização intensiva de mão-de-obra menos qualificada. Enquanto nos EEUU e CEE 90% das empresas constituíam-se de organizações com menos de 10 empregados, no Brasil onde há ausência de dados oficiais a respeito, na pior das hipóteses pode-se estimar que este percentual pode variar entre 50 a 70% do total de empresas, o que não deixa de ser um dado de extrema magnitude. Foram exatamente a expressão destes números, sem considerar o déficit habitacional em torno de 10 milhões de pessoas, um terço da população, moram em condições inadequadas (Exame, 1991), que influenciaram fortemente a escolha do tema da presente proposta de Tese.

Interests prices and the Barosky - Summers resolution of the Gibson paradox under the gold standard

This paper presents a structural monetary úamework featunng a demand function for non-monetary uses of gold, such as the one drawn by Barsky and Summers in their 1988 analy8ÚI of the Gibson Paradox as a natural concomitant of the gold standard period. That structural model predicts that the laws of behavior of nominal prices and interest rates are functions of the rules set by the government to command the money supply. !ta fiduciary vemon obtaina Fisherian relationships &8 particular cases. !ta gold atandard 801ution yields a modelsimilar to the Barsky and Summers model, in which interest rates are exogeneous and subject to shocb. This paper integrates governnment bonds into the analysis, treats interest rates endogenously, and ahifts the responsibility for the shocb to the government budgetary financing policies. The Gibson paradox appears as "practically" the only cl&18 of behavioral pattern open for interest rates and price movements under apure gold standard economy. Fisherian-like relationshipe are utterly ruled out.

Microfounded forecasting

Our focus is on information in expectation surveys that can now be built on thousands (or millions) of respondents on an almost continuous-time basis (big data) and in continuous macroeconomic surveys with a limited number of respondents. We show that, under standard microeconomic and econometric techniques, survey forecasts are an affine function of the conditional expectation of the target variable. This is true whether or not the survey respondent knows the data-generating process (DGP) of the target variable or the econometrician knows the respondents individual loss function. If the econometrician has a mean-squared-error risk function, we show that asymptotically efficient forecasts of the target variable can be built using Hansens (Econometrica, 1982) generalized method of moments in a panel-data context, when N and T diverge or when T diverges with N xed. Sequential asymptotic results are obtained using Phillips and Moon s (Econometrica, 1999) framework. Possible extensions are also discussed.

Can deviation from standard beauty become appealing?: an age perspective

When exploring new perspectives on the impact of non-idealized vs. idealized body image in advertising, studies have focused mainly on body size, i.e., thin vs. heavy (Antioco et al., 2012; Smeesters & Mandel, 2006). Age remains largely unexplored, and the vast majority of ads in the market depict young models. The purpose of this research is therefore to investigate which images in advertisements – young or mature models – are more persuasive for older women (40+ years old). In this investigation, two studies were conducted. The first part was an exploratory analysis with a qualitative approach, which in turn helped to formulate the hypothesis tested in the subsequent experiment. The results of the in-depth interviews suggested a conflict over notions of imprisonment (need to follow beauty standards) and freedom (wish to deviate). The results of the experiment showed essentially that among older consumers, ads portraying older models were as persuasive as ads portraying younger models. Limitations and future research are discussed.

Influência da adição de resíduo de caulim nas propriedades tecnológicas de uma massa padrão de porcelanato produzido em escala industrial

VARELA, M. L. et al. Influência da adição de resíduo de caulim nas propriedades tecnológicas de uma massa padrão de porcelanato produzido em escala industrial. Cerâmica, v.55, n.334 p.209-215. 2009.ISSN 0366-6913.Disponível em: . Acesso em: 06 out. 2010.