Age, Creatinine and Ejection Fraction Score in Brazil: Comparison with InsCor and the EuroSCORE

AbstractBackground:Risk scores for cardiac surgery cannot continue to be neglected.Objective:To assess the performance of “Age, Creatinine and Ejection Fraction Score” (ACEF Score) to predict mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery, and to compare it to other scores.Methods:A prospective cohort study was carried out with the database of a Brazilian tertiary care center. A total of 2,565 patients submitted to elective surgeries between May 2007 and July 2009 were assessed. For a more detailed analysis, the ACEF Score performance was compared to the InsCor’s and EuroSCORE’s performance through correlation, calibration and discrimination tests.Results:Patients were stratified into mild, moderate and severe for all models. Calibration was inadequate for ACEF Score (p = 0.046) and adequate for InsCor (p = 0.460) and EuroSCORE (p = 0.750). As for discrimination, the area under the ROC curve was questionable for the ACEF Score (0.625) and adequate for InsCor (0.744) and EuroSCORE (0.763).Conclusion:Although simple to use and practical, the ACEF Score, unlike InsCor and EuroSCORE, was not accurate for predicting mortality in patients submitted to elective coronary artery bypass graft and/or heart valve surgery in a Brazilian tertiary care center. (Arq Bras Cardiol. 2015; [online].ahead print, PP.0-0)

Colchicine to Reduce Atrial Fibrillation in the Postoperative Period of Myocardial Revascularization

Abstract Background: The high prevalence of atrial fibrillation (AF) in the postoperative period of myocardial revascularization surgery increases morbidity and mortality. Objective: To assess the efficacy of colchicine to prevent AF in the postoperative period of myocardial revascularization surgery, the impact of AF on hospital length of stay and death, and to identify its risk factors. Methods: Between May 2012 and November 2013, 140 patients submitted to myocardial revascularization surgery were randomized, 69 to the control group and 71 to the colchicine group. Colchicine was used at the dose of 1 mg orally, twice daily, preoperatively, and of 0.5 mg, twice daily, until hospital discharge. A single dose of 1 mg was administered to those admitted 12 hours or less before surgery. Results: The primary endpoint was AF rate in the postoperative period of myocardial revascularization surgery. Colchicine group patients showed no reduction in AF incidence as compared to control group patients (7.04% versus 13.04%, respectively; p = 0.271). There was no statistically significant difference between the groups regarding death from any cause rate (5.6% versus 10.1%; p = 0,363) and hospital length of stay (14.5 ± 11.5 versus 13.3 ± 9.4 days; p = 0.490). However, colchicine group patients had a higher infection rate (26.8% versus 8.7%; p = 0.007). Conclusion: The use of colchicine to prevent AF after myocardial revascularization surgery was not effective in the present study. Brazilian Registry of Clinical Trials number RBR-556dhr.

Instruments for image guided procedures - IIGP : review summaries for minimal invasive and image guided technologies and clinical procedures : student review papers on selected topics

Michael Friebe, editor ; Otto-von-Guericke-Universität Magdeburg, Institut für Medizintechnik, Lehrstuhl Kathetertechnologie und bildgesteuerte Therapie (INKA - Intelligente Katheter), Forschungscampus STIMULATE (Solution Centre for Image Guided Local Therapies)

The Compleat cladist : a primer of phylogenetic procedures / E.O. Wiley [et al.]

no.19 (1991)

Eliciting and fostering learners' metacognitive knowledge about language learning in self-directed learning programs: a review of data collection methods and procedures

Són molts els estudis que avui en dia incideixen en la necessitat d’oferir un suport metodològic i psicològic als aprenents que treballen de manera autònoma. L’objectiu d’aquest suport és ajudar-los a desenvolupar les destreses que necessiten per dirigir el seu aprenentatge així com una actitud positiva i una major conscienciació envers aquest aprenentatge. En definitiva, aquests dos tipus de preparació es consideren essencials per ajudar els aprenents a esdevenir més autònoms i més eficients en el seu propi aprenentatge. Malgrat això, si bé és freqüent trobar estudis que exemplifiquen aplicacions del suport metodològic dins els seus programes, principalment en la formació d’estratègies o ajudant els aprenents a desenvolupar un pla de treball, aquest no és el cas quan es tracta de la seva preparació psicològica. Amb rares excepcions, trobem estudis que documentin com s’incideix en les actituds i en les creences dels aprenents, també coneguts com a coneixement metacognitiu (CM), en programes que fomenten l’autonomia en l’aprenentatge. Els objectius d’aquest treball son dos: a) oferir una revisió d’estudis que han utilitzat diferents mitjans per incidir en el CM dels aprenents i b) descriure les febleses i avantatges dels procediments i instruments que utilitzen, tal com han estat valorats en estudis de recerca, ja que ens permetrà establir criteris objectius sobre com i quan utilitzar-los en programes que fomentin l’aprenentatge autodirigit.

The role of central bank operating procedures in an economy with productive government spending

The choice of either the rate of monetary growth or the nominal interest rate as the instrument controlled by monetary authorities has both positive and normative implications for economic performance. We reexamine some of the issues related to the choice of the monetary policy instrument in a dynamic general equilibrium model exhibiting endogenous growth in which a fraction of productive government spending is financed by means of issuing currency. When we evaluate the performance of the two monetary instruments attending to the fluctuations of endogenous variables, we find that the inflation rate is less volatile under nominal interest rate targeting. Concerning the fluctuations of consumption and of the growth rate, both monetary policy instruments lead to statistically equivalent volatilities. Finally, we show that none of these two targeting procedures displays unambiguously higher welfare levels.

Fair procedures. Evidence from games involving lotteries

Procedural fairness plays a prominent role in the social discourse concerning the marketplace in particular, and social institutions in general. Random procedures are a simple case, and they have found application in several important social allocation decisions. We investigate random procedures in the laboratory. We find that an unbiased random procedure is an acceptable substitute for an unbiased allocation: similar patterns of acceptance and rejection result when either is inserted as a feasible proposal in a sequential battle-of-the-sexes. We also find that unbiasedness, known to be a crucial characteristic of allocation fairness, is important to procedural fairness: in the context of a random offer game, a biased outcome is more readily accepted when chosen by an unbiased random draw than by one that is biased. Procedural fairness is conceptually different than allocation fairness or attribution-based behavior, and none of the current models of fairness and reciprocity captures our results. Post hoc extension of one of these models (ERC) suggests that a deeper understanding of procedural fairness requires further investigation of competing fairness norms.

Welfare comparisons: sequential procedures for heterogenous populations

Some analysts use sequential dominance criteria, and others use equivalence scales in combination with non-sequential dominance tests, to make welfare comparisons of oint distributions of income and needs. In this paper we present a new sequential procedure hich copes with situations in which sequential dominance fails. We also demonstrate that there commendations deriving from the sequential approach are valid for distributions of equivalent income whatever equivalence scale the analyst might adopt. Thus the paper marries together the sequential and equivalizing approaches, seen as alternatives in much previous literature. All results are specified in forms which allow for demographic differences in the populations being compared.

Schistosoma mansoni antigenic extracts obtained by different extraction procedures

Solubilization of Schistosoma mansoni antigens was obtained by agitation of adult worms in a 3M KCl solution. The protein contents of the KCl extrats varied from 0.35 to 0.96 mg/ml. Sera from 97 patients with hepatointestinal shistosomiasis and viable eggs in stools from a Brazilian endemic area were studied by immunoelectroomophoresis and Ouchterlony immunodiffusion methods with the KCl extract and with another antigen, obtained by homogenization of adult schistosomes in saline. The rate of positiveness of immunoprecipitation deterctions by immunoelectroomophoresis with the KCl extract was 53.5%. A correlation was verified between methods of detection and extration procedures, resulting in a better association of the extract obtained by agitation in 3M KCl and immunoelectroomophoresis.

Perioperative antiplatelet therapy.

Aspirin is recommended as a lifelong therapy that should never be interrupted for patients with cardiovascular dis- ease. Clopidogrel therapy is mandatory for six weeks after placement of bare-metal stents, three to six months after myocardial infarction, and at least 12 months after placement of drug-eluting stents. Because of the hypercoagulable state induced by surgery, early withdrawal of antiplatelet therapy for secondary prevention of cardiovascular disease increases the risk of postoperative myocardial infarction and death five- to 10-fold in stented patients who are on continuous dual antiplatelet therapy. The shorter the time between revascularization and surgery, the higher the risk of adverse cardiac events. Elective surgery should be postponed beyond these periods, whereas vital, semiurgent, or urgent operations should be performed under continued dual antiplatelet therapy. The risk of surgical hemorrhage is increased approximately 20 percent by aspirin or clopidogrel alone, and 50 percent by dual antiplatelet therapy. The present clinical data suggest that the risk of a cardiovascular event when stopping antiplatelet agents preoperatively is higher than the risk of surgical bleeding when continuing these drugs, except during surgery in a closed space (e.g., intracranial, posterior eye chamber) or surgeries associated with massive bleeding and difficult hemostasis.

A Comparison Of Forecasting Procedures For Macroeconomic Series: The Contribution Of Structural Break Models

This paper compares the forecasting performance of different models which have been proposed for forecasting in the presence of structural breaks. These models differ in their treatment of the break process, the parameters defining the model which applies in each regime and the out-of-sample probability of a break occurring. In an extensive empirical evaluation involving many important macroeconomic time series, we demonstrate the presence of structural breaks and their importance for forecasting in the vast majority of cases. However, we find no single forecasting model consistently works best in the presence of structural breaks. In many cases, the formal modeling of the break process is important in achieving good forecast performance. However, there are also many cases where simple, rolling OLS forecasts perform well.

A Comparison Of Forecasting Procedures For Macroeconomic Series: The Contribution Of Structural Break Models

This paper compares the forecasting performance of different models which have been proposed for forecasting in the presence of structural breaks. These models differ in their treatment of the break process, the parameters defining the model which applies in each regime and the out-of-sample probability of a break occurring. In an extensive empirical evaluation involving many important macroeconomic time series, we demonstrate the presence of structural breaks and their importance for forecasting in the vast majority of cases. However, we find no single forecasting model consistently works best in the presence of structural breaks. In many cases, the formal modeling of the break process is important in achieving good forecast performance. However, there are also many cases where simple, rolling OLS forecasts perform well.

Legal Uncertainty, Competition Law Enforcement Procedures and Optimal Penalties

In this paper we make three contributions to the literature on optimal Competition Law enforcement procedures. The first (which is of general interest beyond competition policy) is to clarify the concept of “legal uncertainty”, relating it to ideas in the literature on Law and Economics, but formalising the concept through various information structures which specify the probability that each firm attaches – at the time it takes an action – to the possibility of its being deemed anti-competitive were it to be investigated by a Competition Authority. We show that the existence of Type I and Type II decision errors by competition authorities is neither necessary nor sufficient for the existence of legal uncertainty, and that information structures with legal uncertainty can generate higher welfare than information structures with legal certainty – a result echoing a similar finding obtained in a completely different context and under different assumptions in earlier Law and Economics literature (Kaplow and Shavell, 1992). Our second contribution is to revisit and significantly generalise the analysis in our previous paper, Katsoulacos and Ulph (2009), involving a welfare comparison of Per Se and Effects- Based legal standards. In that analysis we considered just a single information structure under an Effects-Based standard and also penalties were exogenously fixed. Here we allow for (a) different information structures under an Effects-Based standard and (b) endogenous penalties. We obtain two main results: (i) considering all information structures a Per Se standard is never better than an Effects-Based standard; (ii) optimal penalties may be higher when there is legal uncertainty than when there is no legal uncertainty.

Comparative cost-effectiveness analyses of cardiovascular magnetic resonance and coronary angiography combined with fractional flow reserve for the diagnosis of coronary artery disease.

BACKGROUND: According to recent guidelines, patients with coronary artery disease (CAD) should undergo revascularization if significant myocardial ischemia is present. Both, cardiovascular magnetic resonance (CMR) and fractional flow reserve (FFR) allow for a reliable ischemia assessment and in combination with anatomical information provided by invasive coronary angiography (CXA), such a work-up sets the basis for a decision to revascularize or not. The cost-effectiveness ratio of these two strategies is compared. METHODS: Strategy 1) CMR to assess ischemia followed by CXA in ischemia-positive patients (CMR + CXA), Strategy 2) CXA followed by FFR in angiographically positive stenoses (CXA + FFR). The costs, evaluated from the third party payer perspective in Switzerland, Germany, the United Kingdom (UK), and the United States (US), included public prices of the different outpatient procedures and costs induced by procedural complications and by diagnostic errors. The effectiveness criterion was the correct identification of hemodynamically significant coronary lesion(s) (= significant CAD) complemented by full anatomical information. Test performances were derived from the published literature. Cost-effectiveness ratios for both strategies were compared for hypothetical cohorts with different pretest likelihood of significant CAD. RESULTS: CMR + CXA and CXA + FFR were equally cost-effective at a pretest likelihood of CAD of 62% in Switzerland, 65% in Germany, 83% in the UK, and 82% in the US with costs of CHF 5'794, euro 1'517, £ 2'680, and $ 2'179 per patient correctly diagnosed. Below these thresholds, CMR + CXA showed lower costs per patient correctly diagnosed than CXA + FFR. CONCLUSIONS: The CMR + CXA strategy is more cost-effective than CXA + FFR below a CAD prevalence of 62%, 65%, 83%, and 82% for the Swiss, the German, the UK, and the US health care systems, respectively. These findings may help to optimize resource utilization in the diagnosis of CAD.