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Pushing selected information to clinicians, as opposed to the traditional method of clinicians pulling information from an electronic medical record, has the potential to improve care. A digital notification platform was designed by clinicians and implemented in a tertiary hospital to flag dysglycaemia. There were 112 patients included in the study, and the post-implementation group demonstrated lower rates of dysglycaemia (2.5% vs 1.1%, P = 0.038). These findings raise considerations for information delivery methods for multiple domains in contemporary healthcare.
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Weekend discharges occur less frequently than discharges on weekdays, contributing to hospital congestion. Artificial intelligence algorithms have previously been derived to predict which patients are nearing discharge based upon ward round notes. In this implementation study, such an artificial intelligence algorithm was coupled with a multidisciplinary discharge facilitation team on weekend shifts. This approach was implemented in a tertiary hospital, and then compared to a historical cohort from the same time the previous year. There were 3990 patients included in the study. There was a significant increase in the proportion of inpatients who received weekend discharges in the intervention group compared to the control group (median 18%, IQR 18-20%, vs median 14%, IQR 12% to 17%, P = 0.031). There was a corresponding higher absolute number of weekend discharges during the intervention period compared to the control period (P = 0.025). The studied intervention was associated with an increase in weekend discharges and economic analyses support this approach as being cost-effective. Further studies are required to examine the generalizability of this approach to other centers.
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BACKGROUND: Although modern Australian healthcare systems provide patient-centred care, the ability to predict and prevent suboptimal post-procedural outcomes based on patient demographics at admission may improve health equity. This study aimed to identify patient demographic characteristics that might predict disparities in mortality, readmission, and discharge outcomes after either an operative or non-operative procedural hospital admission. METHODS: This retrospective cohort study included all surgical and non-surgical procedural admissions at three of the four major metropolitan public hospitals in South Australia in 2022. Multivariable logistic regression, with backwards selection, evaluated association between patient demographic characteristics and outcomes up to 90 days post-procedurally. RESULTS: 40 882 admissions were included. Increased likelihood of all-cause, post-procedure mortality in-hospital, at 30 days, and 90 days, were significantly associated with increased age (P < 0.001), increased comorbidity burden (P < 0.001), an emergency admission (P < 0.001), and male sex (P = 0.046, P = 0.03, P < 0.001, respectively). Identification as ATSI (P < 0.001) and being born in Australia (P = 0.03, P = 0.001, respectively) were associated with an increased likelihood of 30-day hospital readmission and decreased likelihood of discharge directly home, as was increased comorbidity burden (P < 0.001) and emergency admission (P < 0.001). Being married (P < 0.001) and male sex (P = 0.003) were predictive of an increased likelihood of discharging directly home; in contrast to increased age (P < 0.001) which was predictive of decreased likelihood of this occurring. CONCLUSIONS: This study characterized several associations between patient demographic factors present on admission and outcomes after surgical and non-surgical procedures, that can be integrated within patient flow pathways through the Australian healthcare system to improve healthcare equity.
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Alta del Paciente , Readmisión del Paciente , Humanos , Masculino , Australia del Sur/epidemiología , Australia , Estudios Retrospectivos , Hospitales Públicos , Factores de Riesgo , DemografíaRESUMEN
Computers are an integral component of modern hospitals. Mouse clicks are currently inherent to this use of computers. However, mouse clicks are not instantaneous. These clicks may be associated with significant costs. Estimated costs associated with 10 additional clicks per day for 20 000 staff exceed AU$500 000 annually. Workflow modifications that increase clicks should weigh the potential benefits of such changes against these costs. Future investigation of strategies to reduce low-value clicks may provide an avenue for health care savings.
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Computadores , Atención a la Salud , Humanos , Factores de Tiempo , Flujo de TrabajoRESUMEN
BACKGROUND: This study aimed to examine the performance of machine learning algorithms for the prediction of discharge within 12 and 24 h to produce a measure of readiness for discharge after general surgery. METHODS: Consecutive general surgery patients at two tertiary hospitals, over a 2-year period, were included. Observation and laboratory parameter data were stratified into training, testing and validation datasets. Random forest, XGBoost and logistic regression models were evaluated. Each ward round note time was taken as a different event. Primary outcome was classification accuracy of the algorithmic model able to predict discharge within the next 12 h on the validation data set. RESULTS: 42 572 ward round note timings were included from 8826 general surgery patients. Discharge occurred within 12 h for 8800 times (20.7%), and within 24 h for 9885 (23.2%). For predicting discharge within 12 h, model classification accuracies for derivation and validation data sets were: 0.84 and 0.85 random forest, 0.84 and 0.83 XGBoost, 0.80 and 0.81 logistic regression. For predicting discharge within 24 h, model classification accuracies for derivation and validation data sets were: 0.83 and 0.84 random forest, 0.82 and 0.81 XGBoost, 0.78 and 0.79 logistic regression. Algorithms generated a continuous number between 0 and 1 (or 0 and 100), representing readiness for discharge after general surgery. CONCLUSIONS: A derived artificial intelligence measure (the Adelaide Score) successfully predicts discharge within the next 12 and 24 h in general surgery patients. This may be useful for both treating teams and allied health staff within surgical systems.
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Inteligencia Artificial , Alta del Paciente , Humanos , Algoritmos , Aprendizaje Automático , Modelos LogísticosRESUMEN
Total wrist arthrodesis, fusion of the carpus to the radius, is a well-established and commonly performed procedure for the management of pancarpal degenerative arthritis, trauma, and other severe diseases of the wrist. A well-known complication of this is radiocarpal nonunion, with a rate of 4.4%. Commonly, bone grafting is done at the time of the surgery using local bone, iliac crest bone graft, or cancellous allograft bone. The Synthes Reamer-Irrigator-Aspirator (RIA) is a flexible reamer originally designed as a single-pass intramedullary reamer that can be used in reaming of long bone fractures prior to insertion of an intramedullary nail. Recently, its use has been expanding to the harvesting of bone graft. We present a case study of 2 patients who had total wrist arthrodesis after severe trauma to the wrist resulting in severe bone loss, in whom we used an RIA to obtain bone graft, and both patients went on to union. The first patient is a 17-year-old male who sustained a blast injury from a firework resulting in a mangling injury to the wrist with soft tissue and severe bone loss of his carpus. After being treated with multiple debridements with an external fixator, he was definitively treated with a wrist fusion with RIA bone graft. He went on to osseous union by his 4-month follow-up. Our second patient is a 53-year-old woman who sustained a gunshot wound to the wrist resulting in massive bone loss of the distal radius. After being initially treated with multiple debridements and external fixation, she was treated with a wrist fusion with RIA bone graft and went on to osseous fusion by her 3-month follow-up. Neither patient had complications from the RIA procedure.
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Artrodesis/instrumentación , Traumatismos por Explosión/cirugía , Trasplante Óseo/instrumentación , Heridas por Arma de Fuego/cirugía , Traumatismos de la Muñeca/cirugía , Adolescente , Traumatismos por Explosión/diagnóstico por imagen , Traumatismos por Explosión/etiología , Femenino , Humanos , Masculino , Persona de Mediana Edad , Irrigación Terapéutica/instrumentación , Heridas por Arma de Fuego/diagnóstico por imagen , Traumatismos de la Muñeca/diagnóstico por imagen , Traumatismos de la Muñeca/etiologíaRESUMEN
A 9-year-old boy sustained an ulnohumeral dislocation with a medial epicondyle fracture and experienced incomplete post-traumatic median nerve palsy in addition to post-traumatic stiffness following closed reduction and cast immobilization. When his motor palsy and stiffness did not improve, MRI and ultrasound were obtained, which demonstrated entrapment of the median nerve in an osseous tunnel at the fracture site, compatible with type 2 median nerve entrapment. Subsequently, the patient underwent surgery to mobilize the medial epicondyle and free the median nerve, resulting in improved range of motion, near complete restoration of motor function, and complete restoration of sensory function in the median nerve distribution within 6 months of surgery. Median nerve entrapment, particularly intraosseous, is a rare complication of posterior elbow dislocation and medial epicondyle fracture that may result in significant, sometimes irreversible, nerve damage if there is a delay in diagnosis and treatment. A high degree of clinical suspicion with early imaging is indicated in patients with persistent stiffness or nerve deficits following reduction of an elbow dislocation. Intra-articular entrapment diagnosed on ultrasound has been reported and intraosseous entrapment diagnosed clinically and on MR neurography have been reported; however, to our knowledge, this is the first reported case of intraosseous (type 2) median nerve entrapment clearly visualized and diagnosed on traditional MRI and ultrasound. The use of ultrasound for diagnosing median nerve entrapment is an accurate, accessible, and non-invasive imaging option for patients presenting with suspected nerve entrapment following elbow dislocation.
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Lesiones de Codo , Luxaciones Articulares/diagnóstico por imagen , Imagen por Resonancia Magnética/métodos , Nervio Mediano/diagnóstico por imagen , Síndromes de Compresión Nerviosa/diagnóstico por imagen , Ultrasonografía/métodos , Niño , Articulación del Codo/diagnóstico por imagen , Humanos , Luxaciones Articulares/complicaciones , Masculino , Nervio Mediano/cirugía , Síndromes de Compresión Nerviosa/etiología , Síndromes de Compresión Nerviosa/cirugíaRESUMEN
CASE: A 19-year-old woman presented with a 3-month history of an enlarging lesion on the proximal aspect of the femur. After imaging studies and a biopsy had been performed, the mass was determined to represent heterotopic ossification (HO). The only known risk factor was a history of concussion. The mass was resected and, as of the 12-month follow-up, had not recurred. CONCLUSION: HO is a potentially serious complication of ossification in soft tissues that can develop secondary to several disease states; it commonly occurs following traumatic brain injury. To our knowledge, this is the only case report that describes HO associated with a concussion and no other risk factors.
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Conmoción Encefálica/complicaciones , Fémur , Osificación Heterotópica , Adulto , Femenino , Fémur/diagnóstico por imagen , Fémur/patología , Fémur/cirugía , Humanos , Osificación Heterotópica/complicaciones , Osificación Heterotópica/diagnóstico por imagen , Osificación Heterotópica/patología , Osificación Heterotópica/cirugía , Tomografía Computarizada por Rayos X , Adulto JovenRESUMEN
Infective endocarditis (IE) is a life-threatening condition often manifesting as a multisystem disease; its heterogeneous features present a diagnostic challenge. We report two cases of IE masquerading as rare extracardiac complications: a splenectomised patient with a periarticular ankle abscess and acute encephalopathy; and a young man with a cutaneous vasculitis following a spontaneous intracerebral haemorrhage. In both cases, the diagnosis was suspected following detection of afebrile bacteraemia and confirmed with echocardiography. Risk factors included a pneumococcal bacteraemia in the asplenic patient and a previously undiagnosed bicuspid aortic valve in the second patient. Both patients recovered well with appropriate antibiotic therapy followed by valve surgery. IE is an important diagnosis to consider in patients with systemic symptoms or organ specific, otherwise unexplained relevant pathology especially in the presence of a cardiac murmur or risk factors for IE including structural heart disease, prosthetic valves or intravascular devices, and in immunosuppressed patients.
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Absceso/microbiología , Bacteriemia/complicaciones , Encefalopatías/microbiología , Ecocardiografía , Endocarditis/diagnóstico por imagen , Endocarditis/diagnóstico , Enfermedad Aguda , Adulto , Tobillo/patología , Válvula Aórtica/anomalías , Válvula Aórtica/diagnóstico por imagen , Bacteriemia/sangre , Enfermedad de la Válvula Aórtica Bicúspide , Hemorragia Cerebral/etiología , Diagnóstico Diferencial , Endocarditis/complicaciones , Endocarditis/microbiología , Femenino , Enfermedades de las Válvulas Cardíacas/complicaciones , Enfermedades de las Válvulas Cardíacas/diagnóstico por imagen , Humanos , Masculino , Persona de Mediana Edad , Infecciones Neumocócicas/complicaciones , Enfermedades Cutáneas Vasculares/microbiología , Esplenectomía/efectos adversos , Streptococcus pneumoniae/patogenicidad , Vasculitis/microbiologíaRESUMEN
BACKGROUND: The European Concerted Action Project 'Homocysteine and Vascular Disease' showed that an elevated homocysteine is associated with a substantially increased risk of cardiovascular disease, and particularly when combined with other factors such as smoking, hypertension and hypercholesterolaemia. The purpose of this study was to examine the potential interactions between homocysteine and individual lipid subfractions. In addition, it was hypothesized that HDL cholesterol may protect against hyperhomocysteinaemia because HDL cholesterol is associated with the enzyme paroxonase, which reduces oxidization of homocysteine to the harmful metabolite, homocysteine thiolactonase. METHODS: Data from a multicentre European case-control study (750 cases and 800 controls) were used for analysis. The risks of vascular disease associated with homocysteine, total cholesterol, LDL cholesterol, HDL cholesterol, triglycerides, apoprotein A1 and apoprotein B were established. The effect of elevated homocysteine on the cardiovascular risk associated with each lipid subfraction was then examined. RESULTS: As expected, homocysteine, total cholesterol, LDL cholesterol, triglycerides and apolipoprotein B were associated with cardiovascular risk. HDL cholesterol was inversely related to risk. Homocysteine increased the risk associated with all lipid measures. In contrast, a low plasma cholesterol does not seem to confer protection against the risk associated with a raised plasma homocysteine. Hyperhomocysteinaemia is associated with an increased risk at all levels of HDL cholesterol, conversely, in those with elevated homocysteine HDL cholesterol levels result in reduced risk. CONCLUSION: In general, the increased cardiovascular risk associated with elevated homocysteine is evident across the spectrum cholesterol subfraction levels.
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Enfermedades Cardiovasculares/etiología , Homocisteína/sangre , Hiperhomocisteinemia/complicaciones , Hiperlipidemias/complicaciones , Lípidos/sangre , Adulto , Apolipoproteína A-I/sangre , Apolipoproteínas B/sangre , Biomarcadores/sangre , Estudios de Casos y Controles , HDL-Colesterol/sangre , LDL-Colesterol/sangre , Europa (Continente) , Femenino , Humanos , Hiperhomocisteinemia/sangre , Hiperlipidemias/sangre , Modelos Logísticos , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Proyectos Piloto , Medición de Riesgo , Factores de Riesgo , Triglicéridos/sangre , Regulación hacia ArribaRESUMEN
Atherosclerotic cardiovascular disease (CVD), which includes coronary heart disease (CHD) and stroke, is now the most common cause of death in the middle aged and elderly in all parts of the world except subSaharan Africa. The direct cause of death is frequently an acute thrombotic arterial occlusion. Because atherosclerosis is a diffuse disease, patients with CHD also have a high risk of ischemic stroke. The hemostatic process is a needed defense mechanism to control hemorrhage after injury but at same time, if overactive, may have the potential to precipitate diseases such as myocardial infarction or stroke in the setting of atherosclerosis. In approximately 1% of all patients with ischemic stroke, and in up to 4% of young adults with stroke, the major precipitant of brain ischemia is a hematologic disorder or coagulopathy that predisposes to thrombosis. von Willebrand factor (vWF) plays an important role in platelet adhesion to subendothelial structures and in the intrinsic pathway of coagulation. It is regarded as an indirect measure of endothelial dysfunction. Deficiency of vWF in von Willebrand's disease is well established. However, much less is known regarding the pathophysiologic implications of an elevated level of vWF, particularly in relation to CVD and cerebrovascular disease. The importance of vWF in the pathogenesis of this disease is poorly defined and information is limited and inconsistent. Elevated levels of vWF have been variably linked with risk of CHD; causal criteria are not fully met. Relationships with stroke risk are even less well established. Measurement of vWF adds little to risk prediction after considering the major risk factors--age, sex, smoking, raised blood cholesterol, and hypertension. vWF may have a greater role in predicting outcome in subjects with acute coronary syndromes (ACS), stroke, and perhaps atrial fibrillation. Investigation of the use of vWF level to guide treatment of ACS or stroke is ongoing; however, there is no compelling evidence to date.
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We evaluated the effectiveness of a dentist-implemented behavioral intervention in which brief escape from dental treatment was provided on a regular basis, independent of the child's behavior. Within a multiple baseline design across subjects, 5 children, ages 4 to 7 years, were provided with temporary escape from dental treatment on a fixed-time schedule. The intervals were signaled by an electronic timer worn by the dentist. Clinically significant reductions were observed in physically disruptive behavior across all 5 children with the introduction of noncontingent escape, and verbally disruptive behavior was markedly reduced in 4 of the 5 children. In addition, the dental staff s use of physical restraint was reduced to near zero across all 5 children. The research extends the literature in both clinical dentistry and in applied behavior analysis by demonstrating that a dentist can easily and effectively implement noncontingent reinforcement to produce clinically significant and socially important changes in children's health behavior.
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Déficit de la Atención y Trastornos de Conducta Disruptiva/prevención & control , Conducta Cooperativa , Restauración Dental Permanente , Reacción de Fuga , Extinción Psicológica , Visita a Consultorio Médico , Odontología Pediátrica , Déficit de la Atención y Trastornos de Conducta Disruptiva/psicología , Niño , Preescolar , Femenino , Humanos , Masculino , Factores de TiempoRESUMEN
BACKGROUND: Almost 40% of patients with heart failure (HF) have preserved left ventricular (LV) ejection fraction (EF) and prognosis similar to those with reduced EF. Data on prognostic markers in such patients are limited. We analyzed the prevalence and prognostic value of left atrial (LA) size in this condition. METHODS: 89 normal subjects (Group I), 38 asymptomatic hypertensive patients (Group II) and 183 HF patients with preserved EF (EF >45%) (Group III) were studied. LA diameter (LAD), LV diastolic (LVD) and systolic (LVS) dimensions and mass (LVmass) and EF were measured. E and A wave velocities and E/A were measured. The primary end point was all cause mortality in group III patients. RESULTS: Groups did not differ in age, gender or EF. Group III patients had larger LAD (4.6+-1.0 cm) compared with both Group I (3.7+/-0.6) and Group II (3.7+/-0.5 cm) (p<0.0001). A markedly enlarged (arbitrarily defined as LAD higher or equal 5 cm) had an odds ratio of 34 (95% CI 8-144) in distinguishing HF patients from normals. After a mean follow-up period of 29+/-27 months, 40 patients (21.9%) died. In Cox univariate analysis, NYHA class (HR 2.8 95% C.I. 1.8-4.3; p<0.0001), diastolic blood pressure (DBP) (HR 0.92 95% C.I. 0.88-0.96; p<0.0001), age (HR 1.059 95% C.I. 1.01-1.11; p=0.02) and LAD (HR 1.72 95% C.I. 1.27-2.3; p=0.0005) were predictors of mortality. LAD predicted survival independently of other variables. CONCLUSION: The left atrium is frequently dilated in HF patients compared with controls despite similar EF. LAD showed powerful prognostic value independent of clinical variables.
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Vasos Coronarios/patología , Insuficiencia Cardíaca/diagnóstico , Insuficiencia Cardíaca/fisiopatología , Disfunción Ventricular Izquierda/diagnóstico , Disfunción Ventricular Izquierda/patología , Anciano , Enfermedad Crónica , Ecocardiografía , Femenino , Humanos , Masculino , Pronóstico , Sensibilidad y Especificidad , Tasa de Supervivencia , Disfunción Ventricular Izquierda/fisiopatologíaRESUMEN
BACKGROUND: The relative importance of new risk factors for heart disease singly or in combination is uncertain. We assessed relationships between C-reactive protein, homocysteine, cysteine, von Willebrand factor, activated factor XII and stable heart disease, as well as interaction with established risk factors. METHODS: A case-control study of 260 cases of stable heart disease from the Irish component of the European Action on Secondary Prevention through Intervention to Reduce Events (EUROASPIRE) II cohort and 260 age, sex-matched controls. C-reactive protein, homocysteine, cysteine, von Willebrand factor, activated factor XII and conventional risk factors were assayed or recorded. Interaction effects between new and conventional factors were assessed using additive and multiplicative models. RESULTS: C-reactive protein, homocysteine, cysteine and von Willebrand factor were significantly higher in cases than controls. Comparing the top fifth with the bottom four-fifths showed independent associations between heart disease and C-reactive protein [odds ratio (OR) 1.79; 95% confidence interval (CI) 1.12-2.86; P = 0.01], cysteine (OR 2.00; 95% CI 1.25-3.20; P = 0.004), von Willebrand factor (OR, 3.0; 95% CI 1.9-4.8; P < 0.0001). For homocysteine, the association was independent comparing the top tenth to the bottom nine-tenths (OR 1.95; 95% CI 1.02-3.41; P = 0.04). Activated factor XII was not associated with risk. The association between C-reactive protein and disease was U-shaped and a graded association existed between homocysteine, cysteine, von Willebrand factor and disease. C-reactive protein, homocysteine, cysteine and von Willebrand factor considerably increased risk associated with other factors, particularly smoking. CONCLUSIONS: Independent associations exist between stable heart disease and C-reactive protein, homocysteine, cysteine and von Willebrand factor. Strong combined effects were observed between these and conventional risk factors, particularly smoking. Smoking cessation may profoundly reduce risk associated with other risk factors. We found no evidence of a relationship between activated factor XII and disease.
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Proteína C-Reactiva/metabolismo , Enfermedad Coronaria/sangre , Cisteína/sangre , Homocisteína/sangre , Fumar/efectos adversos , Factor de von Willebrand/metabolismo , Adulto , Anciano , Biomarcadores/sangre , Enfermedad Coronaria/epidemiología , Ensayo de Inmunoadsorción Enzimática , Femenino , Humanos , Incidencia , Masculino , Persona de Mediana Edad , Oportunidad Relativa , Pronóstico , Estudios Retrospectivos , Factores de Riesgo , Fumar/sangreAsunto(s)
Modelos Animales de Enfermedad , Insuficiencia Cardíaca/fisiopatología , Animales , Perros , HumanosRESUMEN
Five children diagnosed with attention deficit/hyperactivity disorder participated in a summer program designed to evaluate behavioral and pharmacological treatments in a recreational setting. The effect of a contingency for increased sportsmanlike behavior, with and without the use of tokens, was examined during kickball games. The influence of stimulant medication was also examined for 3 of the children. A multiple-baseline, reversal design revealed that a delayed reward condition did not increase sportsmanlike behavior, whereas the addition of tokens (and praise) to the delayed reward increased sportsmanlike behavior for all 5 participants. Stimulant medication appeared to have very little influence on sportsmanlike behavior. Future directions for behavioral social skills interventions using a sports skills model are also discussed.