Two-time Periods Research Articles

Acuity, outcomes, and trends in the transfer of surgical patients: a national study.

With the regionalization of surgical care, reduction in the rural workforce, rising healthcare costs, and increasing focus on surgical outcomes, appropriate transfer of surgical patients is an increasingly important aspect of health care. This study examines patients transferred for surgical intervention through a national sample. The American College of Surgeons National Surgical Quality Improvement Program database was queried from 2005 to 2012 for surgery patients who were transferred from an outside hospital or emergency department (ED) and compared patients undergoing surgery without transfer. Patients were divided into two time periods (TP): 2005-2008 (TP1) and 2008-2012 (TP2) for analysis; patient characteristics and top CPT codes for each TP were collected. Univariate analysis and matched cohorts were used to compare the groups. Overall, 61,204 patients were transferred and underwent surgery. The rate of transferred surgery patients increased from 3.2% in TP1 to 4.5% in TP2 (p < 0.0001). Compared to non-transferred patients, transferred patients had higher rates of diabetes (23.4 vs. 17.6%, p < 0.0001), tobacco use (27.9 vs. 20.3%, p < 0.0001), Charlson comorbidity index (mean score 1.5 vs. 0.8, p < 0.0001), preoperative sepsis (32.0 vs. 9.4%, p < 0.0001), and need for emergent surgery (41.3 vs. 14.4%, p < 0.0001). From TP1 to TP2, there was an increase in transferred patients who were obese (33.9-36.4%, p < 0.0001) and had emergent transfers (39.6-41.8%, p < 0.0001), with a decrease in diabetic patients (24.7-23.1%, p < 0.0001). From TP1 to TP2, transferred patients had more minor complications (17.7-31.0%, p < 0.0001), but fewer major complications (32.1-23.9%, p < 0.0001) and lower 30-day mortality (11.8-8.1%, p < 0.0001). Patients transferred for surgery represent a higher acuity population than non-transferred patients, and the number of transfers continues to rise. Even when matched by comorbidities, transferred patients have worse outcomes. Surgical sub-specialization and physician tiering may complicate future transfer practices. Efficient transfers, effective physician communication, and ready availability of medical records are critical in improving patient transfers.

603P - Improving Clinical Outcomes in Cancer Care Through Centralisation of Treatment and Clinical Audit: the Rectal Cancer Case

ABSTRACT Aim: Using the clinical audit as a quality improvement tool with evidence of better results in high-volume centres in Catalonia (Spain), a re-organisation of specialized surgical procedures and rare tumour distribution among reference hospitals was implemented. Using rectal cancer as a case study, we assess the impact of centralization of high-complexity cancer care services. Methods: Mixed methods combining quantitative and qualitative data were used. Quality of cancer care in rectal cancer was audited in accordance with the clinical practice guideline (CPG), and outcomes in all patients surgically treated for the first time in public hospitals in Catalonia in two-time periods (2005/7 and 2011/12) were assessed. Indicators of the quality of rectal cancer care and its results, comparing both periods, were analysed in order to measure the impact of centralization. In addition, key informant semi-structured interviews (n = 15) were undertaken with the managers and the lead clinicians involved in the process, to obtain their perception of this re-organisation. Results: From 2005/7 to 2011/12 the number of hospitals performing rectal cancer surgery decreased from 51 to 29 centres. A better quality of TME (36.2% vs 79.6%), more preoperative radio-chemotherapy (51% vs 65.8%) and more lymph node extractions (median: 10 vs 14 n.) were observed comparing both periods. Also, the rate of LR during the first year after surgery fell from 3.49 to 2.75/100.000. Qualitative assessment showed a favourable stance towards centralisation among the stakeholders involved, although critical views arose in regard to a surgery-centred concentration, the takeover of the diagnostic process by the referring center including the associated costs, and the lack of policy guidance in respect of continuity of care. Conclusions: Health policy approach combining assessment from the clinical audit with reorganisation of the delivery of complex treatments has been associated with better outcomes. A model of care based on the centralisation of high-complexity cancer treatments should be reinforced by managed regional networks and improved referral of patients. Disclosure: All authors have declared no conflicts of interest.

Part II: temporal and spatial distribution of multiclass pesticide residues in lake sediments of northern Greece: application of an optimized MAE-LC-MS/MS pretreatment and analytical method

The development and application of an analytical methodology for the pretreatment and determination of 253 multiclass pesticides, in lake sediment samples, using liquid chromatography coupled with mass spectrometry (LC-MS/MS) are described in this work. Sediments of lakes Volvi, Doirani, and Kerkini, located in northern Greece, were collected in two-time periods (fall/winter 2010 and spring/summer 2011) and analyzed, applying the developed analytical methodology. Microwave-assisted extraction (MAE) was applied to extract the pesticide residues from lake sediment samples. Analytical results were stored, categorized, and visualized using geographical information systems, in order to assess and observe spatial and temporal variations of the pollution. Main pesticides that were detected included the following: amitrole, tebuconazole, phoxim, diniconazole, sethoxydim, temephos, tetrachlorvinphos, pendimethalin, boscalid, disulfoton sulfone, lenacil, propiconazole, cycloxydim, pyridaben, and terbuthylazine. Amitrole, diniconazole, and tebuconazole were found to be common in all three lakes. Lakes Kerkini and Doirani exhibited increased concentrations during the first sampling period (winter 2010) with predominant pesticide classes, triazines/triazoles and organophosphates. Pollution is mainly located near the populated villages of the lakes and the nearby cultivations. During the second sampling period, pesticide concentrations appear lower and located in sediments near the center of the lake. Lake Volvi exhibits increased pesticide concentrations during the second sampling period, temporal and spatial variations and different pesticide profile pattern. Increased pollution occurs near the center of the lake during the first sampling period, mainly comprised by triazines/triazoles and organophosphates. During the second sampling period, the majority of the sediment samples demonstrated a different pesticide profile dominated by unclassified pesticides and triazines/triazoles. Mineralogical analysis of the samples demonstrates that sediments are mainly composed of clay, mud, and sand particles, and they present spatial variations. Near the center of the lakes, sediments appear to be more fine-grained with higher clay content and are more likely to adsorb pesticides.

The combined effects of cadmium and salinity on some pigments and total phenolic compounds of Myriophyllum heterophyllum Michx. and Potamogeton crispus L.

In this study, the combined effects of different salinity and cadmium concentrations (0, 0.05‰ NaCl + 4 mg L-1 Cd, 0.05‰ NaCl + 64 mg L-1 Cd, 5‰ NaCl + 4 mg L-1 Cd, 5‰ NaCl + 64 mg L-1 Cd) on some pigments (chlorophyll a, chlorophyll b, carotenoids and anthocyanins) and total phenolic compounds were investigated in two aquatic plants (Myriophyllum heterophyllum Michx. and Potamogeton crispus L.) at 24 and 96 h. Chlorophyll a, chlorophyll b and carotenoids decreased depending on Cd + NaCl concentrations and the time (24 h and 96 h) in both species (P<0.05). The anthocyanin concentrations showed differences in combined Cd and NaCl concentrations in both species at 24 and 96 h. In the two time periods (24 and 96 h), the levels of phenolic compounds at all concentrations of Cd + NaCl increased in both M. heterophyllum and P. crispus (P<0.05). Key words: Aquatic plants, cadmium, sodium chloride (NaCl), phenolic compounds, photosynthetic pigments.

Effet de la déleucocytation des concentrés érythrocytaires sur les réactions transfusionnelles

In order to assess the impact of leukocyte reduction, all transfusion reactions reported at Liege Teaching Hospital's Blood Bank 2 years before and after the implementation of universal leukocyte reduction of red blood cells concentrates which started-up on 1 January 2005 were evaluated. A retrospective analysis of transfusion reactions from 1 January 2003 to 31st December 2006 was undertaken. Data were collected from computerized reports, which were entered as soon as a transfusion reaction was reported. Symptoms were classified in different reaction's categories. Blood cultures, antibody screening and direct antiglobulin test were performed. Differences between the two time periods, before (2003-2004) and after (2005-2006) universal leukoreduction were determined by the Chi-square test and significance was defined as a p value less than 0.05. During period before the implementation of systematic leukoreduction, 68.7% of red blood cells transfused were leukoreduced. A total of 365 transfusion reactions in 91,996 red blood cells units transfused (0.4%) were reported, of which 266 were classified as febrile non-hemolytic transfusion reactions (72.9%), followed by allergic reactions (7.1%) and miscellaneous reactions (3.8%). When comparing the two-time periods, the rate of all transfusion reactions in general significantly decreased from 0.49 to 0.31% (p<0.001). Therefore, universal leukocyte reduction significantly reduced the rates of febrile non-hemolytic transfusion reactions (0.35% versus 0.24%; p=0.002) and allergic reactions (0.05% versus 0.01%; p<0.001). Universal leukocyte reduction significantly reduced the rate of transfusion reactions.

The importance of clinical experience for mental health nursing – Part 1: Undergraduate nursing students’ attitudes, preparedness and satisfaction

Government inquiries and workforce data continue to draw attention to the current and impending crisis in mental health nursing. While undergraduate nursing education has been found at least partially responsible for the negative attitudes nursing students tend to hold towards mental health nursing, clinical experience has been identified as a potential strategy in enhancing more positive attitudes. However, research to date has not focused on the impact of clinical experience on specific factors such as attitudes to mental health nursing to people experiencing mental illness and perceived preparedness for the mental health field. This quasi-experimental study measured changes in students' attitudes to the three factors, including satisfaction with clinical experience following a placement in mental health nursing. A questionnaire was administered to undergraduate nursing students on the first and last day of a mental health clinical placement. This, the first of a two-part paper, compares student responses over the two-time periods and describes satisfaction with the clinical experience. The findings suggest that clinical experience in mental health nursing experience can positively influence attitudes, preparedness for practice, and the popularity of mental health nursing. Satisfaction with clinical experience was also high.

Validation d’un modèle de déterminants psychosociaux de la santé au travail de l’infirmière en gériatrie

The purpose of this study was to verify a model of relationships between psychosocial factors and health for 8066 francophone nurses working in geriatric care in Québec. A random sample of 1990 subjects was drawn and a participation rate of 77.9% and 55% was obtained for the two-time study taken twelve months apart. Based on the theory of Maddi and Kobasa (1984), the model was reproduced for the two-time periods with the aid of structural equations. The analyses showed that three variables exert a direct influence on psychological distress: professional burnout, occupational stressors and hardiness. Also, variables have a direct effect on burnout: listed in order of importance, these are hardiness, occupational stressors, work support, active strategies of coping and employment status. In dealing with the work stressors, the nurses who are hardy make use of active strategies of coping and look for support form their colleagues. The results of the study help to better understand the psychological and social resources that best favor adaptation of working women in highly demanding work environments. The fallout of the study converges towards the quality of life of helping professionals and towards the cost and quality of health and social services.

Detecting local regions of change in high-dimensional criminal or terrorist point processes

A method is presented for detecting changes to the distribution of a criminal or terrorist point process between two time periods using a non-model-based approach. By treating the criminal/terrorist point process as an intelligent site selection problem, changes to the process can signify changes in the behavior or activity level of the criminals/terrorists. The locations of past events and an associated vector of geographic, environmental, and socio-economic feature values are employed in the analysis. By modeling the locations of events in each time period as a marked point process, we can then detect differences in the intensity of each component process. A modified PRIM (patient rule induction method) is implemented to partition the high-dimensional feature space, which can include mixed variables, into the most likely change regions. Monte Carlo simulations are easily and quickly generated under random relabeling to test a scan statistic for significance. By detecting local regions of change, not only can it be determined if change has occurred in the study area, but the specific spatial regions where change occurs is also identified. An example is provided of breaking and entering crimes over two-time periods to demonstrate the use of this technique for detecting local regions of change. This methodology also applies to detecting regions of differences between two types of events such as in case–control data.

A method for estimating long-range power law correlations from the electroencephalogram

Recent research has found long-range electroencephalogram (EEG) power law correlations, indicating time scale invariance. However, the EEG is also rather noisy, displaying short-term decorrelation like white noise—i.e., what is scale invariant at one time period may disappear in the next. The paradoxical combination of short-range divergence, but long-range correlations, suggests that any long-range correlations detected in one sample may be spurious, since they could be related to amplitude fluctuations. To overcome this problem, this paper suggests a new technique for analysing EEG signals segmented by zero-crossings, using detrended fluctuation analysis (DFA), evaluated across two time periods (TIME) and different sites (SITE). A mean scaling exponent across all subjects and sites of α=0.67 was observed. MANOVA analysis indicates no significant main effect for TIME or interaction with SITE, suggesting that the zero-crossing method may be successful in determining the fractal nature of EEG dynamics across relatively long time scales.

Rectal cancer in Luxembourg : a national population-based data report, 1988-1998.

BackgroundMorphologic criteria which might help to support the need for a preventive strategy for early detection of rectal cancer were analysed. Population-based data on rectal adenomas with high-grade dysplastic changes (n = 199) and invasive adenocarcinomas (n = 912) registered by the national Morphologic Tumour Registry (MTR) and diagnosed in a central department of pathology in Luxembourg between 1988 and 1998 were considered.MethodsThe analysis concerned time trends in frequency, crude incidence, tumour-stage, the rectal "high-grade" adenoma/invasive adenocarcinoma-ratio and the survival rates. Histopathological tumour-stage parameters (UICC/AJCC, 1997) in a consecutive series of 641 resected rectal cancers and their relationship with the observed patient survival are investigated.ResultsThe majority of invasive adenocarcinomas are diagnosed at a late stage (i.e. Stage II and III) into contrast with the highly significant increase (355 %) in frequency of rectal high-grade adenomas (Stage 0). During the two-time periods 1988–1992 and 1994–1998 Stage I and Stage IV-cases decreased by 11 % and 47 % respectively. Tumour-stage correlates with prognosis. The rectal high-grade adenoma / invasive adenocarcinoma-ratio improved significantly over the last five years.ConclusionOver the study period, there has been a highly significant rise in the incidence of resected rectal adenomas with high-grade intraepithelial neoplasia. The ratio of early tumours to invasive cancers has risen while the numbers of colonoscopies and rectoscopies remained unchanged respectively decreased. As the number of advanced tumour-stages remained stable, mass-screening procedures focusing on the fifty to sixty age group should be reinforced.

Potential use of human urine by greenhouse culturing of microalgae ( Scenedesmus acuminatus), zooplankton ( Daphnia magna) and tomatoes ( Lycopersicon)

The green algae Scenedesmus acuminatus was cultured in three different media: urine (2%), ±trace elements (Fe 3+ and Mg 2+) and an artificial culture medium (MBL) with three inoculum densities (2.5, 5 and 10%). Initially (0–3 days) algal biomass was higher in urine compared to MBL medium, but after 10 days the algal biomass was higher in MBL. The resulting algal solution was either used directly or diluted (two and four times), before the Daphnia magna were added. No Daphnia survived in 2% urine algal solution and survival was reduced to about 50% in the 1% solution. However, both survival and reproduction was good in the 0.5% solution, and the first neonates appeared after 8 days. The decrease in algal growth after 3 days and the toxicity of undiluted urine algal solutions may be due to ammonia toxicity. When the experiment was terminated after 10 days Daphnia survival was better in MBL algal solutions, but reproduction was poorer than in the urine solutions. These laboratory results were used as a pilot study for a stepwise culture of green algae, zooplankton and tomatoes in a greenhouse experiment (total volume of 130 l) in two-time periods from May to August, 114 days (LTT) and from September to October, 30 days (STT). The retention times were 26 days (LTT) and 22 days (STT), respectively. The mean algal biomass was 133±82 mg dw l −1 in the LTT and 39±17 mg dw l −1 in the STT, and the final concentration of Daphnia was 34.3±30.3 mg dw l −1 after LTT and 39.8±27.3 mg dw l −1 after the STT (mean±SD; n=4). A total weight of 1.3 kg tomatoes was harvested from eight plants (two plants per replicate). A reduction of nutrients (N and P) in the water from this constructed food chain was observed, but further investigations are needed to clarify total nutrient recovery from this system. Results suggest that it would be possible to use an aquaculture approach and recycle nutrients from human urine by using a constructed food chain.

1071732 AD-A142 532/1 PRISM: A practical real-time imaging stereo matcher: (Memorandum rept.) Nishihara, H.K. Massachusetts Inst. of Tech. Cambridge, MA. Artificial Intelligence Lab.

Recent research has found long-range electroencephalogram (EEG) power law correlations, indicating time scale invariance. However, the EEG is also rather noisy, displaying short-term decorrelation like white noise—i.e., what is scale invariant at one time period may disappear in the next. The paradoxical combination of short-range divergence, but long-range correlations, suggests that any long-range correlations detected in one sample may be spurious, since they could be related to amplitude fluctuations. To overcome this problem, this paper suggests a new technique for analysing EEG signals segmented by zero-crossings, using detrended fluctuation analysis (DFA), evaluated across two time periods (TIME) and different sites (SITE). A mean scaling exponent across all subjects and sites of α=0.67 was observed. MANOVA analysis indicates no significant main effect for TIME or interaction with SITE, suggesting that the zero-crossing method may be successful in determining the fractal nature of EEG dynamics across relatively long time scales.