49,763 research outputs found

    Aspectos cl铆nicos de la COVID-19

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    La transmisi贸n del SARS-CoV-2 generalmente ocurre por gotitas respiratorias de diferente tama帽o. Los s铆ntomas de presentaci贸n suelen incluir fiebre, tos, astenia, mialgia o disnea. La mayor铆a de las personas infectadas son asintom谩ticas o tienen una enfermedad leve, pero una minor铆a desarrolla insuficiencia respiratoria progresiva que requiere hospitalizaci贸n y soporte respiratorio. El tratamiento es fundamentalmente de soporte, sin embargo, en pacientes hospitalizados, algunos agentes antivirales directos (administrados durante los primeros d铆as de la infecci贸n) y el tratamiento inmunomodulador con esteroides y bloqueadores de citocinas (en el periodo de hiperinflamaci贸n), pueden mejorar el pron贸stico. No obstante, se necesitan nuevas mol茅culas antivirales frente a SARS-CoV-2, con buena tolerancia y que se puedan administrar por v铆a oral, para evitar la progresi贸n de la enfermedad, prevenir el contagio en pacientes de riesgo y cortar la cadena de transmisi贸n. La duraci贸n exacta de la inmunidad despu茅s de la infecci贸n natural o la vacunaci贸n a煤n espera un estudio de seguimiento a largo plazo. Despu茅s de una COVID aguda, un n煤mero significativo de pacientes desarrollan diversos s铆ntomas persistentes que, en la mayor铆a de personas, mejoran espont谩neamente a lo largo de las semanas o meses siguientes. La pandemia de COVID-19 ha provocado millones de infecciones en todo el mundo, con morbi-mortalidad significativa, y generado una tensi贸n extrema en los sistemas sanitarios y econ贸micos. La buena noticia es la aparici贸n de vacunas muy eficaces que est谩n ayudando a controlar la enfermedad en pa铆ses desarrollados; de su implementaci贸n masiva durante los pr贸ximos meses, incluyendo a los pa铆ses con menos recursos, va a depender el control adecuado de esta pandemia

    Women鈥檚 Experiences of Accessing Breastfeeding and Perinatal Health Support in the Context of Intimate Partner Violence: An Interpretive Description Study

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    Background: Women experiencing intimate partner violence are at a heightened risk of negative perinatal and breastfeeding outcomes. This study explored the experiences of accessing breastfeeding support for women who endorse a history of intimate partner violence. A study of five in-depth semi-structured interviews were completed at 12-weeks postpartum with breastfeeding mothers with a history of intimate partner violence. Findings: Women expressed difficulties in accessing a healthcare provider who had specialized skill in breastfeeding support. Trust in their healthcare provider, built through displays of compassion and competence, was important to mitigate obstacles experienced during care access for this population. Trauma-and-violence-informed care principles were beneficial to the development of the therapeutic relationship in perinatal care. Women placed value on breastfeeding support received from both healthcare providers and social supports, which impacted mothers鈥 perceived breastfeeding support and self-efficacy. Further, mothers described increased levels of breastfeeding self-efficacy after engaging in a trauma-and-violence-informed care program aimed at supporting breastfeeding. Conclusions: Trauma-informed care may aid in the development of trust in the therapeutic relationship, which in turn impacts access to breastfeeding support and breastfeeding self-efficacy. The inclusion of trauma-and-violence informed principles in perinatal care may be effective at mitigating barriers to access for women who endorse a history of intimate partner violence. health care on how to employ trauma-informed breastfeeding care to may lead to better support for this population

    Exploring the effects of spinal cord stimulation for freezing of gait in parkinsonian patients

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    Dopaminergic replacement therapies (e.g. levodopa) provide limited to no response for axial motor symptoms including gait dysfunction and freezing of gait (FOG) in Parkinson鈥檚 disease (PD) and Richardson鈥檚 syndrome progressive supranuclear palsy (PSP-RS) patients. Dopaminergic-resistant FOG may be a sensorimotor processing issue that does not involve basal ganglia (nigrostriatal) impairment. Recent studies suggest that spinal cord stimulation (SCS) has positive yet variable effects for dopaminergic-resistant gait and FOG in parkinsonian patients. Further studies investigating the mechanism of SCS, optimal stimulation parameters, and longevity of effects for alleviating FOG are warranted. The hypothesis of the research described in this thesis is that mid-thoracic, dorsal SCS effectively reduces FOG by modulating the sensory processing system in gait and may have a dopaminergic effect in individuals with FOG. The primary objective was to understand the relationship between FOG reduction, improvements in upper limb visual-motor performance, modulation of cortical activity and striatal dopaminergic innervation in 7 PD participants. FOG reduction was associated with changes in upper limb reaction time, speed and accuracy measured using robotic target reaching choice tasks. Modulation of resting-state, sensorimotor cortical activity, recorded using electroencephalography, was significantly associated with FOG reduction while participants were OFF-levodopa. Thus, SCS may alleviate FOG by modulating cortical activity associated with motor planning and sensory perception. Changes to striatal dopaminergic innervation, measured using a dopamine transporter marker, were associated with visual-motor performance improvements. Axial and appendicular motor features may be mediated by non-dopaminergic and dopaminergic pathways, respectively. The secondary objective was to demonstrate the short- and long-term effects of SCS for alleviating dopaminergic-resistant FOG and gait dysfunction in 5 PD and 3 PSP-RS participants without back/leg pain. SCS programming was individualized based on which setting best improved gait and/or FOG responses per participant using objective gait analysis. Significant improvements in stride velocity, step length and reduced FOG frequency were observed in all PD participants with up to 3-years of SCS. Similar gait and FOG improvements were observed in all PSP-RS participants up to 6-months. SCS is a promising therapeutic option for parkinsonian patients with FOG by possibly influencing cortical and subcortical structures involved in locomotion physiology

    Balancing the urban stomach: public health, food selling and consumption in London, c. 1558-1640

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    Until recently, public health histories have been predominantly shaped by medical and scientific perspectives, to the neglect of their wider social, economic and political contexts. These medically-minded studies have tended to present broad, sweeping narratives of health policy's explicit successes or failures, often focusing on extraordinary periods of epidemic disease viewed from a national context. This approach is problematic, particularly in studies of public health practice prior to 1800. Before the rise of modern scientific medicine, public health policies were more often influenced by shared social, cultural, economic and religious values which favoured maintaining hierarchy, stability and concern for 'the common good'. These values have frequently been overlooked by modern researchers. This has yielded pessimistic assessments of contemporary sanitation, implying that local authorities did not care about or prioritise the health of populations. Overly medicalised perspectives have further restricted historians' investigation and use of source material, their interpretation of multifaceted and sometimes contested cultural practices such as fasting, and their examination of habitual - and not just extraordinary - health actions. These perspectives have encouraged a focus on reactive - rather than preventative - measures. This thesis contributes to a growing body of research that expands our restrictive understandings of pre-modern public health. It focuses on how public health practices were regulated, monitored and expanded in later Tudor and early Stuart London, with a particular focus on consumption and food-selling. Acknowledging the fundamental public health value of maintaining urban foodways, it investigates how contemporaries sought to manage consumption, food production waste, and vending practices in the early modern City's wards and parishes. It delineates the practical and political distinctions between food and medicine, broadly investigates the activities, reputations of and correlations between London's guild and itinerant food vendors and licensed and irregular medical practitioners, traces the directions in which different kinds of public health policy filtered up or down, and explores how policies were enacted at a national and local level. Finally, it compares and contrasts habitual and extraordinary public health regulations, with a particular focus on how perceptions of and actual food shortages, paired with the omnipresent threat of disease, impacted broader aspects of civic life

    Uso de las histonas circulantes y sus modificaciones post-traduccionales como biomarcadores en sepsis y shock s茅ptico

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    La sepsis es una afecci贸n potencialmente mortal causada por una respuesta anormal del hu茅sped a una infecci贸n, produciendo respuestas fisiol贸gicas alteradas que da帽an los propios tejidos del paciente y pueden provocar disfunci贸n org谩nica e incluso la muerte. Asimismo, algunos pacientes s茅pticos progresan a shock s茅ptico, caracterizado por alteraciones circulatorias, celulares y metab贸licas sustanciales que aumentan el riesgo de mortalidad. A pesar de que la sepsis se caracteriza por un mal funcionamiento del sistema inmunol贸gico, lo que a su vez conduce a una respuesta inmune alterada e inmunosupresi贸n, la alta complejidad de la fisiopatolog铆a de la sepsis requiere una mayor investigaci贸n para comprender las respuestas inmunes que ocurren durante la sepsis. Asimismo, las histonas extracelulares circulantes han ganado relevancia como mediadores citot贸xicos en la sepsis, ya que act煤an como patrones moleculares asociados a da帽o, que inducen estr茅s oxidativo y activan el inflamasoma NLRP3. Estos mecanismos median la activaci贸n de la piroptosis, un mecanismo de muerte celular programada que produce inflamaci贸n mediante la expresi贸n de IL-18, IL-1尾 and IL-1伪. Sin embargo, a pesar de la evidencia de activaci贸n del inflamasoma en las c茅lulas inmunes durante la sepsis, se desconoce si las histonas extracelulares son capaces de activar los inflamasomas endoteliales y sus consecuencias. En este trabajo destacamos el papel previamente desconocido de las histonas extracelulares, mediando la activaci贸n del inflamasoma NLRP3 y la piroptosis en las c茅lulas endoteliales, contribuyendo a la disfunci贸n endotelial y la desregulaci贸n de la respuesta inmune mediada por el endotelio. Asimismo, tambi茅n demostramos c贸mo la acetilaci贸n de histonas disminuye la activaci贸n de la piroptosis. Adem谩s, demostramos que la piroptosis se produce en pacientes con shock s茅ptico y los niveles de histonas circulantes se correlacionan con la expresi贸n de citoquinas proinflamatorias y citoquinas piropt贸ticas, la liberaci贸n de factores de adhesi贸n endotelial y la gravedad de la enfermedad. Proponemos la piroptosis mediada por histonas como un nuevo objetivo para desarrollar intervenciones cl铆nicas. De manera similar, hemos analizado las respuestas inmunorelacionadas que ocurren durante las primeras etapas de la sepsis con el objetivo de proporcionar nuevos datos comparando las cantidades de citoquinas, inmunomoduladores y otros mediadores endoteliales en pacientes cr铆ticamente enfermos no s茅pticos, s茅pticos y de shock s茅ptico. Nuestro enfoque ayudar谩 a caracterizar r谩pidamente las respuestas inmunes alteradas en pacientes s茅pticos y de shock s茅ptico ingresados en la Unidad de Cuidados Intensivos. Finalmente analizamos el papel de la metilaci贸n del ADN en el control del sistema inmune s茅ptico. Nuestros resultados demostraron el papel central de la metilaci贸n del ADN modulando la respuesta molecular en los pacientes de shock s茅ptico y contribuyendo a la inmunosupresi贸n, a trav茅s de la alteraci贸n de los patrones de metilaci贸n de los promotores de IL-10 y TREM-2.Sepsis is a life-threatening condition caused by an abnormal host response to an infection that produce altered physiological responses which damages own tissues of the patient and can result in organ dysfunction and in some cases death. Likewise, a subset of septic patients progresses to septic shock, characterized by substantial circulatory, cellular and metabolic abnormalities, which substantially increase the risk of mortality. Sepsis is characterized by a malfunction of the immune system and it can lead to an altered immune response and immunosuppression. Moreover, the high complexity of the pathophysiology of sepsis requires of further investigation to characterize the immune responses in sepsis and septic shock. Likewise, circulating extracellular histones have gained relevance as cytotoxic mediators in sepsis pathophysiology, since they act as damage-associated molecular patterns, which induce oxidative stress and activate NLRP3 inflammasome. Subsequently, inflammasome mediates pyroptosis activation, a programmed cell death mechanism that produces inflammation through the release of IL-18, IL-1尾 and IL-1伪. However, despite inflammasome activation may occur in immune cells during sepsis, it is unknown if this process also takes place in endothelial cells and particularly whether extracellular histones are capable of activating endothelial inflammasomes and their consequences. In this work we highlight a previously unknown role for extracellular histones, that mediates the activation of NLRP3 inflammasome and pyroptosis in endothelial cells by contributing to endothelial dysfunction and the dysregulation of the immune response mediated by endothelium. Likewise, we demonstrated how histone acetylation decreases pyroptosis activation. Furthermore, we show how pyroptosis occurs in septic shock patients and how circulating histone levels correlate with the expression of pro-inflammatory and pyroptotic cytokines, the release of endothelial adhesion factors and septic shock severity. We propose histone-mediated pyroptosis as a new target to develop clinical interventions. Similarly, we have analyzed the immune-related responses occurring during the early stages of sepsis with the aim of providing new data by comparing the amounts of cytokines, immune modulators and other endothelial mediators in critically-ill non-septic patients, septic and septic shock patients. Our approach will help to rapidly characterize the altered immune responses in septic and septic shock patients admitted in the Intensive Care Unit. Finally, we also analyzed the role of DNA methylation in the control of septic immune system. Our results demonstrated the central role of DNA methylation modulating the molecular response in septic shock patients and contributing to immunosuppression, through the alteration of DNA methylation patterns of IL-10 and TREM2 promoters

    Conservation agriculture affects grain and nutrient yields of Maize (Zea Mays L.) and can impact food and nutrition security in Sub-Saharan Africa

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    Maize is a major staple and plays an essential role in food and nutrition security in Sub-Saharan Africa (SSA). Conservation agriculture (CA), a climate-smart agriculture practise based on minimum soil disturbance, crop residue retention, and crop diversification, has been widely advocated but without extensive research on the impact it may have on maize nutrient composition, and food and nutrition security. This study assessed the grain yield, macro- and micronutrient mineral content, and nutrient yield of eight maize varieties grown in Malawi, and how these are affected by CA practises over two seasons. The minerals were analysed by inductively coupled plasma (ICP) coupled to optical emission spectroscopy (OES) and to mass spectroscopy (MS). Grain yield and Se content differed among the varieties, while C, N, Fe, K, Mg, Mn, P, and Zn were similar. The local variety Kanjerenjere showed lowest grain and nutrient yields. The open-pollinated varieties (OPVs) concentrated more minerals than the F1 hybrids, but the latter showed higher yields for both grain and nutrients. Typical consumption of the eight maize varieties could fully meet the protein and Mg dietary reference intake (DRIs) of Malawian children (1鈥3 years), as well as Mg and Mn needs of adult women (19鈥50 years), but their contribution to dietary requirements was low for Fe (39鈥41%) and K (13鈥21%). The trials showed that CA increased grain yield (1.2- to 1.8-fold) and Se content (1.1- to 1.7-fold), but that it had no effect on C, K, Mg, P, and Zn, and that N (1.1- to 1.2-fold), Mn (1.1- to 1.8-fold), and Fe (1.3- to 3.4-fold) were reduced. The high increase in grain yield under CA treatments resulted in increased yields of protein and Se, no effect on the yields of K, Mg, Mn, P, Zn, and reduced Fe yield. Conservation agriculture could contribute in reducing the risk of Se deficiency in Malawian women and children but exacerbates the risk of Fe deficiency. A combination of strategies will be needed to mitigate some of the foreseen effects of climate change on agriculture, and food and nutrition security, and improve nutrient intake

    The applied psychology of addictive orientations : studies in a 12-step treatment context.

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    The clinical data for the studies was collected at The PROMIS Recovery Centre, a Minnesota Model treatmentc entre for addictions,w hich encouragesth e membership and use of the 12 step Anonymous Fellowships, and is abstinence based. The area of addiction is contextualised in a review chapter which focuses on research relating to the phenomenon of cross addiction. A study examining the concept of "addictive orientations" in male and female addicts is described, which develops a study conductedb y StephensonM, aggi, Lefever, & Morojele (1995). This presents study found a four factor solution which appeared to be subdivisions of the previously found Hedonism and Nurturance factors. Self orientated nurturance (both food dimensions, shopping and caffeine), Other orientated nurturance (both compulsive helping dimensions and work), Sensation seeking hedonism (Drugs, prescription drugs, nicotine and marginally alcohol), and Power related hedonism (Both relationship dimensions, sex and gambling. This concept of "addictive orientations" is further explored in a non-clinical population, where again a four factor solution was found, very similar to that in the clinical population. This was thought to indicate that in terms of addictive orientation a pattern already exists in this non-clinical population and that consideration should be given to why this is the case. These orientations are examined in terms of gender differences. It is suggested that the differences between genders reflect power-related role relationships between the sexes. In order to further elaborate the significance and meaning behind these orientations, the next two chapters look at the contribution of personality variables and how addictive orientations relate to psychiatric symptomatology. Personality variables were differentially, and to a considerable extent predictably involved with the four factors for both males and females.Conscientiousness as positively associated with "Other orientated Nurturance" and negatively associated with "Sensation seeking hedonism" (particularly for men). Neuroticism had a particularly strong association with the "Self orientated Nurturance" factor in the female population. More than twice the symptomatology variance was explained by the factor scores for females than it was for males. The most important factorial predictors for psychiatric symptomatology were the "Power related hedonism" factor for males, and "Self oriented nurturance" for females. The results are discussed from theoretical and treatment perspectives

    Proyecto Sinf铆n

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    El proyecto 鈥淪inf铆n鈥 aborda el tema de la relaci贸n entre mejores amigas, un tema cuyo tratamiento previo es casi nulo, pero es algo que observamos a nuestro alrededor siempre. Esto es lo que motiv贸 principalmente el desarrollo de este trabajo, con el que se busc贸 comprender los sentimientos y motivaciones de este tipo de relaci贸n, a trav茅s de las similitudes que se encontr贸 en las amistades de las realizadoras del proyecto. A lo que se sumaron las ideas que Arist贸teles se帽alaba y que buscaban describir el proceso de la amistad. As铆, se observa c贸mo el cortometraje va desde el recuerdo de c贸mo surge nuestra primera amistad, c贸mo avanza hacia el intentar comprender las razones por las cuales una amistad permanece, y finalmente c贸mo se enfrenta a complicaciones que ponen en riesgo la continuidad de la amistad. Fue esto lo que brind贸 una estructura para la narraci贸n del cortometraje, que se construye a trav茅s de recuerdos y el intento de explicar la raz贸n detr谩s de escoger una mejor amiga. Con esto, el espectador podr谩 ser parte de est谩 introspecci贸n que posteriormente podr谩 conectar con sus propias vivencias, logrando que se desarrolle una reflexi贸n acerca de las relaciones de amistad que cada quien mantiene y la profundidad que las define.The 鈥淪inf铆n鈥 project addresses the issue of the relationship between best friends, a subject whose previous treatment is almost nil, but it is something that we always observe around us. This is what mainly motivated the development of this work, which sought to understand the feelings and motivations of this type of relationship, through the similarities found in the friendships of the project's creators. To which were added the ideas that Aristotle pointed out and that sought to describe the process of friendship. Thus, it is observed how the short film goes from the memory of how our first friendship arises, how it progresses towards trying to understand the reasons why a friendship remains, and finally how it faces complications that put the continuity of the friendship at risk. It was this that provided a structure for the narration of the short film, which is built through memories and the attempt to explain the reason for choosing a best friend. With this, the viewer will be able to be part of this introspection that will later be able to connect with their own experiences, achieving a reflection about the friendship relationships that each one maintains and the depth that define them.Trabajo de investigaci贸

    Cirug铆a ambulatoria: estudio de la morbilidad tard铆a

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    La cirug铆a ambulatoria es una actividad rutinaria de la mayor铆a de los hospitales de nuestro pa铆s. Su implantaci贸n y desarrollo en los 煤ltimos a帽os ha supuesto una soluci贸n para los grandes retos de la asistencia sanitaria actual, permitiendo reducir considerablemente la lista de espera quir煤rgica bajo criterios de calidad, eficiencia y seguridad. Uno de los aspectos con mayor oportunidad de mejora es el control postoperatorio domiciliario en la fase tard铆a de la recuperaci贸n, especialmente m谩s all谩 de las 24 horas tras la intervenci贸n. El m茅todo m谩s utilizado actualmente en Espa帽a para la evaluaci贸n del estado domiciliario es la entrevista telef贸nica estandarizada. Esta herramienta es 煤til para resolver gran n煤mero de complicaciones; sin embargo, cuando esto no es posible, se remite al paciente a los servicios de urgencias. El an谩lisis cuantitativo y cualitativo de las visitas a urgencias y los reingresos son sucesos objetivos a partir de los cuales identificar factores que puedan alterar la calidad en el postoperatorio y est谩n reconocidos por los organismos oficiales nacionales e internacionales como indicadores de calidad de la asistencia en cirug铆a ambulatoria. En nuestro pa铆s carecemos de estudios que eval煤en el porcentaje de visitas a urgencias como complicaci贸n en el postoperatorio de cirug铆a ambulatoria y existe poca literatura respecto a los reingresos. A nivel internacional, el porcentaje de visitas a urgencias var铆a entre 0.62% y 3.18% y el porcentaje de reingresos se sit煤a entre 0.10% y 2.5%. Llama la atenci贸n la gran variabilidad en los resultados de los diferentes trabajos y la ausencia de criterios de medida homog茅neos entre los diferentes estudios. El objetivo principal de este trabajo es conocer el porcentaje de visitas a urgencias y de reingresos relacionados con la intervenci贸n quir煤rgica tras cirug铆a ambulatoria en el Hospital Universitari i Polit猫cnic La Fe en el a帽o 2014. Los objetivos secundarios son: - Conocer las principales causas de visitas a urgencias y de reingresos relacionados con la intervenci贸n quir煤rgica tras cirug铆a ambulatoria en el Hospital La Fe. - Describir los motivos de la visita a urgencias en los 20 procedimientos de cirug铆a ambulatoria m谩s frecuentes en el Hospital La Fe. - Conocer el tiempo transcurrido en d铆as desde la intervenci贸n hasta que los pacientes acuden a urgencias o reingresan por motivo relacionado con la intervenci贸n. - Describir los procedimientos de cirug铆a ambulatoria del Hospital La Fe donde existe mayor probabilidad de que se produzca una visita a urgencias tras el alta a domicilio. - Describir las variables del paciente y de la intervenci贸n que influyen en el tiempo que se tarda en acudir a urgencias tras el alta a domicilio. - Analizar estad铆sticamente la relaci贸n entre la probabilidad de acudir a urgencias despu茅s del alta domiciliaria con variables perioperatorias como el score telef贸nico, el ASA, el sexo, la edad, la duraci贸n de la intervenci贸n, el tiempo de estancia en la UCSI y el tipo de anestesia. METODOLOG脥A: Se realiz贸 un estudio retrospectivo observacional anal铆tico de casos-controles, con pacientes intervenidos en la UCSI del Hospital La Fe de Valencia. Se incluyeron los datos de todos los episodios quir煤rgicos de pacientes mayores de 15 a帽os, intervenidos en el a帽o 2014 por especialidad quir煤rgica y procedimiento mayor, que se dieron de alta a domicilio el mismo d铆a de la intervenci贸n. Se clasificaron en casos o controles seg煤n presentaran o no respectivamente visita a urgencias en los 30 d铆as posteriores, por motivo relacionado con la intervenci贸n. Este trabajo ha sido posible gracias a la colaboraci贸n de los servicios de documentaci贸n cl铆nica y sistemas de la informaci贸n. A partir de la base de datos del CMBD de los pacientes sometidos a cirug铆a ambulatoria en 2014 se obtuvo informaci贸n sobre 11093 episodios quir煤rgicos codificados. Esa base de datos se cruz贸 con el programa inform谩tico Access con otra base de datos a partir del programa Mizar, que recog铆a los pacientes mayores de 15 a帽os sometidos a cirug铆a ambulatoria en 2014 que hab铆an acudido a urgencias en los 30 d铆as posteriores a la intervenci贸n y en la cual aparecen 1049 pacientes. Una vez eliminados los registros que cumpl铆an los criterios de exclusi贸n se obtuvo una base de datos con 5420 registros de episodios quir煤rgicos con o sin urgencias correspondientes a 4693 pacientes. En la base de datos obtenida se distinguen dos grupos en funci贸n de si se ha producido o no visita a urgencias, de forma que existe un grupo con episodios de urgencias y otro grupo control sin episodios de urgencias. Cada paciente puede tener uno o varios episodios quir煤rgicos y a su vez cada episodio quir煤rgico puede no tener o tener uno o m谩s episodios de urgencias. Para cada episodio se han recogido los siguientes datos: n煤mero de historia del paciente (cifrada y anonimizada), n煤mero de episodio quir煤rgico, presencia de episodio de urgencias, edad, sexo, grado ASA, grado de agresi贸n quir煤rgica (ASI), fecha de intervenci贸n, especialidad, diagn贸stico, procedimiento, tipo de anestesia, duraci贸n de la intervenci贸n, tiempo de estancia en UCSI, score telef贸nico, fecha de visita a urgencias, motivo de visita a urgencias, destino del paciente. Para el an谩lisis de los datos recogidos se emple贸 el programa inform谩tico R. La mayor铆a de los objetivos se resolv铆an con estad铆sticos descriptivos. Se aplicaron modelos estad铆sticos para resolver los dos 煤ltimos objetivos. El primer modelo estad铆stico se refiere a la variable respuesta 鈥淭iempo Urgencias鈥, que sigue una distribuci贸n log normal. As铆 pues, se ha creado un modelo de regresi贸n lineal con la variable respuesta transformada mediante el logaritmo, incluyendo las variables SCORE, ASA, estancia UCSI, edad, y duraci贸n de la intervenci贸n para ver qu茅 efecto tienen en el tiempo que tardan los pacientes en acudir a urgencias. En segundo lugar, se ha creado un modelo de regresi贸n binomial para predecir la probabilidad de que vayan a urgencias en funci贸n de variables como el score telef贸nico, el ASA, el sexo, la duraci贸n de la intervenci贸n, la edad, el tipo de anestesia y el tiempo de estancia en la UCSI. Se obtienen los p-valores y los intervalos de confianza al 95%. RESUMEN DE LOS RESULTADOS: De los 5420 episodios que conforman la muestra, 677 tuvieron visita a urgencias y 4743 no la tuvieron. Ello supone un porcentaje global de visitas a urgencias del 12.5%. De los 677 episodios de urgencias 74 episodios tuvieron como destino la hospitalizaci贸n y 603 fueron remitidos al domicilio; por tanto, el porcentaje de reingresos global ha sido del 1.36%. Las causas de las visitas a urgencias han sido por este orden: infecci贸n (17.3%), motivo m茅dico (16.5%), sangrado (15.7%), dolor (13.4%), alteraci贸n de la herida (8.1%), medidas higi茅nico-diet茅ticas (7.5%), edema (7.4%), hipertensi贸n ocular (4.4%), retenci贸n urinaria (2.7%), reacci贸n adversa medicamentosa (2.4%), alteraci贸n de la visi贸n (1.8%), trombosis (1.2%), ansiedad (0.7%), n谩useas y v贸mitos (0.7%), anestesia (0.1%). Las causas de los reingresos han sido por este orden: motivo m茅dico (43.55%); infecci贸n (30.6%); alteraci贸n de la herida (6.45%); sangrado y dolor (4.8%); anestesia, retenci贸n urinaria, reacci贸n adversa medicamentosa y n谩useas y v贸mitos (1.6%). La edad media de los pacientes es de 57.17 a帽os, el sexo de los pacientes es femenino en un 48.9% y masculino en un 51.1%, la duraci贸n de la intervenci贸n media es de 54.16 minutos, la estancia en UCSI media es de 313.88 minutos. El estado f铆sico de los pacientes medido por la clasificaci贸n ASA es de 1 en un 24%, de 2 en un 36%, de 3 en un 9%, de 4 en un 1%, y ausente en 30%. Los procedimientos m谩s frecuentes son: cataratas, extracci贸n de ureterostom铆a, biopsia de pr贸stata transrectal, fleboextracci贸n de varices, cateterismo ureteral, procedimiento de pies, circuncisi贸n, vasectom铆a, t煤nel carpiano, cistoscopia, exodoncia, excisi贸n de lesi贸n mamaria, turbinectom铆a de cornetes, colecistectom铆a laparosc贸pica, excisi贸n de lesi贸n uterina, vitrectom铆a, meniscectom铆a artrosc贸pica, realizaci贸n de f铆stula arteriovenosa, hemorroidectom铆a, sustituci贸n de nefrostom铆a. El tiempo medio en acudir a urgencias es de 10.96 d铆as. El mayor n煤mero de registros de visitas a urgencias se produce en los cuatro d铆as posteriores a la intervenci贸n, siendo el d铆a 1 de postoperatorio el que mayor frecuentaci贸n presenta. El 52% de las visitas a urgencias en 30 d铆as se producen a partir del octavo d铆a postoperatorio. Aunque va disminuyendo progresivamente su asiduidad, siguen registr谩ndose visitas a urgencias hasta el d铆a 30 tras la cirug铆a. El tipo de anestesia m谩s frecuentemente empleada es la sedaci贸n (41.6%), seguida de la anestesia general (23.8%), anestesia oft谩lmica (20.6%), bloqueo nervioso perif茅rico (10.1%), bloqueo nervioso central o neuroaxial (1.9%), sin anestesia (1.5%) y combinada (general m谩s locorregional, 0.6%). Los motivos de acudir a urgencias en los 20 procedimientos m谩s frecuentes siguen el mismo orden que en el an谩lisis global: infecci贸n, motivo m茅dico, sangrado, dolor, alteraci贸n de la herida, medidas higi茅nico-diet茅ticas, edema, hipertensi贸n ocular, retenci贸n urinaria, reacci贸n adversa medicamentosa, alteraci贸n de la visi贸n, trombosis, ansiedad, n谩useas y v贸mitos, anestesia. Los procedimientos con mayor probabilidad de acudir a urgencias son: f铆stula arteriovenosa (0.30), vitrectom铆a (0.24), hemorroidectom铆a (0.22), sustituci贸n de nefrostom铆a (0.16), colecistectom铆a laparosc贸pica (0.14) y cataratas (0.14). La influencia de variables en el tiempo en acudir a urgencias ha resultado ser: - El score telef贸nico alto se relaciona con un tiempo en acudir a urgencias mayor. - Apenas se presenta variaci贸n en el tiempo en ir a urgencias en funci贸n de la clasificaci贸n ASA. Los pacientes ASA 4 presentan un rango de tiempo m谩s amplio en las visitas a urgencias. - La edad, la duraci贸n de la intervenci贸n y el tiempo de estancia en UCSI no influyen de manera significativa en el tiempo en acudir a urgencias. El modelo realizado para predecir la probabilidad de que el paciente acuda a urgencias en funci贸n de diferentes variables no ha superado la validaci贸n. Esto significa que los resultados no son estad铆sticamente significativos, aunque s铆 tengan valor descriptivo. - El score telef贸nico alto reduce la probabilidad de acudir a urgencias (p <0.001). - El grado de clasificaci贸n ASA alto aumenta la probabilidad de ir a urgencias pero no de forma significativa (p=0.15). - El sexo no tiene influencia significativa (p=0.88). - La variable edad est谩 cerca del umbral de significaci贸n, existiendo mayor probabilidad de ir a urgencias en pacientes j贸venes (p=0.072). - A mayor duraci贸n de la intervenci贸n y a mayor tiempo de estancia en la UCSI se da mayor probabilidad de acudir a urgencias (p=0.25 y p=0.025 respectivamente). - La variable 鈥渢ipo de anestesia鈥 ha sido significativa (p=0.002), con mayor probabilidad de acudir a urgencias en el bloqueo neuroaxial y la anestesia oft谩lmica. CONCLUSIONES La morbilidad tard铆a o domiciliaria detectada en este estudio a partir de las visitas a urgencias es mayor de la esperada y el tiempo en el que los pacientes acuden a urgencias es m谩s prolongado de lo previsto. Las causas por las que se acude a urgencias son similares a las descritas en la literatura. Sin embargo, el tipo de causa predominante es diferente dependiendo del procedimiento quir煤rgico realizado. En general la mayor铆a de visitas a urgencias se resuelven y no generan reingreso, por ello nuestra cifra de reingresos no es tan alta en comparaci贸n con otras publicaciones. Ser铆a conveniente analizar la morbilidad en muestras de poblaci贸n espec铆ficas por procedimiento; incluso dentro de las especialidades, existe diversidad en la agresi贸n quir煤rgica para cada tipo de intervenci贸n. Tambi茅n son diferentes las complicaciones seg煤n el momento del postoperatorio que nos encontremos; siendo el sangrado, el dolor y las NVPO m谩s probables en la primera semana, mientras que la causa m茅dica y las infecciones se pueden mantener elevadas hasta la cuarta semana despu茅s de la cirug铆a. La llamada telef贸nica reduce las visitas a urgencias, pero en pacientes seleccionados deber铆an a帽adirse nuevos controles m谩s tard铆os. A pesar de las limitaciones, los datos obtenidos en este trabajo son de utilidad para establecer puntos de referencia en la autoevaluaci贸n y mejora de la calidad asistencial de nuestros pacientes sometidos a cirug铆a ambulatoria.AMBULATORY SURGERY: STUDY OF HOME MORBIDITY Ambulatory surgery provides a solution to reduce surgical waiting lists but holding quality, efficiency and security criteria. Postoperative home control is a field that needs improvement. Emergency unit visits and readmissions are indicators recognized by official organisms for this stage of assistance. These events happen when telephone control cannot solve a complication. Our main objective is to know the rate of emergency visits and readmissions related to the procedure after 30 days of ambulatory surgery in Hospital La Fe during 2014. Secondary outcomes are to describe the reasons for those visits and readmissions, to describe how long it takes from the surgery to the visit, to see which procedures have more probability of going to emergency department and to investigate if there is any influence of perioperative variables in the time to the visit or in the probability for a visit. A retrospective case-control study was conducted. A cross-match of two hospital databases provided a sample of 5420 surgical episodes. Descriptive statistics, calculation of probabilities and two regression models (lineal and binomial) were used. Analysis was solved with the software R. The emergency visit rate was higher than expected (12.5%) and the time of the visit more prolonged (mean 10.96 days). The reasons for the visits were similar of those in the literature: infection (17.3%), medical condition (16.5%), bleeding (15.7%) and pain (13.4%). However, they had different distribution depending on type of surgery. Most of the emergency visits could be solved and did not cause readmission, so our readmission rate is more like previous studies (1.36%). It would be convenient to perform more exhaustive analysis, separated for each type of procedure given that even in the same specialty we see different levels of surgical harm. We also found different complications depending on the time after surgery: bleeding, pain and nausea were more probably the first week, while medical condition and infection remain higher until the fourth week. Telephone control reduces emergency visits but additional calls should be established after the first week in selected patients. Despite some limitations, this study is useful as a benchmark of self-assessment and healthcare quality improvement of our ambulatory surgery unit

    Recent Hong Kong cinema and the generic role of film noir in relation to the politics of identity and difference

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    This thesis identifies a connection in Hong Kong cinema with classical Hollywood film noir and examines what it will call a 'reinvestment' in film noir in recent films. It will show that this reinvestment is a discursive strategy that both engages the spectator-subject in the cinematic practice and disengages him or her from the hegemony of the discourse by decentring the narrative. The thesis argues that a cinematic practice has occurred in the recent reinvestment of film noir in Hong Kong, which restages the intertextual relay of the historical genre that gives rise to an expectation of ideas about social instability. The noir vision that is seen as related to the fixed categories of film narratives, characterizations and visual styles is reassessed in the course of the thesis using Derridian theory. The focus of analysis is the way in which the constitution of meanings is dependent on generic characteristics that are different. Key to the phenomenon is a film strategy that destabilizes, differs and defers the interpretation of crises-personal, social, political and/or cultural-by soliciting self-conscious re-reading of suffering, evil, fate, chance and fortune. It will be argued that such a strategy evokes the genre expectation as the film invokes a network of ideas regarding a world perceived by the audience in association with the noirish moods of claustrophobia, paranoia, despair and nihilism. The noir vision is thus mutated and transformed when the film device differs and defers the conception of the crises as tragic in nature by exposing the workings of the genre amalgamation and the ideological function of the cinematic discourse. Thus, noirishness becomes both an affect and an agent that contrives a self-reflexive re-reading of the tragic vision and of the conventional comprehension of reality within the discursive practice. The film strategy, as an agent that problematizes the film form and narrative, gives rise to what I call a politics of difference, which may also be understood as the Lyotardian 'language game' or a practice of 'pastiche' in Jameson's terminology. Under the influence of the film strategy, the spectator is enabled to negotiate his or her understanding of recent Hong Kong cinema diegetically and extra-diegetically by traversing different positions of cinematic identification. When the practice of genre amalgamation adopts the visual impact of the noirish film form, the film turns itself into a playing field of 'fatal' misrecognition or a site of question. Through cinematic identification and alienation from the identification, the spectator-subject is enabled to experience the misrecognition as the film slowly foregrounds the way in which the viewer's presence is implicated in the narrative. This thesis demonstrates that certain contemporary Hong Kong films introduce this selfconscious mode of explication and interpretation, which solicits the spectator to negotiate his or her subject-position in the course of viewing. The notions of identity and subjectivity under scrutiny will thus be reread. With reference to The Private Eye Blue, Swordsman II, City a/Glass and Happy Together, the thesis shall explore the ways in which the Hong Kong films enable and facilitate a negotiation of cultural identity
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