Assessment of the effectiveness of electronic gatekeeping as a utilization management tool at Groote Schuur Hospital

BACKGROUND: Utilization management ensures the appropriateness of laboratory testing by reducing the performance of tests which can be reasonably avoided with no adverse effects for the patient. Electronic gatekeeping, a utilization management tool, was introduced at Groote Schuur in 2010. Criteria were based on the minimum retesting interval, healthcare location, level of experience and discipline of the requesting clinician and specific ICD-10 codes. METHODS: A retrospective observational study assessing the effectiveness of electronic gatekeeping at Groote Schuur Hospital (Cape Town, South Africa), by comparing the test request volumes by using absolute test numbers and pre-defined ratios in the year prior to gatekeeping, to the two years following implementation. A secondary aim is to apply selected ratios to the other national academic hospitals to determine the potential for cost saving. RESULTS: At the medical wards of Groote Schuur Hospital there was an overall decrease in number and cost of tests of 24% per inpatient day for 2011. The most dramatic difference in cost is seen for chloride (91%) followed by HbA1c (90%), FT3 (89%) and CRP (82%). The application of ratios to Groote Schuur Hospital show a decrease in 2011 in all ratios apart from PCT: FBC+WCC (0.003 vs 0.002) and Mg: Ca (0.86 vs 0.84). AST: ALT remained the same at 0.55. This suggests overall effectiveness of the eGK rules although there is ongoing panel requesting. If the GSH eGK rules were to be applied at all other national academic hospitals, it could translate into a potential cost saving of $13 411 873.96 (R103 196 838.80) per annum. CONCLUSIONS: Electronic gatekeeping is an effective utilization management tool at Groote Schuur Hospital. It is relatively easy to implement and manage, and when combined with additional tools has the potential to result in larger reductions of unnecessary tests, cost savings and improved patient outcome

Politicising land subsidence in Jakarta: How land subsidence is the outcome of uneven sociospatial and socionatural processes of capitalist urbanization

Jakarta is sinking dramatically because of land subsidence, which in turn increases its vulnerability to tidal flooding. The explanation of land subsidence’s causes and the design of solutions is led by geoscientists and engineers, who tend to treat it as largely a technical problem. This paper takes issue with this. It sets out to contribute to politicizing land subsidence by analysing it as part of the sociospatial and socionatural transformations that characterize processes of urbanization. We propose an approach that allows showing how subsidence happens through urbanization’s interconnected moments of horizontal concentration, vertical extension, and differentiation – the weight of the built environment, the expansion of deep groundwater wells, and the remaking of the city (and beyond). By investigating the sociospatial correlation between land subsidence and the development of buildings, and the temporal correlation between land subsidence and the increase of groundwater wells we illustrate how land subsidence is intrinsic to (post-) New Order capitalism (1965–1998 and 1998-now). We also show that it proceeds in uneven ways: those who cause subsidence are not the ones who suffer most from it. Through a serious treatment of soil–water dynamics, our socionatural theorization also helps appreciate how urbanization is always co-shaped by interactions between human and non-human processes

Urbanization in (post-) New Order Indonesia: connecting unevenness in the city with that in the countryside

This article explores the relationship between the uneven outcomes of development in Indonesian cities with exclusionary outcomes of capitalist development in rural areas. Combining concepts of planetary urbanization with critical agrarian studies, we show how sociospatial and socionatural differentiations in (post-) New Order Java result in the emergence of the Kaum Miskin Kota, a ‘stagnant relative surplus population’ residing in precarious flood-prone urban spaces. These forms of differentiation are dialectically related to rural enclosures caused by the creation of political forest and political water. Tracing such relations forms a good basis to connect rural- and urban-based social movements

The placebo response rate in pharmacological trials in patients with irritable bowel syndrome: a systematic review and meta-analysis

BackgroundClinical trials in irritable bowel syndrome are associated with high placebo response rates. We aimed to identify the magnitude of the placebo response and the contributing factors to this occurrence.MethodsWe did a systematic review and meta-analysis with a search of MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials between April 1, 1959, and April 30, 2020. We included all randomised controlled trials that compared an active pharmacotherapeutic agent with placebo and had a dichotomous outcome of response to therapy (in terms of global improvement or improvement in abdominal pain) in adults (aged ≥18 years) with irritable bowel syndrome. Exclusion criteria were trials reporting on treatment satisfaction as a dichotomous outcome of response to therapy or clinician-reported outcomes and a treatment duration of less than 4 weeks. Our main outcome was identification of the magnitude of the pooled placebo response rate for the following endpoints: global improvement, abdominal pain, and US Food and Drug Administration (FDA) endpoints. We extracted information from published reports and pooled proportions through meta-analysis with random effects. The study was registered with PROSPERO, CRD42020170908.FindingsOf the 6863 publications identified, 70 articles describing 73 randomised controlled trials were included in our analysis. The pooled placebo response rate was 27·3% (95% CI 24·3–30·9) using the global improvement endpoint, 34·4% (31·2–37·8) using the abdominal pain endpoint, and 17·9% (15·2–21·0) using the composite FDA endpoint responder definition, all with substantial heterogeneity between the trials. Studies published before 2006, and those done in Europe, with a parallel design, a run-in period of 2 weeks or less, a dose schedule of three times a day or more, or a smaller sample size of the control group were significantly associated with an increased pooled placebo response rate.InterpretationMore than a quarter of patients with irritable bowel syndrome had a placebo response in terms of global improvement, with multiple associated moderators. We recommend future trials apply a run-in period of at least 2 weeks and dose once or twice a day to minimise the placebo response rate

Factors Associated with Revision Surgery after Internal Fixation of Hip Fractures

Background: Femoral neck fractures are associated with high rates of revision surgery after management with internal fixation. Using data from the Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) trial evaluating methods of internal fixation in patients with femoral neck fractures, we investigated associations between baseline and surgical factors and the need for revision surgery to promote healing, relieve pain, treat infection or improve function over 24 months postsurgery. Additionally, we investigated factors associated with (1) hardware removal and (2) implant exchange from cancellous screws (CS) or sliding hip screw (SHS) to total hip arthroplasty, hemiarthroplasty, or another internal fixation device. Methods: We identified 15 potential factors a priori that may be associated with revision surgery, 7 with hardware removal, and 14 with implant exchange. We used multivariable Cox proportional hazards analyses in our investigation. Results: Factors associated with increased risk of revision surgery included: female sex, [hazard ratio (HR) 1.79, 95% confidence interval (CI) 1.25-2.50; P = 0.001], higher body mass index (fo

Politicising land subsidence in Jakarta: How land subsidence is the outcome of uneven sociospatial and socionatural processes of capitalist urbanization

Jakarta is sinking dramatically because of land subsidence, which in turn increases its vulnerability to tidal flooding. The explanation of land subsidence’s causes and the design of solutions is led by geoscientists and engineers, who tend to treat it as largely a technical problem. This paper takes issue with this. It sets out to contribute to politicizing land subsidence by analysing it as part of the sociospatial and socionatural transformations that characterize processes of urbanization. We propose an approach that allows showing how subsidence happens through urbanization’s interconnected moments of horizontal concentration, vertical extension, and differentiation – the weight of the built environment, the expansion of deep groundwater wells, and the remaking of the city (and beyond). By investigating the sociospatial correlation between land subsidence and the development of buildings, and the temporal correlation between land subsidence and the increase of groundwater wells we illustrate how land subsidence is intrinsic to (post-) New Order capitalism (1965–1998 and 1998-now). We also show that it proceeds in uneven ways: those who cause subsidence are not the ones who suffer most from it. Through a serious treatment of soil–water dynamics, our socionatural theorization also helps appreciate how urbanization is always co-shaped by interactions between human and non-human processes

Transcriptional regulation of ZIP genes is independent of local zinc status in Brachypodium shoots upon zinc deficiency and resupply

The biological processes underlying zinc homeostasis are targets for genetic improvement of crops to counter human malnutrition. Detailed phenotyping, ionomic, RNA-Seq analyses and flux measurements with 67Zn isotope revealed whole-plant molecular events underlying zinc homeostasis upon varying zinc supply and during zinc resupply to starved Brachypodium distachyon (Brachypodium) plants. Although both zinc deficiency and excess hindered Brachypodium growth, accumulation of biomass and micronutrients into roots and shoots differed depending on zinc supply. The zinc resupply dynamics involved 1,893 zinc-responsive genes. Multiple zinc-regulated transporter and iron-regulated transporter (IRT)-like protein (ZIP) transporter genes and dozens of other genes were rapidly and transiently down-regulated in early stages of zinc resupply, suggesting a transient zinc shock, sensed locally in roots. Notably, genes with identical regulation were observed in shoots without zinc accumulation, pointing to root-to-shoot signals mediating whole-plant responses to zinc resupply. Molecular events uncovered in the grass model Brachypodium are useful for the improvement of staple monocots

Understanding natural killer cell biology from a single cell perspective

During the last decade, advances in single cell technologies have ignited increased understanding of natural killer cells (NK cells), which turned out to be far more complex than originally thought. Ample studies have established tissue-specific phenotypic variation within this cell population; however, the functional implication of this vast variation is still unclear. At single-cell level, the function of a NK cell is tightly regulated by several checkpoints however upon proper recognition the cell can deliver a lytic hit as early as 10 min or could take hours before they can kill their target cells. Moreover, only a fraction of NK cells appears to kill target cells while the larger portion of NK cells appear to be non-cytotoxic. All these studies showed that the NK cell compartment is composed of cells with different functional strengths and efficacies, thereby highlighting the necessity of analytical platforms that allow the study of these important innate immune cells at single-cell level. In this review, we discuss and provide an overview on phenotypical and functional heterogeneity within the NK cell population and subsequently provide information regarding emerging technologies that highlight the importance of single-cell studies to understand the biology of these cells