Effect of shared care on blood pressure in patients with chronic kidney disease: A cluster randomised controlled trial

Background: Chronic kidney disease (CKD) is highly prevalent in patients with diabetes or hypertension in primary care. A shared care model could improve quality of care in these patients Aim: To assess the effect of a shared care model in managing patie

Unscheduled return visits to a Dutch inner-city emergency department

© 2014, van der Linden et al.; licensee Springer. Background: Unscheduled return visits to the emergency department (ED) may reflect shortcomings in care. This study characterized ED return visits with respect to incidence, risk factors, reasons and post-ED disposition. We hypothesized that risk factors for unscheduled return and reasons for returning would differ from previous studies, due to differences in health care systems. Methods: All unscheduled return visits occurring within 1 week and related to the initial ED visit were selected. Multivariable logistic regression was conducted to determine independent factors associated with unscheduled return, using patient information available at the initial visit. Reasons for returning unscheduled were categorized into illness-, patient- or physician-related. Post-ED disposition was compared between patients with unscheduled return visits and the patients who did not return. Results: Five percent (n = 2,492) of total ED visits (n = 49,341) were unscheduled return visits. Patients with an urgent triage level, patients presenting during the night shift, with a wound or local infection, abdominal pain or urinary problems were more likely to return unscheduled. Reasons to revisit unscheduled were mostly illness-related (49%) or patient-related (41%). Admission rates for returning patients (16%) were the same as for the patients who did not return (17%). Conclusions: Apart from abdominal complaints, risk factors for unscheduled return differ from previous studies. Short-term follow-up at the outpatient clinic or general practitioner for patients with urgent triage levels and suffering from wounds or local infections, abdominal pain or urinary problem might prevent unscheduled return

Self-referring patients at the emergency department: appropriateness of ED use and motives for self-referral

© 2014, van der Linden et al.; licensee Springer. Background: Nearly all Dutch citizens have a general practitioner (GP), acting as a gatekeeper to secondary care. Some patients bypass the GP and present to the emergency department (ED). To make best use of existing emergency care, Dutch health policy makers and insurance companies have proposed the integration of EDs and GP cooperatives (GPCs) into one facility. In this study, we examined ED use and assessed the characteristics of self-referrals and non-self-referrals, their need for hospital emergency care and self-referrals' motives for presenting at the ED. Methods: A descriptive cohort study was conducted in a Dutch level 1 trauma centre. Differences in patient characteristics, time of presentation and need for hospital emergency care were analysed using χ2 tests and t tests. A patient was considered to need hospital emergency care when he/she was admitted to the hospital, had an extremity fracture and/or when diagnostic tests were performed. Main determinants of self-referral were identified via logistic regression. Results: Of the 5,003 consecutive ED patients registering within the 5-week study period, 3,028 (60.5%) were self-referrals. Thirty-nine percent of the self-referrals had urgent acuity levels, as opposed to 65% of the non-self-referrals. Self-referrals more often suffered from injuries (49 vs. 20%). One third of the self-referrals presented during office hours. Of all self-referrals, 51% needed hospital emergency care. Younger age; non-urgent acuity level; chest pain, ear, nose or throat problems; and injuries were independent predictors for self-referral. Most cited motives for self-referring were ‘accessibility and convenience’ and perceived ‘medical necessity’. Conclusions: A substantial part of the self-referrals needed hospital emergency care. The 49% self-referrals who were eligible for GP care presented during out-of-hours as well as during office hours. This calls for an integrative approach to this health care problem

Impact of Splenic Artery Embolization on the Success Rate of Nonoperative Management for Blunt Splenic Injury

Introduction Nonoperative management (NOM) has become the treatment of choice for hemodynamically stable patients with blunt splenic injury. Results of outcome after NOM are predominantly based on large-volume studies from level 1 trauma centers in the United States. This study was designed to assess the results of NOM in a relatively low-volume Dutch level 1 trauma center. Methods An analysis of a prospective trauma registry was performed for a 6-year period before (period 1) and after the introduction and implementation of splenic artery embolization (SAE) (period 2). Primary outcome was the failure rate of initial treatment. Results A total of 151 patients were reviewed. An increased use of SAE and a reduction of splenic operations during the second period was observed. Compared with period 1, the failure rate after observation in period 2 decreased from 25% to 10%. The failure rate after SAE in period 2 was 18%. The splenic salvage rate (SSR) after observation increased from 79% in the first period to 100% in the second period. During the second period, all patients with failure after observation were successfully treated with SAE. The SSR after SAE in periods 1 and 2 was respectively 100% and 86%. Conclusions SAE of patients with blunt splenic injuries is associated with a reduction in splenic operations. The failure and splenic salvage rates in this current study were comparable with the results from large-volume studies of level 1 trauma centers. Nonoperative management also is feasible in a relatively low-volume level 1 trauma center outside the United State

Moral enhancement: do means matter morally?

One of the reasons why moral enhancement may be controversial, is because the advantages of moral enhancement may fall upon society rather than on those who are enhanced. If directed at individuals with certain counter-moral traits it may have direct societal benefits by lowering immoral behavior and increasing public safety, but it is not directly clear if this also benefits the individual in question. In this paper, we will discuss what we consider to be moral enhancement, how different means may be used to achieve it and whether the means we employ to reach moral enhancement matter morally. Are certain means to achieve moral enhancement wrong in themselves? Are certain means to achieve moral enhancement better than others, and if so, why? More specifically, we will investigate whether the difference between direct and indirect moral enhancement matters morally. Is it the case that indirect means are morally preferable to direct means of moral enhancement and can we indeed pinpoint relevant intrinsic, moral differences between both? We argue that the distinction between direct and indirect means is indeed morally relevant, but only insofar as it tracks an underlying distinction between active and passive interventions. Although passive interventions can be ethical provided specific safeguards are put in place, these interventions exhibit a greater potential to compromise autonomy and disrupt identity

Combining transcriptional profiling and genetic linkage analysis to uncover gene networks operating in hematopoietic stem cells and their progeny

Stem cells are unique in that they possess both the capacity to self-renew and thereby maintain their original pool as well as the capacity to differentiate into mature cells. In the past number of years, transcriptional profiling of enriched stem cell populations has been extensively performed in an attempt to identify a universal stem cell gene expression signature. While stem-cell-specific transcripts were identified in each case, this approach has thus far been insufficient to identify a universal group of core “stemness” genes ultimately responsible for self-renewal and multipotency. Similarly, in the hematopoietic system, comparisons of transcriptional profiles between different hematopoietic cell stages have had limited success in revealing core genes ultimately responsible for the initiation of differentiation and lineage specification. Here, we propose that the combined use of transcriptional profiling and genetic linkage analysis, an approach called “genetical genomics”, can be a valuable tool to assist in the identification of genes and gene networks that specify “stemness” and cell fate decisions. We review past studies of hematopoietic cells that utilized transcriptional profiling and/or genetic linkage analysis, and discuss several potential future applications of genetical genomics

Statistical modeling of ground motion relations for seismic hazard analysis

We introduce a new approach for ground motion relations (GMR) in the probabilistic seismic hazard analysis (PSHA), being influenced by the extreme value theory of mathematical statistics. Therein, we understand a GMR as a random function. We derive mathematically the principle of area-equivalence; wherein two alternative GMRs have an equivalent influence on the hazard if these GMRs have equivalent area functions. This includes local biases. An interpretation of the difference between these GMRs (an actual and a modeled one) as a random component leads to a general overestimation of residual variance and hazard. Beside this, we discuss important aspects of classical approaches and discover discrepancies with the state of the art of stochastics and statistics (model selection and significance, test of distribution assumptions, extreme value statistics). We criticize especially the assumption of logarithmic normally distributed residuals of maxima like the peak ground acceleration (PGA). The natural distribution of its individual random component (equivalent to exp(epsilon_0) of Joyner and Boore 1993) is the generalized extreme value. We show by numerical researches that the actual distribution can be hidden and a wrong distribution assumption can influence the PSHA negatively as the negligence of area equivalence does. Finally, we suggest an estimation concept for GMRs of PSHA with a regression-free variance estimation of the individual random component. We demonstrate the advantages of event-specific GMRs by analyzing data sets from the PEER strong motion database and estimate event-specific GMRs. Therein, the majority of the best models base on an anisotropic point source approach. The residual variance of logarithmized PGA is significantly smaller than in previous models. We validate the estimations for the event with the largest sample by empirical area functions. etc

Comparison of ankle-brachial pressure index and pulse wave velocity as markers of cognitive function in a community-dwelling population

<p>Abstract</p> <p>Background</p> <p>Vascular factors have been implicated in the development of cognitive decline and dementia. The purpose of this study is to determine the association of the Ankle Brachial pressure Index (ABI) and brachial-ankle Pulse Wave Velocity (ba-PWV) to cognitive impairment in a community-dwelling population.</p> <p>Methods</p> <p>The ABI and ba-PWV were measured using the volume-plethymographic apparatus in 388 subjects aged 60 years old and over. The Mini-Mental State Examination was also employed to measure global cognitive status. The effectiveness of the ABI and ba-PWV as putative markers of cognitive impairment were determined by using a multiple logistic regression analysis after adjusting for confounding factors.</p> <p>Results</p> <p>Subjects with poor cognition were significantly older and less well educated than those with normal cognition. According to the multiple logistic regression analysis, the lowest ABI tertile was found to be a significant independent risk factor (OR = 3.19, 95% CI = 1.30 to 7.82) of the cognitive impairment, whereas the highest brachial-ankle PWV tertile was not.</p> <p>Conclusions</p> <p>A low ABI was an independent risk factor for cognitive impairment in community-dwelling older populations, whereas a high ba-PWV may not be. Further research will be required to analyze ABI and PWV with greater accuracy.</p