Postoperative Adverse Outcomes in Intellectually Disabled Surgical Patients: A Nationwide Population-Based Study

Intellectually disabled patients have various comorbidities, but their risks of adverse surgical outcomes have not been examined. This study assesses pre-existing comorbidities, adjusted risks of postoperative major morbidities and mortality in intellectually disabled surgical patients.A nationwide population-based study was conducted in patients who underwent inpatient major surgery in Taiwan between 2004 and 2007. Four controls for each patient were randomly selected from the National Health Insurance Research Database. Preoperative major comorbidities, postoperative major complications and 30-day in-hospital mortality were compared between patients with and without intellectual disability. Use of medical services also was analyzed. Adjusted odds ratios using multivariate logistic regression analyses with 95% confidence intervals were applied to verify intellectual disability's impact.Controls were compared with 3983 surgical patients with intellectual disability. Risks for postoperative major complications were increased in patients with intellectual disability, including acute renal failure (odds ratio 3.81, 95% confidence interval 2.28 to 6.37), pneumonia (odds ratio 2.01, 1.61 to 2.49), postoperative bleeding (odds ratio 1.35, 1.09 to 1.68) and septicemia (odds ratio 2.43, 1.85 to 3.21) without significant differences in overall mortality. Disability severity was positively correlated with postoperative septicemia risk. Medical service use was also significantly higher in surgical patients with intellectual disability.Intellectual disability significantly increases the risk of overall major complications after major surgery. Our findings show a need for integrated and revised protocols for postoperative management to improve care for intellectually disabled surgical patients

Grounding simulation models with qualitative case studies: Toward a holistic framework to make climate science usable for US public land management

Policies directing agencies and public land managers to incorporate climate change into management face several barriers. These stem, in part, from a disconnect between the information that is produced and the information needs of local resource managers. A disproportionate focus on the natural and physical sciences in climate vulnerability and adaptation assessment obscure understandings of complex social systems and the interactions and feedbacks in social-ecological systems. We use a qualitative case study of bison management on Department of the Interior-managed and tribal lands to explore how a social-science driven Determinants and Analogue Vulnerability Assessment (DAVA) can inform ecological response models, specifically simulation models that account for multiple drivers of change. First, we illustrate how a DAVA approach can help to: 1) identify key processes, entities, and interactions across scales; 2) document local impacts, indicators, and monitoring efforts of drought and climate; and 3) identify major tradeoffs and uncertainties. We then demonstrate how qualitative narratives can inform simulation models by: 1) prioritizing model components included in modeling efforts; 2) framing joint management and climate scenarios; and 3) parameterizing and evaluating model performance. We do this by presenting a conceptual joint agent-based/state-and-transition simulation modeling framework. Simulation models can represent multiple interacting variables and can identify surprising, emergent outcomes that might not be evident from qualitative analysis alone, and we argue that qualitative case studies can ground simulation models in local contexts and help make them more structurally realistic and useful. Together, these can provide a step toward developing actionable climate change adaptation strategies. Keywords: Social-ecological systems, Vulnerability, Adaptation, Social science, Ecological drought, Actionable scienc

A method for increased dose conformity and segment reduction for SMLC delivered IMRT treatment of the prostate

The focus of this work is to develop a practical planning method that results in increased dose conformity and reduced treatment time for segmental multileaf collimation (sMLC) based intensity-modulated radiation therapy (IMRT) delivery. Additional regions for dose constraint are introduced within the normal tissue during the planning process by designing a series of concentric ellipsoids around the target. A dose gradient is then defined by assigning dose constraints to each concentric region. The technique was tested at two centers and data for 26 and 10 patients, respectively, are presented allowing for differences in treatment technique, beam energy, ellipsoid definition, and prescription dose. At both centers, a series of patients previously treated for prostate cancer with IMRT were selected, and comparisons were made between the original and new plans. While meeting target dose specifications and normal tissue constraints, the average number of beam directions decreased by 1.6 with a standard error (SE) of 0.1. The average time for delivery at center 1 decreased by 29.0% with an SE of 2.0%, decreasing from 17.5 min to 12.3 min. The average time for delivery at center 2 decreased by 29.9% with an SE of 3.8%, decreasing from 11 min to 7.7 min. The amount of nontarget tissue receiving D 100 decreased by 15.7% with an SE of 2.4%. Nontarget tissue receiving D 95, D 90, and D 50 decreased by 16.3, 15.1, and 19.5%, respectively, with SE values of approximately 2% at center 1. Corresponding values for D 100, D 95, D 90, and D 50 decreased by 13.5, 16.7, 17.1, and 5.1%, respectively, with SE values of less than 3% at center 2. By designating subsets of tissue as concentric regions around the target(s) and carefully defining each region's dose constraints, we have gained an increased measure of control over the region outside the target boundaries. This increased control manifests as two distinct endpoints that are beneficial to the IMRT process: increased dose conformity and decreased treatment time