Over-utilization of Advanced Imaging in the Hospital Setting: An Educational Approach to Reduce Unnecessary Inpatient Studies

By several measures, health care spending continues to rise, forcing businesses and families to cut back on operations and household expenses. In 2008, health care spending in the United States reached $2.4 trillion dollars, and is projected to reach$3.1 trillion in 2012.During the past decades, there has been a steady increase in the utilization of expensive inpatient imaging studies, with an overall increase in health care costs. In particular, advanced imaging includes CT, MRI and Nuclear Medicine, used for the diagnosis and management of hospitalized patients. The reasons for unnecessary imaging examinations include indirect financial benefit to physicians, medico-legal considerations, lack of accepted guidelines or failure to follow established ones. In the United States alone, it is estimated that CT testing accounts for around 6,000 additional cancers per year, with about half of those proving fatal. Each radiologic study using gadolinium presented a 2.4% risk of developing nephrogenic systemic fibrosis, with significant morbidity and mortality. We have shown that education of the ordering physicians is a feasible and cost effective means to decrease the over-otilization of advanced imaging in the inpatient setting

Global managers : how to obtain them in organizations

Thesis (M.B.A.)--Massachusetts Institute of Technology, Sloan School of Management, 2001.Includes bibliographical references (leaves 110-111).We live in a global era; we can find the same products and services around the world. The barriers that used to exist have blurred or disappeared. In the past when we traveled from one country to another, there were many differences-cultural, political, social-and many times travelers had one or two bad experiences. Today things are easier, and countries are adapting to the global market and opening their doors to the world. Technology and Communications are two key factors in this globalization process. However, the people who develop and implement these factors are the ones who are helping the world to become a global marketplace. These people are the global leaders and managers--people who think beyond their cultural and social environments, people who are able to combine the needs of different countries into a single more homogenous need, people who lead organizations and countries as they improve their strategies and join the global era. This thesis highlights the different phases of globalization through which the world has lived over the years, from the trading era where people exchanged valuable goods with each other to the global era where the marketplace is a single global market. The thesis discusses the changes in industry and the various forces driving industry to make these changes, as well as tools to help evaluate the pressures for globalization. I consider globalization from three perspectives: the broad worldview, industry level, and then company or firm level and the different ways of doing business. Moving from the macro level to the micro level, I discuss the people who work in the organizations, those who are responsible for leading and managing the firm during its drive to become a global company. I present and discuss some of the skills needed and the tools that managers can use to facilitate their strategies. Then follows a discussion of some of the generic strategies that companies can pursue and the key success factors needed to develop appropriate global strategies. Next I develop a case study of Vitrocrisa, a Mexican company searching for an approach to globalization that will work best for the company. Here I explain the strategies, structure, and challenges that Vitrocrisa is facing. Also I suggest actions and plans that the company could pursue to facilitate the process. Finally, I present general conclusions about how a company can identify the skills of global managers, and then identify potential candidates, hire, and develop them.by Daniel R. Madero.M.B.A

Alcohol-Based Adsorption Heat Pumps using Hydrophobic Metal-Organic Frameworks

The building climate industry and its influence on energy consumption have consequences on the environment due to the emission of greenhouse gasses. Improving the efficiency of this sector is essential to reduce the effect on climate change. In recent years, the interest in porous materials in applications such as heat pumps has increased for their promising potential. To assess the performance of adsorption heat pumps and cooling systems, here we discuss a multistep approach based on the processing of adsorption data combined with a thermodynamic model. The process provides properties of interest, such as the coefficient of performance, the working capacity, the specific heat or cooling effect, or the released heat upon adsorption and desorption cycles, and it also has the advantage of identifying the optimal conditions for each adsorbent-fluid pair. To test this method, we select several metal-organic frameworks that differ in topology, chemical composition, and pore size, which we validate with available experiments. Adsorption equilibrium curves were calculated using molecular simulations to describe the adsorption mechanisms of methanol and ethanol as working fluids in the selected adsorbents. Then, using a thermodynamic model we calculate the energetic properties combined with iterative algorithms that simultaneously vary all the required working conditions. We discuss the strong influence of operating temperatures on the performance of heat pump devices. Our findings point to the highly hydrophobic metal azolate framework MAF-6 as a very good candidate for heating and cooling applications for its high working capacity and excellent energy efficiency

Prevalence of and Risk Factors for Biliary Carriage of Bacteria Showing Worrisome and Unexpected Resistance Traits

Data on biliary carriage of bacteria and, specifically, of bacteria with worrisome and unexpected resistance traits (URB) are lacking. A prospective study (April 2010 to December 2011) was performed that included all patients admitted for<48 h for elective laparoscopic cholecystectomy in a Spanish hospital. Bile samples were cultured and epidemiological/clinical data recorded. Logistic regression models (stepwise) were performed using bactobilia or bactobilia by URB as dependent variables. Models (P< 0.001) showing the highest R2 values were considered. A total of 198 patients (40.4% males; age, 55.3 17.3 years) were included. Bactobilia was found in 44 of them (22.2%). The presence of bactobilia was associated (R2 Cox, 0.30) with previous biliary endoscopic retrograde cholangiopancreatography (ERCP) (odds ratio [OR], 8.95; 95% confidence interval [CI], 2.96 to 27.06; P< 0.001), previous admission (OR, 2.82; 95% CI, 1.10 to 7.24; P 0.031), and age (OR, 1.09 per year; 95% CI, 1.05 to 1.12; P< 0.001). Ten out of the 44 (22.7%) patients with bactobilia carried URB: 1 Escherichia coli isolate (CTX-M), 1 Klebsiella pneumoniae isolate (OXA-48), 3 high-level gentamicin-resistant enterococci, 1 vancomycin-resistant Enterococcus isolate, 3 Enterobacter cloacae strains, and 1 imipenem-resistant Pseudomonas aeruginosa strain. Bactobilia by URB (versus those by non-URB) was only associated (R2 Cox, 0.19) with previous ERCP (OR, 11.11; 95% CI, 1.98 to 62.47; P 0.006). For analyses of patients with bactobilia by URB versus the remaining patients, previous ERCP (OR, 35.284; 95% CI, 5.320 to 234.016; P<0.001), previous intake of antibiotics (OR, 7.200; 95% CI, 0.962 to 53.906; P 0.050), and age (OR, 1.113 per year of age; 95% CI, 1.028 to 1.206; P 0.009) were associated with bactobilia by URB (R2 Cox, 0.19; P<0.001). Previous antibiotic exposure (in addition to age and previous ERCP) was a risk driver for bactobilia by URB. This may have implications in prophylactic/therapeutic measures

Tamizaje para sífilis en donantes de sangre y reactividad simultánea con otros marcadores en la Fundación Hematológica Colombia

El presente artículo se propone caracterizar los donantes voluntarios de sangre que presentaron reactividad contra Treponema pallidumdurante el periodo 2006-2011 y conocer la reactividad simultánea con otros marcadores en un banco de sangre colombiano. Para ello, se realizó un estudio retrospectivo de corte transversal en el banco de sangre Fundación Hematológica Colombia, Bogotá (Colombia). La población de estudio estuvo conformada por registros de donantes voluntarios de sangre que presentaron reactividad en el tamizaje para Treponema pallidum y otros marcadores entre 2006 y 2011.La población de estudio estuvo conformada por 11.203 registros de donantes voluntarios de sangre, el promedio de edad fue de 43,27 ± 12,04 años, de los cuales el 56,2% (n=6.296) pertenecía al género masculino, el 11,1% (n=1.246) de los sujetos con tamizaje para sífilis presentaron coinfección para los marcadores de reactividad simultánea con sífilis; el de mayor presentación fue Anti-Core con un 67,7% (n=900), seguido de VIH con 10,3%. La prevalencia de sífilis del periodo de estudio fue de 1,9%.En conclusión, se logró describir claramente las características generales de la población con tamizaje para sífilis, además se encontraron datos estadísticamente significativos por género. Es importante conocer este tipo de comportamiento con el fin de fortalecer los procesos de selección de donantes de sangre y demostrar que la reactividad simultánea no es un proceso aislado en un banco de sangre

Efecto del tratamiento J-Synch sobre el porcentaje de preñez en vaquillonas para cría inseminadas a tiempo fijo

The objective of the present work was to evaluate the effect of J-Synch protocol used in heifers on pregnancy rate submitted to fixed time artificial insemination (FTAI). Six hundred and thirteen Angus heifers were used (age range: 13.5 to 15 months; body condition: 3 to 3.5 -scale 1 to 5 (1: emaciated and 5: obese) and weight: ≥ 260 kg. The animals were randomly assigned to the experimental units (heifers) according to a completely randomized design, to the following group: 1) J-Synch (n=205): on day 0 an intravaginal device was inserted with 0.6 g of progesterone (IVD) plus 2 mg of estradiol benzoate. On day 6 the device was removal and 0.15 mg of d-cloprostenol was administered. On day 9 (70-72 h after device removal), 0.10 mg of buserelin was injected and FTAI was performed. 2) Conventional 7D (n=206): on day 0 an intravaginal device (IVD) was inserted plus 2 mg of estradiol benzoate. On day 7 the device was removed and 0.15 mg of d-cloprostenol and 0.5 mg of estradiol cypionate were administered. On day 9 (50-52 h after device removal), FTAI was performed. 3) Conventional 8D (n=202): similar to Conventional group 7D, with the exception that the device remained in the vagina for a period of 8 days. For FTAI, frozen / thawed semen from a bull of proven fertility was used. Gestation diagnosis were performed at 30 days after FTAI. The statistical analysis was made by SAS. A 95% confidence level was established (α=0.05). Animals that lost the device (3.4%) were excluded from the statistical analysis. The pregnancy rate was not different between treatments (J-synch: 50.8%, Conventional 7D: 43.4% and Conventional 8D: 47.7%, p&gt;0.05). In conclusion, J-Synch treatment used in beef heifers (13.5-15 months of age) generates pregnancy rate after FTAI similar to conventional treatment.El objetivo del trabajo fue evaluar el efecto del J-Synch en vaquillonas para cría sobre el porcentaje de preñez post inseminación artificial a tiempo fijo (IATF). Se utilizaron 613 vaquillonas Angus (edad: 13,5 a 15 meses; condición corporal: 3 a 3,5 - escala 1 a 5 (1: emaciada, 5: obesa) y peso: ≥ 260 kg). Los animales fueron asignados aleatoriamente a 3 grupos de unidades experimentales (diseño completamente aleatorizado): 1) J-Synch (n=205): el día 0 se colocó un dispositivo intravaginal con 0,6 g de progesterona (DISP) más 2 mg de benzoato de estradiol (BE). El día 6 se retiró el DISP y se administró 0,15 mg de d-cloprostenol. El día 9 (70-72 h post retiro del DISP), se inyectó 0,10 mg de buserelina y se realizó IATF. 2) Convencional 7D (n=206): el día 0 se colocó un DISP más 2 mg de BE. El día 7 se retiró el DISP y se administraron 0,15 mg de d-cloprostenol y 0,5 mg de cipionato de estradiol. El día 9 (50-52 h post DISP) se realizó IATF. 3) Convencional 8D (n=202): ídem grupo Convencional 7D, con la salvedad que el DISP permaneció colocado durante 8 días. Para la IATF se utilizó semen congelado/descongelado proveniente de un toro de probada fertilidad. El diagnóstico de gestación se realizó a los 30 días post IATF. El análisis estadístico se realizó por SAS (nivel de confianza: 95%). Los animales que perdieron el dispositivo fueron excluidos del análisis. El 3,4% de las vaquillonas perdieron el DISP. El porcentaje de preñez no difirió entre tratamientos (J-Synch: 50,8%; Convencional 7D: 43,4% y Convencional 8D: 47,7%, p&gt;0,05). Se concluye que el tratamiento J-Synch utilizado en vaquillonas para cría (13,5-15 meses de edad) genera porcentajes de preñez post IATF similares al tratamiento convencional

Evaluation of a digital diabetes prevention program adapted for the Medicaid population: Study design and methods for a non-randomized, controlled trial.

Previous studies have shown that lifestyle modification can successfully prevent or delay development of type 2 diabetes. This trial aimed to test if an underserved, low-income population would engage in a digital diabetes prevention program and successfully achieve lifestyle changes to reduce their risk of type 2 diabetes. Participants were recruited from three health care facilities serving low-income populations. The inclusion criteria were: a recent blood test indicating prediabetes, body mass index (BMI) \u3e 24 kg/

Effect of a reduction in glomerular filtration rate after nephrectomy on arterial stiffness and central hemodynamics: rationale and design of the EARNEST study

Background: There is strong evidence of an association between chronic kidney disease (CKD) and cardiovascular disease. To date, however, proof that a reduction in glomerular filtration rate (GFR) is a causative factor in cardiovascular disease is lacking. Kidney donors comprise a highly screened population without risk factors such as diabetes and inflammation, which invariably confound the association between CKD and cardiovascular disease. There is strong evidence that increased arterial stiffness and left ventricular hypertrophy and fibrosis, rather than atherosclerotic disease, mediate the adverse cardiovascular effects of CKD. The expanding practice of live kidney donation provides a unique opportunity to study the cardiovascular effects of an isolated reduction in GFR in a prospective fashion. At the same time, the proposed study will address ongoing safety concerns that persist because most longitudinal outcome studies have been undertaken at single centers and compared donor cohorts with an inappropriately selected control group.&lt;p&gt;&lt;/p&gt; Hypotheses: The reduction in GFR accompanying uninephrectomy causes (1) a pressure-independent increase in aortic stiffness (aortic pulse wave velocity) and (2) an increase in peripheral and central blood pressure.&lt;p&gt;&lt;/p&gt; Methods: This is a prospective, multicenter, longitudinal, parallel group study of 440 living kidney donors and 440 healthy controls. All controls will be eligible for living kidney donation using current UK transplant criteria. Investigations will be performed at baseline and repeated at 12 months in the first instance. These include measurement of arterial stiffness using applanation tonometry to determine pulse wave velocity and pulse wave analysis, office blood pressure, 24-hour ambulatory blood pressure monitoring, and a series of biomarkers for cardiovascular and bone mineral disease.&lt;p&gt;&lt;/p&gt; Conclusions: These data will prove valuable by characterizing the direction of causality between cardiovascular and renal disease. This should help inform whether targeting reduced GFR alongside more traditional cardiovascular risk factors is warranted. In addition, this study will contribute important safety data on living kidney donors by providing a longitudinal assessment of well-validated surrogate markers of cardiovascular disease, namely, blood pressure and arterial stiffness. If any adverse effects are detected, these may be potentially reversed with the early introduction of targeted therapy. This should ensure that kidney donors do not come to long-term harm and thereby preserve the ongoing expansion of the living donor transplant program.&lt;p&gt;&lt;/p&gt