Off-pump coronary artery bypass graft vs. on-pump coronary artery bypass graft surgery : what matters---procedure volume or specificity/specialization?

Context: Existing research has associated higher provider volume with a lower rate of adverse patient outcomes after coronary artery bypass graft (CABG). However, the relationship between surgical procedural volume and specialization and clinical outcomes has been understudied. Research Objectives: This research examined the effect of surgical procedural volume and specialization on patient outcomes for 119,559 patients undergoing CABG in Florida short-term acute hospitals from 2000-2006. Methods: Florida Hospital Discharge Data were linked with Practitioner Profile Database available from Florida Department of Health by using unique surgeon identifiers. Surgeon on-pump and off-pump CABG volume was assessed in quartiles. In-hospital complications were measured by using Patient Safety Indicators developed by the Agency for Healthcare Research and Quality (AHRQ). Analyses included chi-square, t-test, logistic regression and multilevel regression to adjust for nested surgeon and hospital effects. Results: In adjusted analyses stratified by on- and off-pump CABG, patients operated by surgeons with lower volume of a specific CABG type were more likely to have in-hospital mortality: for off-pump CABG quartile 1 OR=3.05, 95% CI: 1.68-5.53, quartile 2 OR=1.57, 95% CI: 1.10-2.26 and quartile 3 OR=1.35, 95% CI: 1.01-1.81, and for on-pump CABG quartile 2 OR=1.82, 95% CI: 1.34-2.47 and quartile 3 OR=1.51, 95% CI: 1.21-1.90. Surgeries performed by physicians in lower on-pump CABG quartiles were also significantly associated with increased odds of complications (quartile 1 OR=1.97, 95% CI: 1.19-3.26, quartile 2 OR=1.43, 95% CI: 1.14-1.80 and quartile 3 OR=1.33, 95% CI: 1.14-1.57). For off-pump CABG only quartile 2 physicians retained significance (OR=1.80, 95% CI: 1.29-2.51) for complications. Discussion: The volume/outcome relationship for CABG surgery is specific to the type of procedure, but not total (all procedures) volume. This finding may suggest the need of specialized and focused training of cardiac surgeons as well as development of specific CABG outcome reporting protocols to enable sufficient differentiation in outcomes of two different types of CABG

Assessement of Debris Flow Influence on the Lattice Type Debris Flow Against Construction

In the work is purpose lattice type debris flow against construction built on the depreciation principle, on which implemented theoretical research for assessement of debris flow influence. As a result of implemented calculation, in the condition of specific assumptions, istablished number value of rectangular structure lattice elements of the operating loads of construction during of cohesive debris flow influence on the construction. Results of above calculations given basis, that purpose construction considered potentially effective debris flow against construction

The Evaluation of Debris Flows Influence on the Pass Through Type Debris Flow against Construction

In the article is presented the pass through type debris flow against construction, builts at the surrounded by the flow principle, has been implemented theoretical researches for evaluation debris flow influence on that. As a result of our implemented calculation, in a condition of specific access, established, a numerical value of current loads on the cylinder form elements at the debris flow impact on the link debris flow. Results of the above calculation provide the basis for considering this construction potentially effectively debris flow against construction

Barriers and facilitators to the implementation of audio-recordings and question prompt lists in cancer care consultations: A qualitative study

Objective: Question prompt lists (QPLs) and consultation audio-recordings (CARs) are two communication strategies that can assist cancer patients in understanding and recalling information. We aimed to explore clinician and organisational barriers and facilitators to implementing QPLs and CARs into usual care. Methods: Semi-structured interviews with twenty clinicians and senior hospital administrators, recruited from four hospitals. Interviews were recorded, transcribed verbatim and thematic descriptive analysis was utilised. Results: CARs and QPLs are to some degree already being initiated by patients but not embedded in usual care. Systematic use should be driven by patient preference. Successful implementation will depend on minimal burden to clinical environments and feedback about patient use. CARs concerns included: medico-legal issues, ability of the CAR to be shared beyond the consultation, and recording and storage logistics within existing medical record systems. QPLs issues included: applicability of the QPLs, ensuring patients who might benefit from QPL’s are able to access them, and limited use when there are other existing communication strategies. Conclusions: While CARs and QPLs are beneficial for patients, there are important individual, system and medico-legal considerations regarding usual care. Practice implications: Identifying and addressing practical implications of CARs and QPLs prior to clinical implementation is essential

Should Consultation Recording Use be a Practice Standard? A Systematic Review of the Effectiveness and Implementation of Consultation Recordings

Objective: To conduct a systematic review of the effectiveness of consultation recordings, and identify factors contributing to their successful implementation in healthcare settings. Methods: A systematic review was conducted for quantitative studies examining the effectiveness of consultation recordings in healthcare. Two independent reviewers assessed the relevance and quality of retrieved quantitative studies using standardized criteria. Study findings were examined to determine consultation recording effectiveness and to identify barriers and facilitators to implementation. A supplementary review of qualitative evidence was performed to further explicate implementation factors. Results: Of the 3,373 articles retrieved in the quantitative search, 26 satisfied the standardized inclusion criteria (12 randomized controlled trials, 1 quasi-experiment, and 13 cross-sectional studies). The majority of patients found consultation recordings beneficial. Statistically significant evidentiary support was found for the beneficial impact of consultation recordings on the following patient reported outcomes: knowledge, perception of being informed, information recall, decisionmaking factors, anxiety, and depression. Implementation barriers included strength of evidence concerns, patient distress, impact of the recording on consultation quality, clinic procedures, medico-legal issues, and resource costs. Facilitators included comfort with being recorded, clinical champions, legal strategies, efficient recording procedures, and a positive consultation recording experience. Conclusions: Consultation recordings are valuable to patients and positively associated with patient reported outcomes. Successful integration of consultation recording use into clinical practice requires an administratively supported, systematic approach to addressing implementation factors

The Online Bingo Boom in the UK: A Qualitative Examination of Its Appeal

Online bingo has seen significant growth in recent years. This study sought to increase understanding of this growth by exploring the appeal of online bingo. Our aim was to examine the content of ten online bingo websites in the UK and analyse a qualitative secondary dataset of 12 female bingo players to investigate the appeal of online bingo. Using two distinct data sources allowed us to assess how the key messages online websites are trying to convey compare with actual players' motivation to play bingo. Our analysis of bingo websites found a common theme where websites were easy to navigate and structured to present a light-hearted, fun, reassuring, social image of gambling. In addition, the design decisions reflected in the bingo sites had the effect of positioning online bingo as a benign, child-like, homely, women-friendly, social activity. Comparison of the website content with our participants' reasons to play bingo showed congruence between the strategies used by the bingo websites and the motivations of bingo players themselves and the benefits which they seek; suggesting that bingo websites strive to replicate and update the sociability of traditional bingo halls. Online bingo differs from traditional forms of bingo in its ability to be played anywhere and at any time, and its capacity to offer a deeply immersive experience. The potential for this type of online immersion in gambling to lead to harm is only just being investigated and further research is required to understand how the industry is regulated, as well as the effects of online bingo on individual gambling ‘careers'

Patients covertly recording clinical encounters: threat or opportunity? A qualitative analysis of online texts

Contains fulltext : 153607.pdf (publisher's version ) (Open Access)BACKGROUND: The phenomenon of patients covertly recording clinical encounters has generated controversial media reports. This study aims to examine the phenomenon and analyze the underlying issues. METHODS AND FINDINGS: We conducted a qualitative analysis of online posts, articles, blogs, and forums (texts) discussing patients covertly recording clinical encounters. Using Google and Google Blog search engines, we identified and analyzed 62 eligible texts published in multiple countries between 2006 and 2013. Thematic analysis revealed four key themes: 1) a new behavior that elicits strong reactions, both positive and negative, 2) an erosion of trust, 3) shifting patient-clinician roles and relationships, and 4) the existence of confused and conflicting responses. When patients covertly record clinical encounters - a behavior made possible by various digital recording technologies - strong reactions are evoked among a range of stakeholders. The behavior represents one consequence of an erosion of trust between patients and clinicians, and when discovered, leads to further deterioration of trust. Confused and conflicting responses to the phenomenon by patients and clinicians highlight the need for policy guidance. CONCLUSIONS: This study describes strong reactions, both positive and negative, to the phenomenon of patients covertly recording clinical encounters. The availability of smartphones capable of digital recording, and shifting attitudes to patient-clinician relationships, seems to have led to this behavior, mostly viewed as a threat by clinicians but as a welcome and helpful innovation by some patients, possibly indicating a perception of subordination and a lack of empowerment. Further examination of this tension and its implications is needed

Ocena bezpieczeństwa środowiskowego elektrowni wodnej Kazbegi z uwagi na działanie lawiny mieszanej powstałej na rzece Kabakhi (Gruzja) spływającej z lodowca Devdorak

Aiming at assessing the environmental safety of small Kazbegi HPP, we have described the catastrophic-scale mudflow formed as a result of movement of Devdorak glacier in the Gorge of the river Kabakhi (left tributary of the river Tergi) on May 17, 2014, which inflicted significant damage to the hydraulic works of Kazbegi HPP. With the purpose of securing the environmental safety of small Kazbegi HPP and regulating the erosive-mudflow processes inter alia, the performance reliability and risk of breakdown of a new springboard-type structure by considering the dynamic and static loads of the mudflow were specified.Mające na uwadze ocenę bezpieczeństwa środowiskowego małej elektrowni wodnej Kazbegi opisano katastroficzną skalę lawiny mieszanej utworzonej w wyniku przemieszczania się lodowca Devdorak w wąwozie rzeki Kabakhi (lewy dopływ rzeki Tergi) w Gruzji 17 maja 2014 r., która spowodowała znaczne uszkodzenia w elektrowni Kazbegi. W celu zapewnienia bezpieczeństwa środowiskowego elektrowni Kazbegi i regulacji procesu powstawania lawin między innymi określono niezawodność i ryzyko wystąpienia awarii nowego typu konstrukcji przy uwzględnieniu dynamicznych i statycznych obciążeń od lawiny mieszanej