Editorial: visceral fat as a predictor of post‐operative recurrence of Crohn’s disease

Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/137608/1/apt14069.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/137608/2/apt14069_am.pd

The meaning of educational change in post-Soviet Tajikistan : educational encounters in Badakhshan : how educators in an in-service institution in rural Badakhshan understand and respond to educational change

Abstract\ud This thesis examines educational change in the province of Badakhshan,\ud Tajikistan, where the processes of change are framed in the post -Soviet\ud transition from communism to incipient forms of democracy and from a command\ud to market economy. It focuses on the encounter of an international development\ud agency, the Aga Khan Foundation (AKF), and a government, in-service, teacher\ud training institution, the Institute of Professional Development (IPD). That\ud interaction is also contextualised in a very particular relationship: the head of\ud AKF, the Aga Khan, is also the spiritual leader of the Badakhshani community.\ud Hence, development and faith perspectives intersect in this change process (es).\ud Using a qualitative approach and a case study design the research makes visible\ud educational change as it impacts structures, institutions and individual educators\ud in post-Soviet Badakhshan. It draws on the work of Birzea (1994), Venda 1991;\ud 1999), Foucault (1972; 1980) and Gramsci (1971) to understand how institutional\ud transformation processes are mediated and contested as the IPD changes from a\ud government body to a 'public-private' one.\ud The research finds that notwithstanding the faith connection, institutional\ud transformation involves ideological, epistemological and hegemonic contestations\ud as well as new learning. Responses include ambivalence, resistance,\ud adaptation, appropriation and reclamation of educational and institutional change\ud through a recasting of social and professional relationships and a mastery of\ud international aid discourses. The study reveals that there is not 'a change\ud process' but, instead, change(s) processes that are multiple, interlinked, iterative,\ud simultaneous and sometimes chaotic. It argues that the change contexts, the\ud macro and micro narratives that attend it and the processes of educational\ud transformation are better understood through a re-conceptualisation of familiar\ud notions of educational change(s), tradition and development. It concludes that\ud the role of faith is central to how development is defined, responded to and\ud appropriated in this little-studied context and contributes to the knowledge of\ud international development across cultures

Semi‐supervised joint learning for longitudinal clinical events classification using neural network models

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/163377/2/sta4305.pdfhttp://deepblue.lib.umich.edu/bitstream/2027.42/163377/1/sta4305_am.pd

Increasing ultraviolet light exposure is associated with reduced mortality from Clostridium difficile infection

Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/166256/1/ueg2bf00112.pd

Correlates of patient satisfaction and provider trust after breast-conserving surgery

BACKGROUND Although breast-conserving therapy (BCS) is considered the standard of care for early-stage breast cancer, up to 20% of patients are dissatisfied. The effect of treatment-related factors on patient satisfaction with their healthcare experiences is unclear. METHODS All BCS patients at the University of Michigan Medical Center who were treated between January 2002 and May 2006 were surveyed (n = 714; response rate, 79.5%). Patients were queried regarding 4 aspects of their decision for surgery: satisfaction with the decision, decision regret, decisional conflict, and trust in surgeons. Independent variables included the number of re-excisions, the occurrence of postoperative complications, and postoperative breast appearance, which was assessed by using the Breast Cancer Treatment and Outcomes scale. Multiple logistic regression was used to assess the effect of the independent variables on each outcome controlling for demographic and clinical characteristics. RESULTS Breast asymmetry after BCS was correlated significantly with patient satisfaction with their treatment experiences and patient distrust in surgeons. Women who reported pronounced asymmetry were significantly less likely to be satisfied with the decision for surgery compared with women who reported minimal asymmetry (odds ratio [OR], 0.43; 95% confidence interval [95% CI], 0.21–0.89). Women with pronounced asymmetry were less likely to be certain about their surgical decision (OR, 0.36; 95% CI, 0.21–0.60) and to believe that they were prepared to make the decision for surgery (OR, 0.25; 95% CI, 0.14–0.43). Increasing breast asymmetry was associated with higher surgeon distrust scores (2.14 vs 2.30 vs 2.35; P = .04) and with the occurrence of postoperative complications (distrust score: 2.23 vs 2.35; P = .03). Reoperation after BCS was not associated with patient satisfaction or trust in providers. CONCLUSIONS Esthetic result after BCS was associated more profoundly with aspects of satisfaction than either surgical therapy or the occurrence of postoperative complications. The current findings indicated that surgeons who care for patients with breast cancer should identify the women at an increased risk for breast asymmetry preoperatively to effectively address their expectations of treatment outcomes. Cancer 2008. © 2008 American Cancer Society.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/58592/1/23351_ftp.pd

Longitudinal study of short‐term corticosteroid use by working‐age adults with diabetes mellitus: Risks and mitigating factors

BackgroundThis study assessed the frequency of short‐term oral corticosteroid use in adults with diabetes, examined the incidence of fractures, venous thromboembolism (VTE), and hospitalization for sepsis after corticosteroid use, and evaluated whether preventative medications mitigated adverse events.MethodsA longitudinal study (2012–14) was conducted of 1 548 945 adults (aged 18–64 years) who received healthcare coverage through a large national health insurer. Incidence rate ratios (IRR) were calculated using conditional Poisson regression.ResultsShort‐term oral corticosteroids were used by 23.9%, 20.8%, and 20.9% of adults with type 2 diabetes, type 1 diabetes, and no diabetes, respectively, during the 3‐year period (P < 0.001). Baseline risks of fracture, VTE, and sepsis were greater for individuals with than without diabetes (P < 0.001). The combined effect of having diabetes and using corticosteroids was greater than the sum of the individual effects (synergy indices of 1.17, 1.23, 1.30 for fracture, VTE, and sepsis, respectively). The IRR for VTE in the 5–30 days after corticosteroid use was 3.62 (95% confidence interval [CI] 2.41–5.45). Fractures increased in the 5–30 days after corticosteroid use (IRR 2.06; 95% CI 1.52, 2.80), but concomitant use of ergocalciferol mitigated this risk (IRR 1.13; 95% CI 0.12, 11.07). The risk of hospitalization for sepsis was elevated with corticosteroid use (IRR 3.79; 95% CI 2.05, 7.01), but was mitigated by the concomitant use of statins.ConclusionsShort‐term oral corticosteroid use is common in adults with diabetes and is associated with an elevated, but low, risk of adverse events. The findings suggest that preventative medications may mitigate risk.摘要背景这项研究在成年糖尿病患者中评估了短期使用口服糖皮质激素的频率,  调查了使用糖皮质激素后骨折与静脉血栓栓塞(venous thromboembolism, VTE)的发生率以及脓毒症的住院率,  并且评估了预防性用药是否会减少不良事件。方法这是一项在1548945名具有大型国家健康保险公司医疗保险的成年(年龄为18‐64岁)患者中进行的纵向研究(2012‐14)。使用有条件的Poisson回归分析来计算发病率比(incidence rate ratios, IRR)。结果在这3年期间,  短期使用口服糖皮质激素治疗的2型糖尿病、1型糖尿病以及非糖尿病成年患者的比例分别为23.9%、20.8%与20.9%(P < 0.001)。与非糖尿病患者相比,  糖尿病患者基线时的骨折、VTE以及脓毒症的风险都更高(P < 0.001)。患糖尿病以及使用糖皮质激素的联合效应大于个体效应之和(骨折、VTE以及脓毒症的协同指数分别为1.17、1.23、1.30)。使用糖皮质激素后的5‐30日内发生VTE的IRR为3.62(95%置信区间[CI]为2.41‐5.45)。使用糖皮质激素后的5‐30日内发生骨折的风险增加(IRR为2.06;95% CI为1.52, 2.80),  但同时使用麦角骨化醇治疗可以减少这种风险(IRR为1.13;95% CI为0.12, 11.07)。使用糖皮质激素后脓毒症的住院风险也增加了(IRR为3.79;95% CI为2.05, 7.01),  但是同时使用他汀类药物治疗可以减少这种风险。结论成年糖尿病患者短期使用口服糖皮质激素治疗很常见并且与不良事件风险轻度升高有关。这项研究结果表明预防性用药可以减少这种风险。HighlightsAdults with diabetes mellitus have a greater risk of fracture, venous thromboembolism, and sepsis than those without diabetes; the use of corticosteroids, even for short durations, increases this risk.Vitamin D mitigated the risk of fracture in patients with diabetes who used corticosteroids, and statins decreased the likelihood of hospitalization for sepsis in corticosteroid users with diabetes.Corticosteroids should be used with caution in patients with diabetes and mitigating factors should be considered.Peer Reviewedhttps://deepblue.lib.umich.edu/bitstream/2027.42/144644/1/jdb12631.pdfhttps://deepblue.lib.umich.edu/bitstream/2027.42/144644/2/jdb12631_am.pd

The Incidence of Upper and Lower Extremity Surgery for Rheumatoid Arthritis Among Medicare Beneficiaries

Background: For elderly patients with rheumatoid arthritis, aggressive immunosuppression can be difficult to tolerate, and surgery remains an important treatment option for joint pain and deformity. We sought to examine the epidemiology of surgical reconstruction for rheumatoid arthritis among older individuals who were newly diagnosed with the disorder. Methods: We identified a 5% random sample of Medicare beneficiaries (sixty-six years of age and older) newly diagnosed with rheumatoid arthritis from 2000 to 2005, and followed these patients longitudinally for a mean of 4.6 years. We used univariate analysis to compare the time from the diagnosis of rheumatoid arthritis to the first operation among the 360 patients who underwent surgery during the study period. Results: In our study cohort, 589 procedures were performed among 360 patients, and 132 patients (37%) underwent multiple procedures. The rate of upper extremity reconstruction was 0.9%, the rate of lower extremity reconstruction was 1.2%, and knee arthroplasty was the most common procedure performed initially (31%) and overall (29%). Upper extremity procedures were performed sooner than lower extremity procedures (fourteen versus twenty-five months; p = 0.02). In multivariable analysis, surgery rates declined with age for upper and lower extremity procedures (p \u3c 0.001). Conclusions: Knee replacement remains the most common initial procedure among patients with rheumatoid arthritis. However, upper extremity procedures are performed earlier than lower extremity procedures. Understanding the patient and provider factors that underlie variation in procedure rates can inform future strategies to improve the delivery of care to patients with rheumatoid arthritis. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence

Cold snare polypectomy for non-pedunculated colon polyps greater than 1 cm

Background and study aims Colonic polyps > 1 cm in size are commonly managed using hot polypectomy techniques. The most frequent adverse events (delayed bleeding, post-polypectomy syndrome, and perforation) are related to electrocautery-induced injury. We hypothesized that cold resection of large polyps may have similar efficacy and improved safety compared to hot polypectomy. Our aims were to evaluate efficacy and safety of piecemeal cold snare resection of colonic polyps > 1 cm. Patients and methods Patients undergoing lift and piecemeal cold snare polypectomy of non-pedunculated colon polyps > 1 cm from October 2013 to September 2015 were identified retrospectively. Efficacy was defined by the absence of residual adenomatous tissue at endoscopic follow-up. Adverse events (AEs), including post-procedural bleeding, bowel perforation, or post-procedural pain requiring hospitalization were assessed by chart review and telephone follow-up.  Results Seventy-three patients underwent piecemeal cold snare polypectomy for 94 colon polyps > 1 cm with 56 of 73 patients completing follow-up on 72 polyps. Residual or recurrent adenoma was found in 7 cases (9.7 %). Median polyp size was significantly greater in those with residual/recurrent adenoma (37.1 vs. 19.1 mm, P < .0001). There were no AEs among all 73 patients enrolled. Conclusions Piecemeal cold snare resection of colon polyps > 1 cm is feasible, safe and efficacious when compared to published hot polypectomy data. Additional observational and randomized comparative effectiveness studies are necessary to demonstrate comparable adenoma eradication and improved safety advantage over existing hot snare polypectomy techniques