Variation in clinical outcomes and process of care measures in Community Acquired Pneumonia: a systematic review

Background: Variation in outcomes of patients with community acquired pneumonia (CAP) has been reported in some, but not all, studies. Although some variation is expected, unwarranted variation in healthcare impacts patient outcomes and equity of care. The aim of this systematic review was to: i) summarise current evidence on regional and inter-hospital variation in the clinical outcomes and process of care measures of patients hospitalised with CAP and ii) assess the strength of this evidence. Methods: Databases were systematically searched from inception to February 2018 for relevant studies and data independently extracted by two investigators in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) statement. Included studies enrolled adults hospitalised with CAP and reported a measure of variation between two or more units in healthcare outcomes or process of care measures. Outcomes of interest were mortality, length of hospital stay (LOS) and re-admission rates. A structured synthesis of the studies was performed.Results:Twenty-two studies were included in the analysis. The median number of units compared across studies was five (IQR 4-15). Evidence for variation in mortality between units was inconsistent; of eleven studies that performed statistical significance testing, five found significant variation. For LOS, of nine relevant studies, all found statistically significant variation. Four studies reported site of admission accounted for 1 – 24% of the total observed variation in LOS. A shorter LOS was not associated with increased mortality or readmission rates. For readmission, evidence was mixed; of seven studies, 4 found statistically significant variation. There was consistent evidence for variation in the use of intensive care, obtaining blood cultures on admission, receiving antibiotics within 8 hours of admission and duration of intravenous antibiotics. Across all outcome measures, only one study accounted for natural variation between units in their analysis.Conclusion: There is consistent evidence of moderate quality for significant variation in length of stay and process of care measures but not for in-patient mortality or hospital re-admission. Evidence linking variation in outcomes with variation in process of care measures was limited; where present no difference in mortality was detected despite POC variation. Adjustment for natural variation within studies was lacking; the proportion of observed variation due to chance is not quantified by existing evidence

Thermoelectric properties of Al-doped mesoporous ZnO thin films

Al-doped mesoporous ZnO thin films were synthesized by a sol-gel process and an evaporation-induced self-assembly process. In this work, the effects of Al doping concentration on the electrical conductivity and characterization of mesoporous ZnO thin films were investigated. By changing the Al doping concentration, ZnO grain growth is inhibited, and the mesoporous structure of ZnO is maintained during a relatively high temperature annealing process. The porosity of Al-doped mesoporous ZnO thin films increased slightly with increasing Al doping concentration. Finally, as electrical conductivity was increased as electrons were freed and pore structure was maintained by inhibiting grain growth, the thermoelectric property was enhanced with increasing Al concentration. © 2013 Min-Hee Hong et al

Retinal thickness measurements in sickle cell patients with HbSS and HbSC genotype

OBJECTIVE: Temporal macula thinning has been reported in sickle cell patients, but it remains unclear if there is a difference between HbSS and HbSC genotypes. We aimed to quantitatively compare macular thickness between eyes with HbSS and HbSC genotype. DESIGN: Retrospective descriptive study. METHODS: Consecutive patients seen over a 5.5-year period in the Ophthalmology Department at St Thomas’ Hospital, London, were identified. Macular optical coherence tomography images were retrospectively analyzed. The retinal thickness in all 9 subfields of the Early Treatment Diabetic Retinopathy Study (ETDRS) grid was compared between HbSS and HbSC eyes. Right eyes and left eyes were analyzed independently, as well as averaged measurements from both eyes. Comparison was made between the 2 genotypes, adjusting for age and sex, and for multiple testing. Scans were excluded in cases of poor fixation or ocular comorbidity affecting retinal thickness. RESULTS: 132 HbSC and 120 HbSS patients were identified. Scans from 166 right and 153 left eyes were included (with approximately equal numbers of HbSS and HbSC genotypes). Mean retinal thickness was lower in HbSS eyes compared with HbSC eyes in all subfields of the ETDRS grid, but in most subfields the difference was <10 microns. Differences reached statistical significance for outer superior, inferior, and temporal subfields and the inner temporal subfield (p < 0.05). CONCLUSION: Although the HbSC genotype is more strongly associated with proliferative retinopathy, HbSS patients had on average more macular thinning

Inspiratory muscle training (IMT) for adults discharged from hospital with community acquired pneumonia (CAP) – a feasibility study

Patients report significant morbidity following community-acquired pneumonia (CAP); 70% report persistent symptoms and up to 50% impaired daily activity at 4 weeks post-discharge. Respiratory muscle weakness is one possible mechanism for delayed recovery. Inspiratory muscle training (IMT) increases strength and endurance of inspiratory muscles, with improvements in patient-reported outcomes in other conditions. To our knowledge IMT has not previously been investigated in CAP. To assess the tolerability of IMT in adults discharged from hospital with community-acquired pneumonia. Patients hospitalised with a diagnosis of CAP between February 2017 and March 2018 were eligible for inclusion and convenience sampling was used for participant selection. Participants received an IMT device (POWERbreath KHP2) following familiarisation. Training frequency (twice daily) and load (50% PImax) were fixed, however training volume was incremental during weeks 1–3 (10, 20, 30 breaths) and constant thereafter (30 breaths.) Participants were followed by combination of telephone and clinic visits for 9 weeks. Outcomes of interest were; utilisation of IMT device per protocol (defined as >94% training adherence), patient-reported IMT acceptability, and number of device-related side effects. Statistical analysis was conducted using Stata (version 15.1.) Twenty-two participants were recruited; 16 were male (72.7%), mean age was 55.2 years (range 27.9–77.3.) Participants completed IMT per protocol in 72.7% cases. One unrelated, unexpected serious adverse event (death) occurred during follow-up and 3 participants active at this time were stopped from further IMT by research sponsor pending investigation. Two participants were lost to follow-up. Side effects during IMT were reported on 15 occasions across 22 participants over a total 1183 training days. Reported side effects included chest pain (x2), cough (x1), dyspnoea (x4), and dizziness (x8). All side-effects were rated grade 1 and did not prevent participants from continuing training. Participant-reported IMT acceptability, defined by participants rating training as both ‘useful’ and ‘helpful’ at each follow-up contact, was 99.4%. Inspiratory muscle training appears to be safe, tolerable, and acceptable to patients following CAP. Distinguishing CAP related symptoms and device-related side effects is challenging in patients recovering following an acute infective illness. A clinical trial to determine efficacy is warranted.Nottingham University Hospitals Trus

Deep Neural Networks - A Brief History

Introduction to deep neural networks and their history.Comment: 14 pages, 14 figure

Longitudinal Study to Assess the Quantitative Use of Fundus Autofluorescence for Monitoring Disease Progression in Choroideremia

BACKGROUND: Characterisation of preserved autofluorescence (PAF) area in choroideremia (CHM) and its validity for monitoring disease progression in clinical trials is of importance. METHODS: Eighty patients with molecularly confirmed CHM were recruited. PAF area was measured manually by 2 graders and half-life was calculated based on exponential decay model. RESULTS: Mean age at baseline and follow-up examination was 38.1 (range, 10-69) and 40.7 (range, 11-70) years. Mean follow-up interval was 29 months (range, 6-104). The median LogMAR visual acuity was 0.10 (OD) and 0.18 (OS). Interobserver repeatability for PAF area was -0.99 to 1.03 mm2 (-6.46 to 6.49% of area). There was a statistically significant relationship between age and rate of PAF area loss (r2 = 0.28, p = 0.012). The half-life for PAF area was 13.7 years (range, 1.7-216.0 years). The correlation between half-life and age was stronger than between half-life and log transformed baseline PAF area, although neither was statistically significant. CONCLUSIONS: The intra- and inter-observer PAF area measurement variability provides a baseline change, which must be overcome in a clinical trial if this metric were to be used. Treatments must slow progression to alter the exponential decay in a timely manner accounting for naturally slow progression patterns

Longitudinal Study to Assess the Quantitative Use of Fundus Autofluorescence for Monitoring Disease Progression in Choroideremia

BACKGROUND: Characterisation of preserved autofluorescence (PAF) area in choroideremia (CHM) and its validity for monitoring disease progression in clinical trials is of importance. METHODS: Eighty patients with molecularly confirmed CHM were recruited. PAF area was measured manually by 2 graders and half-life was calculated based on exponential decay model. RESULTS: Mean age at baseline and follow-up examination was 38.1 (range, 10-69) and 40.7 (range, 11-70) years. Mean follow-up interval was 29 months (range, 6-104). The median LogMAR visual acuity was 0.10 (OD) and 0.18 (OS). Interobserver repeatability for PAF area was -0.99 to 1.03 mm2 (-6.46 to 6.49% of area). There was a statistically significant relationship between age and rate of PAF area loss (r2 = 0.28, p = 0.012). The half-life for PAF area was 13.7 years (range, 1.7-216.0 years). The correlation between half-life and age was stronger than between half-life and log transformed baseline PAF area, although neither was statistically significant. CONCLUSIONS: The intra- and inter-observer PAF area measurement variability provides a baseline change, which must be overcome in a clinical trial if this metric were to be used. Treatments must slow progression to alter the exponential decay in a timely manner accounting for naturally slow progression patterns

The Fear-Avoidance Model of Chronic Pain: Assessing the Role of Neuroticism and Negative Affect in Pain Catastrophizing Using Structural Equation Modeling

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Effect of surfactant concentration variation on the thermoelectric properties of mesoporous ZnO

The electrical and thermal conductivities and the Seebeck coefficient of mesoporous ZnO thin films were investigated to determine the change of their thermoelectric properties by controlling surfactant concentration in the mesoporous ZnO films, because the thermoelectric properties of mesoporous ZnO films can be influenced by the porosity of the mesoporous structures, which is primarily determined by surfactant concentration in the films. Mesoporous ZnO thin films were successfully synthesized by using sol-gel and evaporation-induced self-assembly processes. Zinc acetate dihydrate and Brij-76 were used as the starting material and pore structure-forming template, respectively. The porosity of mesoporous ZnO thin films increased from 29% to 40% with increasing surfactant molar ratio. Porosity can be easily altered by controlling the molar ratio of surfactant/precursor. The electrical and thermal conductivity and Seebeck coefficients showed a close correlation with the porosity of the films, indicating that the thermoelectric properties of thin films can be changed by altering their porosity. Mesoporous ZnO thin films with the highest porosity had the best thermoelectric properties (the lowest thermal conductivity and the highest Seebeck coefficient) of the films examined. © 2013 Min-Hee Hong et al