To determine allopurinol treatment patterns and adherence to published standards of care for patients with gout.
This retrospective claims analysis in a managed care database included patients 18 ...years or older, with continuous eligibility for 1 year before and after the start date and 2 or more visits during which the gout disease code (274.xx) was assigned or 1 or more pharmacy prescriptions for a gout-specific medication between January 1, 2000, and December 31, 2002 (intake period). Factors associated with compliance with allopurinol therapy were measured based on the medication possession ratio, and adherence to 2 quality-of-care indicators for gout management was assessed using multivariable logistic regression analysis.
A total of 64.9% of allopurinol users had a modal daily dose or the most commonly observed daily dose of 300 mg/d, median length of therapy was 3 months, and a high proportion of patients had a medication possession ratio of 10% or less. Suggested quality-of-care indicators for gout had low performance: 53% of patients with renal impairment received a modal daily dose of 300 mg or greater, and 83% of patients who started taking allopurinol did not have their serum urate levels measured within 180 days. Patients with gout flares were less likely to be compliant with allopurinol (odds ratio, 0.50; 95% confidence interval, 0.40-0.63). Patients with renal impairment at baseline were 3.2 times more likely to undergo serum urate testing than patients without renal impairment (odds ratio, 3.20; 95% confidence interval, 1.25-8.23).
There was low compliance with allopurinol therapy for treatment of gout. Patients potentially received suboptimal quality of care as measured by serum urate testing and appropriateness of allopurinol dosing in patients with renal impairment.
Pediatric farm injuries tend to be more severe and have poorer outcomes compared to injuries sustained in non-farm settings. Timely emergency medical service (EMS) response and transport to ...definitive care is crucial for optimizing outcomes for trauma patients. We aimed to determine if pediatric farm injuries were associated with longer EMS response and transport times compared to pediatric non-farm injuries in rural communities.OBJECTIVESPediatric farm injuries tend to be more severe and have poorer outcomes compared to injuries sustained in non-farm settings. Timely emergency medical service (EMS) response and transport to definitive care is crucial for optimizing outcomes for trauma patients. We aimed to determine if pediatric farm injuries were associated with longer EMS response and transport times compared to pediatric non-farm injuries in rural communities.The 2021 National EMS Information System (NEMSIS) database was used to identify rural EMS activations where injured pediatric patients who were transported to a hospital. Median transport times for farm and non-farm injuries, as well as other components of prehospital time and use of air EMS transport, were compared between injuries on farms and injuries in non-farm rural settings.METHODSThe 2021 National EMS Information System (NEMSIS) database was used to identify rural EMS activations where injured pediatric patients who were transported to a hospital. Median transport times for farm and non-farm injuries, as well as other components of prehospital time and use of air EMS transport, were compared between injuries on farms and injuries in non-farm rural settings.The analytic sample included 22,248 rural EMS activations for pediatric injuries, of which 156 (1%) were for pediatric farm injuries. For non-farm and farm injuries, the median transport times were 20 minutes and 28 minutes, respectively. Median total prehospital time was 50 minutes compared to 62 minutes, and 9.8% of patients with non-farm injuries versus 20.5% of those with farm injuries were transported to a hospital by air EMS units. After multivariable adjustment, farm vs. non-farm injury location was associated with a 4 minute increase in EMS transport time, but no difference in initial EMS response time, EMS time on scene, or use of air EMS units.RESULTSThe analytic sample included 22,248 rural EMS activations for pediatric injuries, of which 156 (1%) were for pediatric farm injuries. For non-farm and farm injuries, the median transport times were 20 minutes and 28 minutes, respectively. Median total prehospital time was 50 minutes compared to 62 minutes, and 9.8% of patients with non-farm injuries versus 20.5% of those with farm injuries were transported to a hospital by air EMS units. After multivariable adjustment, farm vs. non-farm injury location was associated with a 4 minute increase in EMS transport time, but no difference in initial EMS response time, EMS time on scene, or use of air EMS units.Among children sustaining an injury that resulted in rural EMS activation, farm injuries were associated with prolonged transport time compared to non-farm injuries, which may contribute to worse in-hospital outcomes described to pediatric farm injuries in prior research.CONCLUSIONAmong children sustaining an injury that resulted in rural EMS activation, farm injuries were associated with prolonged transport time compared to non-farm injuries, which may contribute to worse in-hospital outcomes described to pediatric farm injuries in prior research.
BACKGROUND:The desired serum urate level (SUA) for prevention of gout attacks is widely recommended to be in the subsaturating range, <6.0 mg/dL.
OBJECTIVES:The objectives of this study were to ...evaluate attainment of this target SUA among gout patients on allopurinol in a naturalistic setting and to assess its impact on gout flare risk.
METHODS:This was a retrospective, observational study in a southeastern U.S. managed care organization of approximately 2.2 million members. The first gout claim/prescription within the intake period (January 1, 2000–December 31, 2002) was the index date. Included patients had ≥2 visits with gout International Classification of Diseases, 9th Revision code (274.xx) or ≥1 pharmacy script(s) for allopurinol, colchicine, probenecid, or sulfinpyrazone. Excluded patients were <18 years and/or did not have a 1-year continuous eligibility pre-/postindex date. Gout flares were defined by office/emergency room visit with gout or joint pain code(s) and ≥1 of the following within 7 days of the visitintraarticular aspiration/injection, joint fluid microscopy, or pharmacy claim for nonsteroidal antiinflammatory drug, colchicine, corticosteroid, or ACTH. Multivariable regression analyses were conducted to evaluate gout flare risk/rate and association with target SUA.
RESULTS:Approximately 40% of 5942 gout patients identified used allopurinol postindex. Among allopurinol users with pre-/postindex SUA data (n = 162), mean SUA was lowered from 8.7 mg/dL to 7.1 mg/dL; reduction was significant (P < 0.001). Among allopurinol users who did not have SUA <6.0 mg/dL preindex (n = 147), only 25% reached target levels during postindex. Despite pharmacotherapy, patients with nontarget levels were 59% more likely to flare than those at target. Allopurinol users who were not at target were 75% more likely to flare.
CONCLUSION:The failure of allopurinol users to achieve target SUA levels of <6.0 mg/dL may be attributed to lack of awareness of optimal SUA, allopurinol dosing, compliance, and efficacy. Patients who did not achieve target SUA were at increased flare risk.
Despite proven benefits through the secondary prevention of cardiovascular disease (CVD) and reduction of mortality, cardiac rehabilitation (CR) remains underutilized in cardiac patients. Underserved ...populations most affected by CVD including rural residents, low socioeconomic status patients, and racial/ethnic minorities have the lowest participation rates due to access barriers. Internet-and mobile-based lifestyle interventions have emerged as potential modalities to complement and increase accessibility to CR. An outpatient CR program using virtual world technology may provide an effective alternative to conventional CR by overcoming patient access limitations such as geographics, work schedule constraints, and transportation.
The objective of this paper is to describe the research protocol of a two-phased, pilot study that will assess the feasibility (Phase 1) and comparative effectiveness (Phase 2) of a virtual world-based (Second Life) CR program as an extension of a conventional CR program in achieving healthy behavioral change among post-acute coronary syndrome (ACS) and post-percutaneous coronary intervention (PCI) patients. We hypothesize that virtual world CR users will improve behaviors (physical activity, diet, and smoking) to a greater degree than conventional CR participants.
In Phase 1, we will recruit at least 10 patients enrolled in outpatient CR who were recently hospitalized for an ACS (unstable angina, ST-segment elevation myocardial infarction, non-ST-segment elevation myocardial infarction) or who recently underwent elective PCI at Mayo Clinic Hospital, Rochester Campus in Rochester, MN with at least one modifiable, lifestyle risk factor target (sedentary lifestyle, unhealthy diet, and current smoking). Recruited patients will participate in a 12-week, virtual world health education program which will provide feedback on the feasibility, usability, and design of the intervention. During Phase 2, we will conduct a 2-arm, parallel group, single-center, randomized controlled trial (RCT). Patients will be randomized at a 1:1 ratio to adjunct virtual world-based CR with conventional CR or conventional CR only. The primary outcome is a composite including at least one of the following (1) at least 150 minutes of physical activity per week, (2) daily consumption of five or more fruits and vegetables, and (3) smoking cessation. Patients will be assessed at 3, 6, and 12 months.
The Phase 1 feasibility study is currently open for recruitment which will be followed by the Phase 2 RCT. The anticipated completion date for the study is May 2016.
While research on the use of virtual world technology in health programs is in its infancy, it offers unique advantages over current Web-based health interventions including social interactivity and active learning. It also increases accessibility to vulnerable populations who have higher burdens of CVD. This study will yield results on the effectiveness of a virtual world-based CR program as an innovative platform to influence healthy lifestyle behavior and self-efficacy.
The American Academy of Pediatrics provides this technical report as supplemental background to the accompanying coding and valuation system policy statement. The rapid evolution in health care ...payment modeling requires that clinicians have a current appreciation of the mechanics of service representation and valuation. The accompanying policy statement provides recommendations relevant to this area, and this technical report provides a format to outline important concepts that allow for effective translation of bedside clinical events into physician payment.
The American Academy of Pediatrics provides this revised policy statement to address health care changes that impact procedural and visit coding and valuation as well as the incorporation of coding ...principles into innovative, newer payment models. This policy statement focuses solely on recommendations, and an accompanying technical report provides supplemental coding and valuation background.
Pan-cancer analysis of whole genomes Campbell, Peter J; Getz, Gad; Korbel, Jan O ...
Nature (London),
02/2020, Letnik:
578, Številka:
7793
Journal Article
Recenzirano
Odprti dostop
Cancer is driven by genetic change, and the advent of massively parallel sequencing has enabled systematic documentation of this variation at the whole-genome scale
. Here we report the integrative ...analysis of 2,658 whole-cancer genomes and their matching normal tissues across 38 tumour types from the Pan-Cancer Analysis of Whole Genomes (PCAWG) Consortium of the International Cancer Genome Consortium (ICGC) and The Cancer Genome Atlas (TCGA). We describe the generation of the PCAWG resource, facilitated by international data sharing using compute clouds. On average, cancer genomes contained 4-5 driver mutations when combining coding and non-coding genomic elements; however, in around 5% of cases no drivers were identified, suggesting that cancer driver discovery is not yet complete. Chromothripsis, in which many clustered structural variants arise in a single catastrophic event, is frequently an early event in tumour evolution; in acral melanoma, for example, these events precede most somatic point mutations and affect several cancer-associated genes simultaneously. Cancers with abnormal telomere maintenance often originate from tissues with low replicative activity and show several mechanisms of preventing telomere attrition to critical levels. Common and rare germline variants affect patterns of somatic mutation, including point mutations, structural variants and somatic retrotransposition. A collection of papers from the PCAWG Consortium describes non-coding mutations that drive cancer beyond those in the TERT promoter
; identifies new signatures of mutational processes that cause base substitutions, small insertions and deletions and structural variation
; analyses timings and patterns of tumour evolution
; describes the diverse transcriptional consequences of somatic mutation on splicing, expression levels, fusion genes and promoter activity
; and evaluates a range of more-specialized features of cancer genomes
.
Social identity complexity refers to the way in which individuals subjectively represent the relationships among their multiple ingroup memberships. More specifically, individuals with low social ...identity complexity see their ingroups as highly overlapping and convergent, whereas those with high complexity see their different ingroups as distinct and cross-cutting membership groups. The present study tested the hypothesis that perceived overlap among ingroup memberships would be negatively related to ingroup inclusiveness and tolerance for outgroups, such that individuals with high overlap (low complexity) would be less tolerant and accepting of outgroups in general than those with low overlap (high complexity). Results from a telephone interview survey of adult residents of the state of Ohio supported this hypothesis. Individual differences in complexity of perception of their national, religious, occupational, political, and recreational social identities were systematically related to their attitudes toward ethnic outgroups and diversity.
Abstract
The Cosmology Large Angular Scale Surveyor (CLASS) observes the polarized cosmic microwave background (CMB) over the angular scales of 1° ≲
θ
≤ 90° with the aim of characterizing primordial ...gravitational waves and cosmic reionization. We report on the on-sky performance of the CLASS
Q
-band (40 GHz),
W
-band (90 GHz), and dichroic
G
-band (150/220 GHz) receivers that have been operational at the CLASS site in the Atacama desert since 2016 June, 2018 May, and 2019 September, respectively. We show that the noise-equivalent power measured by the detectors matches the expected noise model based on on-sky optical loading and lab-measured detector parameters. Using Moon, Venus, and Jupiter observations, we obtain power to antenna temperature calibrations and optical efficiencies for the telescopes. From the CMB survey data, we compute instantaneous array noise-equivalent-temperature sensitivities of 22, 19, 23, and 71
μ
K
cmb
s
for the 40, 90, 150, and 220 GHz frequency bands, respectively. These noise temperatures refer to white noise amplitudes, which contribute to sky maps at all angular scales. Future papers will assess additional noise sources impacting larger angular scales.
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