Stroke is a major cause of death and disability worldwide. Hypoxia is common after stroke and is associated with worse outcomes. Oxygen supplementation could prevent hypoxia and secondary brain ...damage.
(1) To assess whether or not routine low-dose oxygen supplementation in patients with acute stroke improves outcome compared with no oxygen; and (2) to assess whether or not oxygen given at night only, when oxygen saturation is most likely to be low, is more effective than continuous supplementation.
Multicentre, prospective, randomised, open, blinded-end point trial.
Secondary care hospitals with acute stroke wards.
Adult stroke patients within 24 hours of hospital admission and 48 hours of stroke onset, without definite indications for or contraindications to oxygen or a life-threatening condition other than stroke.
Allocated by web-based minimised randomisation to: (1) continuous oxygen: oxygen via nasal cannula continuously (day and night) for 72 hours after randomisation at a flow rate of 3 l/minute if baseline oxygen saturation was ≤ 93% or 2 l/minute if > 93%; (2) nocturnal oxygen: oxygen via nasal cannula overnight (21:00-07:00) for three consecutive nights. The flow rate was the same as the continuous oxygen group; and (3) control: no routine oxygen supplementation unless required for reasons other than stroke.
Primary outcome: disability assessed by the modified Rankin Scale (mRS) at 3 months by postal questionnaire (participant aware, assessor blinded). Secondary outcomes at 7 days: neurological improvement, National Institutes of Health Stroke Scale (NIHSS), mortality, and the highest and lowest oxygen saturations within the first 72 hours. Secondary outcomes at 3, 6, and 12 months: mortality, independence, current living arrangements, Barthel Index, quality of life (European Quality of Life-5 Dimensions, three levels) and Nottingham Extended Activities of Daily Living scale by postal questionnaire.
In total, 8003 patients were recruited between 24 April 2008 and 17 June 2013 from 136 hospitals in the UK continuous,
= 2668; nocturnal,
= 2667; control,
= 2668; mean age 72 years (standard deviation 13 years); 4398 (55%) males. All prognostic factors and baseline characteristics were well matched across the groups. Eighty-two per cent had ischaemic strokes. At baseline the median Glasgow Coma Scale score was 15 (interquartile range 15-15) and the mean and median NIHSS scores were 7 and 5 (range 0-34), respectively. The mean oxygen saturation at randomisation was 96.6% in the continuous and nocturnal oxygen groups and 96.7% in the control group. Primary outcome: oxygen supplementation did not reduce disability in either the continuous or the nocturnal oxygen groups. The unadjusted odds ratio for a better outcome (lower mRS) was 0.97 95% confidence interval (CI) 0.89 to 1.05;
= 0.5 for the combined oxygen groups (both continuous and nocturnal together) (
= 5152) versus the control (
= 2567) and 1.03 (95% CI 0.93 to 1.13;
= 0.6) for continuous versus nocturnal oxygen. Secondary outcomes: oxygen supplementation significantly increased oxygen saturation, but did not affect any of the other secondary outcomes.
Severely hypoxic patients were not included.
Routine low-dose oxygen supplementation in stroke patients who are not severely hypoxic is safe, but does not improve outcome after stroke.
To investigate the causes of hypoxia and develop methods of prevention.
Current Controlled Trials ISRCTN52416964 and European Union Drug Regulating Authorities Clinical Trials (EudraCT) number 2006-003479-11.
This project was funded by the National Institute for Health Research (NIHR) Research for Patient Benefit and Health Technology Assessment programmes and will be published in full in
; Vol. 22, No. 14. See the NIHR Journals Library website for further project information.
This study used linked, routinely-collected datasets to explore incidence, clinical characteristics and outcomes of prostate cancer (PC) patients who experience a rise in prostate-specific antigen ...(PSA) levels despite androgen deprivation therapy (ADT), without evidence of metastases in their patient record, termed non-metastatic castration-resistant PC (nmCRPC). Routinely collected administrative data in Wales were used to identify patients diagnosed with PC and nmCRPC from 2000-2015. Logrank tests and Cox proportional hazard models were used to compare time-to-events across subgroups defined by PSA doubling time and age. Of 38,021 patients identified with PC, 1,465 met nmCRPC criteria. PC incidence increased over the study period, while nmCRPC categorizations reduced. Median time from PC diagnosis to nmCRPC categorization was 3.07 years (95% confidence interval CI 2.91-3.26) and from nmCRPC categorization to metastases/death was 2.86 years (95% CI 2.67-3.09). Shorter PSA doubling time (≤ 10 months, versus > 10 months) was associated with reduced time to metastases or death (2.11 years 95% CI 1.92-2.30 versus 5.22 years 95% CI 4.87-5.51). Age was not significantly associated with time to metastases/death. Our findings highlight key clinical characteristics and outcomes for patients with nmCRPC prior to the introduction of recently approved treatments.
IMPORTANCE: Self-monitoring of blood pressure with self-titration of antihypertensives (self-management) results in lower blood pressure in patients with hypertension, but there are no data about ...patients in high-risk groups. OBJECTIVE: To determine the effect of self-monitoring with self-titration of antihypertensive medication compared with usual care on systolic blood pressure among patients with cardiovascular disease, diabetes, or chronic kidney disease. DESIGN, SETTING, AND PATIENTS: A primary care, unblinded, randomized clinical trial involving 552 patients who were aged at least 35 years with a history of stroke, coronary heart disease, diabetes, or chronic kidney disease and with baseline blood pressure of at least 130/80 mm Hg being treated at 59 UK primary care practices was conducted between March 2011 and January 2013. INTERVENTIONS: Self-monitoring of blood pressure combined with an individualized self-titration algorithm. During the study period, the office visit blood pressure measurement target was 130/80 mm Hg and the home measurement target was 120/75 mm Hg. Control patients received usual care consisting of seeing their health care clinician for routine blood pressure measurement and adjustment of medication if necessary. MAIN OUTCOMES AND MEASURES: The primary outcome was the difference in systolic blood pressure between intervention and control groups at the 12-month office visit. RESULTS: Primary outcome data were available from 450 patients (81%). The mean baseline blood pressure was 143.1/80.5 mm Hg in the intervention group and 143.6/79.5 mm Hg in the control group. After 12 months, the mean blood pressure had decreased to 128.2/73.8 mm Hg in the intervention group and to 137.8/76.3 mm Hg in the control group, a difference of 9.2 mm Hg (95% CI, 5.7-12.7) in systolic and 3.4 mm Hg (95% CI, 1.8-5.0) in diastolic blood pressure following correction for baseline blood pressure. Multiple imputation for missing values gave similar results: the mean baseline was 143.5/80.2 mm Hg in the intervention group vs 144.2/79.9 mm Hg in the control group, and at 12 months, the mean was 128.6/73.6 mm Hg in the intervention group vs 138.2/76.4 mm Hg in the control group, with a difference of 8.8 mm Hg (95% CI, 4.9-12.7) for systolic and 3.1 mm Hg (95% CI, 0.7-5.5) for diastolic blood pressure between groups. These results were comparable in all subgroups, without excessive adverse events. CONCLUSIONS AND RELEVANCE: Among patients with hypertension at high risk of cardiovascular disease, self-monitoring with self-titration of antihypertensive medication compared with usual care resulted in lower systolic blood pressure at 12 months. TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN87171227
Microbial keratitis (MK) is the most common non-surgical ophthalmic emergency admission in the UK. However, few prospective health-economic studies of MK have been performed, and no specific ...healthcare resources group (HRG) code exists. This study is designed to determine the feasibility of a data collection tool derived from the microbiology ophthalmology group (MOG) clinical record form, to enable quantification of direct costs of inpatient care, as well as prospective capture of epidemiological data relating to outcomes of MK.
Clinical, demographic and economic data were collected retrospectively between January and December 2013 for 101 consecutive patients admitted with MK, using an adaption of the MOG toolset. The direct cost of admission (COA) was calculated using national reference costs and compared to actual income to generate profit/deficit profiles for individual patients. Indices of multiple deprivation were used to assess effect of deprivation on the COA.
The total income generated through discharge coding was £252,116, compared to a COA of £357,075, yielding a deficit of £104,960 (median: £754 per patient). The cost deficit increased significantly with length of stay (LOS, p < 0.001), whilst patients with short LOS were income generators; cost neutrality occurred at 4.8 days. Greater socioeconomic deprivation was also associated with a significantly higher cost deficit.
LOS is the key driver for COA of care for MK admissions. Protocols should encourage discharge of patients who are able to self-administer treatment after the sterilisation phase. The MOG-derived data collection toolset captures pertinent clinical data for quantification of COA. Further development into a multiuser and multisite platform is required for robust prospective testing, together with expansion to capture indirect costs of disease burden, including impact of treatment, visual morbidity and quality of life.
Clinical Commissioning Groups (CCGs) were created in 2013 to make the NHS more responsive, efficient and accountable. A large number of different indicators can be used to measure the quality and ...outcomes of services provided by CCGs, however there is currently no single measure of overall efficiency available. The performance of CCGs may also be confounded by environmental factors such as deprivation, population size and burden of disease. Data Envelopment Analysis (DEA) is a linear programming technique that can be used to measure the relative efficiency of a given set of organisations. To use DEA to measure the efficiency of English CCGs and assess the impact of environmental factors. This study estimates the technical efficiency of 208 CCGs in England using DEA. The inputs and outputs used include budget allocation, number of general practitioners, mortality rates, patient satisfaction and Quality and Outcomes Framework achievement scores. Regression analysis is used to assess the effects of environmental factors on efficiency, such as population size, prevalence of disease, and socio-economic status. Twenty-three percent (47/208) of CCGs were efficient compared to the others. Three environmental factors were statistically significant predictors of efficiency: CCGs with smaller population sizes were more efficient than those with larger ones, while high unemployment rates and a high prevalence of chronic obstructive pulmonary disease led to a decrease in efficiency scores. Comparative deprivation was not a significant predictor of efficiency. The finding that the relationship between deprivation and efficiency is not statistically significant suggests that NHS England’s adjustment for environmental factors within the CCG-level budget allocation is broadly successful. This study shows the potential of DEA for assessing technical efficiency at CCG-level in the English NHS.
Abstract Background Decision-analytic modeling (DAM) has been increasingly used to aid decision making in health care. The growing use of modeling in economic evaluations has led to increased ...scrutiny of the methods used. Objective The objective of this study was to perform a systematic review to identify and critically assess good practice guidelines, with particular emphasis on contemporary developments. Methods A systematic review of English language articles was undertaken to identify articles presenting guidance for good practice in DAM in the evaluation of health care. The inclusion criteria were articles providing guidance or criteria against which to assess good practice in DAM and studies providing criteria or elements for good practice in some areas of DAM. The review covered the period January 1990 to March 2014 and included the following electronic bibliographic databases: Cochrane Library, Cochrane Methodology Register and Health Technology Assessment, NHS Economic Evaluation Database, MEDLINE, and PubMed (Embase). Additional studies were identified by searching references. Results Thirty-three articles were included in this review. A practical five-dimension framework was developed that describe the key elements of good research practice that should be considered and reported to increase the credibility of results obtained from DAM in the evaluation of health care. Conclusions This study is the first to critically review all available guidelines and statements of good practice in DAM since 2006. The development of good practice guidelines is an ongoing process, and important efforts have been made to identify what is good practice and to keep these guidelines up to date.
En el presente documento se analiza la relación entre el precio de mercado y el valor catastral de los lotes baldíos, urbanizados y de propiedad horizontal, y su distribución espacial dentro del área ...urbana de la ciudad de Cuenca, con una superficie aproximada de 74 km2. El valor catastral de los lotes se obtuvo del portal del Gobierno Municipal Autónomo Descentralizado del Cantón Cuenca. Mientras que el precio de mercado se consiguió de las ofertas inmobiliarias publicadas en el período septiembre 2019 a marzo de 2020. De los 100,203 lotes, dentro del área de estudio, 994 lotes, de los cuales se encuentran disponibles el precio de mercado y el valor catastral, fueron incluidos en el estudio. En total, se utilizaron en el análisis 421 lotes sin construir, 518 parcelas construidas y 55 propiedades horizontales. El precio del suelo según la tasación municipal equivale, en promedio, al 54.15% del precio de mercado, lo que demuestra que el valor catastral de las propiedades está subvalorado. La autocorrelación espacial entre el precio de mercado y el valor catastral se derivó utilizando las estadísticas I de Moran y Gi*. Se determinaron lotes con precio de mercado alto con respecto al valor catastral, el 5% de los predios mostraron valores superiores al 4.82 con un máximo de 11.39. Considerando estos aspectos, los municipios, dado que la sociedad cambia a un ritmo acelerado, deben modernizar y renovar el sistema catastral, que tradicionalmente se considera que funciona bien, pero en muchos casos está desactualizado.
ObjectivesThe aim of this study was to examine the impact of transient ischaemic attack (TIA) service modification in two hospitals on costs and clinical outcomes.DesignDiscrete event simulation ...model using data from routine electronic health records from 2011.ParticipantsPatients with suspected TIA were followed from symptom onset to presentation, referral to specialist clinics, treatment and subsequent stroke.InterventionsIncluded existing versus previous (less same day clinics) and hypothetical service reconfiguration (7-day service with less availability of clinics per day).Outcome measuresThe primary outcome of the model was the prevalence of major stroke after TIA. Secondary outcomes included service costs (including those of treating subsequent stroke) and time to treatment and attainment of national targets for service provision (proportion of high-risk patients (according to ABCD2 score) seen within 24 hours).ResultsThe estimated costs of previous service provision for 490 patients (aged 74±12 years, 48.9% female and 23.6% high risk) per year at each site were £340 000 and £368 000, respectively. This resulted in 31% of high-risk patients seen within 24 hours of referral (47/150) with a median time from referral to clinic attendance/treatment of 1.15 days (IQR 0.93–2.88). The costs associated with the existing and hypothetical services decreased by £5000 at one site and increased £21 000 at the other site. Target attainment was improved to 79% (118/150). However, the median time to clinic attendance was only reduced to 0.85 days (IQR 0.17–0.99) and thus no appreciable impact on the modelled incidence of major stroke was observed (10.7 per year, 99% CI 10.5 to 10.9 (previous service) vs 10.6 per year, 99% CI 10.4 to 10.8 (existing service)).ConclusionsReconfiguration of services for TIA is effective at increasing target attainment, but in services which are already working efficiently (treating patients within 1–2 days), it has little estimated impact on clinical outcomes and increased investment may not be worthwhile.
Existen reflexiones importantes que abordan el derecho a la ciudad en términos conceptuales, con pocas lecturas espaciales y generalmente centradas en espacios formalmente reconocidos como urbanos. ...El presente trabajo expone la construcción de una metodología que interpreta espacialmente el derecho a la ciudad comparando la situación del área urbana de la ciudad de Cuenca, Ecuador, con su conurbación. Se concluye que el análisis espacial permite determinar aquellos componentes de la estructura urbana que requieren atención particular en un proceso de intervención en la ciudad, con miras al cumplimiento de los derechos de la población.
SUMMARYThis article presents new estimates of publicly funded healthcare outputs, inputs and productivity for the period 1995 to 2008. These update the estimates published in Total Public Service ...Output and Productivity in June 2009 (ONS 2009a) by incorporating new methods to improve the measurement of output and input volumes and give the first results for 2008.
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