Abstract Background China introduced a national policy to develop primary care in 2009, with 8669 community health centres (CHCs) established by 2014, employing more than 300 000 staff. However, ...against a background of the “barefoot doctor” legacy in rural China, mistrust of doctors, and over-reliance on specialist care, these facilities have been underused. This study aimed to evaluate the current quality of CHCs in China, including the organisation and infrastructure, as well as the use and training of the health-care professionals within primary care. Methods We selected a random sample of 189 community health centres, stratified on the basis of geographical distribution and urban-suburban ratios, from throughout China between September and December, 2015. Two questionnaires, one for lead clinicians and another for primary care practitioners, covered the demographics of the clinic and clinical and training activities. Responses to the survey were obtained from 149 lead clinicians in community health centres and 3580 primary care practitioners (response rates 79% and 86%, respectively). Ethics committee approvals from a local board (HKU/HAW IRB: UW15-350) and the WHO Regional Office for the Western Pacific (2016.4.CHN.1.HSI) were obtained. Findings Community health centres employed a median of eight doctors (IQR 4–14) and thirteen nurses (8–21) but only half of the doctors were registered as primary care practitioners (798 of 1734, 46%) and very few nurses had training specifically for primary care (92 of 1846, 5%). Most community health centres were in buildings previously designated as hospitals (86 of 149, 58%) and 87% (130) had inpatient beds. Although clinics were equipped with stethoscopes (146, 98%) and sphygmomanometers (145, 97%), only 83% (124) had otoscopes, 43% (64) had ophthalmoscopes, and 64% (95) had facilities for gynaecological examination. Clinical care was selectively skewed towards certain chronic diseases. Doctors saw a median of 12·5 (IQR 5·0–25·8) patients per day. Multivariate analysis showed that community health centres organised by private enterprises (β=11·1, 95% CI 1·3–20·8) and those which had pharmacists (1·9, 0·7–3·1) and nurses (0·32, 0·1–0·5) were associated with higher number of daily patients seen by doctor. Further, doctors saw fewer patients per day in clinics who opened 7 days a week (−3·8, 95% CI −7·2 to −0·3) and in those which provided a wider range of services (−3·3, −5·8 to −0·8). Interpretation The survey shows that China has established a large, mostly young primary-care workforce and provided ongoing professional training. However, facilities are basic, with few clinics providing comprehensive primary care for a wide range of common physical and mental conditions. Use of community health centres by patients remains low. Funding This project was supported by three funding sources: RGC seed fund for basic research, University Grant Council, HK SAR Government, entitled “Survey of the attitudes and needs of integrated HIV and STI services in community health centres in China (2015–16)” (project number 201411159004); Shanghai Key Discipline Construction Program in Public Health (Shanghai Municipal Commission of Health and Family Planning, project number 12GWZX1001); and Shanghai Excellent Academic Leaders Training Program in Public Health (Shanghai Municipal Commission of Health and Family Planning, project number GWDTR201210).
Coronavirus disease 2019 is associated with high mortality rates and multiple organ damage. There is increasing evidence that these patients are at risk for various cardiovascular insults; however, ...there are currently no guidelines for the diagnosis and management of such cardiovascular complications in patients with coronavirus disease 2019. We share data and recommendations from a multidisciplinary team to highlight our institution's clinical experiences and guidelines for managing cardiovascular complications of coronavirus disease 2019.
This was a retrospective cohort study of patients admitted to one of six ICUs dedicated to the care of patients with coronavirus disease 2019 located in three hospitals within one academic medical center in Atlanta, Georgia.
Chart review was conducted for sociodemographic, laboratory, and clinical data. Rates of specific cardiovascular complications were assessed, and data were analyzed using a chi-square or Wilcoxon rank-sum test for categorical and continuous variables. Additionally, certain cases are presented to demonstrate the sub committee's recommendations.
Two-hundred eighty-eight patients were admitted to the ICU with coronavirus disease 2019. Of these, 86 died (29.9%), 242 (84.03%) had troponin elevation, 70 (24.31%) had dysrhythmias, four (1.39%) had ST-elevation myocardial infarction, eight (2.78%) developed cor pulmonale, and 190 (65.97%) with shock. There was increased mortality risk in patients with greater degrees of troponin elevation (
< 0.001) and with the development of arrhythmias (
< 0.001), cor pulmonale (
< 0.001), and shock (
< 0.001).
While there are guidelines for the diagnosis and management of pulmonary complications of coronavirus disease 2019, there needs to be more information regarding the management of cardiovascular complications as well. These recommendations garnered from the coronavirus disease 2019 cardiology subcommittee from our institution will add to the existing knowledge of these potential cardiovascular insults as well as highlight suggestions for the diagnosis and management of the range of cardiovascular complications of coronavirus disease 2019. Additionally, with the spread of coronavirus disease 2019, our case-based recommendations provide a bedside resource for providers newly caring for patients with coronavirus disease 2019.
Endovascular thrombectomy (EVT) access in remote areas is limited. Preliminary data suggest that long distance transfers for EVT may be beneficial; however, the magnitude and best imaging strategy at ...the referring center remains uncertain. We hypothesized that patients transferred >300 miles would benefit from EVT, achieving rates of functional independence (modified Rankin Scale mRS score of 0-2) at 3 months similar to those patients treated at the comprehensive stroke center in the randomized EVT extended window trials and that the selection of patients with computed tomography perfusion (CTP) at the referring site would be associated with ordinal shift toward better outcomes on the mRS.
This is a retrospective analysis of patients transferred from 31 referring hospitals >300 miles (measured by the most direct road distance) to 9 comprehensive stroke centers in Australia and New Zealand for EVT consideration (April 2016 through May 2021).
There were 131 patients; the median age was 64 53-74 years and the median baseline National Institutes of Health Stroke Scale score was 16 12-22. At baseline, 79 patients (60.3%) had noncontrast CT+CT angiography, 52 (39.7%) also had CTP. At the comprehensive stroke center, 114 (87%) patients underwent cerebral angiography, and 96 (73.3%) proceeded to EVT. At 3 months, 62 patients (48.4%) had an mRS score of 0 to 2 and 81 (63.3%) mRS score of 0 to 3. CTP selection at the referring site was not associated with better ordinal scores on the mRS at 3 months (mRS median of 2 1-3 versus 3 1-6 in the patients selected with noncontrast CT+CT angiography,
=0.1). Nevertheless, patients selected with CTP were less likely to have an mRS score of 5 to 6 (odds ratio 0.03 0.01-0.19;
<0.01).
In selected patients transferred >300 miles, there was a benefit for EVT, with outcomes similar to those treated in the comprehensive stroke center in the EVT extended window trials. Remote hospital CTP selection was not associated with ordinal mRS improvement, but was associated with fewer very poor 3-month outcomes.
Most of our understanding of the ecology and evolution of avian influenza A virus (AIV) in wild birds is derived from studies conducted in the northern hemisphere on waterfowl, with a substantial ...bias towards dabbling ducks. However, relevant environmental conditions and patterns of avian migration and reproduction are substantially different in the southern hemisphere. Through the sequencing and analysis of 333 unique AIV genomes collected from wild birds collected over 15 years we show that Australia is a global sink for AIV diversity and not integrally linked with the Eurasian gene pool. Rather, AIV are infrequently introduced to Australia, followed by decades of isolated circulation and eventual extinction. The number of co-circulating viral lineages varies per subtype. AIV haemagglutinin (HA) subtypes that are rarely identified at duck-centric study sites (H8-12) had more detected introductions and contemporary co-circulating lineages in Australia. Combined with a lack of duck migration beyond the Australian-Papuan region, these findings suggest introductions by long-distance migratory shorebirds. In addition, on the available data we found no evidence of directional or consistent patterns in virus movement across the Australian continent. This feature corresponds to patterns of bird movement, whereby waterfowl have nomadic and erratic rainfall-dependant distributions rather than consistent intra-continental migratory routes. Finally, we detected high levels of virus gene segment reassortment, with a high diversity of AIV genome constellations across years and locations. These data, in addition to those from other studies in Africa and South America, clearly show that patterns of AIV dynamics in the Southern Hemisphere are distinct from those in the temperate north.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Anatomically based technologies (computed tomography scans, magnetic resonance imaging, and so on) are in routine use in radiotherapy for planning and assessment purposes. Even with improvements in ...imaging, however, radiotherapy is still limited in efficacy and toxicity in certain applications. Further advances may be provided by technologies that image the molecular activities of tumors and normal tissues. Possible uses for molecular imaging include better localization of tumor regions and early assay for the radiation response of tumors and normal tissues. Critical to the success of this approach is the identification and validation of molecular probes that are suitable in the radiotherapy context. Recent developments in molecular-imaging probes and integration of functional imaging with radiotherapy are promising. This review focuses on recent advances in molecular imaging strategies and probes that may aid in improving the efficacy of radiotherapy.
This study sought to determine the effect of cost sharing on medical care use for acute symptoms and on health status among chronically ill adults.
Data from the Medical Outcomes Study were used to ...compare (1) rates of physician care use for minor and serious symptoms and (2) 6- and 12-month follow-up physical and mental health status among individuals at different levels of cost sharing.
In comparison with a no-copay group, the low- and high-copay groups were less likely to have sought care for minor symptoms, but only the high-copay group had a lower rate of seeking care for serious symptoms. Follow-up physical and mental health status scores were similar among the 3 copay groups.
In a chronically ill population, cost sharing reduced the use of care for both minor and serious symptoms. Although no differences in self-reported health status were observed, health plans featuring cost sharing need careful monitoring for potential adverse health effects because of their propensity to reduce use of care that is considered necessary and appropriate.
Delayed graft function (DGF) is a major complication of deceased donor kidney transplantation. Saline (0.9% sodium chloride) is a commonly used intravenous fluid in transplantation but may increase ...the risk of DGF because of its high chloride content. Better Evidence for Selecting Transplant Fluids (BEST-Fluids), a pragmatic, registry-based, double-blind, randomized trial, sought to determine whether using a balanced low-chloride crystalloid solution (Plasma-Lyte 148) instead of saline would reduce DGF. We sought to evaluate the generalizability of the trial cohort by reporting the baseline characteristics and representativeness of the trial participants in detail.
We compared the characteristics of BEST-Fluids participants with those of a contemporary cohort of deceased donor kidney transplant recipients in Australia and New Zealand using data from the Australia and New Zealand Dialysis and Transplant Registry. To explore potential international differences, we compared trial participants with a cohort of transplant recipients in the United States using data from the Scientific Registry of Transplant Recipients.
During the trial recruitment period, 2373 deceased donor kidney transplants were performed in Australia and New Zealand; 2178 were eligible' and 808 were enrolled in BEST-Fluids. Overall, trial participants and nonparticipants were similar at baseline. Trial participants had more coronary artery disease (standardized difference d = 0.09;
= 0.03), longer dialysis duration (d = 0.18,
< 0.001), and fewer hypertensive (d = -0.11,
= 0.03) and circulatory death (d = -0.14,
< 0.01) donors than nonparticipants. Most key characteristics were similar between trial participants and US recipients, with moderate differences (|d| ≥ 0.2; all
< 0.001) in kidney failure cause, diabetes, dialysis duration, ischemic time, and several donor risk predictors, likely reflecting underlying population differences.
BEST-Fluids participants had more comorbidities and received slightly fewer high-risk deceased donor kidneys but were otherwise representative of Australian and New Zealand transplant recipients and were generally similar to US recipients. The trial results should be broadly applicable to deceased donor kidney transplantation practice worldwide.
Objective: In the United Kingdom, the coronavirus disease 2019 (COVID-19) pandemic has led to the cessation of elective surgery. However, there remains a need to provide urgent and emergency cardiac ...and thoracic surgery as well as to continue time-critical thoracic cancer surgery. This study describes our early experience of implementing a protocol to safely deliver major cardiac and thoracic surgery in the midst of the pandemic. Methods: Data on all patients undergoing cardiothoracic surgery at a single tertiary referral center in London were prospectively collated during the first 7 weeks of lockdown in the United Kingdom. A comprehensive protocol was implemented to maintain a COVID-19–free environment including the preoperative screening of all patients, the use of full personal protective equipment in areas with aerosol-generating procedures, and separate treatment pathways for patients with and without the virus. Results: A total of 156 patients underwent major cardiac and thoracic surgery over the study period. Operative mortality was 9% in the cardiac patients and 1.4% in thoracic patients. The preoperative COVID-19 protocol implemented resulted in 18 patients testing positive for COVID-19 infection and 13 patients having their surgery delayed. No patients who were negative for COVID-19 infection on preoperative screening tested positive postoperatively. However, 1 thoracic patient tested positive on intraoperative bronchoalveolar lavage. Conclusions: Our early experience demonstrates that it is possible to perform major cardiac and thoracic surgery with low operative mortality and zero development of postoperative COVID-19 infection.
This paper is an investigation of the feasibility of applying a mechanically flexible magnetic composite material to radio frequency identification (RFID) planar antennas operating in the lower ...ultrahigh-frequency (UHF) spectrum (~300500 MHz). A key challenge is that the magnetic loss introduced by the magnetic composite must be sufficiently low for successful application at the targeted operating frequency. A flexible magnetic composite comprised of particles of Z-phase Co hexaferrite, also known as Co 2 Z, in a silicone matrix was developed. To the authors' knowledge, this is the first flexible magnetic composite demonstrated to work at these frequencies. The benchmarking structure was a quarter-wavelength microstrip patch antenna. Antennas on the developed magnetic composite and pure silicone substrates were electromagnetically modeled in Ansoft High-Frequency Sounder System full wave electromagnetic software. A prototype of the antenna on the magnetic composite was fabricated, and good agreement between the simulated and measured results was found. Comparison of the antennas on the magnetic composite versus the pure silicone substrate showed miniaturization capability of 2.4 times and performance differences of increased bandwidth and reduced gain, both of which were attributed in part to the increase in the dielectric and magnetic losses. A key finding of this paper is that a small amount of permeability (mu r ~2.5) can provide a substantial capability for miniaturization, while sufficiently low-magnetic loss can be introduced for successful application at the targeted operating frequency. This magnetic composite shows the capability to fulfill this balance and to be a feasible option for RFID, flexible wearable, and conformal applications in the lower UHF spectrum.
BACKGROUND: Since the introduction of the first protease inhibitor in January 1996, there has been a dramatic change in the treatment of persons infected with HIV. The changing nature of HIV care has ...important implications for the types of physicians that can best care for patients with HIV infection. OBJECTIVE: To assess the association of specialty training and experience in the care of HIV disease with the adoption and use of highly active antiretroviral (ARV) therapy (HAART). DESIGN: Observational cohort study of patients under care for HIV infection and their physicians. PATIENTS AND SETTING: This analysis used data collected from a national probability sample of noninstitutionalized persons with HIV infection participating in the HIV Costs and Service Utilization Study and their primary physicians. We analyzed 1,820 patients being cared for by 374 physicians. MEASUREMENTS: Rates of HAART use at 12 months and 18 months after the approval of the first protease inhibitor. RESULTS: Forty percent of the physicians were formally trained in infectious diseases (ID), 38% were general medicine physicians with self-reported expertise in the care of HIV, and 22% were general medicine physicians without self-reported expertise in the care of HIV. The majority of physicians (69%) reported a current HIV caseload of 50 patients or more. In multivariable models controlling for patient characteristics, there were no differences between generalist experts and ID physicians in rates of HAART use in December 1996. When compared to ID physicians, however, patients being treated by non-expert general medicine physicians were less likely to be on HAART (odds ratio OR, 0.32; 95% confidence interval 95% CI, 0.17 to 0.61). Patients being treated by low-volume physicians were also much less likely to be on HAART therapy than those treated by high-volume physicians (OR, 0.26; 95% CI, 0.14 to 0.48). These findings were attenuated by June 1997, suggesting that over time, the broader physician community successfully adopted HAART therapy. This finding is consistent with prior research on the diffusion of innovations. CONCLUSIONS: Similar proportions of patients treated by expert generalists and ID specialists were on appropriate HAART therapy by December 1996 and July 1997. Patients treated by non-expert generalists, most of whom were the lowest-volume physicians, were much less likely to be on appropriate ARV therapy in the earlier time period. Our findings demonstrate that generalists who develop specialized expertise are able to provide care of quality comparable to that of specialists.PUBLICATION ABSTRACT
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