To determine the comparative effectiveness and cost-effectiveness of conventional ventilatory support versus extracorporeal membrane oxygenation (ECMO) for severe adult respiratory failure.
A ...multicentre, randomised controlled trial with two arms.
The ECMO centre at Glenfield Hospital, Leicester, and approved conventional treatment centres and referring hospitals throughout the UK.
Patients aged 18-65 years with severe, but potentially reversible, respiratory failure, defined as a Murray lung injury score > or = 3.0, or uncompensated hypercapnoea with a pH < 7.20 despite optimal conventional treatment.
Participants were randomised to conventional management (CM) or to consideration of ECMO.
The primary outcome measure was death or severe disability at 6 months. Secondary outcomes included a range of hospital indices: duration of ventilation, use of high frequency/oscillation/jet ventilation, use of nitric oxide, prone positioning, use of steroids, length of intensive care unit stay, and length of hospital stay - and (for ECMO patients only) mode (venovenous/veno-arterial), duration of ECMO, blood flow and sweep flow.
A total of 180 patients (90 in each arm) were randomised from 68 centres. Three patients in the conventional arm did not give permission to be followed up. Of the 90 patients randomised to the ECMO arm, 68 received that treatment. ECMO was not given to three patients who died prior to transfer, two who died in transit, 16 who improved with conventional treatment given by the ECMO team and one who required amputation and could not therefore be heparinised. Ninety patients entered the CM (control) arm, three patients later withdrew and refused follow-up (meaning that they were alive), leaving 87 patients for whom primary outcome measures were available. CM consisted of any treatment deemed appropriate by the patient's intensivist with the exception of extracorporeal gas exchange. No CM patients received ECMO, although one received a form of experimental extracorporeal arteriovenous carbon dioxide removal support (a clear protocol violation). Fewer patients in the ECMO arm than in the CM arm had died or were severely disabled 6 months after randomisation, 33/90 (36.7%) versus 46/87 (52.9%) respectively. This equated to one extra survivor for every six patients treated. Only one patient (in the CM arm) was known to be severely disabled at 6 months. Patients allocated to ECMO incurred average total costs of 73,979 pounds compared with 33,435 pounds for those undergoing CM (UK prices, 2005). A lifetime model predicted the cost per quality-adjusted life-year (QALY) of ECMO to be 19,252 pounds (95% confidence interval 7622 pounds to 59,200 pounds) at a discount rate of 3.5%. Lifetime QALYs gained were 10.75 for the ECMO group compared with 7.31 for the conventional group. Costs to patients and their relatives, including out of pocket and time costs, were higher for patients allocated to ECMO.
Compared with CM, transferring adult patients with severe but potentially reversible respiratory failure to a single centre specialising in the treatment of severe respiratory failure for consideration of ECMO significantly increased survival without severe disability. Use of ECMO in this way is likely to be cost-effective when compared with other technologies currently competing for health resources.
Current Controlled Trials ISRCTN47279827.
Objective
To describe the National Heart Lung and Blood Institute (NHLBI) sponsored Disparities Elimination through Coordinated Interventions to Prevent and Control Heart and Lung Disease (DECIPHeR) ...Alliance to support late‐stage implementation research aimed at reducing disparities in communities with high burdens of cardiovascular and/or pulmonary disease.
Study Setting
NHBLI funded seven DECIPHeR studies and a Coordinating Center. Projects target high‐risk diverse populations including racial and ethnic minorities, urban, rural, and low‐income communities, disadvantaged children, and persons with serious mental illness. Two projects address multiple cardiovascular risk factors, three focus on hypertension, one on tobacco use, and one on pediatric asthma.
Study Design
The initial phase supports planning activities for sustainable uptake of evidence‐based interventions in targeted communities. The second phase tests late‐stage evidence‐based implementation strategies.
Data Collection/Extraction Methods
Not applicable.
Principal Findings
We provide an overview of the DECIPHeR Alliance and individual study designs, populations, and settings, implementation strategies, interventions, and outcomes. We describe the Alliance's organizational structure, designed to promote cross‐center partnership and collaboration.
Conclusions
The DECIPHeR Alliance represents an ambitious national effort to develop sustainable implementation of interventions to achieve cardiovascular and pulmonary health equity.
Objective: To examine associations between weight status and number of all-cause and cause-specific hospitalizations overall, and by race and gender. Design: Longitudinal cohort study. Subjects: ...White and black adults (n=15 355) from the Atherosclerosis Risk in Communities Study who were normal weight (body mass index: >or=18.5 to <25.0 kg m-2; n=4997), overweight (>or=25.0 to <30.0 kg m-2; n=6100), or obese (>or=30.0 kg m-2; n=4258) at baseline. Measurements: Information on hospitalizations was collected using community and cohort surveillance methods. Negative binomial models adjusted for race, gender, field center, age, physical activity, education level, smoking status, alcoholic beverage consumption and health insurance at baseline. Adjusted numbers of hospitalizations were calculated after setting covariates to the mean value (for continuous variables) or to the average distribution (for categorical variables) observed in the entire cohort and are expressed as the number of hospitalizations per 1000 adults followed over a period of 13 years. Results: The covariate-adjusted average number of all-cause hospitalizations was 1316 per 1000 normal weight, 1543 per 1000 overweight and 2025 per 1000 obese. Normal weight women had significantly fewer hospitalizations than normal weight men (1173 versus 1515 per 1000), but the increase associated with being obese on the number of all-cause hospitalizations was larger in women than men (791 versus 589 per 1000). There was no significant difference detected between the number of hospitalizations in normal weight whites and blacks, and the increase in hospitalizations with overweight or obesity was also not different. Effects of weight status on several primary causes of hospitalization differed by gender and race group. Conclusion: Our work suggests that obesity prevention may reduce hospitalizations, a major component of rising healthcare costs. The impact of successful obesity prevention is likely to be larger in women than in men, and similar in blacks and whites.
Background
Individuals with intellectual disability (ID) are at greater risk of exposure to traumatic life events compared with the non‐ID population. Yet no study to date has examined the role of ...multiple traumatisation and subsequent psychopathology in people with ID. The aim of this study was to explore the association between multiple traumatisation and subsequent mental health.
Methods
A preliminary cross‐sectional study involving 33 participants with DSM‐5 post‐traumatic stress disorder completed self‐report questionnaires on exposure to traumatic life events and post‐traumatic stress disorder symptoms, anxiety, depression and general distress.
Results
A proportion of 42.4% of the sample reported multiple traumatisation, including exposure to life events in both childhood and adulthood. Those who reported exposure to life events in childhood and adulthood reported significantly higher risk of harm, depression and general psychological distress compared with those who reported exposure to life events only in adulthood.
Conclusions
Preliminary results indicate that more severe psychopathology is associated with multiple traumatisation in childhood and adulthood compared with trauma experienced solely in adulthood.
This review aim to provide an overview of recommendations and quality of existing clinical practice guidelines (CPGs) for the management of traumatic brain injury (TBI) from the rehabilitation ...perspective. Comprehensive literature search, including health databases, CPG clearinghouse/developer websites, and grey literature using Internet search engines up to September 2017. All TBI CPGs published in the last decade were selected if their scope included management of TBI, systematic methods for evidence search, clear defined recommendations, and supporting evidence for rehabilitation interventions. Three authors independently critically appraised the quality of included CPGs using the Appraisal of Guidelines, Research, and Evaluation II (AGREE II) Instrument. Four of 13 potential CPGs met the inclusion criteria. Despite variation in scope, target population, size, and guideline development processes, all four CPGs assessed were good quality (AGREE score of 5-7/7). Key rehabilitation recommendations included education, physical rehabilitation, integrated computer-based management, repetitive task-specific practice in daily living activities, safe equipment usage, cognitive/behavioral feedback, compensatory memory/visual strategies, swallowing/communication, and psychological input for TBI survivors. In conclusion, although rehabilitation is an integral component in TBI management, many published CPGs do not include rehabilitation. These CPGs, however, recommend comprehensive, flexible coordinated multidisciplinary care and appropriate follow-up, education, and support for patients with TBI (and carers).
ObjectivesTo investigate mortality rates and associated factors, and avoidable mortality in children/young people with intellectual disabilities.DesignRetrospective cohort; individual record-linked ...data between Scotland’s 2011 Census and 9.5 years of National Records for Scotland death certification data.SettingGeneral community.ParticipantsChildren and young people with intellectual disabilities living in Scotland aged 5–24 years, and an age-matched comparison group.Main outcome measuresDeaths up to 2020: age of death, age-standardised mortality ratios (age-SMRs); causes of death including cause-specific age-SMRs/sex-SMRs; and avoidable deaths.ResultsDeath occurred in 260/7247 (3.6%) children/young people with intellectual disabilities (crude mortality rate=388/100 000 person-years) and 528/156 439 (0.3%) children/young people without intellectual disabilities (crude mortality rate=36/100 000 person-years). SMRs for children/young people with versus those without intellectual disabilities were 10.7 for all causes (95% CI 9.47 to 12.1), 5.17 for avoidable death (95% CI 4.19 to 6.37), 2.3 for preventable death (95% CI 1.6 to 3.2) and 16.1 for treatable death (95% CI 12.5 to 20.8). SMRs were highest for children (27.4, 95% CI 20.6 to 36.3) aged 5–9 years, and lowest for young people (6.6, 95% CI 5.1 to 8.6) aged 20–24 years. SMRs were higher in more affluent neighbourhoods. Crude mortality incidences were higher for the children/young people with intellectual disabilities for most International Statistical Classification of Diseases and Related Health Problems, 10th Revision chapters. The most common underlying avoidable causes of mortality for children/young people with intellectual disabilities were epilepsy, aspiration/reflux/choking and respiratory infection, and for children/young people without intellectual disabilities were suicide, accidental drug-related deaths and car accidents.ConclusionChildren with intellectual disabilities had significantly higher rates of all-cause, avoidable, treatable and preventable mortality than their peers. The largest differences were for treatable mortality, particularly at ages 5–9 years. Interventions to improve healthcare to reduce treatable mortality should be a priority for children/young people with intellectual disabilities. Examples include improved epilepsy management and risk assessments, and coordinated multidisciplinary actions to reduce aspiration/reflux/choking and respiratory infection. This is necessary across all neighbourhoods.
Getting results with curriculum mapping Jacobs, Heidi Hayes
Association for Supervision and Curriculum Development,
2004, 2004-00-00, 2004-11-15
eBook, Book
This book helps teachers structure curriculum mapping efforts to promote measurable improvements in student performance.
PDF
