This thesis examines the impact of disease and mortality on the Royal Navy in the West Indies from 1770 to 1806. It also investigates the navy’s medical branch which was established to manage the care of sick seamen. Using an interdisciplinary approach, this thesis produces a cohesive understanding of how disease and mortality affected the navy’s presence in the West Indies and the ways in which the navy attempted to mitigate their impact. This thesis explores various aspects of naval medicine including the history of the Sick and Hurt Board, the diseases which distressed seamen, the medicines distributed by the navy, the key personnel who were integral in generating changes to the medical system and the development of hospital facilities. Largely based on Admiralty records including correspondence and minutes from the Sick and Hurt Board, ships’ muster books and surgeons’ journals, this thesis investigates the most prevalent diseases in the West Indies and the prescribed treatments advocated by the navy. It then examines how these diseases and treatments affected seamen on board ships in that region through a quantitative analysis; then focuses on a number of the integral naval personnel who ushered in sweeping changes to naval medicine; and explores the navy’s increasing desire to transition from hired sick quarters to purpose-built naval hospitals on various West Indies islands. It concludes with a case study of the development of Antigua naval hospital which demonstrates the effectiveness of these facilities in convalescing sick seamen. Through a quantitative analysis of ships’ muster books, this thesis argues that the levels of sickness and mortality in the navy in the West Indies during the late eighteenth century are largely exaggerated in historical studies while also discrediting the myth that those islands were the ‘white man’s graveyard’ for many naval personnel. By surveying over 100,000 seamen on board ships in that region, sickness and mortality figures emerge which indicate that, on average, less than 4 per cent of seamen were on the sick list at any given time and only a small percentage died, meaning that the majority remained on active duty. This thesis then argues that many of the changes to the navy’s medical system that facilitated such low percentages were primarily instigated by surgeons, physicians and captains who identified beneficial medicines and championed their general distribution among the entire fleet. By looking at these aspects of naval medicine through a multidisciplinary lens rather than a purely administrative one, it is possible to understand the true state of health of British seamen in the West Indies during the last quarter of the eighteenth century.

Neste estudo, hipotetizou-se que existia alta incidência de cirurgiões dentistas com baixa cobertura vacinal para hepatite B e positividade para contato prévio ou corrente para a hepatite viral do tipo B. O presente estudo transversal avaliou a condição vacinal e perfil sorológico dos cirurgiões dentistas para hepatite viral do tipo B no município de Porto Velho/RO - Brasil. Foram analisadas pela técnica de ELISA oitenta amostras de sangue (soro) dos cirurgiões dentistas residentes no município de Porto Velho/RO, visando a detecção dos marcadores sorológicos do Vírus da hepatite B: HBsAg, anti HBc total, anti-HBc IgM e anti-HBs. As amostras anti HBc Total positivas foram testadas para o marcador anti HBc IgM. Foram analisados os achados laboratoriais com dados de formação profissional, uso de equipamento de proteção individual (EPI) e índice vacinal entre os profissionais. Os dados foram comparados utilizando-se o teste Kruskal-Wallis (p< 0,05). Dos cirurgiões dentistas avaliados, 45% faziam clínica geral e 38% relataram atualizar-se profissionalmente uma vez ao ano. A maioria (p< 0,05) dos participantes (59%) recebeu as três doses da vacina contra hepatite B e 11% apenas duas doses. Dentre os que receberam três doses a maior (p< 0,05) frequência (47%) apresentou soroconversão decorrente da vacinação. Embora abaixo do número esperado de 100%, a maioria dos cirurgiões dentistas de Porto Velho recebeu as três doses da vacina o que em geral acarretou imunidade. Entretanto, o perfil sorológico nem sempre foi compatível com a cobertura vacinal. Nossos achados sugerem a necessidade de execução de provas laboratoriais para confirmação e/ou monitoramento do perfil sorológico decorrente da vacinação contra hepatite B. / This search supposed that it had a high incidence of dentists with low vaccine covering for hepatitis B and a positive for previous or current contact for the virus hepatitis of type B. The transversal study evaluated the vaccines condition and serum profile of the dentists for viral hepatitis of type B in Porto Velhos city in Rondonias state Brazil. eighty samples of blood (serum) of the resident surgeons had been analyzed by the ELISAs technique of the dentists in Porto Velhos city, to only find out about the serums detention markers of the Virus of hepatitis B: HBsAg, anti total HBc, anti-HBc IgM and anti-HBs. The positive samples anti Total HBc had been tested for the marker anti HBc IgM. And also it had been analyzed at the lab findings with data of professional formation, equipment used as an individual protection (EPI) and vaccine index between the professionals. The data had been compared using the test Kruskal-Wallis ( p< 0,05) from the people that had been participated. As a result we can say that from dentists analyzed, 45% were in a general clinical and 38% told that to bring up to date once a year. Most of them (59%) received three quantities against Hepatitis B and 11% only with two quantities. Between the people that received three quantities, showed another serum due to the vaccine. Although the number was not expected, most of the dentists from Porto Velho received three doses of the vaccine which it caused immunity. However, the serum profile nor always it was compatible the vaccine covering. Our findings suggest the necessity of execution of labs tests for confirmation and/or a coordination of the serum profile of the vaccination against hepatitis B.

This dissertation explores U.S. military surgeons’ purposeful efforts to alter how medical and line officers in the U.S. Army and Navy conceived of disease, appreciated surgeons’ roles, and organized medical war preparations through education, training, exposure, and medico-military professionalization between 1884 and 1918. It traces surgeons’ postwar efforts to change American military cultures in response to the revelations of the germ theory of disease and deadly typhoid fever epidemics in the American training camps of the Spanish-American War. Medical and line officers required academic education and practical lessons to contextualize disease, surgeons, and medical care, understand and appreciate germs’ role in medicine, and train to apply these lessons to benefit their soldiers and sailors. Surgeons also reinforced their scientific education and grew military medicine through postgraduate education and tactical training designed to enhance the line’s perception of surgeons and medical science.This dissertation rests on the contention that surgeons contributed to military preparation for the next war by effecting cultural change to prevent the epidemics of previous wars. This culture of medical preparation shaped how military medical departments recruited, organized, and trained medical officers, procured supplies, and managed civil-military relationships. Entwined cultural change and war preparation were expressed in the multiple mobilization activities through which surgeons validated the success or failure of their efforts. Troops participated in organized camps of instruction, maneuver camps, and major mobilizations to the U.S.-Mexico border, allowing surgeons to use the physical encampments, hospitals, and other surgeons to test assumptions, exercise and refine theory, validate operational principles, and improve from previous iterations. As the United States entered the Great War in 1917, epidemics of measles, influenza, and meningitis attacked Army and Navy recruit training camps. Rather than demonstrate failure, this dissertation positions the 1917 and 1918 epidemics to demonstrate medical officers’ successful military cultural change. A comparative approach between 1898 and 1918 also highlights cultural and medico-military evolution through the lenses of preparation and mobilization. Official military reports and archival sources illuminate cultural divisions between line and medical officers and track the curricular development of military hygiene and sanitation courses in undergraduate and professional military schools and specialized fields at military medical schools. This dissertation intervenes in military and medical historiographies by pushing the conversation beyond disease’s impact on war to center disease and changing perceptions of disease, culturally and medically, as features of military preparation. It also recasts military surgeons as central agents in the U.S. military’s turn-of-the-century professionalization and modernization efforts. As the world addresses the outcomes and aftermath of the COVID-19 pandemic, this dissertation demonstrates that physicians and societies met previous epidemics and pandemics on medical science’s past frontiers where the germ theory of disease had barely won acceptance. It also illustrates the power of individuals in subordinate classes to affect institutional cultures for the betterment of all. Lastly, as military operations during future pandemics are all but guaranteed, this dissertation proves that dedication and preparation are just as vital to epidemic defense as good science. / History

Thesis (MPhil)--Stellenbosch University, 2014. / ENGLISH ABSTRACT: This thesis discusses ethical dilemmas faced by district surgeons in South Africa. District surgeons render clinical forensic services, which means that they deal mainly with detainees and victims of crime. The main functions of district surgeons are the collection of forensic evidence from patients and the care of detainees. So the focus is to assist in the administration of justice rather than improvement of patient wellbeing. The district surgeon may therefore find himself in a situation where patients’ interests are in conflict with those of law enforcement agencies. Being a medical practitioner in clinical forensic medicine, the district surgeon has an obligation to assist in the administration of justice, as opposed to the traditional obligation to care for patients and put patient’s interests first. This allegiance to both administration of justice as well as patient wellbeing lead to an ethical dilemma of dual loyalties. A dual obligations presents an ethical dilemma for the district surgeon, especially if they are in conflict and mutually exclusive. I discuss the detention and subsequent death of Steve Biko to illustrate how dual obligations can lead to serious human rights violations and even death. Dual obligations are however not limited to detainees and police custody settings, and I demonstrate this by discussing three other scenarios commonly encountered by district surgeons. There is a lack clear guidance for district surgeons who are faced with a conflict of obligations. I explore several ethical theories including consequentialism, deontology and virtue ethics, in search of an ethical framework suitable for resolving conflicts in clinical forensic medicine. I therefore argue that a duty based ethical framework is central to clinical forensic medicine and the resolution of loyalty conflicts. I recommend the resolution of conflicts by using an approach developed by Benjamin (2006). This approach involves weighing -up the different duties in conflict, applying philosophical reasoning and then amelioration. By adopting a structured and wellreasoned ethical framework, district surgeons will be able to deal with conflicts of obligations better. / AFRIKAANSE OPSOMMING: Hierdie tesis bespreek etiese dilemmas wat in die gesig gestaar word deur distriksgeneeshere in Suid-Afrika. Distriksgeneeshere lewer kliniese forensiese dienste, wat beteken dat hulle handel hoofsaaklik oor die gevangenes en slagoffers van misdaad. Die belangrikste funksies van distriksgeneeshere is die insameling van forensiese getuienis van pasiënte, en die sorg van gevangenes. Met hierdie benadering is die fokus om te help met die administratiewe doeleindes van geregtigheid, eerder as die verbetering van die pasiënt se welstand. Die distriksgeneesheer kan hom dus in 'n situasie vind waarby die pasiënte se belange in konflik is met dié van wetstoepassingsagentskappe. As 'n geneesheer in kliniese forensiese geneeskunde, het die distriksgeneesheer 'n verpligting om te help met die administrasie van geregtigheid, in teenstelling met die tradisionele verpligting om te sorg vir hul pasiënte, en hul welstand eerste te plaas. Hierdie getrouheid gaan gepaard met beide regspleging, sowel as die welstand van die pasiënt, wat kan lei tot 'n etiese dilemma van dubbele lojaliteit. Dubbele verpligtinge bied 'n etiese dilemma vir die distriksgeneesheer, veral as hulle in konflik en wedersyds uitsluitend is. Ek bespreek die aanhouding en die daaropvolgende dood van Steve Biko om te illustreer hoe dubbele verpligtinge kan lei tot ernstige skending van menseregte en selfs die dood. Dubbele verpligtinge is egter nie beperk tot die gevangenes en polisie-aanhouding instellings nie, en ek demonstreer dit deur die bespreking van drie ander “scenario's” wat oor die algemeen eervaar word deur distriksgeneeshere. Daar is 'n gebrek aan duidelike riglyne vir distriksgeneeshere wat 'n botsing van verpligtinge in die gesig staar. Ek verken verskeie etiese teorieë insluitende konsekwensialisme, deontologie en deugde-etiek, op soek na 'n etiese raamwerk geskik vir die oplossing van konflikte in kliniese geregtelike geneeskunde. Ek argumenteer dus dat 'n pligsgebaseerde etiese raamwerk sentraal is tot kliniese forensiese geneeskunde, en die resolusie van lojaliteit konflikte. Ek beveel die oplossing van konflikte deur die gebruik van 'n benadering wat ontwikkel is deur Benjamin (2006). Hierdie benadering behels 'n gewigsoorweging tussen die verskillende pligte in konflik, die toepassing van filosofiese redenasie en verbetering. Deur die aanneming van 'n gestruktureerde en beredeneerde etiese raamwerk, sal distriksgeneeshere dus in staat wees om konflikte van verpligtinge beter te hanteer.

Zur Zeit gibt es keinen quantitativen Gesamtüberblick und keinen bundesweiten Vergleich der Zahlen von Studienanfängern, Absolventen mit abgelegter Tierärztlichen Prüfung (TP), Tierärzten mit Approbation sowie Kammermitgliedschaften. Es wird untersucht, wie sich das Verhältnis zwischen der Anzahl der von den veterinärmedizinischen Bildungsstätten erteilten TP zur Anzahl der in Deutschland erteilten Approbationen und diese wiederum zu den bestehenden Pflichtmitgliedschaften in den Landestierärztekammern für den Untersuchungszeitraum der Abschlussjahrgänge 2000 bis 2010 darstellt. Es wurde Datenmaterial der Stiftung für Hochschulzulassung, der fünf veterinärmedizinischen Bildungsstätten, des Deutschen Tierärzteblattes, der Approbationsbehörden und der Zentralen Tierärztedatei Dresden genutzt. Anschließend wurden die Daten mittels Recherche in öffentlichen Medien ergänzt. Insgesamt wurden n = 8036 Personen zur Untersuchung herangezogen, wovon n = 6715 (84 %) auswertbar waren, dabei lag der Frauenanteil stets bei durchschnittlich 82 %. Es zeigte sich, dass die überwiegende Mehrheit (92 %) der auswertbaren Personen ihre Approbation innerhalb der ersten drei Monate nach Bestehen der TP erhielt. 84 % ließen nur maximal drei Monate zwischen Approbationserhalt und Kammerbeitritt vergehen. 75 % der Absolventen bleiben ihrem Ausbildungsland treu bzw. kehren dorthin zurück, eine veterinärmedizinische Hochschule bzw. Fakultät hat somit einen fachkräftebindenden Effekt für das jeweilige Bundesland. Im Bereich der Haupttätigkeitsfelder geht der Trend nach wie vor in Richtung „Praktiker“ (52 %). Personen ohne Berufsausübung bzw. Doktoranden nehmen den zweitgrößten Anteil (17 %) der Tätigkeitsfelder ein. Dabei steht die Einstufung der Doktoranden der Tiermedizin in tierärztlich „Tätige“ oder „nicht Tätige“ zur Diskussion, da diese in Deutschland noch in einer rechtlichen Grauzone liegt. Das Anmeldesystem ausgehend von der Approbationsbeantragung bis zur Kammermitgliedschaft bei den Tierärzten in Deutschland, mit weniger als 3 % nicht registrierter Kammermitgliedschaften sowie weniger als 1 % niemals beantragter Approbationen, funktioniert recht gut. Dies scheint in erster Linie am starken Pflichtbewusstsein der deutschen Tierärzte zu liegen. Lücken in der Zusammenarbeit zwischen Approbationsbehörden und Landestierärztekammern bzw. Fehlerquellen bei der Datenübermittlung fielen bisher nicht auf und die rechtliche Verfolgung von Versäumnissen einzelner Tierärzte spielt in der Kammerverwaltung eine untergeordnete bis gar keine Rolle, da rechtliche Vergehen tatsächlich Ausnahmen darstellen. Dennoch sollten die Datenbasis und auch der Datenfluss zwischen den beteiligten Institutionen vereinheitlicht, verifiziert und auch regelmäßig ausgewertet werden, denn ohne die Anwendung von Kontroll- und Sanktionsmaßnahmen ist die rechtsverbindliche Pflichtmitgliedschaft de facto eine reine Selbstverpflichtung. Eine einheitliche Stellungnahme zum Status der Doktoranden seitens der berufspolitischen Organe ist dringend notwendig. Doktoranden sollten zur Gruppe der tierärztlich „Tätigen“ zählen und der Nachweis der Approbation für alle mit der Promotion einhergehenden Arbeitsschritte Pflicht sein. In Anbetracht einer diesbezüglich bisher fehlenden bundeseinheitlichen Regelung, ist die Frage, ob man in Deutschland ohne Probleme mit fehlender Approbation tierärztlich tätig werden kann, eindeutig mit „ja“ zu beantworten.

Surgeons of Prague in historical sources of 18th and 19th century Abstract This diploma thesis uses the archival sources on the surgeons' guild and the papers of the central authorities to explore the position of the surgeons within the medical structure in modern times. All the materials are taken from Prague City Archives, The National Archives and Archive of Charles University in Prague (e.g. laws and statutes, registers of all types, statutes of the guild or university charters, personal documents of the guilds' members). The text is focused on surgeons' gaining independence compared with doctors of medicine and moving away from barbers craft organization. The process of their transition under the supervision of the medical faculty and the official start of surgical studies at the university are examined. Furthermore, the study includes an analysis of the role of the guild, the social status of the surgeons in Prague and the character of their education including transformation in this field during the Enlightenment reforms till the revolutionary year 1848. The information extracted from the sources allows to follow the development of surgery from disrespected profession into an inherent part of medical sciences by exploring all the phenomena concerned with the education of surgeons and legal aspects of...

Background: The 30-day readmission rate is considered a quality of care measure for providers and has become important because providers might face reduced reimbursement from any increase in unplanned readmissions Objective: The aim of the first chapter is to investigate the waiting-length of stay (WLOS) and post-length of stay (PLOS) on the 30-day readmission. In the second chapter, we examined the hospital procedural volume and hospital quality on the 30-day readmission. Our objective in the third chapter is to examine the zip code-level SES factors on the 30-day readmission rates. Participants: patients undergoing isolated coronary artery bypass grafting (CABG) in Virginia Methods: A retrospective study design has been conducted using a multi-level logistic model of increasing complexity for all three chapters. The sample used was from the Virginia Cardiac Surgery Quality Initiative (VCSQI) of the periods 2008-2014, the dataset included patient characteristics. Afterward, we merged the sample with both the Virginia Health Information (VHI) to obtain hospital characteristics (ownership, teaching status, and location), and Agency for Healthcare Research and Quality (AHRF) to obtain county-socio-economic status (SES) characteristics (education, employment, and median household income), the previous SES was used for chapter’s one and two. In chapter three, instead of AHRF, we merged the sample with the American Community Survey (ACS) to obtain zip code-SES characteristics (employment, median household income, education, median house price). The main outcome was the 30-day readmission rate. The analytical sample of chapter one n = 22,097, in chapter two the sample n = 25,531, while in chapter three the sample n= 25,829. We conducted a sensitivity analysis in all three chapters. In chapter one we analyzed the data at the patient level, in chapter two we analyzed the data at the hospital level, while in chapter three we conducted the analysis at the area zip code level. Results: In chapter one, we found that readmitted patients after a prolonged PLOS had increased odds of readmission, by 68.7%, compared to readmitted patients with a shorter PLOS in the fully adjusted model; while, WLOS was not significant at the P < 0.05. In chapter two, the fully adjusted model displayed significant results with a reduced odds in readmissions by 22.8% in the middle-volume hospitals compared to the low-volume hospitals, while the middle-quality hospitals had increased odds of readmission by 23.5% compared to the low-quality hospitals. In chapter three, statistically, we did not find that area zip code-SES had an effect on the 30-day readmission rate. While, geographically, we found that addresses of individuals were clustered in certain areas of Virginia. Conclusion: In chapter one, patients undergoing CABG and experience a prolonged PLOS of > 6 days are at risk to be readmitted within 30-days of the procedure. In chapter two, the higher volume hospitals (middle-volume) compared to low-volume hospitals showed a significant reduction in odds in the 30-day readmissions, especially after adjusting the model with hospital quality. In chapter three, even though, there was no association of area-SES with 30-day readmission, in the maps, we found a cluster of patient addresses in the southern parts of Virginia with an increased readmission, which is considered underprivileged area; and the fact might be due to the proximity of these areas to cardiovascular hospitals. Policy Implication: In chapter one, the study provided a model for clinicians to stratify patients at risk of readmission, especially patients with risks of staying longer in the hospital after CABG. In chapter two, policymakers and the CMS should find new ways to help hospitals with low-volumes to reduce their isolated-CABG readmission rates and be able to compete with high-volume hospitals. In chapter three, no significant correlation between area-SES and readmission for patients who underwent CABG was found; these backs prior notion that SES should not be adjusted for the reimbursement penalties of the Hospital Readmission Reductions Program (HRRP) on hospitals

Thesis (M.S.)--State University of New York at Binghamton, Department of Systems Science and Industrial Engineering, 2009. / Includes bibliographical references (leaves: 150-155).

No description available.

Risk assessment models developed from administrative and clinical databases are used for clinical decision making. Since these models are derived from a database, they have an inherent limitation of being as good as the data they are derived from. Many of these models under or overestimate certain clinical outcomes particularly mortality in certain group of patients. Undeniably, there is significant variability in all these models on account of patient population studied, the statistical analysis used to develop the model and the period during which these models were developed. This review aims to shed light on development and application of risk assessment models for cardiac surgery with special emphasis on risk stratification in severe aortic stenosis to select patients for transcatheter aortic valve replacement.