Orientadores: Ilka de Fátima Santana Ferreira Boin, Raquel Silveira Bello Stucch / Dissertação (mestrado) - Universidade Estadual de Campinas, Faculdade de Ciências Médicas / Made available in DSpace on 2018-08-26T07:55:30Z (GMT). No. of bitstreams: 1 CamposJunior_IvanDiasde_M.pdf: 3325530 bytes, checksum: f5ac736cc4b5815d7622935e22caf7f8 (MD5) Previous issue date: 2014 / Resumo: Introdução: Utiliza-se o sistema BAR (Balance of Risk Score) para o prognóstico de sobrevida (SV) dos pacientes pós-transplante hepático.Objetivo: Verificar a aplicação do sistema BAR como predição de SV em pacientes após transplante. Método: Efetuou-se um estudo observacional retrospectivo em 402 pacientes transplantados entre 1997 a 2012. Excluíram-se os pacientes que realizaram técnica tradicional (standard), uso de enxertos duplos ou reduzidos e os com dados incompletos. Avaliaram-se os dados do doador e do receptor. Para cada paciente foi calculado o escore BAR por meio do site http://www.assessurgery.com/bar-score/bar-score-calculator, cuja escala varia de 0 a 27 pontos.Os pontos de corte para BAR foram definidos por meio da área sob a curva ROC. A análise estatística foi efetuada usando-se método de Kaplan-Meier (teste log-rank) para SV, teste de Mann-Whitney para comparação entre grupos e análise regressão logística múltipla. Resultado: A SV aos três meses para BAR ? 11 foi de 46% e para BAR < 11 de 77% (p = 0,001); a SV aos 12 meses para BAR ? 11 foi de 44% e para BAR < 11 de 69% (p = 0,001). A análise de regressão múltipla mostrou como fatores determinantes para SV < três meses: escore BAR ? 11 pontos (OR = 3,08; IC95% = 1,75 - 5,42; p = 0,001) e uso de concentrado de hemácias(CH) acima de 6 unidades(u) no intraoperatório (OR = 4,49; IC95% = 2,73 - 7,39; p = 0,001) e para SV < 12 meses: escore BAR ? 11 pontos (OR = 2,94; IC95% = 1,67 - 5,16; p = 0,001) e CH > 6u intraoperatório (OR = 2,99; IC95% = 1,92 - 4,64; p = 0,001). Conclusão: Este estudo demonstra uma habilidade moderada do escore BAR, e realça a importância da hemotransfusão como fator preditor de sobrevida nesta população / Abstract: Background: The balance of risk (BAR) is a prediction system after liver transplantation. Methods: To assess the BAR system a retrospective observational study was performed for 402 patients who had transplant surgery between 1997 and 2012. BAR score was computed for each patient. Receiver operating characteristic (ROC) curve analysis with the Hosmer-Lemeshow test were used to calculate sensitivity, specificity and model calibration. Cutoff value were selected with the best Younden index. Statistical analysis employed the Kaplan-Meier method (log-rank test) for survival, the Mann-Whitney test for group comparison, and multiple logistic regression analysis. Results: 3-month survival was 46% for BAR ? 11 and 77% for BAR < 11 (p = 0.001); 12-month survival was 44% for BAR ? 11 and 69% for BAR < 11 (p = 0.001). Factors of survival < 3 months were BAR ? 11 (OR = 3.08; IC95% = 1.75 - 5.42; p = 0.001), and intrasurgical use of packed red blood cells (RBC) above 6 units (OR = 4.49; IC95% = 2.73 - 7.39; p = 0.001). For survival < 12 months, factors were BAR ? 11 (OR = 2.94; IC95% = 1.67 - 5.16; p = 0.001), and RBC > 6 units (OR = 2.99; IC95% = 1.92 - 4.64; p = 0.001). Conclusions: Our study is a contribution to the incorporation of the BAR system into Brazilian transplantation centers / Mestrado / Fisiopatologia Cirúrgica / Mestre em Ciências da Cirurgia

Studien undersökte gruppbaserad compassionfokuserad terapi (CFT) i en klinisk miljö hos ungdomar med psykisk ohälsa samt hos omsorgspersoner till ungdomar med psykisk ohälsa. Syftet var att undersöka samband mellan deltagarnas upplevelse av CFT och psykiskt mående före och efter behandling. Deltagarna beskrev fritt sina upplevelser av CFT i en utvärderingsenkät som undersöktes med innehållsanalyser. Psykiskt mående skattades med en anpassad version av The Child Outcome Rating Scale (CORS) och förändring mättes med beroende t-test. Sambandet mellan dessa undersöktes med datan från båda instrumenten. Resultatet visade en övergripande positiv upplevelse av behandlingen. Omsorgspersonernas psykiska mående förbättrades signifikant, men inte ungdomarnas. Ett möjligt samband mellan positiv förändring i psykiskt mående och positiv behandlingsupplevelse syntes. Däremot sågs inget tydligt samband kring försämring i psykiskt mående och en negativ behandlingsupplevelse. CFT tycks vara hjälpsamt för omsorgspersoner till barn med psykisk ohälsa och eventuellt även för ungdomar med psykisk ohälsa men vidare forskning krävs. / The study examined group-based compassion-focused therapy (CFT) for adolescents with mental health problems, and caregivers to adolescents with mental health problems, in a clinical environment. The purpose was to examine the association between participants´ experiences of CFT and changes in psychological distress before and after treatment. Participants freely described their experience in an evaluation questionnaire, which were examined with content analyzes. Psychological distress was rated with a constructed version of The Child Outcome Rating Scale (CORS) and changes were measured with dependent t-test. Comparisons between both assessments examined their association. The results showed positive experiences of the treatment. Caregivers rated a significant improvement in psychological distress, however, adolescents did not. A possible association was discovered between improvement in psychological distress and positive experiences. However, there was no obvious pattern between impairment of psychological distress and negative experiences. CFT seems to be a helpful treatment for caregivers to adolescents with mental health problems and possibly also to adolescents with mental health problems, but further research is required.

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Chronic pain is a complex health issue and a major cause of disability worldwide. Although multimodal rehabilitation (MMR) has been recognized as an effective form of treatment for chronic pain, some patients do not benefit from it. If treatment outcomes could be reliably predicted, then patients who would benefit more from MMR could be prioritized over others. Machine learning has been proven capable of accurately predicting outcomes in other healthcare related domains. Therefore, this study aims to investigate the use of it to predict outcomes of MMR, using data from the Swedish Quality Registry for Pain Rehabilitation (SQRP). XGBoost regression was used for this purpose, and its predictive performance was compared to Ridge regression. 12 models were trained on SQRP data for each algorithm, in order to predict pain and quality of life related outcomes. The results show similar performances for both algorithms, with mean cross-validated R² values of 0.323 and 0.321 for the XGBoost and Ridge models respectively. The average root mean squared errors of 6.744 for XGBoost and 6.743 for Ridge were similar as well. Since XGBoost performed similarly to a less computationally expensive method, the use of this method for MMR outcome prediction was not supported by the results of this study. However, machine learning has the potential to be more effective for this purpose, through the use of different hyperparameter values, correlation-based feature selection or other machine learning algorithms.

Background: Treatment decisions for elderly patients with gallbladder pathology are complex. Little is known about what factors go into treatment decisions in this population. We used Medicare data to examine gender-based differences in the use of cholecystectomy vs. cholecystostomy tube placement in elderly patients with acute cholecystitis. Methods: We queried a 5% random sample of Medicare data (2009-2011) for patients >65 admitted for acute cholecystitis (by ICD-9 code) who subsequently underwent a cholecystectomy and/or cholecystostomy tube placement. Demographic information (age, race), clinical characteristics (Elixhauser index, presence of biliary pathology), and hospital outcomes (case fatality rate, length of stay, need for ICU care) were compared by gender. A multivariable model was used to examine predictors of cholecystectomy vs. cholecystostomy tube placement. Results: Of 4063 patients admitted with cholecystitis undergoing the procedures of interest just over half (58%) were women. The majority of patients (93%) underwent cholecystectomy. Compared to women, men were younger (average age 76 vs. 78, p value < 0.01) and had few comorbidities (average Elixhauser 1.2 vs. 1.4 p value < 0.01). Case fatality rate was similar between men (2.5%) and women (2.4% p value 0.48). A higher percentage of men spent time in the ICU (36%) compared to women (31% p value < 0.01). On multivariable analysis men were 30% less likely to undergo cholecystectomy (OR 0.69, 95% CI 0.53-0.91). Conclusion: Elderly men are less likely than elderly women to undergo cholecystectomy for acute cholecystitis despite being younger with less co morbidity and are more likely to spend time in the ICU. More research is needed to determine whether a difference in treatment is contributing to the higher rate of ICU utilization in elderly men with acute cholecystitis.

Remarkable progress has been made in the development of effective treatments for patients with rheumatoid arthritis (RA). To ensure that a patient is optimally responding to treatment, consistent monitoring of disease activity is recommended. Established composite and individual disease activity measures often cannot be computed due to missing laboratory values. Simplified measures that can be calculated without a lab value have been developed and previous studies have validated these new measures, yet differences in their performance compared with established measures remain. Therefore, the goal of my doctoral research was to examine and evaluate disease activity and composite measures to facilitate monitoring of response in clinical care settings and inclusion of patients with missing laboratory values in epidemiological research. In the first study, the validity of two composite measures, the Clinical Disease Activity Index (CDAI) and the Disease Activity Score with 28 joint count (DAS28) was examined and both were significantly associated with a rheumatologist’s decision to change therapy (CDAI OR=1.58; 95% CI: 1.42, 1.76) (DAS28 OR=1.34; 95% CI 1.27,1.56). However, further evaluation using receiver operating characteristic (ROC) analysis found that they were not strong predictors of physician decisions to change therapy (AUC=0.75, 0.76, respectively). Thus, they should not be used to guide treatment decisions in the clinic. Two measures of disease activity, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) are often not measured and impede the computation of composite measures of disease activity. In the second study, significant factors which may predict the measurement of the ESR and CRP were identified and included physician and clinical variables but no quantitative disease activity measures. Thus the suitability of the ESR and CRP as measures of disease activity is suspect. In the final study, I created a new composite measure, the modified disease activity score with 28 joint count (mDAS28), by replacing the laboratory value in the DAS28. The mDAS28 was then validated by comparing its performance with the DAS28. The measures were strongly correlated (r=0.87), and strong agreement was found between the two measures when categorizing patients to levels of disease activity (ĸ=0.77) and treatment response (ĸ=0.73). Therefore, the mDAS28 could be used in place of the DAS28 when laboratory values needed to compute the DAS28 are missing. In summary, I found that the CDAI and DAS28 were not strong predictors of the rheumatologist’s decision to change therapy. I also found that the variability in the measurement of ESR and CRP was not associated with disease activity. I was able to modify the DAS28 by replacing the laboratory measure and create a new simplified measure, the mDAS28. I also validated the mDAS28 for use in the clinic and in epidemiological research when the DAS28 is unavailable.

No description available.

No description available.

No / To evaluate the effectiveness of a telehealth system, using digital pen-and-paper technology and a modified smartphone, to remotely monitor and support the effectiveness of wound management in nursing home residents. METHOD: A randomised controlled pilot study was conducted in selected nursing homes in Bradford, which were randomised to either the control or evaluation group. All patients with a wound of any aetiology or severity, resident in the selected nursing homes were considered eligible to participate in the study. Residents in the control homes who had, or developed, a wound during the study period, continued to receive unsupported care directed by the nursing home staff (defined as 'standard care'), while those in the evaluation homes received standard care supported by input from the remote experts. RESULTS: Thirty-nine patients with a wound were identified in the 16 participating Bradford nursing homes. Analysis of individual patient management pathways suggested that the system provided improved patient outcomes and that it may offer cost savings by improving dressing product selection, decreasing inappropriate onward referral and speeding healing. Despite initial anxiety related to the technology most nursing-home staff found the system of value and many were keen to see the trial continue to form part of routine patient management. CONCLUSION: The current study supports the potential value of telemedicine in wound care and indicates the value that such a system may have to nursing-home staff and patients. DECLARATION OF INTEREST: This study was funded by a Regional Innovation Fund grant from the Yorkshire and Humberside Strategic Health Authority. The authors have no conflict of interest to declare with respect to the article or its contents.

Chan Wai Hung Fredric. / Thesis (M.Phil.)--Chinese University of Hong Kong, 2006. / Includes bibliographical references (leaves 67-72). / Abstracts in English and Chinese. / Acknowledgement --- p.i / Abstract --- p.ii / 摘要 --- p.iv / Table of contents --- p.vi / Publications --- p.ix / List of figures --- p.x / List of tables --- p.xi / Abbreviations --- p.xii / Chapter Chapter 1 --- Introduction / Chapter 1.1 --- Anticoagulation effect of warfarin --- p.2 / Chapter 1.2 --- Indications of warfarin therapy --- p.3 / Chapter 1.3 --- Monitoring systems for anticoagulation therapy --- p.4 / Chapter 1.4 --- Optimum target intensities for anticoagulation therapy --- p.5 / Chapter 1.5 --- Factors affecting anticoagulation effect of warfarin --- p.6 / Chapter 1.5.1 --- Drugs --- p.7 / Chapter 1.5.2 --- Diet --- p.8 / Chapter 1.5.3 --- Health supplements --- p.8 / Chapter 1.5.4 --- Comorbidities --- p.9 / Chapter 1.5.5 --- Genetic factors --- p.10 / Chapter 1.6 --- Management of anticoagulation therapy in Chinese patients --- p.11 / Chapter 1.7 --- Barriers to optimal INR control --- p.13 / Chapter 1.8 --- Two models of care for anticoagulation therapy - routine medical care and co-ordinated anticoagulation service --- p.14 / Chapter 1.9 --- Outcomes of two models of anticoagulation management --- p.14 / Chapter 1.9.1 --- Clinical outcomes --- p.14 / Chapter 1.9.2 --- Economic outcomes --- p.16 / Chapter 1.10 --- Clinical pharmacist involvement in the management of anticoagulation therapy --- p.17 / Chapter 1.11 --- Anticoagulation management in Hong Kong --- p.18 / Chapter 1.12 --- Hypothesis and objectives --- p.19 / Chapter Chapter 2 --- Materials and Methods / Chapter 2.1 --- Setting and subjects --- p.22 / Chapter 2.2 --- Interventions --- p.23 / Chapter 2.2.1 --- Newly proposed model --- p.23 / Chapter 2.2.1.1 --- Training of clinical pharmacist --- p.23 / Chapter 2.2.1.2 --- Development of management protocol --- p.24 / Chapter 2.2.1.3 --- Treatment algorithm of pharmacist-managed anticoagulation service --- p.25 / Chapter 2.2.1.4 --- Validation of the Coagucheck Pro DM --- p.28 / Chapter 2.2.2 --- Usual practice model --- p.29 / Chapter 2.3 --- Outcome measures --- p.29 / Chapter 2.3.1 --- Primary clinical outcomes --- p.29 / Chapter 2.3.1.1 --- Therapeutic and expanded therapeutic INR ranges --- p.29 / Chapter 2.3.1.2 --- A method to determine the amount of patient-time spent in each INR category --- p.30 / Chapter 2.3.2 --- Secondary clinical outcomes --- p.31 / Chapter 2.3.3 --- Economic outcomes --- p.32 / Chapter 2.3.4 --- Humanistic outcomes --- p.34 / Chapter 2.4 --- Sample size estimation --- p.34 / Chapter 2.5 --- Statistical analysis --- p.35 / Chapter Chapter 3 --- Results / Chapter 3.1. --- Patient demographics and indications --- p.37 / Chapter 3.2. --- Control of INR --- p.42 / Chapter 3.3. --- Incidence of major bleeding and thromboembolism --- p.44 / Chapter 3.4. --- Direct medical cost analysis --- p.46 / Chapter 3.5. --- Patient satisfaction --- p.48 / Chapter Chapter 4 --- Discussion and Conclusion / Chapter 4.1 --- Discussion --- p.51 / Chapter 4.1.1 --- Clinical outcomes of anticoagulation clinic --- p.52 / Chapter 4.1.2 --- Direct medical cost analysis --- p.56 / Chapter 4.1.3 --- Patient satisfaction --- p.59 / Chapter 4.1.4 --- Limitations --- p.62 / Chapter 4.1.5 --- Future studies --- p.63 / Chapter 4.2 --- Conclusion --- p.66 / References --- p.67 / Appendices / Appendix A. Management protocol --- p.73 / Appendix B. Data collection form --- p.96 / Appendix C. PSQ-18 --- p.104