Proefschrift Maastricht. / Lit. opg.: p. 119-124. - Met samenvatting in het Engels.

Thesis (M.D.)--Boston University

Acute low back pain is a commonly occurring symptom that can impact considerably upon a person's life. It is poorly defined, difficult to classify and challenging to measure. However, due to the high prevalence rates of the symptom, cited in the epidemiological literature, and the costs incurred by individuals, health services and society in general, it is vital that clients are encouraged to take more responsibility for their health. This thesis is concerned with perceptions of control in people with acute low back pain. It is about how they respond to this symptom and the way it impacts upon their lives. The underpinning literature is drawn from both medical and social science research, as the work crosses faculty boundaries. Problems are addressed from a physiotherapeutic and social science perspective, as links are formed between the different disciplines. From this literature, a significant theoretical development was the creation of a framework, which enabled the systematic review of existing outcome measures. A number of instruments, relevant to clients with acute low back pain, were reviewed using this framework, for the dimensions of control, function, pain and anxiety. The findings were used to inform the selection of outcome measures in this research. Four studies were then undertaken, all linked to studying clients with acute low back pain. The first study was a survey of general practitioners in Southampton and the New Forest, which identified their strategies for managing clients with acute low back pain. The second study focused on clients' experiences and was a randomized controlled trial, which tested the effectiveness of an information leaflet, designed to encourage clients to take more responsibility for their own health. The third study primarily focused on clients' perceptions of control over time, addressing the question of how these perceptions change during a one-year period. Finally, since recruitment of clients by their doctors was problematic throughout this research, a follow-up survey was undertaken with these health professionals to establish the reasons for this. The results of these studies are used to discuss the importance of clients' perceptions of control and the implications for clinical practice.

Acute aortic syndrome (AAS) is a life threatening clinical syndrome resulting from three distinct diagnoses; acute aortic dissection, penetrating atherosclerotic ulcer and intramural hematoma. There are no widely accepted guidelines that are both safe and efficient to guide the clinician on when to suspect AAS. Our aim was to assess the need for a clinical decision rule to help improve diagnosis of AAS. We conducted a diagnostic accuracy systematic review and meta-analysis, a historical case control study and historical cohort study. We found wide variation in practice with a perceived need by physicians for a clinical decision rule. In addition we found it feasible to risk stratify patients at risk for AAS by historical, clinical and laboratory features. Therefore we conclude there is a need for the development of a clinical decision rule for the risk stratification of patients with a clinical suspicion of AAS.

Objective- This study aims to identify the microorganisms and antibiotic resistance patterns in necrotising fasciitis. Methods- This is a retrospective audit over two consecutive years (June 2015 - July 2017) of all patients who had surgery for necrotising fasciitis at an ACS unit. Results- Necrotising fasciitis accounted for 15% of all skin and soft tissue sepsis that required surgery. There were 10 male (52.6%) and nine female (47.4%) patients. The most common co-morbidity was diabetes mellitus in 10 (52.6%) patients, the compliance and control were monitored by glycosylated haemoglobin (HbA1C) in 50% of the diabetic group, with a mean of 8.98 (Range 5-12.9). Fifteen percent of cases (n=3) had a confirmed diagnosis of HIV, with a negative result in eight (42%). ICU was required in three patients two of whom were on inotropes and one patient required renal replacement therapy. Surgery was performed within 24 hours for 11 (57%) patients. The most common anatomical site for debridement was perineum in nine patients (47%). Monomicrobial infection was the most common subtype of necrotising fasciitis withmethicillin sensitive staphylococcus aureus in five (26%) as the predominant microbe. Gram-negative organism Escherichia-coli was the second most common monomicrobial infection. All Gram-positive organisms were sensitive to cloxacillin and co- amoxiclavulanic acid. Two gram negatives(15%) of the 13 organisms cultured were resistant to coamoxiclavulanic acid. The 30 day mortality was 15%. Conclusion- Necrotising fasciitis is a rare but lethal infection.In our limited series, monomicrobial infection is the most common subtype. 15% of the community acquired organisms were resistant to the empiric antibiotic of choice co-amoxiclavulanic acid. (word count= 261).

A research report submitted to the Faculty of Health Sciences, University of Witwatersrand, Johannesburg, in partial fulfillment of the requirements for the degree of Master of Medicine in the branch of Internal Medicine Johannesburg, 2017 / Objective: There is limited data describing acute kidney injury (AKI) in HIV-infected adult patients in resource-limited settings where increasingly, tenofovir (TDF), which is potentially nephrotoxic, is prescribed. We describe risk factors for, and prognosis of AKI in HIV-infected individuals receiving and naïve to TDF. Methods: This was a prospective case cohort study of hospitalized HIV-infected adults with AKI (as defined by the 2012 KDIGO Clinical Practice Guideline for AKI) stratified by TDF exposure. Adults (≥18 years) were recruited: clinical and biochemical data was collected at admission; their renal recovery, discharge or mortality was ascertained as an in-patient and, subsequently, to a scheduled 3-month follow-up. Results: Amongst this predominantly female (61%), almost exclusively black African cohort of 175 patients with AKI, 93 (53%) were TDF exposed; median age was 41 years (IQR 35-50). Median CD4 count and VL and creatinine at baseline was 116 cells/mm3 and 110159 copies/ml, respectively. A greater proportion of the TDF group had severe AKI on admission (61% v 43% p=0.014); however, both groups had similar rates of newly diagnosed tuberculosis (TB) (52%) and NSAID (32%) use. Intravenous fluid was the therapeutic mainstay; only 7 were dialyzed. Discharge median serum creatinine (SCr) was higher in the TDF group (p=0.032) and fewer in the TDF group recovered renal function after 3-months (p=0.043). 3-month mortality was 27% in both groups but 55% of deaths occurred in hospital. Those that died had a higher SCr and more severe AKI than survivors; TB was diagnosed in 33 (70%) of those who died. Conclusions: AKI was more severe and renal recovery slower in the TDF group; comorbidities, risk factors and prognosis were similar regardless of TDF exposure. Because TB is linked to higher mortality, TB co-infection in HIV-infected patients with AKI warrants more intensive monitoring. In all those with poor renal recovery, our data suggests that a lower threshold for dialysis is needed. / MT2017

Improving hospital efficiency is a critical concern for health care managers and policy makers. Hospital technical efficiency is measured as the ratio of what quantity and quality of care is produced to what could be produced given the level of resources available to the hospital (its budget). What a hospital should produce given the resources at its disposal is called the “production frontier”. In order to improve hospital performance, health policy makers need knowledge and information about how well the hospitals they fund are utilizing the resources they receive. Data Envelopment Analysis, a non-parametric technique, is applied to administrative data on hospitals in Canada to produce the “technical frontier” and get insight into the variation of technical efficiency of acute hospitals at the Pan-Canadian level (except for the province of Quebec, which does not report its data on hospitals in a way that would make them comparable to the rest of Canada). DEA is preferred to the alternative method of stochastic frontier for the following reasons: DEA does not require to impose a specification on the production function of hospitals (for which theory is clearly lacking), and it allows the analyst to estimate a multi-output frontier (a stochastic frontier would have to weight arbitrarily the value of quantity versus that of quality of care in hospitals, whereas the DEA approach generates these weights from the data). Efficiency scores are serially de-correlated using a bootstrap technique and then entered as the dependent variable in regressions to identify the main factors of efficiency or inefficiency. Specifically, this thesis aims to: 1) estimate the level of technical efficiency of acute inpatient care in 35 teaching hospitals, 54 large hospitals and 90 medium-size hospitals respectively in Canada and identify the potential factors that have influence on technical efficiency; 2) uncover and measure the existence of possible spatial spillovers of hospital efficiency in Canada and examine its potential determinants while taking into account the interaction between hospitals by means of spatial regression; and 3) examine the technical and scale efficiency of the 229 small and rural hospitals across Canada (outside Quebec), as well as estimate the impact of institutional and contextual variables on hospital technical and scale efficiency respectively. The major findings are: 1) hospital output (combination of number and quality of stays; quality being measured as the inverse of in-hospital mortality) in Canada could be increased by 24 percent with the same resources by eliminating inefficiency. Highly efficient teaching hospitals benefit from producing care under favourable environments. Higher efficiency could be achieved by increasing cooperation within the health system and making more post- acute care beds available to both large and medium hospitals; 2) There is a substantial and significantly positive spatial spillover effect on the efficiency of acute inpatient care (elasticity of 0.3): Canadian hospitals are clearly complements to each other and work in networks much more than in competition. The hospital size (the number of beds), the percent of transfers between acute hospitals, and the percent of patient transfers to home care are the main drivers of efficiency among acute hospitals in Canada while controlling of the dependence between hospitals; and 3) Among small hospitals, the average output orientation technical efficiency on all types of services is 54% at the current input-output mix. To improve their technical efficiency, small hospitals should provide with more home care facilities to discharge their patients to (so-called Alternative Level of Care patients) and strengthen their cooperation with larger, urban hospitals. Small hospitals are scale inefficient, specifically, rural hospitals could reduce their size by 34% on average (around 6 acute beds) to achieve the optimal size. The study also found that the spending on diagnosis tests and the nursing as the percentages of total hospital spending (cost shares) are positively and significantly related to the scale efficiency. / Thesis / Doctor of Philosophy (PhD) / A hospital is technically efficient if it uses its resources (its budget) to get the most in terms of quantity (number of stays) and quality of care it can. A hospital can be more or less technically efficient for reasons independent of its control (typically, because of the environment in which the hospital operates) and efficiency is a value-neutral measure. This thesis aims to: 1) estimate the technical efficiency of acute inpatient care in Canada and identify the potential factors that influence the level of efficiency achieved by a given hospital; 2) uncover the existence of possible geographic clusters of efficiency (hospitals that are close geographically are also close in the efficiency scale, something called spatial spillovers in the literature) in Canada.; and 3) examine the role that size plays in the variation of technical efficiency among small and rural hospitals across Canada. The major findings are: 1) hospital output could be increased by 24 percent with the same resources by eliminating technical inefficiency; 2) There is a substantial and significantly positive spatial spillover effect on the efficiency of acute inpatient care: being close to an efficient hospital increases the efficiency score of a hospital, everything else being the same; and 3) The level of technical efficiency of small and rural hospitals across Canada is low overall and, perhaps surprisingly, larger rural hospitals are among the least efficient: among small hospitals, scale does not yield economies of resources.

Acute medical patients constitute the single largest group of patients in hospitals. The processes by which they are cared for in the United Kingdom (UK) have changed over the past few decades and now the majority of acute medical care is delivered within acute medical units (AMUs). The AMU model is also increasingly being adopted outside of the UK, including in Ireland, Australasia and Europe. AMUs emerged as a result of local service innovations and there is evidence to suggest that care within AMUs varies across settings. Although there are published recommendations for care delivery, empirical evidence is lacking. In this thesis I aim to examine the concept of the AMU model with regard to the literature; its definition; its components; and how these components are delivered across Scottish sites. This is with the aim of informing service provision and contributing to the development of an evidence base relating to AMUs. Firstly, I undertook a systematic review of the evidence relating to the effectiveness of and variation in the AMU model. I found limited, observational and possibly confounded evidence that the AMU model was associated with reductions in hospital length of stay and mortality compared to other models of care in European and Australasian settings. I also found variation in the admission criteria, entry sources, functions and staff work patterns across the 12 AMUs described in the literature. Given this finding that AMUs do not operate in a uniform way, I undertook a second systematic review to assess the published evidence evaluating different methods of delivery of care within AMUs. I identified nine studies of ten interventions. From this I concluded that there was little discerning evidence pertaining to how best to deliver care in AMUs. This led me to undertake a qualitative descriptive study of all the AMUs in Scotland with the aim of further delineating the AMU model. During a visit to each AMU, I collected data through semi-structured interviews with healthcare professionals working in the units. This totalled 171 interviews of 275 participants across 29 sites. I used this data to provide a report detailing how care was delivered in each AMU. I then thematically analysed these reports using framework analysis. There were three principal findings from this qualitative study. Firstly, I found that acute medical care was delivered in acute medical services rather than single AMUs. Secondly, I identified a framework of 12 key components of AMU care that were integral to the functioning of the AMU irrespective of the setting. Examples include nurse staffing and the physical areas contained within the AMU. Lastly, I described how these components were delivered across Scottish AMUs and, where possible, identified distinct models of care delivery. For example, I identified 13 models of AMU functions and seven models of consultant work patterns. In summary, I found that care in Scottish AMUs is delivered variably. The reasons for the variation are unclear. The findings of this thesis are the first in-depth study into AMUs. They provide a useful foundation for discussions and onward planning of resources, capacity and standards of care at both a national and local level. These findings are also an impetus for further research to delineate how best to deliver care in AMUs, and form an essential precursor to such work.

Thesis (Doctoral)--Departments of Surgical Pathophysiology and Anaesthesiology, University of Lund, University Hospital MAS. / Added t.p. with thesis statement inserted. Summary in Swedish. Includes bibliographical references.

Thesis (Ph. D.)--University of Hong Kong, 1998. / Includes bibliographical references (leaves 132-144).