No description available.

As multiple trauma is ubiquitous, affects predominantly young people and is attended by a high mortality, it seemed a fruitful area for study in an effort to reduce morbidity and mortality. One of the main problems in trauma research has been accurate description of the severity of injury and associating severity with subsequent outcome. While a number of scoring systems have been proposed the Injury Severity Score has been the most widely adopted and validated. The Injury Severity score was adopted with a number of other systems of scoring infection and other complications in a retrospective study of multiple trauma patients admitted to an Intensive Therapy Unit. This study revealed an unexpected increased in mortality in the latter two years of the study period which was not associated with an increase in injury severity as assessed by the ISS nor by any other change in patient characteristics which might explain this finding. Eventually it was noted that the introduction of a hypnotic drug etomidate for use in sedation of ventilated patients seemed to be associated with the increased mortality. Clinical evidence suggested that etomidate might inhibit adrenocortical function and an experimental study indeed confirmed that etomidate had a direct effect on adrenal steroidogenesis such that cortisol and aldosterone production were completely suppressed. Following analysis of the retrospective clinical study etomidate was withdrawn from use in our unit. Analysis of mortality rates both for trauma patients and the general patient population indicated a reversion to the rate which pertained prior to introduction of etomidate. The results of retrospective and prospective clinical studies strongly implied that the administration of etomidate was associated with an increased mortality among trauma patients. The experimental study based on clinical observations clearly demonstrated that etomidate infusion was a potent inhibitor of adrenal steroidogenesis. It seems highly likely that the detrimental effect of etomidate was mediated by its direct inhibitory effect on the production of cortisol and aldosterone by the adrenal gland. Subsequent clinical and experimental studies from other authors tend to confirm these findings.

No description available.

Sepsis causes major health care problems in the United States, resulting in long hospitalizations, complications, and even patient death. Lack of nursing knowledge regarding sepsis signs and symptoms is a significant problem at a hospital in the northeast. Local hospital data showed a high patient mortality rate for patients diagnosed with sepsis. The purpose of this project was to develop an educational module on sepsis for intensive care nurses. The educational module was developed using current sepsis evidence-based guidelines. The practice-focused question for the project asked whether an educational module on sepsis would increase the intensive care nurse's knowledge on sepsis recognition and treatment guidelines. The adult learning theory was used as a conceptual model to guide project development. After development, the educational module was evaluated by a panel of 8 experts, including a nurse educator, infection control nurse, a charge nurse, a staff nurse, and an infectious disease physician. Program content evaluations included a 10-question pretest/posttest questionnaire completed by each panel member. Program content was modified based on pretest/posttest results. Results of the panel evaluation indicated agreement that the sepsis module content would benefit nurses on sepsis recognition and management for patients. Improving nursing knowledge on sepsis can provide a positive social change to improve patient outcomes, including mortality rates and complications from sepsis.

When faced with death counts strati ed by age, analysts often calculate a crude mortality rate (CMR) as a single summary measure. This is done by simply dividing total death counts by total population counts. However, the crude mortality rate is not appropriate for comparing different populations due to the significant impact of age on mortality and the possibility of having different age structures for different populations. While a set of age-adjustment methods seeks to collapse age-specific mortality rates into a single measure that is free from the confounding effect of age structure, we focus on one of these methods called "direct age-standardization" method which summarizes and compares age-specific mortality rates by adopting a reference population. While qualitative insights in relation to age-standardization are often discussed, we seek to approximate age-standardized mortality rate of a population based on the corresponding CMR and the 90th quantile of its population distribution. This approximation is most useful when age-specific mortality data is unavailable. In addition, we provide quantitative insights related to age-standardization. We derive our model based on mathematical insights drawn from the explication of exact calculations and validate our model by using empirical data for a large number of countries under a large number of circumstances. We also extend the application of our approximation model to other age-standardized mortality indicators such as cause-specific mortality rate and potential years of life lost. In the second part of the thesis, we consider the formulation of a general risk management procedure, where risk needs to be measured and further mitigated. The formulation admits an optimization representation and requires as input the distributional information about the underlying risk factors. Unfortunately, for most risk factors it is known to be difficult to identify their distribution in full details, and more problematically the risk management procedure can be prone to errors in the input distribution. In particular, one of the most important distribution information is the covariance hat captures the spread and correlation among risk factors. We study the issue of covariance uncertainty in the problem of mitigating tail risk and by admitting an uncertainty set of covariance of risk factors, we propose a robust optimization model which minimizes risk for the worst scenario especially when data is insufficient and the number of risk factors is large. We will then transform our model into a computationally solvable one and test the model using real-world data.

This thesis is missing page 168. The other copies do not have this page. -Digitization Centre / The Canadian Health Insurance program has been in place for quite some time now and it has always been said that Canadians have some of the best healthcare in the world. Canadian healthcare is very well known throughout the world because every Canadian citizen has the right to healthcare without having to pay for it. The benefits of this program are quite well known but some benefits one might think would result, just might not be there. This paper looks at whether the inception of Canadian Health Insurance has had an effect on the mortality rates of Canadians. Through a statistical analysis, this paper shows that there is no evidence that the Canadian Health Insurance program has had an effect on Canadian aggregate mortality rates. This paper shows that Canadian mortality rates follow a trend to that of the United States. To say Canadians have a similar trend in mortality rate to the United States is perhaps surprising since Canadians are supposed to have a far superior healthcare system. / Thesis / Master of Science (MS)

Yes / IMPORTANCE Patients undergoing emergency laparotomy have high mortality, but few studies exist to improve outcomes for these patients. OBJECTIVE To assess whether a collaborative approach to implement a 6-point care bundle is associated with reduction in mortality and length of stay and improvement in the delivery of standards of care across a group of hospitals. DESIGN, SETTING, AND PARTICIPANTS The Emergency Laparotomy Collaborative (ELC) was a UK-based prospective quality improvement study of the implementation of a care bundle provided to patients requiring emergency laparotomy between October 1, 2015, and September 30, 2017. Participants were 28 National Health Service hospitals and emergency surgical patients who were treated at these hospitals and whose data were entered into the National Emergency Laparotomy Audit (NELA) database. Post-ELC implementation outcomes were compared with baseline data from July 1, 2014, to September 30, 2015. Data entry and collection were performed through the NELA. INTERVENTIONS A 6-point, evidence-based care bundle was used. The bundle included prompt measurement of blood lactate levels, early review and treatment for sepsis, transfer to the operating room within defined time goals after the decision to operate, use of goal-directed fluid therapy, postoperative admission to an intensive care unit, and multidisciplinary involvement of senior clinicians in the decision and delivery of perioperative care. Change management and leadership coaching were provided to ELC leadership teams. MAIN OUTCOME AND MEASURES Primary outcomes were in-hospital mortality, both crude and Portsmouth Physiological and Operative Severity Score for the enumeration of Mortality and morbidity (P-POSSUM) risk-adjusted, and length of stay. Secondary outcomes were the changes after implementation of the separate metrics in the care bundle. RESULTS A total of 28 hospitals participated in the ELC and completed the project. The baseline group included 5562 patients (2937 female [52.8%] and a mean [range] age of 65.3 [18.0-114.0] years), whereas the post-ELC group had 9247 patients (4911 female [53.1%] and a mean [range] age of 65.0 [18.0-99.0] years). Unadjusted mortality rate decreased from 9.8% at baseline to 8.3% in year 2 of the project, and so did risk-adjusted mortality from a baseline of 5.3% to 4.5% post-ELC. Mean length of stay decreased from 20.1 days during year 1 to 18.9 days during year 2. Significant changes in 5 of the 6 metrics in the care bundle were achieved. CONCLUSIONS AND RELEVANCE A collaborative approach using a quality improvement methodology and a care bundle appeared to be effective in reducing mortality and length of stay in emergency laparotomy, suggesting that hospitals should adopt such an approach to see better patient outcomes and care delivery performance. / This study was funded by The Health Foundation, United Kingdom, as part of a Scaling Up Award.

La réduction de la mortalité maternelle et infantile est universellement acceptée comme un objectif du millénaire pour le développement. L'aide étrangère est un des moyens utilisés pour l'atteindre. Cependant, malgré les succès, à l'échelle microéconomique, de certains programmes de santé financés par les aides étrangères, l'efficacité globale de ces aides demeure inconnue. Plusieurs travaux ont traité de l'efficacité de l'aides sur la croissance économique, mais peu d'entre eux concernent le secteur de la santé. Le but de cette thèse, est précisément d'évaluer l'efficacité des aides étrangères sur des indicateurs de santé à l'échelle macroéconomique. On va essayer d'explorer l'impact des aides étrangères octroyées par des bailleurs privés et publics sur l'état de santé telle que la mortalité infantile, maternelle et des adultes dans les pays en développement. La thèse examine l'affectation des aides étrangères au secteur de la santé, à travers trois documents de travail à soumettre à publication. / The reduction of child and maternal mortality is universally accepted as a millennium development goal (MDG). Foreign aid for health is one of the means implemented to reach it. However, even if many successes of health aid activities have been underlined at the microeconomic level, the effectiveness of health aid in general remains unknown. In spite of many macroeconomic works on aid effectiveness on economic growth, only little deals with its effectiveness in health. The purpose of this thesis is precisely to assess the effectiveness of foreign aid in improving health measurements, at the macroeconomic level. I tried to explore the impact of health aid disbursed by the donors through the government and private sector on health outcomes like child, maternal and adult mortality rates in developing economies. The thesis examines the issue of foreign aid earmarked for health sector using a three-paper format. The three chapters of this thesis can be read independently.

Este trabalho buscou compreender como os adolescentes percebem, refletem e se relacionam com o tema da morte e verificar como explicam as altas taxas de mortalidade na sua faixa etária. Além disso, investigou-se a necessidade de discutir o tema da morte com a família, amigos, profissionais e quais as maneiras que consideram melhor. Esta reflexão é relevante e fundamental uma vez que as estatísticas mostram dados alarmantes sobre o aumento da mortalidade entre adolescentes, principalmente relacionadas com acidentes e mortes violentas. Buscou-se compreender o processo da adolescência e a sua relação com o tema da morte, a partir de uma abordagem qualitativa na coleta e na compreensão dos dados. Participaram desta pesquisa adolescentes do Ensino Fundamental e Médio de duas escolas da cidade de São Paulo. Foi exibido o vídeo “Falando de morte com o adolescente" (do Laboratório de Estudos sobre a Morte do Instituto de Psicologia da Universidade de São Paulo) e foram propostas discussões com os adolescentes inspiradas na modalidade denominada Grupo Focal. Categorias temáticas foram destacadas com o intuito de formar alguns eixos de análise. As reflexões feitas pelos adolescentes envolveram o tema da morte e a dificuldade de pensar na possibilidade da perda de pessoas queridas. De uma forma geral, os adolescentes não percebem a morte como possibilidade pessoal, expressando sentimentos de imortalidade e onipotência. Ao relatarem perdas de amigos também adolescentes, os sentimentos de choque e tristeza intensa são freqüentes e os amigos são importantes fontes de apoio num processo de identificação. Algumas das hipóteses sobre os altos índices de mortalidade na adolescência foram: uso de drogas; violência; banalização da morte; situações sociais desfavoráveis; AIDS; falta de emprego e de perspectivas de futuro; suicídios; dificuldade na comunicação com profissionais, amigos e familiares; dificuldades na expressão de sentimentos e pedidos de ajuda; acidentes; falta de limites e a postura de desafiar o mundo; más influências; não imposição de responsabilidade pela sociedade; entraves na educação etc. Foi estabelecido um contato com profissionais de educação que refletiu como a escola compreende um importante espaço para possibilitar a discussão e a reflexão sobre o tema da morte entre os profissionais e entre/com os alunos. / This work investigated how the adolescents perceive, reflect and deal with the subject of death and verify how the teenagers explain the high rates of mortality in their age group. Moreover, it was investigated the need of discussing the subject of death with family, friends, professionals and the best way to do it. This reflection is relevant and fundamental once the statistics show astonishing data about the increase of mortality between adolescents, mainly related to accidents and violent deaths. It was intended to comprehend the process of adolescence and its relation to the subject of death, using a qualitative approach. Teenagers (ages 14 to 17) from two schools in the city of São Paulo participated in this study. The video “Talking about death with the adolescent" (Laboratory of Death Studies of Psychology Institute of University of São Paulo) was shown and discussions with the adolescents were proposed, inspired in the modality called Focal Group. Thematic categories were stood out with the intention of construct some points of analyses. The reflections made by the adolescents envolved: the subject of death and the difficulty of thinking about the possibility of loss of dear persons. In general, the adolescents don’t notice death as a personal possibility, expressing feelings of immortality and onipotence. When losses of adolescent friends were mentioned, the feelings of shock and intense sadness were frequent and friends are important sources of support in a process of identification. Some of the hypothesis about the high rates of mortality in adolescence were: use of drugs; violence; banalization of death; unfavourable social situations; AIDS; unemployment and lack of perspectives of future; suicide; difficulty in the communication with professionals, friends and family; difficulty in the expression of feelings and help requests; accidents; lack of limits and attitude of challenging the world; bad influences; non-imposition of responsability by society; difficulties in education etc. It was stablished a contact with professionals of education that reflected how schools are an important space to offer the discussion and reflection about the subject of death between professionals and between/with the students.

Made available in DSpace on 2016-08-10T10:53:39Z (GMT). No. of bitstreams: 1 DJALMA ANTONIO DA SILVA JUNIOR.pdf: 3848227 bytes, checksum: 1904d70387982421a30c0d626079c004 (MD5) Previous issue date: 2012-05-04 / Dengue is a major re-emerging diseases in the world, provided mainly by environmental and economic changes in the social space organized. With increasing national incidence of severe forms and deaths, it is necessary to better understand the real magnitude of the disease at the local level, aiming to characterize the demographic distribution of dengue cases in the city of Goiânia, from 2001 to 2009. This is a descriptive and transversal epidemiological study whose data were provided by the Department of Epidemiology Municipal Health Secretariat of Goiânia, and extracted the information about the variables of the form of the Information System for Notifiable Diseases. In the analyzed period were 124,629 dengue cases reported, affecting more females, caucasians, living in urban areas with the highest incidence in age from 15 to 24 years (p<0.001). During the study period, was identified the three serotypes DENV 1, DENV 3 and DENV 2, the latter being identified in all the years of the series, alternating with the other. There was no preference for a particular serotype of gender, race and age of infected individuals. Of 124,629 cases of dengue, 4.4% required hospitalization with greater involvement of the age group 5- 14 years (p=0.04), those with a more favorable course of the disease, unlike the hospitalized population over 55 years whose mortality rate was above 5.6% (p=0.04). The DENV serotype 2 was most related to the infections that led to hospitalization (p<0.001). Goiânia is figured as an urban center with a high incidence of dengue in all years of the series, especially in 2008 when they accounted for 36.6% of all reported cases and 75% of deaths in the Midwest. The dengue fever was the most prevalent clinical form (99.7%). Cases with complications (Dengue Hemorrhagic Fever and Dengue Shock Syndrome), had increasing reports since the beginning of the series, especially in the years 2008 and 2009, occurred when recirculation of DENV 1 and DENV 2, respectively, also providing a high case fatality. The spatial distribution of deaths from dengue in Goiânia, showed that the administrative districts of Campinas and the Centre had the highest prevalence (22.2% and 17.1%) respectively. / A dengue é uma das principais doenças reemergentes no mundo, proporcionada principalmente pelas mudanças ambientais e econômicas no espaço social organizado. Com o aumento da incidência nacional das formas graves e de óbitos, torna-se necessário um melhor entendimento da real magnitude da doença a nível local, tendo como objetivo a caracterização da distribuição demográfica dos casos de dengue no município de Goiânia, no período de 2001 a 2009. Trata-se de um estudo epidemiológico descritivo e transversal, cujo dados foram fornecidos pelo Departamento de Epidemiologia da Secretaria Municipal de Saúde de Goiânia, sendo extraídas as informações referentes as variáveis da ficha do Sistema de Informação de Agravos de Notificação. No período analisado foram notificados 124.629 casos de dengue, comprometendo mais indivíduos do sexo feminino, da raça branca, que residiam na zona urbana, com maior incidência na etária de 15 a 24 anos (p<0,001). Durante o período de estudo, foram identificados os três sorotipos DENV 1, DENV 2 e DENV 3, sendo este último identificados em todos os anos da série, com alternância dos demais. Não houve preferências de um determinado sorotipo quanto ao sexo, a raça e a idade dos indivíduos infectados. De 124.629 casos de dengue, 4,4% necessitaram de hospitalização com acometimento maior do grupo etário de 5 a 14 anos (p=0,04), estes com uma evolução mais favorável da doença, ao contrário da população hospitalizada acima de 55 anos, cuja taxa de mortalidade esteve acima de 5,6% (p=0,04). O sorotipo DENV 2 foi o mais relacionado com as infecções que motivaram a hospitalização (p<0,001). Goiânia figurou-se como centro urbano de alta incidência de dengue em todos os anos da série, principalmente em 2008, quando foi responsável por 36,6% de todos os casos notificados e 75% dos óbitos da região Centro-Oeste. A dengue clássica foi a forma clínica com maior prevalência (99,7%). Os casos com complicações (Febre Hemorrágica da Dengue e Síndrome do Choque da Dengue), tiveram notificação crescente desde o início da série, em especial nos anos de 2008 e 2009, quando ocorreu a recirculação do DENV 2 e DENV 1, respectivamente, proporcionando também uma alta letalidade de casos. A distribuição espacial dos óbitos pela dengue em Goiânia, revelou que os distritos administrativos do Centro e de Campinas foram os de maior prevalência (22,2% e 17,1%) respectivamente.