Episode 1.48 Full Movie Hd Download
Dayna Delabarre
Since the differential diagnosis between cyclosporine (CyA) nephrotoxicity and acute graft rejection is still a problem in clinical routine, we studied retrospectively the value of 111-indium (In) platelet scintigraphy in 53 patients immunosuppressed with CyA and prednisolone. Autologous platelets were labeled once per week. After daily gamma camera imaging, the platelet deposition in the graft was expressed as platelet-uptake ratio (PUR). The patients were monitored during the first 4-6 weeks after surgery. PUR values measured during an episode of graft dysfunction were compared to the histological diagnosis. The PUR of well-functioning and stable grafts measured 1.07 +/- 0.11 (mean +/- SD). The 111-In platelet scintigraphy failed to register acute interstitial rejection. The PUR values in episodes of chronic vascular rejection, of acute tubular necrosis due to prolonged ischemia times, of tubular CyA nephrotoxicity and of cytomegalovirus (CMV) infection did not differ from the PUR of well-functioning and stable grafts as well. The PUR was significantly increased to 1.48 +/- 0.26 because of a marked platelet deposition in the graft in episodes of acute vascular rejection. In 4 cases of microvascular CyA nephrotoxicity the same phenomenon of significantly increased PUR (1.33 +/- 0.18), could be encountered, too. Two of these 4 cases resembled the hemolytic uremic syndrome (HUS). The value of PUR measurement for diagnosis of acute vascular rejection and microvascular CyA nephrotoxicity together, was: sensitivity 0.62, specificity 0.95, predictive value of positive result 0.64, predictive value of negative result 0.94.(ABSTRACT TRUNCATED AT 250 WORDS)
It is well known that older adults figure prominently in the use of emergency departments (ED) across the United States. Previous research has differentiated ED visits by levels of clinical severity and found health status and other individual characteristics distinguished severe from non-severe visits. In this research, we classified older adults into population groups that persistently present with severe, non-severe, or indeterminate patterns of ED episodes. We then contrasted the three groups using a comprehensive set of covariates.
Using a unique dataset linking individual characteristics with Medicare claims for calendar years 1991-2007, we identified patterns of ED use among the large, nationally representative AHEAD sample consisting of 5,510 older adults. We then classified one group of older adults who persistently presented to the ED with clinically severe episodes and another group who persistently presented to the ED with non-severe episodes. These two groups were contrasted using logistic regression, and then contrasted against a third group with a persistent pattern of ED episodes with indeterminate levels of severity using multinomial logistic regression. Variable selection was based on Andersen's behavioral model of health services use and featured clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects.
We identified 948 individuals (17.2% of the entire sample) who presented a pattern in which their ED episodes were typically defined as severe and 1,076 individuals (19.5%) who typically presented with non-severe episodes. Individuals who persistently presented to the ED with severe episodes were more likely to be older (AOR 1.52), men (AOR 1.28), current smokers (AOR 1.60), experience diabetes (AOR (AOR 1.80), heart disease (AOR 1.70), hypertension (AOR 1.32) and have a greater amount of morbidity (AOR 1.48) than those who persistently presented to the ED with non-severe episodes. When contrasted with 1,177 individuals with a persistent pattern of indeterminate severity ED use, persons with severe patterns were older (AOR 1.36), more likely to be obese (AOR 1.36), and experience heart disease (AOR 1.49) and hypertension (AOR 1.36) while persons with non-severe patterns were less likely to smoke (AOR 0.63) and have diabetes (AOR 0.67) or lung disease (AOR 0.58).
We distinguished three large, readily identifiable groups of older adults which figure prominently in the use of EDs across the United States. Our results suggest that one group affects the general capacity of the ED to provide care as they persistently present with severe episodes requiring urgent staff attention and greater resource allocation. Another group persistently presents with non-severe episodes and creates a considerable share of the excess demand for ED care. Future research should determine how chronic disease management programs and varied co-payment obligations might impact the use of the ED by these two large and distinct groups of older adults with consistent ED use patterns.
In this research, our objective was to build on these previous efforts and examine ED use from a population-based perspective. We used a unique dataset including a comprehensive set of individual characteristics linked with Medicare claims, and observed a large nationally representative sample of older adults over a 17-year period. We created three groups based on their individual patterns of ED use. The first group consisted of older adults with a persistent pattern of presenting to the ED with severe clinical conditions that required urgent care. The second group consisted of older adults who persistently presented to the ED with non-severe episodes. A third group consisted of those who had a persistent pattern of indeterminate severity episodes. We then differentiated the groups using an expanded version of Andersen's behavioral model of health services use [19] featuring covariates including clinical status, demographic and socioeconomic characteristics, health behaviors, health service use patterns, local health care supply, and other contextual effects. By testing for group differences with such a comprehensive model, we expected to identify previously unexamined variables that could be readily modified and targeted toward large population groups in such a manner to positively impact their ED use patterns.
In our previous study, we delineated a process for bundling these individual Medicare claims into a single episode of ED care consistent with Medicare guidelines [3]. In particular, we bundled outpatient claims for which the "from" and "through" dates overlapped or were within 3 days, consistent with Medicare policy requiring outpatient claims files to be bundled if they occur within 72 hours. For the carrier files, we bundled claims with overlapping dates or those that were within 1 day of each other. This was necessary because Medicare claims have date but not time stamps, and therefore it is possible for a late-night ED encounter to carry over into the next calendar day. We then bundled the outpatient and carrier claims with overlapping dates and defined them as belonging to the same ED episode. We recognized that bundling claims over a consecutive three-day period may underestimate the actual number of episodes given that some individuals may enter and complete an ED episode on one day and then return to the ED on the next day. Therefore, we identified the number of episodes in which all claims were filed in a one day period from those in which claims spanned a two or three day period. This approach represented a significant methodological advancement because we eliminated the over-counting bias that otherwise occurs when ED use is constructed as a discrete visit measured by an individual claim. We used this same bundling approach to define the ED episodes in this study, extending our observation period through 2007.
We then measured the clinical severity of each ED episode using an approach created by Billings et al. [26], then refined by Wharam and his colleagues [27], and recently validated by Ballard et al. [28]. Originally, Billings et al. created an algorithm (i.e., the NYU algorithm) to classify the severity of ED care by using the ICD9-CM diagnostic codes as identified in the ED. Using the diagnostic information, Billings and his colleagues calculated the probability that an ED claim fell into one of four categories: 1) non-emergent (NE); 2) emergent, primary care treatable (EPCT); 3) ED care needed, preventable/avoidable (EDCNPA); and 4) ED care needed, not avoidable (EDCNNPA; ). Since administrative records do not contain adequate information to make absolute determinations as to the appropriate category, the original NYU algorithm assigns probabilities that a visit falls into each of the four above categories, yielding four probability estimates.
We identified 41,739 ED claims among our sample. However, 14,116 (33.8%) of these included primary diagnoses of trauma (n = 8,652), alcohol (n = 21), drug-related (n = 6), psychiatric (n = 560), and 4,877 other diagnoses and were not included in our analysis because Billings et al. did not classify the severity of these types of visits when originally developing their algorithm. This left 27,623 ED claims that were bundled into 20,169 episodes of care.
We measured individual ED use patterns by counting the total number of ED episodes during the observation period and determining if any particular type (severe, non-severe, indeterminate) constituted 50% or more of an individual's total number of episodes. If an individual presented to the ED three times over a six-year observation period and two episodes were rated as severe, then she was grouped with those consistently presenting to the ED with clinically severe episodes. If another individual presented six times in 10 years and three of these episodes were defined as non-severe, two were indeterminate and one was severe, then she was grouped with those who typically present to the ED with non-severe conditions. Individuals who presented with indeterminate levels of severity at least 50% of the time were placed into a third group. Other individuals who did not use the ED or did not display a definitive pattern (had less than 50% of any particular type of episode) during the observation period were not included in the analysis.
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