A case-mix classification system for medical rehabilitation

Dissatisfaction with Medicare's current system of paying for rehabilitation care has led to proposals for a rehabilitation prospective payment system, but first a classification system for rehabilitation patients must be created. Data for 36,980 patients admitted to and discharged from 125 rehabilitation facilities between January 1, 1990, and April 19, 1991, were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The Functional Independence Measure version of the Function Related Groups (FIM-FRGs) uses four predictor variables: diagnosis leading to disability, admission scores for motor and cognitive functional status subscales as measured by the Functional Independence Measure, and patient age. The system contains 53 FRGs and explains 31.3% of the variance in the natural logarithm length of stay for patients in a validation sample. The FIM-FRG classification system is conceptually simple and stable when tested on a validation sample. The classification system contains a manageable number of groups, and may represent a solution to the problem of classifying medical rehabilitation patients for payment, facility planning, and research on the outcomes, quality, and cost of rehabilitation.     

Gender moderates the relationship between testosterone and marital interaction.

Higher testosterone levels are related to assertiveness and dominance. Given the relevance of those behavioral correlates to spouses' daily transactions, links between testosterone levels and marital interaction were explored among 92 newlywed couples. Marital problem-solving and social support transactions were assessed, and saliva was collected and assayed for testosterone. Whether marital behavior was related to husbands' and wives' testosterone levels was examined. The link between spouses' testosterone and their behavior was contingent on the partner's testosterone levels. Husbands exhibited more adaptive problem-solving behaviors and social support provision when husbands and wives were concordant for lower testosterone levels. In contrast, wives exhibited more adaptive support provision when spouses had discordant testosterone levels such that wives had higher levels and husbands had lower levels. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Overview of randomized trials of intravenous heparin in patients with acute myocardial infarction treated with thrombolytic therapy

Intravenous heparin is routinely given after thrombolytic therapy for patients with acute myocardial infarction in the United States and in some, but by no means all, other countries. Several trials have documented improved infarct-artery patency in patients treated with heparin; however, none was large enough individually to assess the effect of heparin on clinical outcomes. We performed a systematic overview of the 6 randomized controlled trials (1,735 patients) to summarize the available data concerning the risks and benefits of intravenous heparin versus no heparin after thrombolytic therapy. Mortality before hospital discharge was 5.1% for patients allocated to intravenous heparin compared with 5.6% for controls (relative risk reduction of 9%, odds ratio 0.91, 95% confidence interval 0.59 to 1.39). Similar rates of recurrent ischemia and reinfarction were observed among those allocated to heparin therapy or control. The rates of total stroke, intracranial hemorrhage, and severe bleeding were similar in patients allocated to heparin; however, the risk of any severity of bleeding was significantly higher (22.7% vs 16.2%; odds ratio 1.55, 95% confidence interval 1.21 to 1.98). There was no significant difference in the observed effects of heparin between patients receiving tissue-type plasminogen activator and those receiving streptokinase or anisoylated plasminogen streptokinase activator complex, or between patients who did and did not receive aspirin. The findings of this overview demonstrate that insufficient clinical outcome data are available to support or to refute the routine use of intravenous heparin therapy after thrombolysis. It is not known if these findings are due to lack of statistical power, inappropriate levels of anticoagulation, or lack of benefit of intravenous heparin. Large randomized studies of heparin (and of new antithrombotic regimens) are needed to establish the role of such therapy.     

Activated partial thromboplastin time and outcome after thrombolytic therapy for acute myocardial infarction: results from the GUSTO-I trial

BACKGROUND: Although intravenous heparin is commonly used after thrombolytic therapy, few reports have addressed the relationship between the degree of anticoagulation and clinical outcomes. We examined the activated partial thromboplastin time (aPTT) in 29,656 patients in the Global Utilization of Streptokinase and t-PA for Occluded Coronary Arteries (GUSTO-I) trial and analyzed the relationship between the aPTT and both baseline patient characteristics and clinical outcomes. METHODS AND RESULTS: Intravenous heparin was administered as a 5000-U bolus followed by an initial infusion of 1000 U/h, with dose adjustment to achieve a target aPTT of 60 to 85 seconds. aPTTs were collected 6, 12, and 24 hours after thrombolytic administration. Higher aPTT at 24 hours was strongly related to lower patient weight (P < .00001) as well as older age, female sex, and lack of cigarette smoking (all PT< .0001). At 12 hours, the aPTT associated with the lowest 30-day mortality, stroke, and bleeding rates was 50 to 70 seconds. There was an unexpected direct relationship between the aPTT and the risk of subsequent reinfarction. There was a clustering of reinfarction in the first 10 hours after discontinuation of intravenous heparin. CONCLUSIONS: Although the relationship between aPTT and clinical outcome was confounded to some degree by the influence of baseline prognostic characteristics, aPTTs higher than 70 seconds were found to be associated with higher likelihood of mortality, stroke, bleeding, and reinfarction. These findings suggest that until proven otherwise, we should consider the aPTT range of 50 to 70 seconds as optimal with intravenous heparin after thrombolytic therapy.     

Classifying rehabilitation inpatients by expected functional gain

OBJECTIVES: To create a more suitable payment system for medical rehabilitation, the authors developed a companion classification system to the original functional independence measure-function-related groups (FIM-FRGs), which classify patients having similar lengths of stay in a rehabilitation hospital or inpatient unit. The companion system presented here groups patients according to their gains in functional status during the rehabilitation stay. METHODS: Data from 84,492 patients discharged from 252 rehabilitation facilities in 1992 were provided by the Uniform Data System for Medical Rehabilitation. Classification rules were formed using clinical judgment and a recursive partitioning algorithm. The gain-FRGs system used four predictor variables: (1) diagnosis leading to disability, admission scores on the (2) motor and (3) cognitive subscales of the FIM, and (4) patient age. RESULTS: The gain-FRGs system contained 74 patient groups and explained 21% of the variation in functional gain for patients in a different set of records withheld for validation. CONCLUSIONS: The gain-FRGs system should be considered for prospective payment systems because it gives the provider an incentive to improve patient outcomes, which is missing in a payment system based on FIM-FRGs alone.     

Synthesis, characterization, and catalytic properties of polysiloxanes with pendant 4-(3-pyridinyl)butyl and 4-(1-oxypyridin-3-yl)butyl groups

New silane monomers with the pendant 4-(3-pyridine)butyl group have been synthesized by hydrosilation of 3-(3-butenyl)pyridine with Me _n Si(OEt)_3-n H (n=0, 1) using a platinum catalyst. Only -addition products were observed. The products were characterized by elemental analysis, infrared,¹H- and¹³C-NMR spectroscopy, and gas chromatography-mass spectrometry. Hydrolysis-polycondensation of the difunctional monomer with a basic catalyst, Me₄NOH, gave a mixture of cyclic oligomers, principally cyclic tetramer, and linear homopolymer. Under similar reaction conditions, the trifunctional monomer gave crosslinked material which was soluble in common organic solvents. The linear homopolymer and crosslinked polymer were trimethylsilyl end-blocked with hexamethyldisilazane. The cyclic and end-blocked polymers were characterized by elemental analysis and spectroscopic methods. Molecular weights of the polymers were obtained by end-group analysis using¹H-NMR spectral data, size exclusion chromatography, and direct insertion-probe mass spectrometry. The cyclic, linear, and crosslinked materials were N-oxidized withm-chloroperoxybenzoic acid and characterized by spectroscopic methods. The polymeric N-oxide derivatives were shown to be effective transacylation catalysts in the synthesis of mixed carboxylic acid anhydrides in immiscible solvents (H₂O/CH₂Cl₂) under phase-transfer conditions. The implications of the results on the mechanism of catalysis are discussed.     

Urban flood risk assessment using sewer flooding databases

Sustainable water management is a global challenge for the 21st century. One key aspect remains protection against urban flooding. The main objective is to ensure or maintain an adequate level of service for all inhabitants. However, level of service is still difficult to assess and the high-risk locations difficult to identify. In this article, we propose a methodology, which (i) allows water managers to measure the service provided by the urban drainage system with regard to protection against urban flooding; and (ii) helps stakeholders to determine effective strategies for improving the service provided. One key aspect of this work is to use a database of sewer flood event records to assess flood risk. Our methodology helps urban water managers to assess the risk of sewer flooding; this approach does not seek to predict flooding but rather to inform decision makers on the current level of risk and on actions which need to be taken to reduce the risk. This work is based on a comprehensive definition of risk, including territorial vulnerability and perceptions of urban water stakeholders. This paper presents the results and the methodological contributions from implementing the methodology on two case studies: the cities of Lyon and Mulhouse.     

Enhanced Signal-to-Background Ratios in Voltammetric Measurements Made at Diamond Thin-Film Electrochemical Interfaces

Large signal-to-background (S/B) ratios for the Fe(CN)(6)(3)(-)(/4)(-) and IrCl(6)(2)(-)(/3)(-) redox couples in KCl have been observed in cyclic voltammetric measurements made at a conductive diamond thin-film electrode without any conventional surface pretreatment. The S/B ratios were a factor of ～16 and 8 larger at diamond than at freshly polished glassy carbon (GC) for Fe(CN)(6)(3)(-)(/4)(-) and IrCl(6)(2)(-)(/3)(-), respectively. The polycrystalline diamond film, grown on a p-Si(100) substrate, possessed significant cubic {100} faceting, as evidenced by AFM images, and was of high quality, as indicated by Raman spectroscopy. The high degree of electrochemical activity without surface pretreatment, the enhanced S/B ratios, and the excellent response stability demonstrate that diamond might be an attractive new electrode material for electroanalysis.