Naturalistic Research on Recovery Processes: Looking to the Future.

Because recovery is an ongoing process, conducting research on the recovery process presents multiple challenges. The process can play out over many years, but change also can occur quickly. Although researchers are keenly interested in the precursors of these sudden changes, a researcher is unlikely to be present at critical moments; however, technology offers new options not available in prior years. Recovery research at this point, however, must be pursued largely through observational methods. Experiments involving aspects of recovery can and should be done, but observation is an essential part of recovery research. Hence, this paper focuses on technologies for conducting and analyzing observational studies. The author briefly reviews methods for gathering intensive longitudinal data and discusses how recovery researchers can take advantage of existing technology to delve more deeply into the complex processes associated with recovery and relapse. The future of recovery research, however, will require examining new ways of investigating recovery phenomena, including a new option for gathering data based on decision theory. Taking maximum advantage of existing and new technology for recovery research will require increasing collaboration between recovery researchers and quantitative scientists.

Importance of operating room case scheduling on analyses of observed reductions in surgical site infections from the purchase and installation of capital equipment in operating rooms.

BACKGROUND: We review the impact of the consequences of operating room (OR) management decision making on power analyses for observational studies of surgical site infections (SSIs) among patients receiving care in ORs with interventions versus without interventions involving physical changes to ORs. Examples include ventilation systems, bactericidal lighting, and physical alterations to ORs. METHODS: We performed a narrative review of operating room management and surgical site infection articles. We used 10-years of operating room data to estimate parameters for use in statistical power analyses. RESULTS: Creating pivot tables or monthly control charts of SSI per case by OR and comparing among ORs with or without intervention is not recommended. This approach has low power to detect a difference in SSI rates among the ORs with or without the intervention. The reason is that appropriate OR case scheduling decision making causes risk factors for SSI to differ among ORs, even when stratifying by surgical specialty. Such risk factors include case duration, urgency, and American Society of Anesthesiologists' Physical Status. Instead, analyze SSI controlling for the OR, where the patient had surgery, and matching patients using these variables is preferable. With α = 0.05, 600 cases per OR, 5 intervention ORs, and 5 or 1 control patients for each intervention patient, reasonable power (≅94% or 78%, respectively) can be achieved to detect reductions (3.6% to 2.4%) in the incidence of SSI between ORs with or without the intervention. CONCLUSIONS: By using this matched cohort design, the effect of the purchase and installation of capital equipment in ORs on SSI can be evaluated meaningfully.

Diseño y validación de una herramienta de observación para porteros en balonmano playa / Design and validation of an observational instrument for goalkeepers in beach handball / Elaboração e validação de um instrumento de observação para guarda redes de andebol de praia

El objetivo de esta investigación fue crear un instrumento de observación en el contexto del balonmano playa para analizar las acciones del portero ante los lanzamientos de los atacantes. La herramienta ha sido diseñada ad hocmediante un sistema mixto de formatos de campo y sistema de categorías exhaustivas y mutuamente excluyentes (E/ME). Está constituida por 11 criterios y 85 categorías, destacando entre ellas el jugador que lanza, el tipo de lanzamiento, la acción defensiva realizada para dificultar ese lanzamiento y la acción del portero para intentar repelerlo. Se ha realizado un análisis de Calidad del Dato y un análisis de Generalizabilidad, se ha realizado un procedimiento de concordancia consensuada. Además, se han estimado los coeficientes de correlación Pearson, Spearman, Tau b de Kendall y el índice Kappa de Cohen. Los resultados han mostrado índices adecuados de correlación (≤ 0,936) y Kappa de Cohen (≤ 0,906). Los resultados obtenidos en el análisis de Generalizabilidad son también excelentes, resultando unos coeficientes G relativo y G absoluto de 0,985, en la concordancia interobservador, y de 0.998, en la concordancia intraobserbador. En conjunto, los datos presentados en este trabajo ponen de relieve una elevada validez, precisión y fiabilidad de las observaciones efectuadas con la herramienta analizada

The objectives of this research were to create an instrument of observation to analyze the actions of the goalkeeper in handb all beach and determine the reliability of the observers, assessing the goodness of the categories and estimating the minimum number of sessions necessary to generalize with precision. The tool ad hoc has been designed using a mixed system of field format an d a system of categories, exhaustive and mutually exclusive (E / ME). It is made up of 11 criteria and 85 categorie s . The results have shown adequate correlation rates ( ≤ 0 , 936) and Cohen's Kappa ( ≤ 0 , 906). The results obtained in the Generalizability analysis are also excellent, resulting in relative G coefficients and absolute G of 0 , 985, in the interobserver agreem ent, and 0.998, for the intraobserver agreement. Overall, the results presented in this work highlight the high validity, accuracy and reliability of the observations made with the tool analyzed

Os objectivos deste trabalho foram a criação de um instrumento de observação para analisar as acções do guarda redes de andeb ol de praia e determinar a fiabilidade dos observadores, valorizando a bondade das categorias e estimar o número mínimo de sessões necessárias para generalizar com precisão. A ferramenta foi desenhada com base ad hoc mediante um sistema misto de formato de campo e sistema de categorias, exaustivas e mutuamente exclusivas (E/ME). Ela é co mposta por 11 critérios e 85 categorias. Os resultados obtidos demonstram índices adequados de relação ( ≤ 0,936) e Kappa de Cohen ( ≤ 0,906). Os resultados obtidos na análise da generalização são excelentes também, resultando coeficientes G relativo e G abs oluto de 0,985, no acordo interobservador, e de 0,998 para o acordo inter - observador. De maneira geral, os resultados apresentados neste trabalho revelam uma alta validade, precisão e fiabilidade das observações efectuadas com esta ferramente analizada

Clinical outcome after surgical clipping or endovascular coiling for cerebral aneurysms: a pragmatic meta-analysis of randomized and non-randomized trials with short- and long-term follow-up.

BACKGROUND: Two randomized trials have evaluated clipping and coiling in patients with ruptured aneurysms. Aggregated evidence for management of ruptured and unruptured aneurysms is missing. OBJECTIVE: To conduct a meta-analysis evaluating clinical outcome after aneurysm treatment. METHODS: PubMed, Cochrane Central Register of Controlled Trials, and Clinicaltrials.gov were searched for studies evaluating aneurysm treatment. The primary outcome measure was an independent clinical outcome (modified Rankin scale 0-2, Glasgow Outcome Scale 4-5, or equivalent). Secondary outcomes were poor outcome and mortality. ORs were calculated on an intention-to-treat basis with 95% CIs. Outcome heterogeneity was evaluated with Cochrane's Q test (significance level cut-off value at <0.10) and I2 (significance cut-off value >50%) with the Mantel-Haenszel method for dichotomous outcomes. A p value <0.05 was regarded as statistically significant. RESULTS: Searches yielded 18 802 articles. All titles were assessed, 403 abstracts were evaluated, and 183 full-text articles were read. One-hundred and fifty articles were qualitatively assessed and 85 articles were included in the meta-analysis. Patients treated with coiling (randomized controlled trials (RCTs)) had higher independent outcome at short-term follow-up (OR=0.67, 95% CI 0.57 to 0.79). Independent outcome was favored for coiling at intermediate and long-term follow-up (RCTs and observational studies combined-OR=0.80, 0.68 to 0.94 and OR=0.81, 0.71 to 0.93, respectively). Independent outcome and lower mortality was favored after coiling in unruptured aneurysms (database registry studies) at short-term follow-up (OR=0.34, 0.29 to 0.41 and OR=1.74, 1.52 to 1.98, respectively). CONCLUSIONS: This meta-analysis evaluating clinical outcome after coiling or clipping for intracranial aneurysms, indicates a higher independent outcome and lower mortality after coiling.

Coiling Is Not Superior to Clipping in Patients with High-Grade Aneurysmal Subarachnoid Hemorrhage: Systematic Review and Meta-Analysis.

BACKGROUND: Outcomes of coiling embolization versus clipping for patients with high-grade aneurysmal subarachnoid hemorrhage (aSAH) have not been previously compared. We reviewed current evidence regarding the safety and efficacy of clipping versus coiling for high-grade aSAH. METHODS: We conducted a meta-analysis of studies that compared clipping with coiling in patients with high-grade aSAH published from January 1999 to February 2016 in Medline, Embase, and Cochrane databases based on PRISMA inclusion and exclusion criteria. Binary outcome comparisons between clipping and coiling were described using odds ratios (ORs). RESULTS: Three randomized controlled trials (RCTs) and 16 observational studies were included. There was no statistical difference in good outcome rates between the clipping and coiling groups (OR, 1.44; 95% confidence interval [CI], 0.97-2.13). Subgroup analysis showed no significant difference between the 2 treatments in non-RCTs (OR, 1.49; 95% CI, 0.95-2.36) and RCTs (OR, 1.15; 95% CI, 0.59-2.25). Coiling was associated with higher mortality (OR, 0.55; 95% CI, 0.41-0.75). Lower mortality was associated with clipping in non-RCTs (OR, 0.54; 95% CI, 0.40-0.74), but there was no difference in the RCTs (OR, 0.79; 95% CI, 0.19-3.39). Coiling was not associated with lower rates of complications including rebleeding (OR, 0.62; 95% CI, 0.30-1.29), ischemic infarct (OR, 0.89; 95% CI, 0.53-1.49), symptomatic vasospasm (OR, 0.76; 95% CI, 0.45-1.29), or shunt-dependent hydrocephalus (OR, 1.33; 95% CI, 0.52-3.40). CONCLUSION: The outcome with coiling is not superior to clipping in patients with high-grade aSAH; moreover, coiling has a greater risk of mortality.

Análisis coste-efectividad de la cirugía del glioma maligno guiada por fluorescencia con ácido 5-aminolevulínico / Cost-effectiveness of 5-aminolevulinic acid-induced fluorescence in malignant glioma surgery

Objetivo: Evaluar el coste-efectividad del ácido 5-aminolevulínico (5-ALA, Gliolan(R)) en pacientes intervenidos quirúrgicamente de glioma maligno, en condiciones de práctica médica habitual en España. Material y métodos: Se determinaron las ratios de coste incremental por resección completa (RC) y de coste incremental por año de vida ajustado por calidad (AVAC) ganado, sobre la base de los datos recogidos en el estudio observacional VISIONA. Resultados. El coste incremental con 5-ALA frente a la cirugía convencional con luz blanca asciende a 4.550 Euros por RC adicional conseguida y a 9.021 Euros por AVAC ganado. Estos resultados se muestran consistentes en un análisis de sensibilidad. Conclusión: La cirugía del glioma maligno guiada por fluorescencia con 5-ALA conlleva un incremento de costes moderado respecto a la práctica quirúrgica actual y muestra una relación coste-efectividad favorable

Objective: This study evaluates the cost-effectiveness of 5-aminolevulinic acid (5-ALA, Gliolan®) in patients undergoing surgery for malignant glioma, in standard clinical practice conditions in Spain. Material and methods: Cost-effectiveness ratios were determined in terms of incremental cost per complete resection (CR) and incremental cost per additional quality-adjusted life year (QALY), based on data collected in the VISIONA observational study. Results: Incremental cost with 5-ALA versus conventional surgery using white light only amounts to Euros 4550 per additional CR achieved and Euros 9021 per QALY gained. A sensitivity analysis shows these results to be robust. Conclusion: Malignant glioma surgery guided by 5-ALA fluorescence entails a moderate increase in hospital costs compared to current surgical practice and can be considered a cost-effective innovation

Cumplimiento de indicadores de proceso en personas con diabetes tipo 2 y la vinculación a incentivos en Atención Primaria / Compliance with process indicators in people with type 2 diabetes and linking incentives in Primary Care

OBJETIVO: Los programas de pago por desempeño para mejorar la calidad de la atención sanitaria se están extendiendo de forma progresiva, en particular para en Atención Primaria. Nuestro objetivo fue explorar la relación entre el grado de cumplimiento de los indicadores de proceso (IPr) de la diabetes mellitus tipo 2 (DM2) en Atención Primaria y la vinculación a incentivos económicos. DISEÑO: Estudio descriptivo observacional, descriptivo y transversal. Emplazamiento: Seis centros de salud del Distrito Aljarafe, Sevilla, seleccionados de forma aleatoria y estratificada por tamaño poblacional. PARTICIPANTES: De un total de 3.647 sujetos incluidos en el Proceso Asistencial Integrado de DM2 durante el 2008, se incluyó a 366 pacientes, según cálculo de tamaño muestral, mediante muestreo aleatorio estratificado. Mediciones: IPr: exploración de fondo de ojo y pies, hemoglobina glucosilada (HbA1c), perfil lipídico, microalbuminuria y electrocardiograma. Variables potencialmente confusoras: edad, género, característica de zona de residencia en pacientes y variables de los médicos. RESULTADOS: La edad media fue de 66,36 (desviación estándar -DE- 11,56 años); el 48,9% eran mujeres. Los IPr con mejor cumplimiento fueron la exploración de pies, HbA1c y perfil lipídico (59,6, 44,3 y 44, respectivamente). El 2,7% de los pacientes presentaban cumplimiento simultáneo de los 6 IPr y el 11,74% de los 3 IPr vinculados a incentivos. El cumplimiento de IPr vinculado y no a incentivos mostró asociación significativa (p = 0,001). CONCLUSIONES: El cumplimiento de los IPr para el cribado de complicaciones crónicas de la DM2 es en su mayoría bajo, aunque este fue superior en los indicadores vinculados a incentivos

OBJECTIVE: Pay-for-performance programs to improve the quality of health care are extending gradually, particularly en Primary Health Care. Our aim was to explore the relationship between the degree of compliance with the process indicators (PrI) of type 2 diabetes (T2DM) in Primary Care and linkage to incentives. DESIGN: Cross-sectional, descriptive, observational study. SETTING: Six Primary Health Care centers in Seville Aljarafe District randomly selected and stratified by population size. PARTICIPANTS: From 3.647 adults included in Integrated Healthcare Process of T2DM during 2008, 366 patients were included according sample size calculation by stratified random sampling. Measurements: PrI: eye and feet examination, glycated hemoglobin, lipid profile, microalbuminuria and electrocardiogram. Confounding: Age, gender, characteristics town for patients and professional variables. RESULTS: The mean age was 66.36 years (standard deviation [DE]: 11,56); 48.9% were women. PrI with better compliance were feet examination, glycated hemoglobin and lipid profile (59.6%, 44.3% and 44%, respectively). 2.7% of patients had simultaneous compliance of the six PrI and 11.74% of patients three PrI linkage to incentives. Statistical association was observed in the compliance of the PrI incentives linked or not (P = .001). CONCLUSIONS: The degree of compliance with the PrI for screening chronic complications of T2DM is mostly low but this was higher on indicators linked to incentives

Cambio en la estrategia terapéutica ante una respuesta inadecuada al tratamiento farmacológico para el trastorno por déficit de atención/hiperactividad / Change in the therapeutic strategy when faced with an inadequate response to the pharmacological treatment of attention deficit hyperactivity disorder

Introducción. El trastorno por déficit de atención/hiperactividad (TDAH) es un trastorno del neurodesarrollo cerebral de origen biológico. Se estima que el 3-7% de los niños en edad escolar presentan TDAH. Dentro del tratamiento farmacológico, las anfetaminas y el metilfenidato (MPH) son los más utilizados. Aunque las tasas de respuesta al MPH son altas, las tasas de remisión completa llegan sólo al 56%. Un 25% de los pacientes que no responden al MPH sí lo haría a otros estimulantes, y viceversa. Objetivo. Valorar clínicamente a los pacientes con detección de respuestas inadecuadas y la eficacia de un cambio a lisdexanfetamina dimesilato (LDX). Pacientes y métodos. Estudio observacional prospectivo. Se consideró respuesta inadecuada al MPH aquella que presentaba falta de cobertura o de efecto. Se utilizaron las escalas de evaluación Attention-Deficit/Hyperactivity Disorder Rating Scale IV (ADHD-RS-IV) y Clinical Global Impression-Severity (CGI-S) para la valoración clínica, así como la escala de evaluación del deterioro funcional de Weiss (WFIRS) y el perfil de salud infantil (CHIP-AE). También se recogieron los efectos adversos. Resultados. Cumplieron criterios de respuesta inadecuada al tratamiento 41 pacientes: 13,6 ± 3,4 años, 54,6 ± 13,2 kg, 158,5 ± 17,2 cm e índice de masa corporal de 20,9 ± 3,5 kg/m2. Motivos del cambio (no excluyentes): falta de cobertura (76%), falta de intensidad del efecto (68%) y presencia de efectos adversos con la medicación anterior (16%). La puntuación media basal y a los nueve meses, en la ADHD-RS, fue de 24,54 ± 6,3 frente a 12,01 ± 3,2 (p < 0,01), respectivamente, y para la CGI-S, de 5,09 ± 0,5 frente a 2,91 ± 0,8 (p < 0,01), respectivamente. El perfil de seguridad coincidió con el de otros tratamientos estimulantes para el TDAH. Conclusión. Cuando la respuesta al MPH presenta falta de cobertura o falta de efecto, el cambio a LDX se ha mostradoeficaz, con una mejoría en el 86,7% de los casos, similar a la de otros estudios, por lo que resulta una buena opción terapéutica en estos pacientes (AU)

Introduction. Attention deficit hyperactivity disorder (ADHD) is a disorder of a biological origin affecting the neurodevelopment of the brain. It is estimated that 3-7% of school-age children present ADHD. The most commonly used pharmacological treatments are amphetamines and methylphenidate (MPH). Although response rates to MPH are high, full remission rates reach only 56%. The 25% of patients who do not respond to MPH would show a response to other stimulants and vice-versa. Aims. To clinically evaluate patients by detecting inadequate responses and the efficacy of a change to lisdexamfetamine dimesylate (LDX). Patients and methods. The study was prospective and observation-based. Inadequate responses were considered to be hose that presented non-coverage or no effect. The Attention-Deficit/Hyperactivity Disorder Rating Scale IV (ADHD-RS-IV) and Clinical Global Impression-Severity (CGI-S) assessment scales were used for the clinical assessment, together with the Weiss Functional Impairment Rating Scale (WFIRS) and the Child Health and Illness Profile (CHIP-AE). Data regarding adverse side effects were also collected. Results. Forty-one patients met criteria for inadequate response to treatment: 13.6 ± 3.4 years, 54.6 ± 13.2 kg, 158.5 ± 17.2 cm and body mass index of 20.9 ± 3.5 kg/m2. Reasons for change (non-exclusive): non-coverage (76%), lack of intensity of effect (68%) and presence of adverse side effects with the previous medication (16%). The mean score both at baseline and at nine months, on the ADHD-RS, was 24.54 ± 6.3 versus 12.01 ± 3.2 (p < 0.01), respectively, and for the CGI-S values were 5.09 ± 0.5 versus 2.91 ± 0.8 (p < 0.01), respectively. The safety profile coincided with that of other stimulant-based treatments for ADHD. Conclusions. When the response to MPH presents non-coverage or lack of effect, changing to LDX has proved to be effective, with an improvement in 86.7% of cases, which is similar to that of other studies. It is therefore a good therapeutic option in these patients (AU)

Mary Ainsworth's legacy: a systematic review of observational instruments measuring parental sensitivity.

Since Mary Ainsworth's formulation of the Sensitivity-Insensitivity to Infant Signals and Communications observational scale, new instruments have been developed to observe parental sensitivity. In this paper, we provide an overview of eight commonly used observational instruments to measure parental sensitivity. Their similarities and differences in comparison to the original Ainsworth sensitivity construct and its applications will be discussed. Consistent with the search criteria, each of the instruments clearly includes the key elements of Ainsworth's definition of sensitivity. Notable deviations from the original scale are the use of composite scales rather than a single global scale and the related inclusion of new elements, and specifically the inclusion of positive affect as an indicator of sensitivity. Further, most of the instruments have a wider scope than Ainsworth's sensitivity scale in terms of target age groups and the assessment of sensitivity in fathers. We discuss the interpretation of the sensitivity construct depending on variations in how the construct is defined in different observational instruments, and advances in the application of the construct.