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Le syndrome VEXAS se caractérise par une activation des voies de l’inflammasome dans le sang et les tissus et par une dérégulation du compartiment monocytaire. Rev Med Interne 2022. [DOI: 10.1016/j.revmed.2022.10.097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study. Lancet Digit Health 2022; 4:e520-e531. [PMID: 35750401 DOI: 10.1016/s2589-7500(22)00069-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2021] [Revised: 01/07/2022] [Accepted: 04/06/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications. METHODS We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC). FINDINGS In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]). INTERPRETATION In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required. FUNDING British Journal of Surgery Society.
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Increasing specialist intensity at weekends to improve outcomes for patients undergoing emergency hospital admission: the HiSLAC two-phase mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09130] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background
NHS England’s 7-day services policy comprised 10 standards to improve access to quality health care across all days of the week. Six standards targeted hospital specialists on the assumption that their absence caused the higher mortality associated with weekend hospital admission: the ‘weekend effect’. The High-intensity Specialist-Led Acute Care (HiSLAC) collaboration investigated this using the implementation of 7-day services as a ‘natural experiment’.
Objectives
The objectives were to determine whether or not increasing specialist intensity at weekends improves outcomes for patients undergoing emergency hospital admission, and to explore mechanisms and cost-effectiveness.
Design
This was a two-phase mixed-methods observational study. Year 1 focused on developing the methodology. Years 2–5 included longitudinal research using quantitative and qualitative methods, and health economics.
Methods
A Bayesian systematic literature review from 2000 to 2017 quantified the weekend effect. Specialist intensity measured over 5 years used self-reported annual point prevalence surveys of all specialists in English acute hospital trusts, expressed as the weekend-to-weekday ratio of specialist hours per 10 emergency admissions. Hospital Episode Statistics from 2007 to 2018 provided trends in weekend-to-weekday mortality ratios. Mechanisms for the weekend effect were explored qualitatively through focus groups and on-site observations by qualitative researchers, and a two-epoch case record review across 20 trusts. Case-mix differences were examined in a single trust. Health economics modelling estimated costs and outcomes associated with increased specialist provision.
Results
Of 141 acute trusts, 115 submitted data to the survey, and 20 contributed 4000 case records for review and participated in qualitative research (involving interviews, and observations using elements of an ethnographic approach). Emergency department attendances and admissions have increased every year, outstripping the increase in specialist numbers; numbers of beds and lengths of stay have decreased. The reduction in mortality has plateaued; the proportion of patients dying after discharge from hospital has increased. Specialist hours increased between 2012/13 and 2017/18. Weekend specialist intensity is half that of weekdays, but there is no relationship with admission mortality. Patients admitted on weekends are sicker (they have more comorbid disease and more of them require palliative care); adjustment for severity of acute illness annuls the weekend effect. In-hospital care processes are slightly more efficient at weekends; care quality (errors, adverse events, global quality) is as good at weekends as on weekdays and has improved with time. Qualitative researcher assessments of hospital weekend quality concurred with case record reviewers at trust level. General practitioner referrals at weekends are one-third of those during weekdays and have declined further with time.
Limitations
Observational research, variable survey response rates and subjective assessments of care quality were compensated for by using a difference-in-difference analysis over time.
Conclusions
Hospital care is improving. The weekend effect is associated with factors in the community that precede hospital admission. Post-discharge mortality is increasing. Policy-makers should focus their efforts on improving acute and emergency care on a ‘whole-system’ 7-day approach that integrates social, community and secondary health care.
Future work
Future work should evaluate the role of doctors in hospital and community emergency care and investigate pathways to emergency admission and quality of care following hospital discharge.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 13. See the NIHR Journals Library website for further project information.
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Abstract No. 80 Inferior vena cava filter placement and retrieval in pediatric patients: a multicenter retrospective analysis. J Vasc Interv Radiol 2021. [DOI: 10.1016/j.jvir.2021.03.503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Changes in weekend and weekday care quality of emergency medical admissions to 20 hospitals in England during implementation of the 7-day services national health policy. BMJ Qual Saf 2020; 30:536-546. [PMID: 33115851 PMCID: PMC8237174 DOI: 10.1136/bmjqs-2020-011165] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2020] [Revised: 10/06/2020] [Accepted: 10/11/2020] [Indexed: 12/23/2022]
Abstract
Background In 2013, the English National Health Service launched the policy of 7-day services to improve care quality and outcomes for weekend emergency admissions. Aims To determine whether the quality of care of emergency medical admissions is worse at weekends, and whether this has changed during implementation of 7-day services. Methods Using data from 20 acute hospital Trusts in England, we performed randomly selected structured case record reviews of patients admitted to hospital as emergencies at weekends and on weekdays between financial years 2012–2013 and 2016–2017. Senior doctor (‘specialist’) involvement was determined from annual point prevalence surveys. The primary outcome was the rate of clinical errors. Secondary outcomes included error-related adverse event rates, global quality of care and four indicators of good practice. Results Seventy-nine clinical reviewers reviewed 4000 admissions, 800 in duplicate. Errors, adverse events and care quality were not significantly different between weekend and weekday admissions, but all improved significantly between epochs, particularly errors most likely influenced by doctors (clinical assessment, diagnosis, treatment, prescribing and communication): error rate OR 0.78; 95% CI 0.70 to 0.87; adverse event OR 0.48, 95% CI 0.33 to 0.69; care quality OR 0.78, 95% CI 0.70 to 0.87; all adjusted for age, sex and ethnicity. Postadmission in-hospital care processes improved between epochs and were better for weekend admissions (vital signs with National Early Warning Score and timely specialist review). Preadmission processes in the community were suboptimal at weekends and deteriorated between epochs (fewer family doctor referrals, more patients with chronic disease or palliative care designation). Conclusions and implications Hospital care quality of emergency medical admissions is not worse at weekends and has improved during implementation of the 7-day services policy. Causal pathways for the weekend effect may extend into the prehospital setting.
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Compulsory vaccination: case isolation is likely to be more effective. BMJ 2019; 366:l4472. [PMID: 31272950 DOI: 10.1136/bmj.l4472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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SUN-179 The AKORDD study of AKI Outreach – experience from the UK’s first controlled trial in unselected acute kidney injury. Kidney Int Rep 2019. [DOI: 10.1016/j.ekir.2019.05.581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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How to manipulate friends and influence practice: Application of complexity science leads to quality improvement in laboratory sample submissions. J Infect Prev 2019; 20:91-98. [PMID: 30944593 DOI: 10.1177/1757177419831348] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2018] [Accepted: 01/24/2019] [Indexed: 11/16/2022] Open
Abstract
Background We sought to reduce healthcare-associated infections (HCAIs) through the application of complexity science. Objective To confirm incidental findings that altering the structure of microbiology reports with targeted education led to better utilisation of laboratory resources, while participating in efforts to reduce HCAI. Methods We adopted a different approach to laboratory result authorisation, using narrative to engage the clinicians and induce behavioural change. Subsequent educational opportunities emphasised key messages. Findings/Results Positive urine means calculated by the analysis tool numbered 2179/month throughout the study period. Negative urines started at 5576/month, reduced to 5134/month in November 2014 and to 4602/month in April 2016, coinciding with our changes. Opportunity costs were saved. Discussion The changes in both policy and reporting were contemporaneous with a decline in negative samples. There were no significant changes in the number of positive specimens. The efficiency and effectiveness of the laboratory was improved and resources released: £145,000 ($182,000) for a resident population of 384,000. This suggests an annual release of about £25 million ($31 million) may be possible in the UK and £122 million ($155 million) in the USA.
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Implementing the future hospital. Future Healthc J 2018; 5:5-6. [PMID: 31098522 PMCID: PMC6510051 DOI: 10.7861/futurehosp.5-1-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
For the last 4 years, this part of the Future Healthcare Journal has been the place to find regular overview updates on progress made by the Future Hospital Programme of the Royal College of Physicians, together with its partners, in realising the vision of the Future Hospital Commission. As outlined in this article, the Future Hospital Programme has now concluded. However, much of its work is being carried on by the RCP Quality Improvement Programme, which can be contacted on RCPQI@rcplondon.ac.uk. Follow the Quality Improvement Programme on Twitter: @RCP_QI.
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Abstract
The aim of the defence medical services (DMS) is to maintain the health of those individuals who volunteer for service in HM Armed Forces, in order that they may efficiently discharge their duties.
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Deviation from national guidance can have better results. BMJ 2017; 359:j5083. [PMID: 29122743 DOI: 10.1136/bmj.j5083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Smart phones at the ready! Future Healthc J 2017; 4:156-157. [PMID: 31098462 PMCID: PMC6502582 DOI: 10.7861/futurehosp.4-3-156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Update from the Future Hospital Programme. Future Healthc J 2017; 4:158-159. [PMID: 31098463 PMCID: PMC6502589 DOI: 10.7861/futurehosp.4-3-158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This part of the Future Healthcare Journal is where you will find regular overview updates on progress made by the Future Hospital Programme of the Royal College of Physicians, together with its partners, in realising the vision of the Future Hospital Commission. We very much welcome your feedback. If you have any comments, or would like to be involved in the work of the Programme, please contact futurehospital@rcplondon.ac.uk. Follow the Future Hospital Programme on Twitter: @RCPFutureHosp.
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Update from the Future Hospital Programme. Future Healthc J 2017; 4:78-79. [PMID: 31098439 PMCID: PMC6502635 DOI: 10.7861/futurehosp.4-2-78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
This part of the Future Hospital Journal is where you will find regular overview updates on progress made by the Future Hospital Programme of the Royal College of Physicians, together with its partners, in realising the vision of the Future Hospital Commission. We very much welcome your feedback. If you have any comments, or would like to be involved in the work of the Programme, please contact futurehospital@rcplondon.ac.uk. Follow the Future Hospital Programme on Twitter: @RCPFutureHosp.
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Will the digital cavalry rescue the NHS? Future Healthc J 2017; 4:76-77. [PMID: 31098438 PMCID: PMC6502631 DOI: 10.7861/futurehosp.4-2-76] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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The Case for Using An Evolutionary Professional Protocol for Improving Care: Act Local, Think Global. J R Coll Physicians Edinb 2017; 47:10-12. [DOI: 10.4997/jrcpe.2017.104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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A Critique of the National Clinical Strategy for Scotland. J R Coll Physicians Edinb 2017; 47:8-9. [DOI: 10.4997/jrcpe.2017.103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Abstract
This part of the Future Hospital Journal is where you will find regular overview updates on -progress made by the Future Hospital Programme of the Royal -College of Physicians, together with its -partners, in realising the vision of the Future -Hospital -Commission. We very much welcome your feedback. If you have any comments, or would like to be involved in the work of the Programme, please contact futurehospital@rcplondon.ac.uk.
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Abstract
BACKGROUND Increased mortality rates associated with weekend hospital admission (the so-called weekend effect) have been attributed to suboptimum staffing levels of specialist consultants. However, evidence for a causal association is elusive, and the magnitude of the weekend specialist deficit remains unquantified. This uncertainty could hamper efforts by national health systems to introduce 7 day health services. We aimed to examine preliminary associations between specialist intensity and weekend admission mortality across the English National Health Service. METHODS Eligible hospital trusts were those in England receiving unselected emergency admissions. On Sunday June 15 and Wednesday June 18, 2014, we undertook a point prevalence survey of hospital specialists (consultants) to obtain data relating to the care of patients admitted as emergencies. We defined specialist intensity at each trust as the self-reported estimated number of specialist hours per ten emergency admissions between 0800 h and 2000 h on Sunday and Wednesday. With use of data for all adult emergency admissions for financial year 2013-14, we compared weekend to weekday admission risk of mortality with the Sunday to Wednesday specialist intensity ratio within each trust. We stratified trusts by size quintile. FINDINGS 127 of 141 eligible acute hospital trusts agreed to participate; 115 (91%) trusts contributed data to the point prevalence survey. Of 34,350 clinicians surveyed, 15,537 (45%) responded. Substantially fewer specialists were present providing care to emergency admissions on Sunday (1667 [11%]) than on Wednesday (6105 [42%]). Specialists present on Sunday spent 40% more time caring for emergency patients than did those present on Wednesday (mean 5·74 h [SD 3·39] vs 3·97 h [3·31]); however, the median specialist intensity on Sunday was only 48% (IQR 40-58) of that on Wednesday. The Sunday to Wednesday intensity ratio was less than 0·7 in 104 (90%) of the contributing trusts. Mortality risk among patients admitted at weekends was higher than among those admitted on weekdays (adjusted odds ratio 1·10, 95% CI 1·08-1·11; p<0·0001). There was no significant association between Sunday to Wednesday specialist intensity ratios and weekend to weekday mortality ratios (r -0·042; p=0·654). INTERPRETATION This cross-sectional analysis did not detect a correlation between weekend staffing of hospital specialists and mortality risk for emergency admissions. Further investigation is needed to evaluate whole-system secular change during the implementation of 7 day services. Policy makers should exercise caution before attributing the weekend effect mainly to differences in specialist staffing. FUNDING National Institute for Health Research Health Services and Delivery Research Programme.
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Update on the Future Hospital Programme. Future Hosp J 2016; 3:87-88. [DOI: 10.7861/futurehosp.3-2-87] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Update on the Future Hospital Programme. Future Hosp J 2016; 3:10-12. [DOI: 10.7861/futurehosp.3-1-10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Update on the Future Hospital Programme. Future Hosp J 2015; 2:158-160. [DOI: 10.7861/futurehosp.2-3-158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Update on the Future Hospital Programme. Future Hosp J 2015; 2:81-83. [DOI: 10.7861/futurehosp.2-2-81] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Update on the Future Hospital Programme. Future Hosp J 2015; 2:8-9. [PMID: 31098067 PMCID: PMC6465880 DOI: 10.7861/futurehosp.2-1-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
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Update on the Future Hospital Programme. Future Hosp J 2015. [DOI: 10.7861/futurehosp.15.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Contradiction is inherent in business model for hospitals. BMJ 2014; 349:g6162. [PMID: 25315812 DOI: 10.1136/bmj.g6162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Impact of hand washing on bacteraemia rates. BMJ 2012; 344:e4299. [PMID: 22734098 DOI: 10.1136/bmj.e4299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Postoperative hemorrhage following adenoidectomy. Laryngoscope 2012; 122:1246-53. [PMID: 22522935 DOI: 10.1002/lary.23279] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2011] [Revised: 02/08/2012] [Accepted: 02/10/2012] [Indexed: 11/08/2022]
Abstract
OBJECTIVES/HYPOTHESIS To examine postoperative hemorrhage following adenoidectomy. STUDY DESIGN Prospective multicenter observational study. METHODS The Surgical Instrument Surveillance Programme (SISP) was established in 2003 to monitor tonsil and adenoid surgery in all hospitals in Wales. Data were examined between April 1, 2003 and June 30, 2008, for risk factors that may contribute to primary (R1) or secondary (R2) postoperative hemorrhage from the adenoid bed, of a severity sufficient to require a return to the operating room. RESULTS There were 5,588 procedures included, of which 4,225 included simultaneous tonsillectomy. The study included 2,903 (52%) males with a median age of 5.8 years (interquartile range [IQR], 4.5-7.7 years) and 2,685 (48%) females with a median age of 6.5 years (IQR, 5.0-9.1 years). There were 22 patients (0.4%; confidence interval [CI], 0.2-0.6) who returned to the operating room with a postoperative hemorrhage arising from the adenoid bed. These were exclusively R1 hemorrhage; there were no instances of R2 hemorrhage (0.0%; CI, 0.0-0.1). No specific risk factors for R1 hemorrhage could be identified. There were 38 patients in the adenotonsillectomy group who returned to operating room with a postoperative hemorrhage arising from the tonsil bed (0.5%; CI, 0.3-0.8). R1 was seen in 22 patients (0.5%; CI, 0.3-0.8) and R2 in 16 patients (0.4%; CI, 0.2-0.6). CONCLUSIONS Adenoidectomy appears to be primarily a procedure performed in childhood. The rate of R1 hemorrhage following adenoidectomy is one in 200 (0.5%) and is similar to the R1 hemorrhage rate for tonsillectomy. R2 hemorrhage following an adenoidectomy appears to be extremely rare. In children, the risk of a serious primary hemorrhage following an adenotonsillectomy is double that of either procedure when performed alone.
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Re: Improvement in quality of life by adenotonsillectomy in children with adenotonsillar disease. Clin Otolaryngol 2011; 36:281-2. [PMID: 21752216 DOI: 10.1111/j.1749-4486.2011.02301.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Evidence of person-to-person transmission of oseltamivir-resistant pandemic influenza A(H1N1) 2009 virus in a hematology unit. J Infect Dis 2011; 203:18-24. [PMID: 21148492 DOI: 10.1093/infdis/jiq007] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
We describe the first confirmed person-to-person transmission of oseltamivir-resistant pandemic influenza A(H1N1) 2009 virus that occurred in a hematology unit in the United Kingdom. Eleven cases of (H1N1) 2009 virus infection were identified, of which, ten were related as shown by sequence analysis of the hemagglutinin and neuraminidase genes. H275Y analysis demonstrated that 8 of 10 case patients had oseltamivir-resistant virus, with 4 of 8 case patients infected by direct transmission of resistant virus. Zanamivir should be considered as first-line therapy for influenza in patients with lymphopenic hematological conditions and uptake of influenza vaccination encouraged to further reduce the number of susceptible individuals.
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Risk factors for postoperative hemorrhage following tonsillectomy. Laryngoscope 2010; 121:279-88. [DOI: 10.1002/lary.21242] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Revised: 07/27/2010] [Accepted: 07/29/2010] [Indexed: 11/06/2022]
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Audit of a network of sexually transmitted infections centred in South Wales. Int J STD AIDS 2009; 21:63-5. [PMID: 19833690 DOI: 10.1258/ijsa.2009.009066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
The aim of this article is to audit the distribution and frequency of sexually transmitted infections (STIs) within a sexual network centred in South Wales. After diagnosis of a new case of HIV in February 2007, partner notification, HIV and STI testing were undertaken. Those traced were given information regarding safe sex practices and informed they had been in contact with HIV. Genitourinary (GU) medicine case-notes of contacts identified in the network were reviewed from February 2007 to 1 July 2008. Frequency and distribution of new diagnoses of STIs made on original identification in the network in 2007 were compared with subsequent new diagnoses within the network. One hundred and eighteen men who have sex with men (MSMs) and five women were identified in the original network in 2007. By 1 July 2008, 65 new sexual contacts (all MSMs) were added to the network and there were 25 new STI diagnoses in 13 contacts. Seven contacts originally identified in the cluster in 2007 were diagnosed with 16 of the new STIs. In conclusion, the sexual network has evolved by increasing in size with multiple new STIs diagnosed. The highest risk of STIs occurred in relatively few individuals. Standard interventions in health promotion in the GU medicine setting were not universally successful in preventing high-risk behaviour.
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Abstract
OBJECTIVE To describe an HIV transmission cluster centred in South Wales by the analysis of partner notification outcomes and demographic characteristics of individuals identified in the sexual network. METHODS After diagnosis of the index case, HIV testing and partner notification were undertaken by Cardiff Genitourinary Medicine Clinic in collaboration with the local Health Protection Team, National Public Health Service for Wales and Terrence Higgins Trust Cymru. Rapid test and standard venepuncture methods were used for HIV screening and the resulting clinical and behavioural data were analysed. RESULTS Of the 123 individuals identified in the sexual network, all were men who had sex with men (MSM) except for seven men who self-identified as bisexual and five heterosexual women. Fifteen new cases of HIV were diagnosed; all were men. Partner notification outcomes are as follows: 104 provider referrals were made, 57 were successfully contacted with known outcomes, 14 were successfully contacted but with unknown outcomes and 33 were uncontactable. Fifteen patient referrals were made, 11 had known outcomes but four had unknown outcomes. Four patients self-referred. Eleven reported previous HIV diagnosis. The sexual network was distributed over South and West Wales extending into England, with high reported rates of unprotected anal intercourse, previous HIV tests and concurrent sexually transmitted infections. A one in four positive rate for those with a known HIV status outcome and a 68% provider referral success rate compares favourably with other studies. CONCLUSIONS Partner notification revealed a relatively young, well-educated HIV network with high-risk behaviour and ongoing transmission despite previous knowledge and awareness of HIV. This analysis adds to the evidence supporting HIV partner notification in MSM.
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P1048 Pandemicfiu preparedness - role of antibiotics. Int J Antimicrob Agents 2007. [DOI: 10.1016/s0924-8579(07)70889-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Health impact assessment and community involvement in land remediation decisions. Public Health 2006; 120:915-22. [PMID: 16962621 DOI: 10.1016/j.puhe.2006.05.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2005] [Revised: 01/11/2006] [Accepted: 05/05/2006] [Indexed: 11/16/2022]
Abstract
This paper describes a collaborative health impact assessment (HIA) of land remediation options at the site of a former smokeless fuel factory, where action had been delayed by conflict between stakeholders. The likely impacts of the processes involved on the physical and mental health of the community were examined in terms of the relevant scientific and medical literature, history of the site and evidence of local people. Although all remediation options were likely to have some adverse health effects, they could be mitigated by making choices based on the best evidence. The steering group concluded that the adverse effects of remediation would be relatively short term and could be justified by the medium- to long-term benefits of removing toxic substances. The HIA steering group's recommendations were accepted by the project working group, resulting in the resolution of long-running conflict between the residents, activists and those responsible for site remediation, which has now commenced.
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Instrumentation and patient characteristics that influence postoperative haemorrhage rates following tonsil and adenoid surgery. Clin Otolaryngol 2006; 30:338-46. [PMID: 16209676 DOI: 10.1111/j.1365-2273.2005.01045.x] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVES To investigate the effect of the type instrumentation used and the age and gender characteristics of patients on postoperative haemorrhage rates following tonsil and adenoid surgery. DESIGN A retrospective analysis of 13 593 procedures was performed from The Patient Episode Database for Wales between 1 January 1999 and 31 March 2004. SETTING National health policy changes created four periods of different instrument usage (reusable, single-use with diathermy, single-use alone, specified single-use with diathermy). These and the age and gender distribution of the patients were examined against four categories of postoperative haemorrhage. MAIN OUTCOME MEASURES Postoperative haemorrhage rates were expressed as the number of complications per operations performed. Primary postoperative haemorrhage that occurred during the initial admission either required a return to theatre [R1] or was managed conservatively [N1]; secondary postoperative haemorrhage that required a return to hospital either returned to theatre [R2] or was managed conservatively [N2], were compared. RESULTS Primary haemorrhage with return to theatre doubled, from the baseline rate with reusable instruments, from 0.6% (CI 0.5-0.8) to 1.2% (CI 0.7-1.9) when single-use instruments were introduced and remained high at 1.4% (CI 0.9-2.1) after the withdrawal of single-use diathermy. This haemorrhage rate returned to the baseline rate (0.6% CI 0.3-1.0) when specified single-use instruments were introduced. None of the other haemorrhage rates changed significantly throughout the four observation periods. Adenotonsillectomy and tonsillectomy patients have different age and gender patterns. In a univariate analysis, males over the age of 12 years were twice as likely to have haemorrhage with return to theatre than girls of the same age, 3.8% (CI 3.0-4.7) versus 1.7% (CI 1.4-2.1). CONCLUSIONS A significant rise in serious postoperative primary haemorrhage but not secondary haemorrhage was seen following the initial introduction of single-use instruments that reverted to baseline with the introduction of specified single-use instruments. Diathermy does not appear to have affected the haemorrhage rates. There is a distinct age and gender pattern for tonsil and adenoid surgery and risk of postoperative haemorrhage. The use of arbitrary divisions of age may be misleading in studies that examine post-tonsillectomy haemorrhage.
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Effects of dose and duration of continuous GnRH-agonist treatment on induction of estrus in beagle dogs: competing and concurrent up-regulation and down-regulation of LH release. Theriogenology 2006; 66:1488-96. [PMID: 16563490 DOI: 10.1016/j.theriogenology.2006.02.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
Dose-response estrus-induction trials were conducted during anestrus in 93 treated and 6 control bitches, a continuous administration of the GnRH-agonist lutrelin with a potency 150 x GnRH, and at six different doses from 0.2 to 4.8 microg/kg/d for 7-14 days in 15 groups of six to eight dogs each in defined stages of natural or pharmacologically determined anestrus. Agonist treatment induced clinically and cytologically normal proestrus (in 89% of cases) within 4.8 +/- 0.2 x days, and resulted in behavioral estrus (71%), spontaneous late-proestrus LH (and FSH) surges, ovulation (59%) and pregnancy (44%) in a dose dependent manner. Outcomes of ovulation and pregnancy in most cases required that the dose be sufficiently large enough to routinely stimulate a large initial increase in LH and FSH (i.e., > or = 0.6 microg/kg/d), and of sufficient duration (i.e., > 7 days) to ensure that supra-basal gonadotropin levels persistedntil no longer needed for spontaneous continuation of an induced proestrus. Success additionally required that the GnRH dose be modest enough (i.e., < 1.8 microg/kg/d) to not excessively down-regulate spontaneous pre-ovulatory surge release of gonadotropin or be removed shortly before or at the time when the LH surges typically occurred (10-13 days after initiation of treatment). The 1.8 microg dose was compared to saline to assess the time course of its down-regulation action on serum LH in six ovariohysterectomized bitches compared to four saline-related controls. Results in intact bitches receiving the 1.8-microg doses demonstrated an LH-releasing effect for 10-11 days that overlapped a period of obvious down-regulation seen with the same dose after 3 days in the ovariohysterectomized bitches. In the latter, however, complete down-regulation to anestrus-like values did not occur until after 18-21 days of treatment. A dose of 0.6 microg/kg/d for 12 days yielded the best estrus-induction results, including pregnancy rates of 100% in six bitches treated in natural-anestrus bitches, six bitches in which anestrus had been advanced by a luteolytic prostaglandin treatment and in six bitches in which anestrus had been extended by progesterone implants administered for 3 months. Although lutrelin is not commercially available, these results provide guidelines for the development of estrus-inducing protocols with other GnRH-agonists of known biopotencies.
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P17.48 The Single-Use Instrument Surveillance Programme (SISP) as a Model System for Safe Introduction of Disposable Instrumentation and New Surgical Procedures. J Hosp Infect 2006. [DOI: 10.1016/s0195-6701(06)60319-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
OBJECTIVES To compare the quality and consistency of single-use adenotonsillectomy instruments available in the UK with reusable instruments and examine their performance in a clinical setting. DESIGN A laboratory assessment of each reusable instrument created a detailed specification for the respective single-use equivalent. A surveillance system monitored the performance of a selected set of specified single-use instruments. SETTING Single-use instruments were withdrawn shortly after their introduction in 2001. Persisting concerns from the Spongiform Encephalopathy Advisory Committee led to an investigation into the feasibility of continuing to use such instruments. MAIN OUTCOME MEASURES The numbers of instruments from each set judged as unacceptable or as good as the original. The number and cause of instrument failure during clinical surveillance. RESULTS Between 40% and 93% of the instruments on each set were as good as the original and between 0% and 40% of the instruments were unacceptable from six sets of steel and one set of polymer instruments. 4151 procedures were monitored between 1 February 2003 and 31 March 2004 using a total of 41 376 instruments. Problems were reported with 335 (0.8%) instruments, 46% attributable to instrument design, 14% to poor design control and 13% to instruments escaping quality control systems. Following correction of the faults, between 1 January 2004 and 31 March 2004 the problem rate fell to 0.4%. CONCLUSIONS High quality single-use instruments for tonsil and adenoid surgery are available in the UK. Some companies offered inferior instruments not fit for their purpose. The procurement, introduction and subsequent clinical approval of single-use instruments requires a radically different approach to that currently applied to the purchase of reusable surgical equipment. Careful monitoring of their introduction is essential.
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Abstract
BACKGROUND There are currently no prostate cancer screening guidelines specific to the end-stage renal disease (ESRD) population. With this in mind, we evaluated the clinical usefulness of digital rectal examination (DRE), serum total prostate-specific antigen (PSA), prostate-specific antigen density (PSAD) and transrectal ultrasound (TRUS) in predicting prostate cancer in men with ESRD. METHODS Fifty male ESRD patients age 40 years and older with no prior history of prostate cancer were enrolled in the study. All patients underwent PSA measurement and a DRE followed by a TRUS. PSAD was calculated as the total PSA divided by the prostate volume. Ultrasound-guided prostate biopsies were performed on any patient with 1 or more of the following abnormal findings: a nodule detected on DRE; an abnormal TRUS; PSA > 4.0 ng/ml, or a PSAD > 0.15 ng/ml/cm3. RESULTS Abnormal findings were detected in 19 patients. Two (4%) had an abnormal DRE, 3 (6%) had PSA > 4.0 ng/ml, 3 (6%) had PSAD > 0.15 ng/ml/cm3 and 16 (32%) had abnormal findings on TRUS. Three patients had 2 abnormal findings and 1 had 3. Of the 15 prostate biopsies performed, 4 (27%) revealed prostate cancer and 3 (20%) high-grade prostatic intraepithelial neoplasm (HGPIN) comprising 8% and 6%, respectively, of the studied population. Of the 4 patients diagnosed with prostate cancer, none had abnormal DRE, 2 (50%) had PSA > 4.0 ng/ml (sensitivity = 66.7% and PPV = 50% (p = 0.236)), 3 (75%) had PSAD > 0.15 ng/ml/cm3 (sensitivity = 100% and PPV = 75% (p < 0.018)), and 3 (75%) had abnormal findings on TRUS (sensitivity = 30% and PPV = 75% (p = 1.000)). CONCLUSION Routine screening with PSA and DRE does not seem sensitive enough to predict the presence of the disease. Although TRUS detected abnormalities in 16 patients (32%), sensitivity was very low (30%). In our patients, PSAD increased the sensitivity and positive predictive value (PPV) of detecting prostate cancers compared to PSA alone.
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Delayed discharge. Must get out more often. THE HEALTH SERVICE JOURNAL 2004; 114:22-3. [PMID: 15357120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 04/30/2023]
Abstract
Delayed discharge fines increase pressure on trusts to prevent delays. The loss of vital information between health and social services undermines discharges' credibility. Pooled budgets between the two sectors are a powerful means of fostering innovation.
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A prospective, longitudinal study of central venous catheter-related deep venous thrombosis in boys with hemophilia. J Thromb Haemost 2004; 2:737-42. [PMID: 15099279 DOI: 10.1111/j.1538-7836.2004.00653.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Central venous catheters (CVCs) are often inserted into boys with hemophilia to secure venous access for factor prophylaxis and immune tolerance induction therapy. Complications associated with CVCs include catheter-related infections, local hemorrhage, and mechanical failure. Less frequently reported is CVC-related deep venous thrombosis (DVT). We conducted a prospective study to determine the frequency and outcome of this complication. METHODS All boys (n = 16) with congenital hemophilia A or B with a CVC in place who were registered in the pediatric comprehensive care program at the Hospital for Sick Children, Toronto, were included in the study. They were prospectively assessed by imaging studies and clinical examinations for CVC-related DVT at two time-points, 2 years apart. Each boy was evaluated for inherited hypercoagulability. RESULTS Eleven (69%) of the 16 boys had radiological evidence of DVT at the first evaluation and 13/16 (81%) at the second evaluation. In two boys there was improvement in the venogram findings at the second evaluation. None of the CVC-related DVTs completely resolved. Median age at the time of initial insertion of a CVC was 1.0 years (range 0.02-6.7 years). Median duration of CVC placement was 6.4 years (range 3.3-15.5 years). Only 4/13 boys with DVTs had clinical evidence of upper venous system obstruction. Only one boy, who did not develop a DVT, had a low protein C level. CONCLUSIONS CVC-related DVTs occur in the majority of boys with hemophilia who have CVCs inserted for a prolonged period of time. Annual screening with imaging is recommended for boys with CVCs in place for >/= 3 years. Consideration should be given to removing CVCs as soon as peripheral venous access is feasible.
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Rapid collaborative health impact assessment: a three-meeting process. Public Health 2004; 118:218-24. [PMID: 15003411 DOI: 10.1016/j.puhe.2003.08.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2003] [Revised: 06/13/2003] [Accepted: 08/01/2003] [Indexed: 11/17/2022]
Abstract
A three-meeting process for collaborative health (inequality) impact assessment [H(I)IA] of a proposed new road is described in which local residents worked with professionals to produce a jointly agreed evidence-based report. Collaborative H(I)IA provided a forum for people to express fears that they believed had been ignored, and for planners to understand the concerns of the community and the health impacts of developments on the most vulnerable. The report has been passed to those who will influence the future of the road development plan and a decision is awaited.
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Systematic review of the use and value of computer simulation modelling in population health and health care delivery. J Public Health (Oxf) 2004; 25:325-35. [PMID: 14747592 DOI: 10.1093/pubmed/fdg075] [Citation(s) in RCA: 352] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The objective of the review was to evaluate the extent, quality and value of computer simulation modelling in population health and health care delivery. METHODS A narrative systematic review was carried out of world literature from 1980 to 1999, searching Medline, INSPEC, Embase, HealthSTAR, Science Citation Index, CINAHL, MathSci, INFORMS Online and SIGLE databases, and researchers in the field were contacted. Papers were included if they contained a computer simulation model of individuals in a stochastic system and the topic or setting related to population health or health service delivery. RESULTS A total of 182 papers met the inclusion criteria. Simulation modelling has been undertaken in a wide range of health care topic areas, including hospital scheduling and organization, communicable disease, screening, costs of illness and economic evaluation. However, the quality of published papers was variable and few reported on the outcomes of implementation of models, so that the value of modelling could not be assessed. CONCLUSION Simulation modelling is a powerful method for modelling both small and large populations to inform policy makers in the provision of health care. It has been applied to a wide variety of health care problems. Although the number of modelling papers has grown substantially over recent years, further research is required to assess the value of modelling.
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Military psychiatry. West J Med 2002. [DOI: 10.1136/bmj.324.7348.s161a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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A career in military psychiatry? J ROY ARMY MED CORPS 2001; 147:339-42. [PMID: 11766219 DOI: 10.1136/jramc-147-03-15] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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