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Blood transfusions are among the most common therapeutic procedures performed in hospitalized patients. This study evaluates contemporary national trends in red blood cell (RBC), plasma, platelet, and cryoprecipitate transfusions. National Inpatient Sample, the largest all-payer inpatient database representing 94% to 97% of the US population, was evaluated from the fourth quarter (Q4) of 2015 through 2018. Quarterly trends for the percentage of hospitalizations with a transfusion procedure were separately examined for each blood product using log binomial regression and reported as quarterly percent change (QPC). The percentage of hospitalizations with an RBC transfusion decreased from 4.22% (2015Q4) to 3.79% (2018Q4) (QPC = −0.72; 95% confidence interval [CI], −1.26 to −0.19; Ptrend = .008). Although plasma transfusions also decreased, QPC = −1.33 (95% CI, −2.00 to −0.65; Ptrend < .001), platelet transfusions remained stable QPC = −0.13 (95% CI, −0.99 to 0.73; Ptrend = .766). In contrast, hospitalizations with cryoprecipitate utilization significantly increased QPC = 2.01 (95% CI, 0.57 to 3.44; Ptrend = .006). Significant quarterly reductions in RBC transfusions were also seen among many, but not all, strata of sex, race/ethnicity, patient risk severity, and admission type (elective vs nonelective). Despite significant declines in RBC transfusions among older adults, there were no significant changes among pediatric age-group (<18 years) and those 18 to 49 years. The decline in RBC and plasma transfusions suggests steady incorporation of robust evidence base showing safety of restrictive transfusions. Increased cryoprecipitate use may be reflective of wider adoption of hypofibrinogenemia management and hemostasis testing for coagulopathic patients.

Blood transfusions are among the most common therapeutic procedures performed in hospitalized patients. This study evaluates contemporary national trends in red blood cell (RBC), plasma, platelet, and cryoprecipitate transfusions. National Inpatient Sample, the largest all-payer inpatient database representing 94% to 97% of the US population, was evaluated from the fourth quarter (Q4) of 2015 through 2018. Quarterly trends for the percentage of hospitalizations with a transfusion procedure were separately examined for each blood product using log binomial regression and reported as quarterly percent change (QPC). The percentage of hospitalizations with an RBC transfusion decreased from 4.22% (2015Q4) to 3.79% (2018Q4) (QPC = −0.72; 95% confidence interval [CI], −1.26 to −0.19; Ptrend= .008). Although plasma transfusions also decreased, QPC = −1.33 (95% CI, −2.00 to −0.65; Ptrend< .001), platelet transfusions remained stable QPC = −0.13 (95% CI, −0.99 to 0.73; Ptrend= .766). In contrast, hospitalizations with cryoprecipitate utilization significantly increased QPC = 2.01 (95% CI, 0.57 to 3.44; Ptrend= .006). Significant quarterly reductions in RBC transfusions were also seen among many, but not all, strata of sex, race/ethnicity, patient risk severity, and admission type (elective vs nonelective). Despite significant declines in RBC transfusions among older adults, there were no significant changes among pediatric age-group (<18 years) and those 18 to 49 years. The decline in RBC and plasma transfusions suggests steady incorporation of robust evidence base showing safety of restrictive transfusions. Increased cryoprecipitate use may be reflective of wider adoption of hypofibrinogenemia management and hemostasis testing for coagulopathic patients.

Results of DNA mismatch repair testing are used to detect Lynch syndrome and have prognostic and therapeutic implications among patients with sporadic colorectal carcinomas. Immunohistochemistry for mismatch repair proteins (MLH1, PMS2, MSH2, MSH6) and PCR for microsatellite instability are two established methods for assessing mismatch repair function. Older literature suggested a discordance rate of approximately 5% between these assays, leading some institutions to perform dual testing on all cases. Although universal mismatch repair testing is now recommended by multiple professional organizations, none provide guidelines regarding preferred assays. We surveyed 96 academic and nonacademic institutions to assess Lynch syndrome screening practices and evaluated discordance rates between immunohistochemistry and PCR among 809 colorectal cancers tested in our own institution. Our survey demonstrated no significant differences between academic and nonacademic practices with respect to testing strategies. Eighty six percent performed universal screening, and usually (76%) employed immunohistochemistry on initial biopsy samples. Only 20% employed PCR; these were mostly academic practices that used both immunohistochemistry and PCR (p< 0.01 compared with the nonacademic groups). Loss of MLH1/PMS2 staining was often (90%) followed by either BRAFmutational analysis or MLH1methylation assays. Only 24% adhered to WHO recommendations to assign histologic grade based on mismatch repair status. We found only 3 cases (0.4%) with discordant immunohistochemistry and PCR results in our own practice: 1 reflected decreased MSH-6 staining in a neoadjuvantly treated microsatellite stable tumor, 1 MLH1-deficient tumor showed diminished MLH1/PMS2 in the tumor compared with internal control, and 1 case reflected an error in the molecular laboratory. Overall, our results showed extremely low discordance between methods assessing mismatch repair status and would suggest immunohistochemistry as the preferred single screening test. PCR can be reserved for cases that show equivocal immunostaining patterns.

Results of DNA mismatch repair testing are used to detect Lynch syndrome and have prognostic and therapeutic implications among patients with sporadic colorectal carcinomas. Immunohistochemistry for mismatch repair proteins (MLH1, PMS2, MSH2, MSH6) and PCR for microsatellite instability are two established methods for assessing mismatch repair function. Older literature suggested a discordance rate of approximately 5% between these assays, leading some institutions to perform dual testing on all cases. Although universal mismatch repair testing is now recommended by multiple professional organizations, none provide guidelines regarding preferred assays. We surveyed 96 academic and nonacademic institutions to assess Lynch syndrome screening practices and evaluated discordance rates between immunohistochemistry and PCR among 809 colorectal cancers tested in our own institution. Our survey demonstrated no significant differences between academic and nonacademic practices with respect to testing strategies. Eighty six percent performed universal screening, and usually (76%) employed immunohistochemistry on initial biopsy samples. Only 20% employed PCR; these were mostly academic practices that used both immunohistochemistry and PCR (p< 0.01 compared with the nonacademic groups). Loss of MLH1/PMS2 staining was often (90%) followed by either BRAFmutational analysis or MLH1methylation assays. Only 24% adhered to WHO recommendations to assign histologic grade based on mismatch repair status. We found only 3 cases (0.4%) with discordant immunohistochemistry and PCR results in our own practice: 1 reflected decreased MSH-6 staining in a neoadjuvantly treated microsatellite stable tumor, 1 MLH1-deficient tumor showed diminished MLH1/PMS2 in the tumor compared with internal control, and 1 case reflected an error in the molecular laboratory. Overall, our results showed extremely low discordance between methods assessing mismatch repair status and would suggest immunohistochemistry as the preferred single screening test. PCR can be reserved for cases that show equivocal immunostaining patterns.

Firearm injury (FI) is the leading cause of death in children and adolescents in the United States (US). We describe the epidemiology of pediatric FI-associated emergency department (ED) visits and hospitalizations in the US stratified by race and ethnicity.

There is little formal guidance to direct neonatal blood banking practices and, as a result, practices vary widely across institutions. In this vulnerable patient population with a high transfusion burden, considerations for blood product selection include freshness, extended-storage media, pathogen inactivation, and other modifications. The authors discuss the potential unintended adverse impacts in the neonatal recipient. Concerns such as immunodeficiency, donor exposures, cytomegalovirus transmission, volume overload, transfusion-associated hyperkalemia, and passive hemolysis from ABO incompatibility have driven modifications of blood components to improve safety.

A hand method of estimating the period of free vibration of building structures, for use in determining the minimum base shear for their earthquake design, is presented. The method is for structures that have uniform properties through their height, and that are symmetrical in plan and symmetrically loaded so that they do not twist. The structures may consist of rigid frames, coupled walls, wallframes and braced frames, or any combination of these. The basis of the method is that all of the above described types of bent behave as members of a family of shearflexure structures whose static deflections can be predicted by coupled wall theory. A method of decoupling the static deflection into a flexural component and a shear plus flexure wallframe type of component is extended to dynamic behavior of a corresponding decoupled eigenvalue approach, to determine the periods of free vibration. The derivation of the method, an assessment of its accuracy, and a worked example to illustrate its application are presented.

Background:Among patients with psychiatric disorders, there are 10 times as many preventable deaths from physical disorders as there are from suicide. We investigated whether compulsory community treatment, such as community treatment orders, could reduce all-cause mortality among patients with psychiatric disorders.Methods:We conducted a population-based survival analysis of an inception cohort using record linking. The study period extended from November 1997 to December 2008. The cohort included patients from all community-based and inpatient psychiatric services in Western Australia (state population 1.8 million). We used a 2-stage design of matching and Cox regression to adjust for demographic characteristics, previous use of health services, diagnosis and length of psychiatric history. We collected data on successive cohorts for each year for which community treatment orders were used to measure changes in numbers of patients, their characteristics and outcomes. Our primary outcome was 2-year all-cause mortality. Our secondary outcomes were 1-and 3-year all-cause mortality.Results:The study population included 2958 patients with community treatment orders (cases) and 2958 matched controls (i.e., patients with psychiatric disorders who had not received a community treatment order). The average age for cases and controls was 36.7 years, and 63.7% (3771) of participants were men. Schizophrenia and other nonaffective psychoses were the most common diagnoses (73.4%) among participants. A total of 492 patients (8.3%) died during the study. Cox regression showed that, compared with controls, patients with community treatment orders had significantly lower all-cause mortality at 1, 2 and 3 years, with an adjusted hazard ratio of 0.62 (95% confidence interval 0.45–0.86) at 2 years. The greatest effect was on death from physical illnesses such as cancer, cardiovascular disease or diseases of the central nervous system. This association disappeared when we adjusted for increased outpatient and community contacts with psychiatric services.Interpretation:Community treatment orders might reduce mortality among patients with psychiatric disorders. This may be partly explained by increased contact with health services in the community. However, the effects of uncontrolled confounders cannot be excluded.

There is accumulating correlational evidence that the effect of specific types of reading instruction depends on children's initial language and literacy skills, called child characteristics × instruction (C×I) interactions. There is, however, no experimental evidence beyond first grade. This randomized control study examined whether C×I interactions might present an underlying and predictable mechanism for explaining individual differences in how students respond to third‐grade classroom literacy instruction. To this end, we designed and tested an instructional intervention (Individualizing Student Instruction [ISI]). Teachers (n = 33) and their students (n = 448) were randomly assigned to the ISI intervention or a vocabulary intervention, which was not individualized. Teachers in both conditions received professional development. Videotaped classroom observations conducted in the fall, winter, and spring documented the instruction that each student in the classroom received. Teachers in the ISI group were more likely to provide differentiated literacy instruction that considered C×I interactions than were the teachers in the vocabulary group. Students in the ISI intervention made greater gains on a standardized assessment of reading comprehension than did students in the vocabulary intervention. Results indicate that C×I interactions likely contribute to students' varying response to literacy instruction with regard to their reading comprehension achievement and that the association between students' profile of language and literacy skills and recommended instruction is nonlinear and dependent on a number of factors. Hence, dynamic and complex theories about classroom instruction and environment impacts on student learning appear to be warranted and should inform more effective literacy instruction in third grade. هناك أدلة مترابطة ومتراكمة تدل على أن آثار أنواع معينة من تعليمات القراءة تعتمد على مهارات الطفل الأولى في القراءة والكتابة واللغة، وتسمى تفاعلات تعليمات خصائص الطفل (CXI). ومع ذلك، فلا يوجد أي دليل تجريبي بعد الفصل الدراسي الأول. فحصت هذه الدراسة الاختبارية العشوائية فيما إذا كان يمكن لتفاعلات CXI أن تقدم ميكانيزمات خفية, ويمكن التنبؤ بها من أجل شرح الفروق الفردية في كيفية استجابة الطلاب لتعليمات القراءة والكتابة في الفصل الدراسي الثالث من التعليم الإبتدائي. وتحقيقا لهذه الغاية، تم تصميم واختبار تدخل تعليمي ( إضفاء الطابع الشخصي على تعليم الطلاب:ISI) . تم اختيار المدرسين (عددهم 33) وطلابهم (عددهم 488) بشكل عشوائي لتدخل ISI، أو تدخل للمفردات التي لم تكن فردية. تلقى المدرسون في كلتي الحالتين تدريبا مهنيا. و سجلت ملاحظات الفصل الدراسي على أشرط الفيديو التعليمات التي حصل عليها كل تلميذ في الصف في فصل الخريف والشتاء والربيع. كان المدرسون في مجموعة ISI أكثر احتمالا لإعطاء تعليمات متمايزة في القراءة والكتابة. واعتبرت تدخلات المدرسين في CXI أكثر من تدخلات نظرائهم في مجموعة المفردات. حقق التلاميذ في تدخل ISI مكاسب أكبر في تقييم موحَد لفهم القراءة على تلاميذ تدخل المفردات. تشير النتائج أن تفاعلات CXI تسهم في استجابة متفاوتة للطلاب لتعليمات القراءة والكتابة فيما يتعلق بإنجازهم في فهم القراءة، وأن الربط بين ملف التلميذ الشخصي بالنسبة لمهارات اللغة والقراءة والكتابة والتعليمات الموصى بها غيرُ خطية ومنوطةٌ بعدد من العوامل. لذلك يبدو أن النظريات الديناميكية والمعقدة حول وقع تأثير التعليم والبيئة في الفصل الدراسي على تعلم التلميذ لها ما يبررها وبإمكانها الإبلاغ عن تعليم أكثر فعالية بالنسبة للقراءة والكتابة في الصف الثالث من التعليم الابتدائي. 特定类型的阅读教学效果取决于儿童的初始语言和识字技能，这种称为「孩子特征X教学类型」(简称CXI)交互作用的相关式证据，正在累积。然而，到目前为止，这些实验证据只局限于小学一年级。本随机对照研究，考查CXI交互作用，是否能作为一个基础性和可预测性的机制，以解释小学三年级学生如何应对课堂读书识字教学的个别差异。为此，作者设计并测试一个名为「ISI学生个性化教学」的教学干预。教师(n=33)和他们的学生(n=488)，一同被随机分配到ISI干预组或不个性化的词汇干预组。该两组的教师均接受专业发展。课堂录像观察分别在秋、冬、春季进行，记录每个学生在教室里接受特定教学的情况。ISI组中的老师比词汇组中的教师，会较大可能提供差异化读书识字教学，提供这些差异化教学就是顾及到CXI交互作用。在一个标准化阅读理解评估中，ISI干预组的学生比词汇干预组的学生获益较大。研究结果表示，在阅读理解成绩方面，学生对识字教学的应对有个别差异的原因，有可能就是因为CXI交互作用；同时，儿童的语言及识字技能状况与所推荐的教学类型之间的关联，是非线性及取决于很多因素。因此，用动态性和复杂性的理论去解释课堂教学与环境如何影响学生的学习，似乎是恰当的，对寻求更有效的小学三年级读书识字教学，是具有启迪意义的。 Il y a de plus en plus de corrélations montrant que l'effet d'un type spécifique d'enseignement de la lecture dépend des compétences linguistiques initiales des enfants et de leur savoir lire‐écrire, ce que l'on appellera interactions entre caractéristiques des enfants et enseignement (CXE). Il n'y a cependant pas de preuves au‐delà de la premiíre année. Cette étude, avec groupe contrôle et randomisation, a examiné si les interactions CXE pourraient présenter un mécanisme sous‐jacent prédictible qui pourrait expliquer les différences individuelles concernant la façon dont les élíves répondent à l'enseignement de la lecture‐écriture en troisiíme année. C'est dans ce but que nous avons planifié et testé une intervention didactique (Intervention Didactique Individualisée, IDI). Des enseignants (n=33) et leurs élíves (n=488) ont été assignés au hasard à l'intervention individualisée IDI ou à une intervention non individualisée sur le vocabulaire. Les enseignants dans les deux conditions ont reçu une formation. Des observations vidéoscopées effectuées en classe à l'automne, en hiver et au printemps, ont apporté des informations sur l'enseignement reçu par chaque élíve en classe. Les enseignants du groupe IDI se sont avérés plus susceptibles de réaliser un enseignement individualisé de la lecture‐écriture avec des interactions CXE que les enseignants du groupe vocabulaire. Les élíves de l'intervention IDI ont obtenu de meilleurs résultats dans une évaluation de compréhension de la lecture que les élíves de la condition vocabulaire. Les résultats montrent que les interactions CXE sont susceptibles de contribuer à l'évolution des réponses en fonction de l'enseignement de la lecture‐écriture en ce qui concerne leur réussite en compréhension de la lecture, et que l'association entre le profil linguistique et les compétences en lecture‐écriture et l'enseignement recommandé n'est pas linéaire et dépend de nombreux facteurs. Par conséquent, les théories dynamiques et complexes sur l'enseignement en classe et les impacts de l'environnement sur l'apprentissage de l'élíve semblent être établies et devraient contribuer à un enseignement de la lecture‐écriture en troisiíme année plus efficace. Постепенно накапливаются доказательства взаимосвязи между эффективностью определенных подходов к обучению чтению и теми навыками общения с языком, которые заложены у ребенка к началу обучения. Данная корреляция называется CхI (характеристики ребенка умноженные на обучение). Однако экспериментальные подтверждения этой идеи имеются лишь для первоклассников. В данном исследовании рассматривалась возможность применения этой формулы в третьем классе, чтобы достоверно предсказать и обосновать результаты обучения чтению для каждого отдельного ребенка. Авторы разработали и применили индивидуализированное учебное вмешательство (ISI). Учителя (n=33) и их ученики (n=488) были по случайному принципу подвергнуты либо ISI, либо обучению на основе неиндивидуализированной работы по расширению словарного запаса. Учителя в обеих ситуациях получали дополнительную профессиональную поддержку. Трижды в течение учебного года – осенью, зимой и весной – проводилась видеосъемка, которая фиксировала, какое обучение получает каждый ребенок. Выяснилось, что учителя в группе ISI в большей степени склонны к дифференцированному обучению грамотности, которое учитывает CхI, нежели учителя из “словарной” группы. Учащиеся в группе ISI набрали более высокие баллы в рамках стандартизированного тестирования на понимание прочитанного, чем их сверстники из “словарной” группы. Результаты показывают, что CхI, по всей вероятности, влияют на способность ребенка воспринять обучение, нацеленное на понимание прочитанного, и что взаимосвязь между профилем грамотности ребенка и рекомендуемым обучением является нелинейной и зависит от целого ряда факторов. Из этого и следует исходить, чтобы добиться более эффективного обучения третьеклассников. Hay cada vez más evidencia correlativa que el efecto de ciertas formas de enseñar a leer depende de la destreza inicial de lenguaje y alfabetización de los niños, llamadas interacciones de características X de instrucción del niño (CXI por sus siglas en inglés). Sin embargo no hay ninguna evidencia experimental más allá del primer grado. Este estudio aleatorio controlado investigó si las interacciones CXI podrían presentar algún mecanismo subyacente y previsible para explicar las diferencias individuales sobre cómo los estudiantes de tercer grado reaccionan a la alfabetización. Para lograr esto, diseñamos y verificamos una intervención de enseñanza (Enseñanza Individualizada al Estudiante, ISI por sus siglas en inglés). Los maestros (n=33) y sus estudiantes (n=488) fueron escogidos al azar para la intervención ISI o una intervención de vocabulario que no era individualizada. Los maestros en ambos grupos recibieron adiestramiento profesional. Las observaciones grabadas en video en el otoño, el invierno y la primavera documentaron la instrucción recibida por cada estudiante en el salón de clase. Los maestros en el grupo de ISI estaban más dispuestos a usar la instrucción diferenciada de alfabetización que tomaba en cuenta las interacciones CXI que los maestros del grupo de vocabulario. Los estudiantes de la intervención ISI lograron hacer mejor en un examen estandardizado de comprensión de lectura que los estudiantes del grupo de vocabulario. Los resultados muestran que las interacciones CXI probablemente contribuyen a la reacción de los estudiantes a la instrucción en cuanto a la comprensión de lectura, y que la relación entre el cuadro de destrezas de lenguaje y alfabetización de los niños y la instrucción recomendada no es lineal y depende de varios factores. Por lo tanto, teorías dinámicas y complejas sobre la instrucción en el salón de clase y el efecto del medio ambiente en el aprendizaje del estudiante parecen ser justificadas y deben ser tomadas en cuenta para la mejor instrucción en el tercer grado.

ObjectiveTo measure the effectiveness of the quadrivalent human papillomavirus (HPV) vaccine against cervical abnormalities four years after implementation of a nationally funded vaccination programme in Queensland, Australia.DesignCase-control analysis of linked administrative health datasets.SettingQueensland, Australia.ParticipantsWomen eligible for free vaccination (aged 12-26 years in 2007) and attending for their first cervical smear test between April 2007 and March 2011. High grade cases were women with histologically confirmed high grade cervical abnormalities (n=1062) and “other cases” were women with any other abnormality at cytology or histology (n=10 887). Controls were women with normal cytology (n=96 404).Main outcome measuresExposure odds ratio (ratio of odds of antecedent vaccination (one, two, or three vaccine doses compared with no doses) among cases compared with controls), vaccine effectiveness ((1−adjusted odds ratio)×100), and number needed to vaccinate to prevent one cervical abnormality at first screening round. We stratified by four age groups adjusted for follow-up time, year of birth, and measures of socioeconomic status and remoteness. The primary analysis concerned women whose first ever smear test defined their status as a case or a control.ResultsThe adjusted odds ratio for exposure to three doses of HPV vaccine compared with no vaccine was 0.54 (95% confidence interval 0.43 to 0.67) for high grade cases and 0.66 (0.62 to 0.70) for other cases compared with controls with normal cytology, equating to vaccine effectiveness of 46% and 34%, respectively. The adjusted numbers needed to vaccinate were 125 (95% confidence interval 97 to 174) and 22 (19 to 25), respectively. The adjusted exposure odds ratios for two vaccine doses were 0.79 (95% confidence interval 0.64 to 0.98) for high grade cases and 0.79 (0.74 to 0.85) for other cases, equating to vaccine effectiveness of 21%.ConclusionThe quadrivalent HPV vaccine conferred statistically significant protection against cervical abnormalities in young women who had not started screening before the implementation of the vaccination programme in Queensland, Australia.