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Objective Serum protein concentrations are diagnostically and prognostically valuable in cancer and other diseases, but their measurement via blood test is uncomfortable, inconvenient, and costly. This study investigates the possibility of predicting albumin, globulin, and albumin-globulin ratio from easily accessible physical characteristics (height, weight, Body Mass Index, age, gender) and vital signs (systolic blood pressure, diastolic blood pressure, mean arterial pressure, pulse pressure, pulse) using advanced machine learning techniques. Methods We obtained albumin concentration, globulin concentration, albumin-globulin ratio and predictor information (physical characteristics, vital signs) from physical exam records of 46,951 healthy adult participants in Hangzhou, China. We trained a computational model to predict each serum protein concentration from the predictors and then evaluated the predictive accuracy of each model on an independent portion of the dataset that was not used in model training. We also determined the relative importance of each feature within the model. Results Prediction accuracies were r=0.540 (95% CI: 0.539-0.540; Pearson r) for albumin, r=0.250 (95% CI: 0.249-0.251) for globulin, and r=0.373 (95% CI: 0.372-0.374) for albumin-globulin ratio. The most important predictive features were age (100% ± 0.0%; mean ± 95% CI of normalized importance), gender (34.4% ± 0.7%), pulse (25.6% ± 1.3%) and Body Mass Index (24.4% ± 2.3%) for albumin, pulse (83.7% ± 3.8%) for globulin, and age (99.2% ± 1.0%), gender (59.2% ± 1.7%), Body Mass Index (46.1% ± 4.2%) and height (40.0% ± 3.8%) for albumin-globulin ratio. Conclusions Our models predicted serum protein concentrations with appreciable accuracy showing the promise of this approach. Such models could serve to augment existing tools for identifying "at-risk" individuals for follow-up with a blood test.

Anecdotally accepted practice for evaluation of children with clinically suspected or radiographically proven wrist fracture in many urgent care and primary care settings is concurrent imaging of the forearm and elbow, despite the lack of evidence to support additional images. These additional radiographs may be an unnecessary source of radiation and use of health care resources. Our study assesses the necessity of additional radiographs of the forearm and elbow in children with wrist injury. We reviewed electronic medical records of children 17 and younger in whom wrist fracture was diagnosed in the emergency department. We identified the frequency with which additional radiographs of the proximal forearm and distal humerus demonstrated another site of acute injury. We identified 214 children with wrist fracture. Of those, 129 received additional radiographs of the elbow. Physical examination findings proximal to the wrist were documented in only 16 (12%) of these 129 children. A second injury proximal to the wrist fracture was present in 4 (3%) of these 129 children, all of whom exhibited physical examination findings at the elbow. No fractures were documented in children with a negative physical examination of the elbow. Although elbow fractures occasionally complicate distal forearm fractures in children, our findings indicate that a careful physical evaluation of the elbow is sufficient to guide further radiographic investigation. Routine radiographs of both the wrist and elbow in children with distal forearm fracture appear to be unnecessary when an appropriate physical examination is performed.

OBJECTIVE In young people, traumatic head and brain injuries are the leading cause of morbidity and mortality. In some cases, no neurological deficits are present, even after penetrating trauma. These patients have a greater risk of suffering from secondary injuries due to secondary infections, brain edema, and hematomas. We present a case report which illustrates that brain injuries that do not induce neurological deficits can still result in a fatal clinical course and death, with medicolegal consequences. CLINICAL PRESENTATION A 19-year-old patient was admitted to hospital suffering from a head injury due to an assault. He reported that he was attacked from behind. Medical examination showed no neurological deficits, and only a small occipital wound. Neuroimaging of the cranium revealed that a knife blade was penetrating the cranial bone and touching the superior sagittal sinus. INTERVENTION After removing the foreign body, magnetic resonance imaging showed that the superior sagittal sinus remained open. CONCLUSION We want to stress that possible problems can arise due to the retention of objects in the cranium, while also highlighting the risk of superficial clinical examination.

PurposeThe purpose of this paper is to propose a systematic approach to measuring, tracking, monitoring and continuously improving efficiency, availability and quality in healthcare operational settings.Design/methodology/approachThe proposed measure of healthcare operational effectiveness (HOE) consists of three indicators. They include an availability indicator, an quality indicator, and an efficiency indicator. The proposed approach tends to facilitate the systematic improvement at the different facets of operational effectiveness.FindingsThe proposed operational performance approach based on the HOE is consistent with the themes of performance measures and measurement reported in the literature.Research limitations/implicationsThe proposed healthcare operational effectiveness approach represents a serious attempt at quantifying the key facets of service effectiveness in healthcare operational settings. The validation of this performance assessment and measurement approach is worthy of future research.Practical implicationsThe approach advocated by the HOE has operational and strategic relevance to decision makers of healthcare organizations.Originality/valueThis paper presents a practical, systematic approach toward enhancing operational effectiveness in healthcare organizations. Relevant implementation issues associated with the proposed approach are also addressed.

El dispositivo de cierre arterial StarClose (Abbott Vascular, Redwood City, CA) utiliza un clip de nitinol extraluminal para establecer la hemostasia. El objetivo de este estudio fue determinar la seguridad y la eficacia de StarClose a partir de un registro prospectivo de arteriopatia periferica (AP). A lo largo de un periodo de 18 meses se utilizaron 500 dispositivos StarClose en 378 pacientes consecutivos con AP sintomatica tras la intervencion endovascular diagnostica y/o terapeutica. Se analizaron las caracteristicas demograficas de los pacientes junto con criterios objetivos derivados del examen con eco-Doppler, la velocidad del flujo de la arteria femoral comun y el indice tobillo-brazo (ITB) obtenidos antes y despues de la colocacion del dispositivo StarClose. Todos los pacientes ambulatorios recibieron un tratamiento preventivo con antibiotico (una dosis), heparina perioperatoria (sin reversion con protamina) y tratamiento antiagregante plaquetario. Se administro acido acetilsalicilico y clopidogrel (Plavix) a todos los pacientes sometidos a intervencion terapeutica. Trescientos setenta y ocho pacientes fueron sometidos a intervenciones por una AP aortoiliaca o infrainguinal, 99 de las cuales fueron bilaterales. De los 500 cierres de abordaje arterial realizados, en 296 casos se trato de intervenciones terapeuticas con introductores de 6 a 8F en la arteria femoral comun. Los estudios diagnosticos (n = 204 abordajes arteriales) se realizaron a traves de un introductor 5F. Se consiguio con exito tecnico la hemostasia en el 97,2%; unicamente 14 dispositivos presentaron un problema de sangrado persistente en el que fue necesario prolongar la compresion manual prolongada. La mediana de la duracion de la hospitalizacion en los pacientes ambulatorios fue de 157 min. Once de los 260 seguimientos con eco-Doppler (4,2%) presentaron un aumento del doble de la velocidad sistolica maxima, siendo asintomatico solamente uno de ellos. El seguimiento tardio mostro una reduccion del ITB > 0,10 en 42 de 360 (11,7%) cierres. Se identificaron 9 complicaciones mayores (2,0%) durante el seguimiento. El dispositivo de cierre StarClose tiene una tasa de complicaciones mayores baja, y es seguro y eficaz en pacientes con AP, aunque puede producirse una estenosis en el lugar del abordaje arterial. El dispositivo consiguio una rapida hemostasia sin necesidad de reversion de la anticoagulacion y precisa, de forma significativa, menos tiempo de reposo para la deambulacion que la compresion manual.

The StarClose (Abbott Vascular, Redwood City, CA) arterial closure device utilizes an extraluminal nitinol clip to establish hemostasis. The purpose of this study was to determine the safety and efficacy of StarClose from a prospective peripheral arterial disease (PAD) registry. Over an 18-month time interval, 500 StarClose devices were used in 378 consecutive patients with symptomatic PAD after diagnostic and/or therapeutic endovascular cases. Patient demographics along with objective criteria including duplex ultrasound images, common femoral artery flow velocities, and ankle-brachial indexes (ABIs) were analyzed before and after StarClose placement. All outpatients received prophylactic antibiotic (one dose), periprocedural heparin (without protamine reversal), and antiplatelet therapy. Aspirin and clopidogrel (Plavix) was used for all patients undergoing therapeutic intervention. There were 378 patients who underwent procedures for aortoiliac or infrainguinal PAD, 99 of which were bilateral. Of the 500 arteriotomy closures, 296 were therapeutic interventions with sheath sizes of 6-8 F in the common femoral artery. The diagnostic studies (n = 204 arteriotomies) were performed with a 5F sheath. The technical success in achieving hemostasis was 97.2%; only 14 devices had a deployment problem requiring prolonged manual compression. Median length of stay was 157 min for patients done on an outpatient basis. Eleven of 260 (4.2%) on duplex follow-up had a doubling of the peak systolic velocity, only one of which was symptomatic. Late follow-up showed 42 of 360 (11.7%) with a drop in ABI >0.10. Nine major complications (2.0%) were identified in follow-up. The StarClose closure device has a low major complication rate and is safe and efficacious in patients with PAD, although stenosis at the arteriotomy site may occur. The device has achieved rapid hemostasis without need for anticoagulant reversal and requires significantly less time to ambulation than manual compression.

Le dispositif de fermeture arterielle StarClose (Abbott Vascular, Redwood City, CA, Etats-Unis) utilise un clip hemostatique extraluminal en nitinol. L'objectif de cette etude etait de determiner l'efficacite et la surete du dispositif StarClose a partir d'un registre de patients porteurs d'une arteriopathie obliterante des membres inferieurs (AOMI). Au cours d'une periode de 18 mois, 500 dispositifs StarClose ont ete mis en place chez 378 patients ayant une AOMI symptomatique apres arteriographie diagnostique ou traitement endovasculaire. Les caracteristiques demographiques des patients, les echo-doppler, les vitesses des flux Doppler au niveau des arteres femorales communes (AFC) et les index des pressions cheville-bras (IPS) ont ete analyses avant et apres mise en place du StarClose. Tous les patients ont recu une antibioprophylaxie (dose unique), une injection d'heparine pendant la procedure (sans neutralisation a la protamine), et un traitement antiaggregant plaquettaire. L'aspirine et le clopidogrel (Plavix) ont ete utilises chez tous les patients ayant eu une procedure a videe therapeutique. 378 patients ont beneficie d'une intervention pour arteriopathies aorto-iliaques ou sous-inguinales, dont 99 etaient bilaterales. Parmi les 500 fermetures d'arteriotomies, 296 etaient des interventions therapeutiques avec des tailles d'introducteurs dans l'AFC comprises entre 6 et 8 F. Les procedures diagnostiques (n = 204 arteriotomies) ont ete realisees avec un introducteur de 5F. L'hemostase a ete satisfaisante dans 97,2% des cas. Un echec de deploiement du dispositif est survenu dans 14 cas, exigeant une compression manuelle prolongee. La duree mediane de sejour en ambulatoire etait de 157 minutes. 11/ 260 (4,2%) patients ont presente un doublement du pic de vitesse systolique sur le doppler de controle, entrainant des symptomes dans un cas seulement. Le suivi a long terme a montre une baisse de l'IPS > 0,10 chez 42/ 360 (11,7%) patients. Neuf complications majeures (2,0%) sont survenues durant le suivi. Le dispositif de fermeture StarClose s'accompagne d'un taux de complications majeures peu eleve. Il est fiable et efficace chez les patients presentant une AOMI, bien qu'une stenose au niveau de l'arteriotomie puisse survenir. Le dispositif a permis de realiser une hemostase rapide sans arret des anticoagulants et a diminue de maniere significative le temps d'hospitalisation ambulatoire par rapport a la compression manuelle.