ارائه یک الگو برای سیستم ملی طبقه بندی اقدامات پزشکی ایران

مقدمه:مدیران اطلاعات بهداشتی، اطلاعات مربوط به مراقبت و درمان را بر اساس سیستم های طبقه بندی اقدامات پزشکی طبقه بندی نموده و براساس اطلاعات طبقه بندی شده گزارشات آماری را تهیه و تحلیل می نمایند . امروزه مراقبت بهداشتی با کیفیت مطلوب بدون وجود یک سیستم طبقه بندی اقدامات پزشکی کامل و کارآمد امکانپذیر نخواهد بود . با استفادهد از این سیستم نتایج عملیات مراقبت در پرونده بیمار به صورت کدهای استاندارد ثبت می شود . این کدها اساس تحلیل اطلاعات برای پرسنل درمانی ، پژوهشگران ، سیاستگذاران و برنامه ریزان بهداشتی است. با توجه به اینکه در حال حاضر در کشور ما یک سیتم طبقه بندی اقدامات که بتواند نیازهای کدگذاران را برآورده کند وجود ندارد، ضرورت ارائه یک الگو مناسب احساس گردیده است. روش بررسی : این تحقیق به صورت یک مطالعه مقطعی ـ مقایسه ای در سال های 82-1381 به منظور ارائه یک الگوی مناسب برای سیستم ملی طبقه بندی اقداماتی پزشکی کشورمان انجام شده است . ابزار گردآوری داده های این پژوهش کتاب ها ، نشریات ، پایان نامه های موجود در کتابخانه ، اینترنت و پست الکترونیکی بوده است . در این پژوهش با مطالعه سیر پیدایش و تکامل ، ساختار ، سازمان ایجادکننده ، مزایا و محدودیت ها و استانداردهای به کار رفته در طراحی سیستم های طبقه بندی اقدامات به زبان انگلیسی و یک الگو برای سیستم ملی طبقه بندی اقدامات پزشکی کشورمان پیشنهاد شد. الگوی پیشنهادی طی دو مرحله به روش دلفی آزمون شده است . سرانجام پس از تحلیل نتایج آزمون ، الگویی مناسب برای سیستم ملی طبقه بندی اقدامات کشورمان ارائه گردیده است . یافته ها : نتایج مطالعه سیستم های ملی طبقه بندی اقدامات نگاشته شده به زبان انگلیسی همراه سیستم های موجود در کشورمان به طور مقایسه ای آورده شده است . همچنین الگوی نهایی در پنج محور اصلی به طور مبسوط تشریح گردیده است. به طور خلاصه می توان چند محوری بودن ، امکان گسترش سیستم بدون تغییر در ساختار آن ، وسعت بیشتر ، در نظر گرفتن راهنمای فارسی کدگذاری اقدامات ، وجود توصیف گرهای مورد نیاز ، استاندارد بودن و تنظیم فصول بر اساس نوع اقدام یا مداخله از مزیت های الگوی ارائه شده در مقایسه با سیستم های اقدامات موجود کشور دانست : نتیجه گیری : الگوی ارائه شده برای سیتسم ملی طبقه بندی اقدامات کشورمان در مقایسه با سیستم ملی طبقه بندی کشورهای انگلیسی زبان بیانگر آن است که این الگو بیشتر منطبق بر سیستم ملی طبقه بندی اقدامات کشورهای اروپای شمالی است. به دلیل نوپا بودن سیستم ملی طبقه بندی اقدامات پزشکی کشورمان و امکان نادیده گرفتن برخی اقدامات ، کدهایی برای موارد طبقه بندی نشده پیش بینی گردید

Bad research is not all bad

In this commentary, we discuss a recent article in Trials that raised concerns about the number of poorly performed randomised trials in the medical literature and discuss the trials literature more widely. Although we all aim for higher methodological standards in trials, we argue that (i) the idea that ‘most randomised trials are bad’, which the recent article concludes is an overly simplistic representation of the situation, and (ii) the suggestion that an increased focus on methodological review during trial development (e.g. ethical boards performing some assessment of the methodologists on a trial), while well meaning, may have negative unintended consequences. We therefore propose that (a) trials should be assessed on their merits and weaknesses, including an assessment of risk of bias but placing that in a wider context; (b) we should recognise that although the methodological conduct of trials is of utmost importance, interventions that aim to improve this could have unintended consequences—such as bureaucracy—that have an overall negative effect; and (c) we should therefore generate an evidence base for policy interventions to improve conduct of trials rather than applying arbitrary rules.</p

The value of MALDI-TOF failure to provide an identification of Staphylococcal species direct from blood cultures and rule out Staphylococcus aureus bacteraemia:a post-hoc analysis of the RAPIDO trial

INTRODUCTION: Rapid differentiation between Staphylococcus aureus (SA) and coagulase-negative staphylococci (CoNS) is critical in clinical infection. Direct matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF) identification from blood culture is highly accurate, but is associated with a significant failure rate, delaying identification. However, MALDI-TOF failure may itself be indicative of CoNS infection. AIM: We sought to examine whether failure of MALDI-TOF direct ID was indicative of CoNS infection and could be used as a diagnostic tool to promote antimicrobial stewardship. METHODOLOGY: Results of Gram stains, MALDI-TOF identification and formal identification were extracted from the large, multi-centre RAPIDO trial. All blood cultures with presumed staphylococci were included. MALDI-TOF performance (correct identification, incorrect identification, failed identification) was calculated for each sample and across sites. Risk of SA disease was calculated for each group (correct, incorrect, failed) and across sites. Logistic regression was used to identify if clinical features are associated with MALDI-TOF performance. RESULTS: In the RAPIDO trial, 4312 patients were allocated to the MALDI-TOF arm. After exclusions, 880 patients were eligible and had a blood culture with a Gram stain consistent with presumed staphylococci. In total, 204 of these (23.2 %) were ultimately identified as SA. MALDI-ID was successful 83.9 % of the time, and was 100 % accurate when successful. Failure was more common in CoNS isolates (124/641, 19.3 %) than in SA (13/191, 6.4 %). When MALDI-TOF failed, the risk of SA disease was 9.2 % across the whole cohort, although failure rates and risk of SA disease varied significantly between centres. MALDI-TOF failure was independent of clinical characteristics. CONCLUSION: Presumed staphylococci that fail direct MALDI-TOF identification from blood culture are significantly more likely to be CoNS isolates than SA. In low-risk or low-prevalence settings, SA therapy can be withheld if MALDI-TOF is unsuccessful

Patients with transplantation have reduced mortality in bacteraemia:Analysis of data from a randomised trial

Objectives Infection remains a major complication of organ transplantation. Paradoxically, epidemiological studies suggest better survival from serious infection. We analysed the relationship between organ transplantation and short -term mortality of patients with bloodstream infection. Methods Data on transplantation status was extracted from a large prospective, multi-centre clinical trial in bloodstream infection. Logistic regression for 28-day mortality was performed on the whole cohort and a propensity-matched cohort (3:1). Infective pathogen, focus of infection, and clinical variables were included in the model. Mediation analysis was performed on clinical variables to explore causation. Results 4,178 participants were included in the full cohort, with 868 in the matched cohort, of which 217 received an organ transplant. Haematopoietic stem cell transplants (HSCT) were the most common transplant (n = 99), followed by kidney (n = 70). The most common pathogens were staphylococci and Enterobacterales. Transplantation status was associated with a reduced mortality in both the whole (Odds Ratio, OR 0.53; 95% CI 0.28, 0.77) and matched (OR 0.55, 95% CI 0.34, 0.90) cohort, while steroid use was robustly associated with increased mortality OR 4.4 (95% CI 3.12, 6.20) in the whole cohort and OR 5.24 (95% CI 2.79, 9.84) in the matched cohort. There was no interaction between steroid use and transplant status, so transplant patients on steroids generally had increased mortality relative to those without either. Conclusions Organ transplantation is associated with a near halving of short term mortality in bloodstream infection, including a cohort matched for comorbidities, infective pathogen and focus. Steroid usage is associated with increased mortality regardless of transplant status. Understanding the mechanism and causation of this mortality benefit should be a focus of future research

Integrating transwomen athletes into elite competition:the case of elite archery and shooting

The inclusion of transwomen into elite female sport has been brought into question recently with World Rugby banning transwomen from the elite female competition, aiming to prioritise safety over fairness and inclusion, citing the size, force and power-producing advantages conferred to transwomen. The same question is being asked of all Olympic sports including non-contact sports such as archery and shooting. As both these Olympic sports are the polar opposite to the contact sport of rugby in terms of the need to consider the safety of athletes, the IF of both archery and shooting should consider the other elements when deciding the integration of trans individuals in their sports. Studies on non-athletic transwomen have reported muscle mass and strength loss in the range of 5–10% after 1 year of their transition, with these differences no longer apparent after 2 years. Therefore, based on the current scientific literature, it would be justified for meaningful competition and to prioritise fairness, that transwomen be permitted to compete in elite archery after 2 years of GAT. Similarly, it would be justified in terms of shooting to prioritise inclusion and allow transwomen after 1 year of GAT given that the only negligible advantage that transwomen may have is superior visuospatial coordination. The impact of this considered integration of transwomen in elite sports such as archery and shooting could be monitored and lessons learned for other sports, especially where there are no safety concerns from contact with an opponent.</p

Time-to-positivity in bloodstream infection is not a prognostic marker for mortality:analysis of a prospective multicentre randomized control trial

Objectives Time to positivity (TTP), calculated automatically in modern blood culture systems, is considered a proxy for microbial load and has been suggested as a potential prognostic marker in bloodstream infections. In this large, multicentre, prospectively collected cohort, our primary analysis aimed to quantify the relationship between the TTP of monomicrobial blood cultures and mortality. Methods Data from a multicentre randomized controlled trial (RAPIDO) in bloodstream infection were analysed. Bloodstream infections were classified into 13 groups/subgroups. The relationship between mortality and TTP was assessed by logistic regression, adjusted for site, organism, and clinical variables, and linear regression was applied to examine the association between clinical variables and TTP. Robustness was assessed by sensitivity analysis. Results In total 4468 participants were included in the RAPIDO. After exclusions, 3462 were analysed, with the most common organisms being coagulase-negative staphylococci (1072 patients) and Escherichia coli (861 patients); 785 patients (22.7%) died within 28 days. We found no relationship between TTP and mortality for any groups except for streptococci (odds ratio (OR) with each hour 0.98, 95%CI 0.96–1.00) and Candida (OR 1.03, 95%CI 1.00–1.05). There was large variability between organisms and sites in TTP. Fever (geometric mean ratio (GMR) 0.95, 95%CI 0.92–0.99), age (GMR per 10 years 1.01, 95%CI 1.00–1.02), and neutrophilia were associated with TTP (GMR 1.03, 95%CI 1.02–1.04). Conclusions Time to positivity is not associated with mortality, except in the case of Candida spp. (longer times associated with worse outcomes) and possibly streptococci (shorter times associated with worse outcomes). There was a large variation between median times across centres, limiting external validity