A new study about alternatives to blood transfusion, published recently in the Archives of Internal Medicine, seems to rest on a faulty premise. JEHOVAH’S Witnesses, whose faith forbids them from blood transfusions, recover from heart surgery faster and with fewer complications than those who do get blood, in a study that may change thinking on current practice. Patients who are Jehovah’s Witnesses had better survival rates, shorter hospital stays, fewer additional operations for bleeding and spent fewer days in the intensive care unit than those who received blood transfusions during surgery, a study in the Archives of Internal Medicine shows. Researchers in the study included 322 Jehovah’s Witness patients and 87,453 other patients who underwent heart surgery at the Cleveland Clinic from 1983 to 2011. What this study has done is to compare the outcomes for ALL of the Jehovah’s Witness patients with the sicker patients in the conventional treatment group. In the study, a total of 322 Jehovah’s Witnesses who underwent cardiac surgery at the Cleveland Clinic between January 1, 1983 and January 1, 2011 and who prospectively refused blood transfusions were included.
Even so, they were being compared to a group who all needed blood transfusions, which is only the case for half of all patients. The actual article in Internal Medicine has much more detail about the propensity score matching technique and analytical techniques used to compare adverse effects. I’m sure the experimenters at Cleveland Clinic covered themselves against this, but how? How to kill a discipline: Worship the theorists, diss the implementors & the evaluators!
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Since the Model for End-stage Liver Disease (MELD) organ allocation system was implemented in 2002, patients who are least in need of an organ transplant have been receiving livers that are higher-risk, or of a poorer-quality. Results from the study - set to appear in the November issue of Gastroenterology - ultimately reveal that MELD has changed how high-risk organs are allocated to patients, and not always for the better, says lead study author  Michael L.
The overall quality of transplanted livers has gotten worse since the implementation of the MELD organ allocation system. In the five years since the MELD system began, there has been an increased risk for graft failure in patients who are lower on the organ wait list.


As the result of receiving higher-risk organs, there has been a decline in post-transplant survival among patients with low MELD scores. Under MELD, a patient's place on the donor organ wait list is determined not by waiting time, but by disease severity. When a donor liver becomes available, the United Network for Organ Sharing reviews the patient wait list, which is prioritized by MELD scores.
The decision to accept or reject an organ is certainly a complex one, which transplant physicians must make quickly and at all hours of the day. With plans to further study this issue, the researchers believe that there may be several factors now affecting transplant physicians' decisions to give higher-risk organs to patients - the desire to improve a patient's quality of life, rather than quantity of life; and concern that with a limited supply of available donor livers, a patient low on the list may wait indefinitely for an organ. Despite the physician being the one to make the final call on an available donor organ, Volk advocates for transplant patients to be informed about the quality of a potential donor organ, as well as have an understanding of the transplant process and MELD. Volk and his colleagues are currently conducting a study to learn more about this issue, and hope in the future to offer recommendations about how best to educate patients. Methodology: The researchers used data from the United Network for Organ Sharing Standard Transplant Analysis and Research for the study. Funding: The study work was support by a grant from the Robert Wood Johnson Foundation and the Department of Veteran Affairs, and by Health Resources and Services Administration.
They were compared with the same number of propensity-matched controls, with similar comorbidities, taken from 48 986 patients who underwent cardiac surgery during that period and did receive blood. So unless this reflects differences among surgeons (eg with some using transfusions for all of their patients and some for none) it is likely to indicate something about the nature of their condition or surgery which might make the groups not sufficiently comparable.
We chose to use propensity matching and to identify a control group that received transfusions to minimize selection and referral biases. Michael Scriven and Jane Davidson on Evaluation-Specific Methodology (3)What is Value for Investment, and how should we evaluate it? As a result, the study shows post-transplant survival among non-urgent patients - those with MELD scores that place them lower on the wait list - has gotten worse since MELD was implemented. Today, however, patients who are least in need of a liver transplant are paired with higher-risk organs.


MELD relies solely on objective laboratory data to accurately predict a patient's probability of death within three months, to maximize patient survival from the limited supply of donor livers. The physician whose patient is at the top of list is contacted, and he or she must then decide if they want to accept the organ or wait for a better option to become available. As a result, patients with less severe liver disease are more likely to receive a higher risk organ, which has reduced their post-transplant survival," says Volk. Still the study shows that changing the organ allocation process from one based on patients' time on the wait list and subjective measure of disease severity, to one based entirely upon objective measures of disease severity, has ultimately impacted how physicians decide which organs are best suited to their patients. You are free to copy, distribute, adapt, transmit, or make commercial use of this work as long as you attribute the University of Michigan Health System as the original creator and include a link to this article. Nonetheless, propensity methods can account only for those variables that were available and properly recorded.
Therefore, the sickest patients - those with the highest MELD scores - are placed at the top of the wait list.
Volk explains that in many cases, physicians with high MELD score patients opt to wait for a better liver for their patient - especially when the organ is high risk.
1, 2007 - which spans five years prior to and five years following the implementation of MELD - were analyzed.
We did not record data on many Witness care-specific practice variables that may have changed over time. Researchers examined patients' risk of graft failure, or donor risk index, and survival after transplantation. Thus, our analyses do not allow us to identify which practices may have contributed to the outcomes. Finally, Witnesses who came to our center and who were accepted by our surgeons likely represent a select group who might have been expected by their physicians to have better outcomes.




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