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Deep partial thickness and full thickness circumferential or near circumferential burns of the neck, chest, abdomen, or extremities can cause serious local or systemic complications and need surgical release of the burn eschar to relieve obstruction or high pressures and restore perfusion.
Circumferential burns of the neck can cause airway obstruction.
Circumferential burns of the chest can cause respiratory compromise with increased peak inspiratory pressures, hypoxia, and hypercapnia.
Circumferential burns of the abdomen can cause intra- abdominal hypertension and abdominal compartment syndrome.
Circumferential burns of the extremities can cause muscle compartment syndrome.
Deep partial or full thickness circumferential extremity burns require prophylactic escharotomy.
Near circumferential extremity burns require frequent neurovascular checks to assess for need of escharotomy. Worsening neurovascular exam or pressure measurement >30 mmHg should prompt urgent escharotomy of the affected extremity.
In severe burns requiring massive fluid resuscitation, abdominal or extremity compartment syndromes may develop independent of circumferential burns. It is important that these high-risk patients are monitored closely and decompressive laparotomy or extremity fasciotomies are performed timely in the appropriate cases.
Electrical burns or burns associated with crush injuries may require fasciotomies, in addition to escharotomies, to restore adequate perfusion.
Deep partial or full thickness skin wounds, with an underlying vascularized bed, may be closed by autologous skin grafting, especially if healing by contracture would lead to prolonged healing time or functional or aesthetic deformity. Split thickness skin grafts (STSGs) are used most often for large wounds. Thin (0.06–0.010 in.), intermediate (0.010–0.013 in.), and thick (>0.014 in.) split thickness grafts can be harvested. Thinner grafts survive more reliably on a less vascular bed and have faster donor site healing; however, thinner grafts contract more than thicker grafts and the esthetic results are inferior. Most STSGs are of intermediate thickness, 0.012 in. Thinner grafts (0.010) should be considered in children and the elderly due to their thinner dermis.
STSG donor sites heal by re-epithelialization with proper wound care. The lateral thigh or back are the most common donor sites, although STSGs may be harvested from nearly any uninjured anatomic area, including buttocks, abdomen, scrotum, and scalp.
Meshed STSGs can be expanded and require less donor site than sheet grafts, but contract more and the esthetic results are not as good. Sheet grafts are used in children or in areas where contracture is unacceptable.
Full thickness skin grafts have little role in acute wound closure. These are reserved for delayed reconstruction of critical areas, such as the hands and face.
Meticulous technique is important for graft success, and includes hemostasis, placement of dressings, and adequate postoperative immobilization.
In this study, we applied ultra-short time series of interbeat intervals (RR-intervals) to evaluate heart rate variability through default chaotic global techniques with the purpose of discriminating obese youths from non-obese youth patients.
Chaotic global analysis of the RR-intervals from the electrocardiogram and pre-processing adjustments was undertaken. The effect of cubic spline interpolations was assessed, while the spectral parameters remained fixed. Exactly, 125 RR-intervals of data were recorded.
CFP1, CFP3, and CFP6 were the only significant combinations of chaotic globals when the standard conditions were enforced and at the level p<0.01 (or <1%). These significances were acheived via Kruskal–Wallis and Cohen’s ds effects sizes tests of significance after Anderson–Darling and Lilliefors statistical tests indicated non-normal distributions in the majority of cases. Adjustments of the cubic spline interpolation from 1 to 13 Hz were revealed to be inconsequential when measured by Kruskal–Wallis and Cohen’s ds, regarding the outcome between the two datasets.
Chaotic global analysis was offered as a robust technique to distinguish autonomic dysfunction in obese youths. It can discriminate the two different groups using ultra-short data lengths, and no cubic spline interpolations need be applied.
When citizens are offered cash and gifts by candidates, they can either vote for candidates offering the money, refuse the money, or take the money and vote for whichever candidate they prefer (e.g., “vote their conscience”). Which citizens “vote their conscience” versus the other options available to them? This manuscript examines the effect of poverty, education, and social pressure on how citizens in the Central Java city of Semarang, Indonesia react to offers of cash from politicians. We find that poverty and education interact to create important and interesting patterns of responses. The citizens most likely to “vote their conscience” are those with lower income yet higher levels of formal education whereas higher income, more highly educated citizens are most likely to refuse the money. We also examine factors that create social pressure for citizens to “sell” their votes by supporting the candidates offering cash.
This article argues for the (re)construction of citizenship of the European Union as an autonomous status. As opposed to the current legal regime, whereby individuals with nationality of a Member State are automatically granted citizenship of the Union, under this proposal individuals would be free to choose whether or not to adopt the status of citizen of an incipient European polity. At present, the telos and essence of citizenship of the Union is contested. It may be argued that the status is partial or incomplete. This has informed competing normative perspectives. ‘Maximalist’ positions praise the judicial construction of Union citizenship as destined to be the ‘fundamental status’ for all Member State nationals. By contrast, ‘minimalist’ positions argue that the status should remain ‘additional to’ Member State nationality, and the rights created therein should remain supplementary to the status and rights derived from national citizenship. This article will argue for a new approach to the dilemma. By emancipating the condition for acquisition of EU citizenship from nationality of a Member State, and reconstructing it as an autonomous choice for individuals, it is tentatively suggested that a new constitutional settlement for Europe may be generated.
This article, written by Helen Garner, reviews the progress of the Moys Reclassification Project at the Bodleian Law Library and covers the issues relating to the lessons learnt and the benefits of changing to a different classification scheme. The Bodleian Law Library started work on the Moys Reclassification Project in 2006 and work is still on-going to complete the project.
In recent years, several initiatives have sought to encourage redemption of food assistance benefits at direct-to-consumer (DTC) market venues such as community supported agriculture programs and farmers’ markets in the USA, with the dual goal of increasing access to healthy foods for low-income families and sales of locally-grown foods for farmers. Proponents of these interventions assert that these programs have a positive impact on local economies yet there is limited evidence to validate this argument. This research project used a customized input-output model to simulate potential economic impacts of programs and policies that enable Supplemental Nutrition Assistance Program (SNAP) recipients to shift purchases from traditional food retailers to DTC venues in four states. Two different scenarios were explored: (1) increased outreach to low-income consumers and (2) financial support for using SNAP benefits at DTC market channels. We found a positive, though modest, economic impact at the state level under both scenarios when accounting for (a) business losses in the food retail and wholesale sectors, (b) a shift in acreage from commodity to specialty crops and (c) the cost to taxpayers. Since most of the increased economic activity would be in the produce farming sector, we discuss the opportunities and challenges for this sector along with potential policy implications.
We present for the first time the feasibility to recover the stiffness (here shear modulus) distribution of a three-dimensional heterogeneous sample using measured surface displacements and inverse algorithms without making any assumptions about local homogeneities and the stiffness distribution. We simulate experiments to create measured displacements and augment them with noise, significantly higher than anticipated measurement noise. We also test two-dimensional problems in plane strain with multiple stiff inclusions. Our inverse strategy recovers the shear modulus values in the inclusions and background well, and reveals the shape of the inclusion clearly.
Vaccination is increasingly being recognised as a potential tool to supplement ‘stamping out’ for controlling foot-and-mouth disease (FMD) outbreaks in non-endemic countries. Infectious disease simulation models provide the opportunity to determine how vaccination might be used in the face of an FMD outbreak. Previously, consistent relative benefits of specific vaccination strategies across different FMD simulation modelling platforms have been demonstrated, using a UK FMD outbreak scenario. We extended this work to assess the relative effectiveness of selected vaccination strategies in five countries: Australia, New Zealand, the USA, the UK and Canada. A comparable, but not identical, FMD outbreak scenario was developed for each country with initial seeding of Pan Asia type O FMD virus into an area with a relatively high density of livestock farms. A series of vaccination strategies (in addition to stamping out (SO)) were selected to evaluate key areas of interest from a disease response perspective, including timing of vaccination, species considerations (e.g. vaccination of only those farms with cattle), risk area vaccination and resources available for vaccination. The study found that vaccination used with SO was effective in reducing epidemic size and duration in a severe outbreak situation. Early vaccination and unconstrained resources for vaccination consistently outperformed other strategies. Vaccination of only those farms with cattle produced comparable results, with some countries demonstrating that this could be as effective as all species vaccination. Restriction of vaccination to higher risk areas was less effective than other strategies. This study demonstrates consistency in the relative effectiveness of selected vaccination strategies under different outbreak start up conditions conditional on the assumption that each of the simulation models provide a realistic estimation of FMD virus spread. Preferred outbreak management approaches must however balance the principles identified in this study, working to clearly defined outbreak management objectives, while having a good understanding of logistic requirements and the socio-economic implications of different control measures.
Objectives: Value assessment frameworks have gained prominence recently in the context of U.S. healthcare. Such frameworks set out a series of factors that are considered in funding decisions. The UK's National Institute of Health and Care Excellence (NICE) is an established health technology assessment (HTA) agency. We present a novel application of text analysis that characterizes NICE's Technology Appraisals in the context of the newer assessment frameworks and present the results in a visual way.
Methods: A total of 243 documents of NICE's medicines guidance from 2007 to 2016 were analyzed. Text analysis was used to identify a hierarchical set of decision factors considered in the assessments. The frequency of decision factors stated in the documents was determined and their association with terms related to uncertainty. The results were incorporated into visual representations of hierarchical factors.
Results: We identified 125 decision factors, and hierarchically grouped these into eight domains: Clinical Effectiveness, Cost Effectiveness, Condition, Current Practice, Clinical Need, New Treatment, Studies, and Other Factors. Textual analysis showed all domains appeared consistently in the guidance documents. Many factors were commonly associated with terms relating to uncertainty. A series of visual representations was created.
Conclusions: This study reveals the complexity and consistency of NICE's decision-making processes and demonstrates that cost effectiveness is not the only decision-criteria. The study highlights the importance of processes and methodology that can take both quantitative and qualitative information into account. Visualizations can help effectively communicate this complex information during the decision-making process and subsequently to stakeholders.
Deep brain stimulation (DBS), which uses an implantable device to modulate brain activity, is an adjunctive treatment for partial-onset seizures in patients with medically refractory epilepsy. Our objective was to perform an exploratory cost-utility analysis of DBS in conjunction with medical therapy, compared with medical therapy alone, using the latest clinical data and costs for the Australian healthcare system.
A deterministic five-state Markov model was used to project treatment response and outcomes over the patients’ lifetimes, based on 5-year data from the recent Stimulation of the Anterior Nucleus of the Thalamus for Epilepsy (SANTE) DBS trial and drug outcome data identified through a literature search. Costs were based on 2017 data for the Australian healthcare system, and response-specific utilities were derived from published literature. We estimated the lifetime discounted incremental cost-effectiveness ratio (ICER) in Australian dollars per quality-adjusted life-year (QALY) for patients 36 years of age, fifty-five percent of whom were men. Costs and effects were discounted at five percent per annum. The robustness of projections was evaluated through scenario and sensitivity analyses.
Under assumed continued treatment benefit, DBS was projected to add 3.48 QALYs over the patients’ lifetimes, at an increased cost of AUD 142,304 (USD 105,960), resulting in an ICER of AUD 40,951 (USD 30,492) per QALY gained. Reducing the analysis horizon to 20 years increased the ICER to AUD 49,803 (USD 37,083). Increasing the DBS generator life from 3 to 6 years decreased the ICER to AUD 23,956 (USD 17,838) per QALY. Longer follow-up periods and younger age at treatment were associated with greater cost effectiveness. Results were sensitive to assumptions about health state-specific utility estimates and long-term treatment effects.
Our exploratory findings suggest that DBS is a cost-effective treatment strategy in the Australian healthcare system for patients with medically refractory epilepsy. DBS therapy might meaningfully improve patient outcome at a health economic profile that compares favorably to other well accepted therapies. Consideration of indirect costs would further add to this value proposition.
During the eighteenth century the rise of manufactures and manufacturing became one of the central concerns for economic policymakers in the territorial states of the Holy Roman Empire. This theme also occupied a prominent place in the treatises on cameralism that proliferated during the second half of the century. This essay explores this relationship through an examination of the institutional framework of ‘industrial policy’ (Gewerbepolicey) as discussed in cameralist works and applied to policy.
Consideration of the economic and social context of the Holy Roman Empire explains why the focus on manufacturing and manufactories is typical for cameralism in the second half of the eighteenth century. This sector offered possibilities for the employment of a growing population and so resolve the increasingly acute problem of poverty, in particular after the grain shortage of 1771–72. For these reasons the states governments in the Holy Roman Empire were under pressure, and were also prompted to introduce measures of Gewerbepolicey advocated by the flourishing economic discourse of the second half of the eighteenth century, including the cameral sciences. Furthermore, this sector had to be developed to offset a perception of economic backwardness in comparison to France, England, and the Dutch Republic, and to confront economic competition among the states of Holy Roman Empire. Given the impossibility of most German states increasing their power through territorial and colonial conquest, development of their industry was a primary objective. According to recent studies, this is a criterion that distinguishes German cameralism – centred on agricultural and industrial production – from trade-oriented English mercantilist discourse, which gave priority to a positive balance of trade.
A few preliminary observations will be useful. First, an analysis of the relationship between cameralist proposals and their application in German states (in other words, the relationship between theory and practice) points to a number of unresolved issues. Showing that theoretical proposals and particular policies have similarities is one thing; demonstrating that the former influenced the latter is quite another. One can also ask to what extent cameralists took any account of policies already in place, thereby reversing the terms of the question. Second, distinguishing an interventionist mercantilism or cameralism from a liberalism hostile to state intervention is not a helpful approach to the writings of the cameral sciences.
This article examines ambivalence—the simultaneous holding of two or more conflicting values or beliefs about a political issue—among Indonesian citizens’ attitudes about vote buying. Using an original survey taken during the 2014 Indonesian elections, we analyse the factors related both to citizens’ normative views about vote buying and their willingness to accept gifts from candidates. A large number of citizens demonstrate ambivalence by viewing the practice as unjustified or corrupt and yet expressing willingness to accept money from candidates. We also examine the differential effects of education and income on these attitudes. Consistent with “demand side” theories of vote buying, low income creates economic pressure to accept money but does not influence normative attitudes about vote buying. Education, however, has a broader effect by influencing both normative attitudes and willingness to accept money. We consider implications of these results for Indonesian officials focused on reducing vote-buying behavior.
Objectives: Some countries make considerable effort to involve patients and patient groups in their health technology assessment (HTA) processes; others are only just considering or are yet to consider patient involvement in HTA.
Methods: This commentary offers four arguments why patient involvement should be prioritized by those HTA agencies that do not yet involve patients: (1) from a patients’ rights perspective, (2) based on patient and community values, (3) centering on evidentiary contributions, and (4) from a methodological perspective.
Results: The first argument builds on the Alma-Ata Declaration, which holds that patients have a right and duty to have a say in the planning and delivery of their health care, individually and collectively. Where HTA is used to determine access to technologies and services, we argue that patients have a right to be heard. The second argues that decisions about treatments and services need to be aligned with the core values and morals of the patients whom the health system serves. The third argues that patients have unique knowledge and insights about living with a health condition and their needs for services and treatments regarding that condition, which can add to the knowledge base and value of the HTA process. The fourth argues that involvement of patients can facilitate methodological advancement of HTA, in areas such as early scientific advice and managed entry with evidence development.
Conclusions: An HTA process that includes patient perspectives can, therefore, provide added value to patients, policy makers and healthcare professionals alike.