Predictors and Significance of Readmission after Esophagogastric Surgery: A Nationwide Analysis.

Objective: The aim of this study is to identify risk factors for readmission after elective esophagogastric cancer surgery and characterize the impact of readmission on long-term survival. The study will also identify whether the location of readmission to either the hospital that performed the primary surgery (index hospital) or another institution (nonindex hospital) has an impact on postoperative mortality. Background: Over the past decade, the center-volume relationship has driven the centralization of major cancer surgery, which has led to improvements in perioperative mortality. However, the impact of readmission, especially to nonindex centers, on long-term mortality remains unclear. Methods: This was a national population-based cohort study using Hospital Episode Statistics of adult patients undergoing esophagectomy and gastrectomy in England between January 2008 and December 2019. Results: This study included 27,592 patients, of which overall readmission rates were 25.1% (index 15.3% and nonindex 9.8%). The primary cause of readmission to an index hospital was surgical in 45.2% and 23.7% in nonindex readmissions. Patients with no readmissions had significantly longer survival than those with readmissions (median: 4.5 vs 3.8 years; P < 0.001). Patients readmitted to their index hospital had significantly improved survival as compared to nonindex readmissions (median: 3.3 vs 4.7 years; P < 0.001). Minimally invasive surgery and surgery performed in high-volume centers had improved 90-day mortality (odds ratio, 0.75; P < 0.001; odds ratio, 0.60; P < 0.001). Conclusion: Patients requiring readmission to the hospital after surgery have an increased risk of mortality, which is worsened by readmission to a nonindex institution. Patients requiring readmission to the hospital should be assessed and admitted, if required, to their index institution.

Evaluation of blood glucose changes with regular versus rapid-acting insulin for hyperglycaemia management in the emergency department.

OBJECTIVES: As emergency department (ED) visits secondary to hyperglycaemia increase, goals should focus on optimising treatment to minimise the length of stay (LOS). Both regular and rapid-acting insulins can effectively treat hyperglycaemia, but have different pharmacokinetic profiles. The purpose of this study is to compare blood glucose (BG) reduction over time in patients receiving subcutaneous regular versus rapid-acting insulin in the ED. METHODS: This retrospective chart review from 1 January 2018 to 31 December 2020 included adult ED patients with a BG ≥200 mg/dl who received subcutaneous regular insulin or insulin aspart. The primary endpoint was a change in BG immediately before and ≥30 min after insulin administration over time. RESULTS: There were 279 patients included in the study (108 regular insulin and 171 insulin aspart). Change in BG over time was 41.5 mg/dl/h in the regular insulin group and 47 mg/dl/h in the insulin aspart group (P = 0.36). There was no difference in hypoglycaemic events, ED LOS, time from insulin administration to discharge and total change in BG during ED stay. Patients who received regular insulin required less additional insulin doses (8.3% vs. 18.1%, P = 0.02), received a greater volume of intravenous fluids (1629 ml vs. 1280 ml, P = 0.02) and higher weight-based dose for the first insulin dose (0.11 units/kg vs. 0.10 units/kg, P = 0.02). CONCLUSION: There was no significant difference in BG reduction between insulin types for hyperglycaemic patients treated in the ED. This suggests that regular insulin and rapid-acting insulin have similar efficacy in the treatment of hyperglycaemia in the ED.

Major adverse cardiovascular events and all-cause mortality after emergency general surgery among kidney failure patients.

BACKGROUND: Emergency general surgery (EGS) is associated with increased mortality, with kidney failure a contributing risk, but comparative outcomes between patients with kidney failure and the general population are lacking. METHODS: In this retrospective population-cohort study, data were analysed for all EGS procedures performed in England between 1 April 2004 and 31 March 2019. EGS was defined as partial colectomy, small bowel resection, cholecystectomy, appendicectomy, lysis of peritoneal adhesions, surgery for peptic ulcer, or laparotomy. The main outcome measure was major adverse cardiovascular events (MACEs) and all-cause mortality after surgery. RESULTS: From 691 064 procedures, 0.16 per cent (n = 1097) and 0.23 per cent (n = 1567) were performed on kidney transplant and dialysis recipients respectively. Laparotomy was the most frequent EGS procedure for kidney transplant (46 per cent of procedures, n = 507) and dialysis (45 per cent of procedures, n = 704) recipients, with the highest 30-day and 1-year mortality. In logistic regression analysis, both kidney failure cohorts had higher risk for experiencing MACEs in the postoperative interval after emergency laparotomy; within 3 months (dialysis; OR 2.44 (95 per cent c.i. 2.08 to 2.87), P < 0.001 and transplant; OR 2.05 (95 per cent c.i. 1.57 to 2.68), P < 0.001) and within 1 year (dialysis; OR 2.39 (95 per cent c.i. 2.06 to 2.77), P < 0.001 and transplant; OR 2.21 (95 per cent c.i. 1.76 to 2.77), P < 0.001); however, in a propensity-score-matched cohort, increased risk for MACEs was observed among dialysis patients after emergency laparotomy (HR 2.10 (95 per cent c.i. 1.82 to 2.43), P < 0.001) but not kidney transplant recipients (HR 1.17 (95 per cent c.i. 0.97 to 1.41), P = 0.096). CONCLUSION: Mortality after emergency surgery is higher for patients with kidney failure and dialysis is worse than kidney transplantation, with cardiovascular deaths more common than the general population.

Is there an improvement of antibiotic use in China? Evidence from the usage analysis of combination antibiotic therapy for type I incisions in 244 hospitals.

The improvement of antibiotic rational use in China was studied by usage analysis of combination antibiotic therapy for type I incisions in 244 hospitals. Five kinds of hospitals, including general hospital, maternity hospital, children's hospital, stomatological hospital and cancer hospital, from 30 provinces were surveyed. A systematic random sampling strategy was employed to select outpatient prescriptions and inpatient cases in 2011 and 2012. A total of 29 280 outpatient prescriptions and 73 200 inpatient cases from 244 hospitals in each year were analyzed. Data were collected with regards to the implementation of the national antibiotic stewardship program (NASP), the overall usage and the prophylactic use of antibiotic for type I incisions. Univariate analysis was used for microbiological diagnosis rate before antimicrobial therapy, prophylactic use of antibiotics for type I incision operation, and so on. For multivariate analysis, the use of antibiotics was dichotomized according to the guidelines, and entered as binary values into logistic regression analysis. The results were compared with the corresponding criteria given by the guidelines of this campaign. The antibiotic stewardship in China was effective in that more than 80% of each kind of hospitals achieved the criteria of recommended antibiotics varieties. Hospital type appeared to be a factor statistically associated with stewardship outcome. The prophylactic use of antibiotics on type I incision operations decreased by 16.22% (P<0.05). The usage of combination antibiotic therapy for type I incisions was also decreased. Region and bed size were the main determinants on surgical prophylaxis for type I incision. This national analysis of hospitals on antibiotic use and stewardship allows relevant comparisons for bench marking. More efforts addressing the root cause of antibiotics abuse would continue to improve the rational use of antibiotics in China.

What limits the utilization of health services among the rural population in the Dabie Mountains- evidence from Hubei province, China?

BACKGROUND: Individuals living in rural mountain areas tend to use health services less to manage discomfort or illness. This study aims to identify the variables that best explain the health service utilization of a sample of the rural population in the Dabie Mountains in China. METHODS: To obtain information about health service utilization, a cross-sectional household survey was conducted using face-to-face interviews among the residents of a poor town in the Dabie Mountains. A total of 1,003 residents aged 15 or more, who had felt unwell in the last two weeks before the survey, were included in the analysis. The χ2 test and binary logistic regression were used to analyze the factors influencing health service utilization. RESULTS: A total of 51.2% of those surveyed had not used health services when they felt unwell, higher than the data reported in the 4th National Health Services Survey of China. Enabling variables played an important role in predicting the utilization of health services. Factors associated with increased health service utilization included being younger, travelling longer to the nearest clinic, and higher household net income. CONCLUSION: To reduce disparities in health service utilization, (1) some effort should be made to change the perceptions and attitudes of older people; (2) reimbursement levels of the New Rural Cooperative Medical Care System should be improved to reduce economic barriers to health service utilization.

Is nationwide special campaign on antibiotic stewardship program effective on ameliorating irrational antibiotic use in China? Study on the antibiotic use of specialized hospitals in China in 2011-2012.

With dwindling number of new antibiotics and inappropriate use of antibiotics, the emergence and spread of antibiotics resistance occurs commonly in healthcare institutions worldwide. In China, antibiotics are commonly over prescribed and misused. This study is to assess the effect of the nationwide special campaign on antibiotic stewardship program (ASP) at specialized hospitals in China by investigating prescription information from 2011 to 2012. Data on the hospital consumption and prescription of systemic antibiotics were obtained from four specialized hospitals, including maternity, children's, stomatological and cancer hospitals. Systematic random sampling was used to select outpatient prescriptions and inpatient cases. A total of 105 specialized hospitals in 2011 and 121 specialized hospitals in 2012 were analysed. The defined daily doses (DDDs) per 100 inpatient days, the percentage of antibiotic use in outpatient prescriptions, and the percentage of antibiotic use in inpatient cases were used as measurements of antibiotic use. The overall antibiotic use density in the selected hospitals decreased between 2011 and 2012 from 39.37 to 26.54 DDD/100 inpatient days (P<0.001). The percentage of antibiotic use in outpatient prescriptions (range: 24.12%-18.71%, P=0.109) and inpatient cases (64.85%-60.10%, P=0.006) also decreased within the two years. Significant changes were observed among regions and different hospitals within the two years. And antibiotic consumption was correlated with the type and size of specialized hospital in 2012, but not with the regions. This analysis of antibiotic consumption of specialized hospitals allows relevant comparisons for benchmarking and shows that national ASP has improved antibiotic rational use in China. The data will assist policymakers in formulating effective strategies to decrease antibiotic overuse and identify areas that require further work.