Effectiveness of out-patient based acute heart failure care: a pilot randomised controlled trial.

OBJECTIVES: Acute heart failure (AHF) hospitalisation is associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM). METHODS: We randomised patients with AHF, considered to need IV diuretic treatment for ≥2 days, to IPM or OPM. We recorded all-cause mortality, and the number of days alive and out-of-hospital (DAOH). Quality of life, mental well-being and Hope scores were assessed. Mean NHS cost savings and 95% central range (CR) were calculated from bootstrap analysis. Follow-up: 60 days. RESULTS: Eleven patients were randomised to IPM and 13 to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [p = .86]. The OPM group accrued more DAOH {47 [36,51] vs 59 [41,60], p = .13}. Two patients randomised to IPM (vs 6 OPM) were readmitted [p = .31]. Hope scores increased more with OPM within 30 days but dropped to lower levels than IPM by 60 days. More out-patients had increased total well-being scores by 60 days (p = .04). OPM was associated with mean cost savings of £2658 (95% CR 460-4857) per patient. CONCLUSIONS: Patients with acute HF randomised to OPM accrued more days alive out of hospital (albeit not statistically significantly in this small pilot study). OPM is favoured by patients and carers and is associated with improved mental well-being and cost savings.

The Obesity Paradox in Emergency General Surgery Patients.

BACKGROUND: Operative management of emergency general surgery (EGS) diagnoses involves a range of procedures which can carry high morbidity and mortality. Little is known about the impact of obesity on patient outcomes. The aim of this study was to examine the association between body mass index (BMI) >30 kg/m2 and mortality for EGS patients. We hypothesized that obese patients would have increased mortality rates. METHODS: A regional integrated health system EGS registry derived from The American Association for the Surgery of Trauma EGS ICD-9 codes was analyzed from January 2013 to October 2015. Patients were stratified into BMI categories based on WHO classifications. The primary outcome was 30-day mortality. Longer-term mortality with linkage to the Social Security Death Index was also examined. Univariate and multivariable analyses were performed. RESULTS: A total of 60 604 encounters were identified and 7183 (11.9%) underwent operative intervention. Patient characteristics include 53% women, mean age 58.2 ± 18.7 years, 64.2% >BMI 30 kg/m2, 30.2% with chronic obstructive pulmonary disease, 19% with congestive heart failure, and 31.1% with diabetes. The most common procedure was laparoscopic cholecystectomy (36.4%). Overall, 90-day mortality was 10.9%. In multivariable analysis, all classes of obesity were protective against mortality compared to normal BMI. Underweight patients had increased risk of inpatient (OR = 1.9, CI = 1.7-2.3), 30-day (OR = 1.9, CI = 1.7-2.1), 90-day (OR = 1.8, CI 1.6-2.0), 1-year (OR = 1.8, CI = 1.7-2.0), and 3-year mortality (OR = 1.7, CI = 1.6-1.9). CONCLUSIONS: When stratified by BMI, underweight EGS patients have the highest odds of death. Paradoxically, obesity appears protective against death, even when controlling for potentially confounding factors. Increased rates of nonoperative management in the obese population may impact these findings.

Efficacy of single phototherapy with low-cost reflective sheets versus single phototherapy alone in mild-to-moderate unconjugated hyperbilirubinaemia in full-term neonates.

BACKGROUND: An economical alternative method of increasing the light intensity of phototherapy for neonatal jaundice is the use of reflective sheets placed on the sides of the incubator. AIM: To determine whether reflective sheets in addition to phototherapy increase the reduction of bilirubin levels and the duration of hospital stay. METHODS: The study was undertaken in the neonatal intensive care unit of Cairo University Children's Hospital. There were two groups: a study group of 90 full-term neonates with neonatal jaundice who received single phototherapy in incubators covered with white plastic reflective sheets and a control group of 90 full-term neonates with neonatal jaundice who received single phototherapy without the reflective sheets. RESULTS: The mean (SD) rate of bilirubin decline in the first 24 hours of phototherapy was greater in the study group [3.7 (0.86) µmol/L/hr] than in the control group [2.2 (0.14) µmol/L/hr] (p<0.001). CONCLUSION: Use of reflective sheets decreases the total duration of phototherapy and the cost and duration of hospitalisation without any added complications.Abbreviations: AAP: American Academy of Pediatrics; HIDS: high-intensity double-surface; LMIC: low- and middle-income countries; MCTP: mirror-covered tunnel phototherapy; NICU: neonatal intensive care unit; TSB: total serum bilirubin.

Reducing Healthcare Costs Using ACS NSQIP-Driven Quality Improvement Projects: A Success Story from Sheikh Khalifa Medical City (SKMC).

INTRODUCTION: Surgical complications increase hospital length of stay and costs and lead to poor patient experience. We aim to evaluate our complication rates over time and the financial impact of joining the adult multi-specialty American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) at Sheikh Khalifa Medical City (SKMC). METHODS: Sheikh Khalifa Medical City is a Joint Commission International-accredited ACS NSQIP member since 2009. For the purpose of quality improvement, we have established several task forces (2010-2014) to decrease high rates of venous thromboembolism (VTE), urinary tract infection (UTI), surgical site infection (SSI), unplanned intubation (UI), and ventilator more than 48 h (Vent > 48 h). Our aim is to evaluate our complication rates over time and calculate the cost savings from prevented occurrences in VTE, UTI, SSI, UI, and Vent > 48 h. Cost savings are calculated using the return on investment calculator from ACS NSQIP. In addition, the cost of joining and maintaining ACS NSQIP at SKMC is calculated to determine the total cost savings after subtracting these costs. RESULTS: During the study period, we performed 8842 cases (2009-2015) and our overall morbidity improved significantly from observed/expected (O/E) 1.61% to (O/E) 0.85%. We prevented 12 VTE cases (2011-2015), 56 UTI cases (2013-2015), 12 SSI cases (2013-2015), 4 UI cases (2014-2015), and 7 Vent > 48 h cases (2014-2015). The cost saving from all these four task forces was $1,680,000. The cost of joining and maintaining ACS NSQIP at SKMC since 2009 was $336,000. Hence, the total saving for SKMC was $1,344,000. CONCLUSION: ACS NSQIP-driven quality improvement projects have resulted in reduction in complications and healthcare costs at SKMC over a 6-year period.

Mandatory Risk Assessment Reduces Venous Thromboembolism in Bariatric Surgery Patients.

INTRODUCTION: Bariatric surgery patients are at high risk for venous thromboembolism (VTE), and chemoprophylaxis is recommended. METHODS: Sheikh Khalifa Medical City (SKMC) is an American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) member since 2009. We report the rates of VTE in bariatric surgery patients from 2010 to 2016 compared to ACS NSQIP bariatric surgery programs before and after switching from heparin to low molecular weight heparin (LMWH), initiating mandatory risk assessment using Caprini scoring for VTE and adopting an aggressive strategy for high-risk patients regarding dosage of LMWH and chemoprophylaxis after discharge. RESULTS: During the study period, there were 1152 cases (laparoscopic Roux-en-Y gastric bypass (LRYGB) 625 and laparoscopic sleeve gastrectomy (LSG) 527) at Bariatric & Metabolic Institute (BMI) Abu Dhabi compared to 65,693 cases (LRYGB 32,130 and LSG 33,563) at ACS NSQIP bariatric surgery programs. VTE rates remained stable at ACS NSQIP bariatric surgery programs from 2010 to 2016 (0.45, 0.45, 0.45, 0.25, 0.35, 0.3, and 0.3%). In contrast, VTE rates at BMI Abu Dhabi decreased from 2.2% in 2011 to 0.35% after we adopted an aggressive strategy to VTE without an increase in bleeding complications. LRYGB patients with VTE had higher OR time, leak, collection, and mortality at ACS NSQIP hospitals compared to those at BMI Abu Dhabi. In contrast, rates were similar in LSG patients with VTE. CONCLUSION: Changing our approach to VTE management led our VTE rates to decrease and become like those of ACS NSQIP bariatric surgery patients in LSG and LRYGB.

Education and assortative marriage in northern and urban Sudan: 1945-79.

This study examines the extent of assortative mating for education in Northern Sudan and urban Khartoum. More males than females were found at higher levels of education. Increasingly, people tend to marry persons of equal educational level, but the unequal educational opportunities for males and females have led to the emergence of educational exogamy in which members of different educational levels are more likely to marry from the adjacent educational category than from distant categories. The increasing level of education for both sexes, and especially for females, may in part explain the rising trend in age at marriage.

PIP: The results suggest that similarities in education level between spouses is an important factor in mate selection. When there are differences in educational groups, there is a greater likelihood of educational groups being adjacent rather than distant groups. The trend is more marital homogamy. The implications for the future with rising educational levels would be for rising age at marriage for females. Data from the Sudan Fertility Survey and the Changing African Family Project are used to construct log linear models of the association between husband's and wife's education. The sample includes the ever married population of Northern Sudan and the urban population of Khartoum. There are more males of higher educational level. Fewer females married males of lower educational level than their own. A positive association is found in Northern Sudan for all levels of education, which indicates a degree of educational homogamy. The association, which increased for more recent marriage cohorts, is stronger for Khartoum. Three log linear models are used to show the extent of homogamy (an independence model, a diagonal model, and a uniform association model). The independence model shows an association between husband's and wife's education. The diagonal model shows educational homogamy reduces the variability by over 62% for Northern Sudan and 38% for urban Khartoum. Variability is reduced for more recent times. The uniform association model reveals a good fit of the data and a pattern of educational similarity in marriage. In Northern Sudan in the independence model, the odds of marrying at equal educational levels is 3.56, and for Khartoum educational similarity in marriage is 1.43 times more likely. In the uniform association model, the odds are reduced to 1.26 and 1.43, respectively. Educational homogamy is stronger in Khartoum.