Should primary care physicians consult on their admitted patients? A single-center survey study.

Background: With the rise of hospital medicine, care has become fragmented between inpatient and outpatient settings. Having primary care physicians (PCPs) consult on their admitted patients through televisits could improve patient and hospital outcomes, but perspectives on this model are unknown in adult hospital medicine. Methods: A single-center cross-sectional survey was conducted to compare PCP and hospitalist attitudes regarding PCP telemedicine consultation for admitted patients in a large US academic hospital. Results: A total of 120 participants (52 hospitalists and 68 PCPs) responded to the survey. Most hospitalists believed that their patients would benefit from PCP consultation, with 45.8% believing it was slightly important, 18.8% moderately important, and 22.9% quite important. The level of importance did not seem to influence the effort required, as most hospitalists would put in only a little effort (35.4%) to obtain a PCP consultation. PCPs were more inclined to consult on their admitted patients; 18.6% considered it slightly important to obtain their consultation, 35.6% believed it was moderately important, and 23.7% believed it was quite important. PCPs were willing to put more effort into setting up a PCP consultation (some effort, 45.8%) vs hospitalists (little effort, 35.4%). The most common challenge perceived by both groups was time commitment (hospitalists, 78.8%; PCPs, 75.0%). Conclusions: Both hospitalists and PCPs agree that a PCP consultation would benefit the patient's medical care in specific situations. However, views on the importance and frequency of PCP consultations vary between the two groups.

Outcomes of Percutaneous Atrial Septal Defect Closure With Mitral Transcatheter Edge-to-Edge Repair and Transseptal Mitral Valve Replacement (2015 to 2020).

Patients who underwent transcatheter edge-to-edge repair (TEER) or transcatheter mitral valve replacement (TMVR) have a transeptal access created by an iatrogenic atrial septal defect (ASD) which leads to significant complications requiring closure. Given limited data, we used the National Inpatient Sample between 2015 and 2020 to evaluate the clinical outcomes of percutaneous closure of ASD (PC-ASD) in TEER/TMVR hospitalizations. A total of 44,065 eligible weighted hospitalizations with either TEER (n = 39,625, 89.9%) or TMVR (n = 4,440, 10.1%) with a higher rate of PC-ASD in the TMVR group (10.7% vs 2.0%, p <0.01). The TEER with PC-ASD group were more likely to experience acute heart failure and right ventricular failure and had longer hospital stays but there was no difference in in-hospital mortality compared with the no PC-ASD group. In the TMVR group, there was no difference in the odds of acute heart failure, right ventricular failure, cardiogenic shock, or acute hypoxic respiratory failure, but the odds of mechanical circulatory support, in-hospital mortality, and length of stay were significantly higher in patients with PC-ASD in the TMVR group. In conclusion, rates of percutaneous closure of ASD after TEER were lower than after TMVR and associated with worse in-hospital mortality in TMVR but not in TEER. Further prospective clinical trials are needed to identify patients who would benefit from the closure of iatrogenic ASD.

Delayed vs early cardioversion in patients with paroxysmal atrial fibrillation: a population-based study (2015-2020).

Aim: There is limited data on clinical outcomes of delayed cardioversion (DCV) compared with early cardioversion (ECV) in paroxysmal atrial fibrillation (AF) patients. Methods: We utilized data from National Inpatient Sample (2015-2020) and propensity-score matched analysis to determine adjusted odds ratio (aOR) of major clinical outcomes, including 17,879 AF cases: 9725 and 8154 underwent ECV and DCV, respectively. Results: Compared with ECV, DCV was associated with higher odds of acute heart failure (AHF; aOR 1.79 [1.67-1.92]; p < 0.01), median length of stay (4 vs 2 days; p < 0.01) and cost of hospitalization ($33,410 vs $21,738; p < 0.01) with no significant difference in inpatient mortality and other cardiovascular and neurological outcomes. Conclusion: Compared with ECV, DCV was associated with more AHF and resource utilization.

Functional and oncological outcome of patients with benign hindfoot tumors treated by curettage.

BACKGROUND: Only 3 % of osseous tumors occur in the foot. The metatarsals are the -most common site whereas the calcaneus and talus are less common sites. Because these tumors are rare, the aim of our study is to assess the functional and the oncological outcome of patients with benign hindfoot tumors managed by curettage. METHODS: The clinical and radiological data of 41 patients diagnosed with benign hindfoot tumors were retrospectively reviewed. The study included 31 males and 10 females. The average age was 23.68 (range, 5-49) years. The average follow-up period was 92.7 (range, 12-244) months. RESULTS: At the last follow-up visit, the average Musculoskeletal Tumor Society scoring system (MSTS) score was 28.12 (range, 21-30). MSTS scores were higher in patients with latent tumors (P = .028) and patients managed by simple curettage (P = .018). The recurrence rate in calcaneal tumors was higher than those in the talus. The overall complication rate was 12.2 % (5 of 41 patients). Infection and subtalar arthritis were the most common complications. CONCLUSION: Curettage of benign bone tumors of talus or calcaneus proved to be an effective method in the management of these patients. Their functional outcome is also excellent. All the complications are manageable without long term morbidity. LEVEL OF EVIDENCE: Level IV Therapeutic study.

COVID-19 Infection Is Associated With Increased In-Hospital Mortality and Complications in Patients With Acute Heart Failure: Insight From National Inpatient Sample (2020).

Introduction: Patients with acute heart failure (AHF) exacerbation are susceptible to complications in the setting of COVID-19 infection. Data regarding the clinical outcomes of COVID-19 in patients admitted with AHF is limited. Methods: We used the national inpatient sample database by utilizing ICD-10 codes to identify all hospitalizations with a diagnosis of AHF in 2020. We classified the sample into AHF with COVID-19 infection versus those without COVID-19. Primary outcome was in-hospital mortality. Secondary outcomes were acute myocardial infarction, need for pressors, mechanical cardiac support, cardiogenic shock, and cardiac arrest. Also, we evaluated for acute pulmonary embolism (PE), bacterial pneumonia, need for a ventilator, and acute kidney injury (AKI). Results: We identified a total of 694,920 of AHF hospitalizations, 660,463 (95.04%) patients without COVID-19 and 34,457 (4.96%) with COVID-19 infection. For baseline comorbidities, diabetes mellitus, chronic heart failure, ESRD, and coagulopathy were significantly higher among AHF patients with COVID-19 (P < .01). While CAD, prior MI, percutaneous coronary intervention, and coronary artery bypass graft, atrial fibrillation, chronic obstructive pulmonary disease, and peripheral vascular disease were higher among those without COVID-19. After adjustment for baseline comorbidities, in-hospital mortality (aOR 5.08 [4.81 to 5.36]), septic shock (aOR 2.54 [2.40 to 2.70]), PE (aOR 1.75 [1.57 to 1.94]), and AKI (aOR 1.33 [1.30 to 1.37]) were significantly higher among AHF with COVID-19 patients. The mean length of stay (5 vs 7 days, P < .01) and costs of hospitalization ($42,143 vs $60,251, P < .01) were higher among AHF patients with COVID-19 infection. Conclusion: COVID-19 infection in patients with AHF is associated with significantly higher in-hospital mortality, need for mechanical ventilation, septic shock, and AKI along with higher resource utilization. Predictors for mortality in AHF patients during the COVID-19 pandemic, COVID-19 infection, patients with end-stage heart failure, and atrial fibrillation. Studies on the impact of vaccination against COVID-19 in AHF patients are needed.

Gastrointestinal Bleeding in Patients Supported with Left Ventricular Assist Devices: The Journey from Bridging to Destination.

End-stage heart failure is a prevalent and fatal cardiovascular disease. Almost 1 in 4 cases of mortality in the United States is attributed to heart failure. Left ventricular assist devices (LVADs) have emerged as a safe destination therapy or bridge to transplant. Despite remarkable results, LVAD is associated with significant adverse events, such as gastrointestinal bleeding (GIB). In this review, we aimed to understand the incidence and prevalence, pathophysiologic mechanisms, predictors, diagnostic mechanisms, management, and preventative measures of GIB in patients with an LVAD. GIB is a common adverse event in patients with an LVAD with an incidence of 15% to 25%. The exact pathogenesis of GIB is poorly understood. However, different mechanisms of bleeding have been described, such as arteriovenous malformations, acquired von Willebrand syndrome, coagulopathy, and treatment with antithrombotic therapy. Upper GIB is the most common site of GIB in patients with an LVAD. The management of GIB in patients with LVAD includes ensuring hemodynamic stability, holding or reversing antithrombotic therapy, and investigating and controlling the source of GIB through diagnostic and interventional endoscopic and radiologic means. Prophylactic medication use (e.g., danazol, octreotide, and bevacizumab) can decrease the risk of GIB in patients with an LVAD by decreasing arteriovenous malformations. Despite that the overall risk of GIB has decreased with new advancements in LVAD technology, further studies are needed regarding predictors, risk stratification, and optimal antithrombotic therapy to minimize the morbidity and mortality in patients with an LVAD. In conclusion, prompt diagnosis and management in a multidisciplinary team approach are crucial and lifesaving in such a life-threatening condition.

Cardiac Arrest Secondary to Inferior ST-Segment-Elevation Myocardial Infarction in Patient with Paroxysmal Nocturnal Hemoglobinuria and COVID-19 Infection.

Patients with paroxysmal nocturnal hemoglobinuria (PNH) have transient attacks of complement-mediated hemolysis and thrombosis that can be spontaneous or secondary to precipitating factors such as infections. We present a case of a 63-year-old male patient with a medical history of PNH who presented with typical chest pain, fever, cough, jaundice, and dark-colored urine. On examination, he was hemodynamically stable but had conjunctival icterus. A few minutes after presentation, the patient suffered a ventricular fibrillation cardiac arrest and then achieved a return of spontaneous circulation after receiving two defibrillator shocks. EKG showed inferior wall ST-segment elevation myocardial infarction. Labs showed hemoglobin of 6.4 g/dl, elevated cardiac markers, serum lactate dehydrogenase, and indirect bilirubin. Serum haptoglobin was < 1 mg/dl. His COVID-19 polymerase chain reaction test was positive. Immediately, the patient received 2 units of packed RBCs and underwent a coronary angiogram (CA), which revealed total proximal occlusion of the right coronary artery. He underwent successful percutaneous coronary intervention (PCI), and two drug-eluting stents were placed. His peripheral blood immunophenotyping and flow cytometry showed loss of glycosylphosphatidylinositol-linked antigens and decreased expression of CD 59/14/24. He was started on ravulizumab, a humanized monoclonal antibody complement five inhibitor. Both PNH and COVID-19 increase the risk of thrombosis. Endothelial injury and cytokine storm increase the risk of thrombosis in COVID-19 patients, whereas the activation of the coagulation system and the impairment of the fibrinolytic system by complement cascade leads to thrombosis in PNH patients. Regardless of which pathway leads to coronary artery thrombosis, CA and PCI can be life-saving.

Hemophagocytic lymphohistiocytosis in inflammatory bowel disease: a nationwide analysis.

Hemophagocytic lymphohistiocytosis (HLH) is a rare but life-threatening immune dysregulation disease. Patients with inflammatory bowel disease (IBD) can become profoundly immunocompromised due to immunosuppressive therapy, hence increasing the risk of viral infections that can trigger HLH. However, data on the association between IBD and HLH remains limited. We used data from the National Inpatient Sample (2012-2019) utilizing International Classification of Diseases (ICD)-9 or ICD-10 codes to identify individuals with IBD, either Crohn's disease (CD) or ulcerative colitis (UC), and HLH. The primary outcome was to compare the prevalence of HLH among patients with IBD with those without IBD. Secondary outcomes included in-hospital mortality, mean hospital length of stay, and description of HLH-associated triggers in IBD patients. A total of 513,322 hospitalizations included a diagnosis of IBD, 188,297 had UC and 325,025 had CD. Compared to the general population, patients with IBD were older (median age of 52 vs. 49 years, p < 0.05), more likely to be male, and of Asian/Pacific Islander descent, and had a higher median household income. There was also a higher prevalence of liver disease, autoimmune diseases, tobacco abuse, and hypothyroidism (all had p-value of < 0.001) in IBD patients. There were 94 hospitalizations identified with a diagnosis of HLH in IBD patients. Compared to patients without IBD, patients with IBD had increased odds of developing HLH (0.02% vs 0.01%, p-value < 0.001). After adjusting for various demographic characteristics, co-morbidities, and HLH-related conditions, IBD was an independent predictor for developing HLH (adjusted OR, 2.3; 95% CI, 1.847-2.866, p-value of < 0.001). There was no statistical difference between CD and UC in the odds of developing HLH. Compared to IBD patients without HLH, patients with IBD and HLH had a lower mean age at diagnosis (38 vs 52, p-value of < 0.001), higher in-hospital mortality (14.9% vs 1.5%, p-value of < 0.001), and longer mean hospital length of stay (days) (17 vs 5.4, p-value of < 0.001). Prevalence of different HLH-associated illnesses was identified in HLH patient's discharge data. Lymphoma was the most common associated malignancy (18.1%) and cytomegalovirus infection was the most common associated infection (16.0%). Our population-based study suggests that IBD is independently associated with developing HLH. Early recognition of IBD patients presenting with features suggestive of HLH is warranted to aide early diagnosis and aggressive treatment.

Trends and Outcomes of Transcatheter Tricuspid Valve Repair and Surgical Tricuspid Valve Repair in Patients With Tricuspid Valve Regurgitation; A Population Based Study.

Data on clinical outcomes of transcatheter tricuspid valve repair (TTVR) compared with surgical tricuspid valve repair (STVR) in patients with tricuspid valve regurgitation (TVR) remains limited. Data from the national inpatient sample (2016-2020) and propensity-score matched (PSM) analysis was utilized to determine adjusted odds ratio (aOR) of inpatient mortality and major clinical outcomes of TTVR compated with STVR in patients with TVR. A total of 37,115 patients with TVR were included: 1830 (4.9%) and 35,285 (95.1%) underwent TTVR and STVR, respectively. After PSM, there was no statistically significant difference in baseline characteristics and medical comorbidities between both groups. Compared with STVR, TTVR was associated with lower inpatient mortality (aOR 0.43 [0.31-0.59], P < 0.01), cardiovascular complications (aOR 0.47 [0.3-0.45], P < 0.01), hemodynamic complications (aOR 0.47 [0.4-0.55], P < 0.01), infectious complications (aOR 0.44 [0.34-0.57], P < 0.01), renal complications (aOR 0.56 [0.45-0.64], P < 0.01), and need for blood transfusion. There was no statistically significant difference in odds of major bleeding events (aOR 0.92 [0.64-1.45], P 0.84). Also, TTVR was associated with less mean length of stay (7 days vs 15 days, P < 0.01) and less cost of hospitalization ($59,921 vs $89,618) compared with STVR. There was an increase in the utility of TTVR associated with a decrease in the utility of STVR from 2016 to 2020 (P < 0.01). Our study showed that compared with STVR, TTVR was associated with lower inpatient mortality and clinical events. Nevertheless, further studies are needed to investigate the difference in outcomes between both procedures.

Relapsed chronic lymphocytic leukemia with a cardiac mass: A case report.

Chronic lymphocytic leukemia (CLL) is the most common hematological malignancy in the USA. Extra-medullary disease is very rare and is not well characterized. In practice, clinically significant cardiac or pericardial involvement by CLL is extremely rare with only a few case reports in literature. We report a 51-year-old male patient with a past medical history of CLL in remission, who presented with fatigue, dyspnea on exertion, night sweats and left supraclavicular lymphadenopathy. Laboratory investigations were notable for leukopenia and thrombocytopenia. Due to high suspicion of an underlying malignant process, a full body computerized tomography (CT) scan was obtained and showed an 8.8 cm soft tissue mass-like lesion occupying the majority of the right atrium and extending into the right ventricle, with probable pericardial involvement. Enlarged left supraclavicular and mediastinal lymph nodes were also present and had a mild mass effect on the traversing left internal thoracic artery and left pulmonary artery. A transesophageal echocardiogram and cardiac magnetic resonance imaging (MRI) were done to better characterize the cardiac mass. They confirmed a large infiltrating mass (measuring 10 × 7.4 cm) in the right atrium and ventricle, extending into the inferior vena cava inferiorly and coronary sinus posteriorly. A left supraclavicular excisional lymph node biopsy was performed and histopathology was consistent with Small Lymphocytic Lymphoma (SLL)/CLL. This case represents one of the few known cases of cardiac extramedullary-CLL presenting with an isolated cardiac mass. Further studies are needed to characterize the course of the disease, prognosis and optimum management along with the role of surgery.

Predictors of Mortality in Patients With Refractory Cardiac Arrest Supported With VA-ECMO: A Systematic Review and a Meta-Analysis.

Cardiac arrest (CA) is associated with high mortality rate, ranging between 75% and 93%. Given its significance, venoarterial extracorporeal membrane oxygenation (VA-ECMO) has been used for end-organs perfusion and to maintain adequate oxygenation as a life-saving option in refractory CA. The predictors for the success of VA-ECMO in this setting have not been established yet. In this meta-analysis, we aim to identify the variables associated with increased mortality in patients with CA supported with VA-ECMO. We conducted a systematic review and meta-analysis to evaluate mortality-predicting factors in patients with CA supported with VA-ECMO that were published between January 2000 and July 2022. To identify relevant articles, the MEDLINE (Pubmed, Ovid) and Cochrane Databases were queried with various combinations of our prespecified keywords, including VA-ECMO, CA, and mortality predictors. We performed a meta-analysis using a random-effects model to calculate the odds ratio (OR). We retrieved a total of 4476 records, out of which we included 10 observational studies in our study. A total of 931 patients were included in our study with the age range of 47-68 years, predominantly males (63.9%). The overall mortality was 69.4%. The predictors for mortality were age >65 (OR 4.61, 95% CI 1.63-13.03, P < 0.01), history of chronic kidney disease (OR 2.42, 95% CI 1.37-4.28, P < 0.01), cardiopulmonary resuscitation duration prior to ECMO > 40 minutes (OR 6.62 [95% CI 1.39, 9.02], P < 0.01), having an initial nonshockable rhythm (OR 2.62 [95% CI 1.85, 3.70], P < 0.01) and sequential organ failure assessment score >14 (OR 12.29, 95% CI 2.71-55.74, P <0.01). Regarding blood work, an increase in lactate by 5 mmol/L increased the odds of mortality by 121% (2 studies; OR 2.21 [95% CI 1.26, 3.86], P < 0.01; I2 = 0%) while the increase in lactate by 1 mmol/L increases odd of mortality by 15% (2 studies, OR 1.15 [95% CI 1.02, 1.31], P = 0.03, I = 0%), and an increase in creatinine by 1 mg/dL increased the odds of mortality by 225% (1 study; OR 3.25 [95% CI 1.22, 8.7], P = 0.02). Albumin was protective as for each 1 g/dL increase, the odds of mortality decreased by 68% (1 study; OR 0.32 [95% CI 0.14, 0.74], P < 0.01). Refractory CA requiring VA-ECMO has a high mortality. Predictors of mortality include age >65, history of chronic kidney disease, cardiopulmonary resuscitation duration prior to ECMO > 40 minutes, initial rhythm being non-shockable and Sequential Organ Failure Assessment score >14.

Pediatric ventriculoperitoneal shunt: a comparative study between anterior fontanel ultrasound-guided versus conventional cranial end insertion.

PURPOSE: Ventriculoperitoneal (V-P) shunt is one of the most common neurosurgical procedures in pediatrics for the treatment of hydrocephalus. Shunt failure is one of the common mechanical complications which lead to major morbidities. This study aims to compare between cranial part insertions of the V-P shunts guided by trans-anterior fontanel ultrasound versus conventional insertion. METHODS: A prospective comparative randomized study was conducted on 60 pediatric patients aged ≤ 2 years who suffered hydrocephalus and allocated into 2 groups. In the first group (n = 30), the cranial parts of the ventriculoperitoneal shunts were inserted guided by trans-anterior fontanel ultrasound, and in the second group (n = 30), the insertions were by the conventional method. The follow-up duration of the patients was 3 months. RESULTS: Proximal part obstruction of the V-P shunt was found in 3 cases of the conventional group during follow-up with statistical insignificance (p = 0.237) while adequate proximal part location recorded statistical significance (p = 0.0005) in favor of ultrasound-guided group. CONCLUSION: The use of the anterior fontanel ultrasound guide during ventriculoperitoneal shunt insertion is a feasible, safe, and effective technique for the placement of ventricular catheters in pediatric patients with a patent anterior fontanel.

Micro-RNA 18b and interleukin 17A profiles in relapsing remitting multiple sclerosis.

BACKGROUND: The involvement of micro RNAs (miRNAs) in multiple sclerosis (MS) has been recently explored. Up-regulated miRNAs may play critical roles in MS pathogenesis and may be used as a signature for MS. Besides, the role of inflammatory cytokines has been long established with recent focus on interleukin-17 (IL-17). OBJECTIVE: To evaluate the level of expression miR-18b in relation to IL-17A in relapsing remitting (RR) MS patients during relapse and remission SUBJECTS AND METHODS: Twenty-eight RRMS patients and 26 age and sex matched control subjects were included. Serum miR-18b was assessed by quantitative real-time PCR, and serum level of IL-17A was measured by ELISA. RESULTS: Serum miR-18b expression was higher in relapse compared with remission and with controls (24.8 ±â€¯21.91 vs 2.49 ±â€¯0.97 vs 1 ±â€¯0.36 respectively; P < 0.001). Serum IL-17Awas higher in MS patients during relapse than during remission and controls (8.49 ±â€¯1.26 vs 5.78 ±â€¯2.27 vs 4.18 ±â€¯2.13, respectively; P < 0.001). No correlations existed between miR-18 and IL-17 in MS patients during relapse (r = 0.35; P = 0.22) or remission (r = 0.340; P = 0.234). CONCLUSION: Upregulation of miR-18 during relapse in patients with RRMS points to a possible contribution to the pathogenesis of the inflammatory process in MS. The lack of a significant correlation between upregulated miR-18 and IL-17A implicates that the influence of miR-18 may be exhibited via another inflammatory pathway.

Effect of whole body vibration on leg muscle strength after healed burns: a randomized controlled trial.

OBJECTIVE: To investigate the effects of eight weeks whole body vibration training program on leg muscle strength (force-producing capacity) in adults after healed burns. DESIGN: Randomized controlled trial. SETTING: Faculty of Physical Therapy, Cairo University. SUBJECTS: Thirty-one burned patients participated in the study and were randomized into whole body vibration group and control group. Non-burned healthy adults were assessed similarly to burned subjects and served as matched healthy controls. METHODS: The whole body vibration group performed an eight weeks vibration program three times a week on a vibration platform; the control group received home based physical therapy program without vibration training. MAIN MEASURES: Assessment of knee extensors and ankle planter flexor strength by isokinetic dynamometer at 150°/s were performed at the beginning of the study and at the end of the training period for both groups. RESULTS: Subjects with burns more than 36% TBSA produced significantly less torque in the quadriceps and calf muscle than non-burned healthy subjects. Patients in whole body vibration group showed a significant improvement in knee extensor and ankle planter flexor strength as compared with those in the control group. Knee extensor strength and percent improvement was 233.40±5.74 (64.93±3.03 change score) and 38.54% for the vibration group and 190.07±3.99 (21.66±4.41 change score) and 12.86% for the control group, ankle plantar flexor strength and percent improvement was 156.27±5.95 (54.53±6.16 change score) and 53.70% for the vibration group and 116.13±3.24 (14.66±2.71 change score) and 14.52% for the control group. CONCLUSIONS: Participation in whole body vibration program resulted in a greater improvement in quadriceps and calf muscle strength in adults with healed thermal burn compared to base line values; a WBV program is an effective for strength gain in rehabilitation of burned patients.

Re-engineering pre-employment check-up systems: a model for improving health services.

PURPOSE: The purpose of this paper is to develop a model for improving health services provided by the pre-employment medical fitness check-up system affiliated to Egypt's Health Insurance Organization (HIO). DESIGN/METHODOLOGY/APPROACH: Operations research, notably system re-engineering, is used in six randomly selected centers and findings before and after re-engineering are compared. The re-engineering model follows a systems approach, focusing on three areas: structure, process and outcome. The model is based on six main components: electronic booking, standardized check-up processes, protected medical documents, advanced archiving through an electronic content management (ECM) system, infrastructure development, and capacity building. The model originates mainly from customer needs and expectations. FINDINGS: The centers' monthly customer flow increased significantly after re-engineering. The mean time spent per customer cycle improved after re-engineering--18.3 +/- 5.5 minutes as compared to 48.8 +/- 14.5 minutes before. Appointment delay was also significantly decreased from an average 18 to 6.2 days. Both beneficiaries and service providers were significantly more satisfied with the services after re-engineering. The model proves that re-engineering program costs are exceeded by increased revenue. RESEARCH LIMITATIONS/IMPLICATIONS: Re-engineering in this study involved multiple structure and process elements. The literature review did not reveal similar re-engineering healthcare packages. Therefore, each element was compared separately. PRACTICAL IMPLICATIONS: This model is highly recommended for improving service effectiveness and efficiency. ORIGINALITY/VALUE: This research is the first in Egypt to apply the re-engineering approach to public health systems. Developing user-friendly models for service improvement is an added value.