Monopolar diathermy versus a vessel-sealing device for reducing postoperative drain output after simple mastectomy: randomized clinical trial.

BACKGROUND: Electrosurgical devices are commonly used during mastectomy for simultaneous dissection and haemostasis, and can provide potential benefits regarding vessel and lymphatic ligation. The aim of this prospective RCT was to assess whether using a vessel-sealing device (LigaSure™) improves perioperative outcomes compared with monopolar diathermy when performing simple mastectomy. METHODS: Patients were recruited prospectively and randomized in a 1 : 1 manner to undergo simple mastectomy using either LigaSure™ or conventional monopolar diathermy at a single centre. The primary outcome was the number of days the drain remained in situ after surgery. Secondary outcomes of interest included operating time and complications. RESULTS: A total of 86 patients were recruited (42 were randomized to the monopolar diathermy group and 44 were randomized to the LigaSure™ group). There was no significant difference in the mean number of days the drain remained in situ between the monopolar diathermy group and the LigaSure™ group (7.75 days versus 8.23 days; P = 0.613) and there was no significant difference in the mean total drain output between the monopolar diathermy group and the LigaSure™ group (523.50 ml versus 572.80 ml; P = 0.694). In addition, there was no significant difference in the mean operating time between the groups, for simple mastectomy alone (88.25 min for the monopolar diathermy group versus 107.20 min for the LigaSure™ group; P = 0.078) and simple mastectomy with sentinel lymph node biopsy (107.20 min for the monopolar diathermy group versus 114.40 min for the LigaSure™ group; P = 0.440). CONCLUSION: In this double-blinded single-centre RCT, there was no difference in the total drain output or the number of days the drain remained in situ between the monopolar diathermy group and the LigaSure™ group. REGISTRATION NUMBER: EudraCT 2018-003191-13 BEAUMONT HOSPITAL REC 18/66.

Health economic evaluation of blended collaborative care for older multimorbid heart failure patients: study protocol.

BACKGROUND: Integrated care, in particular the 'Blended Collaborative Care (BCC)' strategy, may have the potential to improve health-related quality of life (HRQoL) in multimorbid patients with heart failure (HF) and psychosocial burden at no or low additional cost. The ESCAPE trial is a randomised controlled trial for the evaluation of a BCC approach in five European countries. For the economic evaluation of alongside this trial, the four main objectives were: (i) to document the costs of delivering the intervention, (ii) to assess the running costs across study sites, (iii) to evaluate short-term cost-effectiveness and cost-utility compared to providers' usual care, and (iv) to examine the budgetary implications. METHODS: The trial-based economic analyses will include cross-country cost-effectiveness and cost-utility assessments from a payer perspective. The cost-utility analysis will calculate quality-adjusted life years (QALYs) using the EQ-5D-5L and national value sets. Cost-effectiveness will include the cost per hospital admission avoided and the cost per depression-free days (DFD). Resource use will be measured from different sources, including electronic medical health records, standardised questionnaires, patient receipts and a care manager survey. Uncertainty will be addressed using bootstrapping. DISCUSSION: The various methods and approaches used for data acquisition should provide insights into the potential benefits and cost-effectiveness of a BCC intervention. Providing the economic evaluation of ESCAPE will contribute to a country-based structural and organisational planning of BCC (e.g., the number of patients that may benefit, how many care managers are needed). Improved care is expected to enhance health-related quality of life at little or no extra cost. TRIAL REGISTRATION: The study follows CHEERS2022 and is registered at the German Clinical Trials Register (DRKS00025120).

Lifecycle evaluation of medical devices: supporting or jeopardizing patient outcomes? A comparative analysis of evaluation models.

OBJECTIVES: Lack of evidence regarding safety and effectiveness at market entry is driving the need to consider adopting a lifecycle approach to evaluating medical devices, but it is unclear what lifecycle evaluation means. This research sought to explore the tacit meanings of "lifecycle" and "lifecycle evaluation" as embodied within evaluation models/frameworks used for medical devices. METHODS: Drawing on qualitative evidence synthesis methods and using an inductive approach, novel methods were developed to identify, appraise, analyze, and synthesize lifecycle evaluation models used for medical devices. Data was extracted (including purpose; audience; characterization; outputs; timing; and type of model) from key texts for coding, categorization, and comparison, exploring embodied meaning across four broad perspectives. RESULTS: Fifty-two models were included in the synthesis. They demonstrated significant heterogeneity of meaning, form, scope, timing, and purpose. The "lifecycle" may represent a single stage, a series of stages, a cycle of innovation, or a system. "Lifecycle evaluation" focuses on the overarching goal of the stakeholder group, and may use a single or repeated evaluation to inform decision-making regarding the adoption of health technologies (Healthcare), resource allocation (Policymaking), investment in new product development or marketing (Trade and Industry), or market regulation (Regulation). The adoption of a lifecycle approach by regulators has resulted in the deferral of evidence generation to the post-market phase. CONCLUSIONS: Using a "lifecycle evaluation" approach to inform reimbursement decision-making must not be allowed to further jeopardize evidence generation and patient safety by accepting inadequate evidence of safety and effectiveness for reimbursement decisions.

Health-related quality of life in patients with diabetic foot ulcers in the Arab world: a systematic review.

OBJECTIVE: To conduct a systematic review to identify the impact of diabetic foot ulceration (DFU) on health-related quality of life (HRQoL) in individuals within the Arab world. METHOD: A PRISMA-guided systematic search for HRQoL studies in Arab populations was conducted in CINAHL, PubMed, Scopus and EBSCO. Relevant studies were critically appraised using the STROBE statement checklist. RESULTS: A total of five studies were included. Three studies originated from Saudi Arabia, one from Jordan and one from Tunisia. The studies consistently demonstrated lower (poorer) HRQoL in patients with DFU, and worse HRQoL compared with both patients with diabetes and no DFU, and with healthy subjects. CONCLUSION: This review confirmed the negative impact of DFU on HRQoL in individuals with diabetes. It also highlights the scarcity of HRQoL studies from the Arab world. However, given that all studies included were conducted between 2013-2019, this could reflect a growing interest in DFU and HRQoL in the Arab world, and could potentially indicate that more studies will follow. In light of this, there is a need for a renewed focus on the completion of a high-quality standardised approach to research in this region.

Treatment of inborn errors of immunity patients with inflammatory bowel disease phenotype by allogeneic stem cell transplantation.

Patients with inborn errors of immunity (IEI) can suffer from treatment-refractory inflammatory bowel disease (IBD) causing failure to thrive and consequences of long-term multiple immunosuppressive treatments. Allogeneic haematopoietic stem cell transplantation (alloHSCT) can serve as a curative treatment option. In this single-centre retrospective cohort study we report on 11 paediatric and young adult IEI patients with IBD and failure to thrive, who had exhausted symptomatic treatment options and received alloHSCT. The cohort included chronic granulomatous disease (CGD), lipopolysaccharide-responsive and beige-like anchor protein (LRBA) deficiency, STAT3 gain-of-function (GOF), Wiskott-Aldrich syndrome (WAS), dedicator of cytokinesis 8 (DOCK8) deficiency and one patient without genetic diagnosis. All patients achieved stable engraftment and immune reconstitution, and gastrointestinal symptoms were resolved after alloHSCT. The overall survival was 11/11 over a median follow-up of 34.7 months. Graft-versus-host disease (GVHD) was limited to grade I-II acute GVHD (n = 5), one case of grade IV acute GVHD and one case of limited chronic GVHD. Since treatment recommendations are limited, this work provides a centre-specific approach to treatment prior to transplant as well as conditioning in IEI patients with severe IBD.

Costs associated with adverse drug reactions in an older population admitted to hospital: a prospective cohort study.

PURPOSE: This study examines healthcare costs associated with adverse drug reactions (ADR) in an older population admitted acutely to an Irish tertiary hospital. METHODS: Prospective cohort study involving older persons admitted to hospital with and without an ADR. Data was collected at baseline, during hospitalisation and post-discharge. Participants provided information on healthcare resource use three months before admission (baseline) and three months after discharge (follow-up). For each healthcare resource, unit costs were derived and applied. The average cost (standard deviation (SD)) associated with the hospital admission for the ADR and non-ADR are presented. In addition, baseline and follow-up care costs were compared using difference-in-difference analysis and presented with 95% confidence intervals (CI). Costs by preventability and severity of ADR are also presented. RESULTS: A total of n = 230 participants were included (n = 93 ADR and n = 137 without ADR). The average cost associated with hospital admission for an ADR was €9538 (SD €10442) and €9828 (SD €11770) for non-ADR. The additional follow-up costs (difference-in-difference) associated with the ADR was estimated at €2047 (95% CI: -€889 to €4983). The mean incremental follow-up cost of definite preventable ADRs was estimated at €1648 (95% CI: -€4310 to €7605), possible preventable ADRs €2259 (95 CI: -€1194 to €5712) and unavoidable ADRs €1757 (95% CI: -€3377 to €6890). The mean incremental follow-up cost associated with moderate severe ADRs was estimated at €1922 (95% CI: -€1088 to €4932) and €3580 (95% CI: -€4898 to €12,058) for severe ADRs.  CONCLUSION: ADRs leading to hospital admission are associated with modest incremental healthcare costs during and three months after admission. Severe and possibly preventable ADRs were associated with higher costs.

To develop, implement and evaluate an integrated care pathway for patients presenting with pneumothorax.

BACKGROUND AND PURPOSE: Pneumothorax is a common presentation to acute healthcare services in Ireland, however there is wide variation in management approaches between centres. There is robust evidence to demonstrate that ambulatory management of pneumothorax is feasible and safe. The purpose of this study was to evaluate whether the implementation of an integrated care pathway (ICP) for pneumothorax patients with a focus on ambulatory care would be economically beneficial for the healthcare system. METHODS: This study developed, implemented and evaluated an ICP for all patients presenting with pneumothorax, with a specific focus on ambulatory management for suitable patients. The ICP was designed to be utilised in the Irish healthcare setting, and was evaluated using a prospective multi-centre observational study, with a rigorous economic analysis at the centre of study design. MAIN FINDINGS: Implementation of the ICP resulted in a statistically significant reduction in inpatient length of stay of 2.84 days from 7.4 to 4.56 days (p = 0.001). The incremental per patient cost reduction of treating a patient according to the pneumothorax ICP was 2314 euro. There were no adverse events related to drain insertion at the study sites. CONCLUSIONS: This study demonstrates therefore that standardisation of care for pneumothorax patients with a focus on ambulatory management are economically beneficial for the publicly-funded healthcare service. It is envisaged that this work will be used to inform healthcare policy at a national level across Ireland.

The health-related quality of life in patients with diabetic foot ulcers in the Kingdom of Bahrain.

AIMS: The aims of this study were to assess the health-related quality of life (HRQoL) of adult Bahraini patients with diabetic foot ulcers (DFU) and to explore factors associated with poor HRQoL. METHODS: Cross-sectional HRQoL data were obtained from a sample of patients in active treatment for DFU at a large public hospital in Bahrain. Patient-reported HRQOL was measured using the following instruments: DFS-SF, CWIS and EQ-5D. RESULTS: The patient sample included 94 patients, with a mean age of 61.8 (SD: 9.9) years, 54 (57.5%) were males, and 68 (72.3%) were native Bahrainis. Poorer HRQoL was found among patients who were unemployed, divorced/widowed, and those with a shorter duration of formal education. Additionally, patients with severe DFUs, persisting ulcers, and a longer duration of diabetes reported statistically significantly poorer HRQoL. CONCLUSIONS: Findings from this study demonstrate a low level of HRQoL among Bahraini patients with DFUs. A longer duration of diabetes, in addition to ulcer severity and status statistically significantly influence HRQoL.

Assessing the healthcare costs associated with venous leg ulcer compression bandages - A scoping review.

AIM: To determine the monetary costs identified in economic evaluations of treatment with compression bandages among adults with venous leg ulcers (VLU). METHOD: A scoping review of existing publications was conducted in February 2023. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used. RESULTS: Ten studies met the inclusion criteria. To place the costs of treatment into context, these are reported in conjunction with the healing rates. Three comparisons were made: 1.4 layer compression versus no compression (3 studies). One study reported that 4 layer compression was more expensive than usual care (£804.03 vs £681.04, respectively), while the 2 other studies reported the converse (£145 vs £162, respectively) and all costs (£116.87 vs £240.28 respectively). Within the three studies, the odds of healing were statistically significantly greater with 4 layer bandaging (OR: 2.20; 95% CI: 1.54-3.15; p = 0.001).; 2.4 layer compression versus other compression (6 studies). For the three studies reporting the mean costs per patient associated with treatment (bandages alone), over the treatment period, analysis identified a mean difference (MD) in costs for 4 layer vs comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) of -41.60 (95% CI: 91.40 to 8.20; p = 0.10). The OR of healing for 4 layer compression vs comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) is: 0.70 (95% CI: 0.57-0.85; p = 0.004). For 4 layer vs comparator 2 (2 layer compression) the MD is: 14.00 (95% CI: 53.66 to -25.66; p < 0.49). The OR of healing for 4 layer compression vs comparator 2 (2 layer compression) is: 3.26 (95% CI: 2.54-4.18; p < 0.00001). For comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) vs comparator 2 (2 layer compression) the MD in costs is: 55.60 (95% CI: 95.26 to -15.94; p = 0.006). The OR of healing with Comparator 1 (2 layer compression, short-stretch compression, 2 layer compression hosiery, 2 layer cohesive compression, 2 layer compression) is: 5.03 (95% CI:4.10-6.17; p < 0.00001). Three studies presented the mean annual costs per patient associated with treatment (all costs). The MD is 172 (150-194; p = 0.401), indicating no statistically significant difference in costs between the groups. All studies showed faster healing rates in the 4 layer study groups. 3. Compression wrap versus inelastic bandage (one study). Compression wrap was less expensive than inelastic bandage (£201 vs £335, respectively) with more wounds healing in the compression wrap group (78.8%, n = 26/33; 69.7%, n = 23/33). CONCLUSION: The results for the analysis of costs varied across the included studies. As with the primary outcome, the results indicated that the costs of compression therapy are inconsistent. Given the methodological heterogeneity among studies, future studies in this area are needed and these should use specific methodological guidelines to generate high-quality health economic studies.

A comparison of four quasi-experimental methods: an analysis of the introduction of activity-based funding in Ireland.

BACKGROUND: Health services research often relies on quasi-experimental study designs in the estimation of treatment effects of a policy change or an intervention. The aim of this study is to compare some of the commonly used non-experimental methods in estimating intervention effects, and to highlight their relative strengths and weaknesses. We estimate the effects of Activity-Based Funding, a hospital financing reform of Irish public hospitals, introduced in 2016. METHODS: We estimate and compare four analytical methods: Interrupted time series analysis, Difference-in-Differences, Propensity Score Matching Difference-in-Differences and the Synthetic Control method. Specifically, we focus on the comparison between the control-treatment methods and the non-control-treatment approach, interrupted time series analysis. Our empirical example evaluated the length of stay impact post hip replacement surgery, following the introduction of Activity-Based Funding in Ireland. We also contribute to the very limited research reporting the impacts of Activity-Based-Funding within the Irish context. RESULTS: Interrupted time-series analysis produced statistically significant results different in interpretation, while the Difference-in-Differences, Propensity Score Matching Difference-in-Differences and Synthetic Control methods incorporating control groups, suggested no statistically significant intervention effect, on patient length of stay. CONCLUSION: Our analysis confirms that different analytical methods for estimating intervention effects provide different assessments of the intervention effects. It is crucial that researchers employ appropriate designs which incorporate a counterfactual framework. Such methods tend to be more robust and provide a stronger basis for evidence-based policy-making.

Association of cause of uremia with degree of iliac artery calcification.

OBJECTIVES: We aimed to investigate whether the cause of uremia is associated with degree of calcification, and to report the proportion excluded from kidney transplantation due to iliac artery calcification. METHOD: We enrolled 306 patients with a pre-transplant computed tomography scan who went through the comprehensive assessment program in 2013-2015. Calcification score was measured for each iliac artery segment and patient records viewed for a variety of variables. Interobserver variation was assessed for 135 paired observations. RESULTS: The patients' mean age was 55.5 years. Of the 306 patients, 133 did not undergo transplantation, and for 21 of these, heavy calcification was the primary explanation for this. External iliac artery calcification was positively associated with male sex, age, systolic blood pressure, diabetes and cardiovascular disease, and differed significantly among the causes of uremia subgroups; the least calcification was seen in patients with autoimmune causes, and the highest in those with diabetic causes. Similarly, the proportion of patients who underwent renal transplantation differed significantly with regard to causes of uremia (ranging from 72.3% for autoimmune disease to 40.6% for diabetic nephropathy). CONCLUSION: The degree of iliac artery calcification differs according to the cause of uremia and influences the likelihood of receiving a kidney transplantation.

A Randomized Clinical Trial Evaluating the Efficacy and Quality of Life of Antibiotic-only Treatment of Acute Uncomplicated Appendicitis: Results of the COMMA Trial.

OBJECTIVE: Evaluate the efficacy and quality of life associated with conservative treatment of acute uncomplicated appendicitis. SUMMARY BACKGROUND DATA: Conservative management with antibiotics only has emerged as a potential treatment option for acute uncomplicated appendicitis. However the reported failure rates are highly variable and there is a paucity of data in relation to quality of life. METHODS: Symptomatic patients with radiological evidence of acute, uncomplicated appendicitis were randomized to either intravenous antibiotics only or undergo appendectomy. RESULTS: One hundred eighty-six patients underwent randomization. In the antibiotic-only group, 23 patients (25.3%) experienced a recurrence within 1 year following randomization. There was a significantly better EQ-VAS quality of life score in the surgery group compared with the antibiotic-only group at 3 months (94.3 vs 91.0, P < 0.001) and 12 months postintervention (94.5 vs 90.4, P < 0.001). The EQ-5D-3L quality-of-life score was significantly higher in the surgery group indicating a better quality of life (0.976 vs 0.888, P < 0.001). The accumulated 12-month sickness days was 3.6 days shorter for the antibiotics only group (5.3 vs 8.9 days; P < 0.01). The mean length of stay in both groups was not significantly different (2.3 vs 2.8 days, P = 0.13). The mean total cost in the surgery group was significantly higher than antibiotics only group (€4,816 vs €3,077, P < 0.001). CONCLUSIONS: Patients with acute, uncomplicated appendicitis treated with antibiotics only experience high recurrence rates and an inferior quality of life. Surgery should remain the mainstay of treatment for this commonly encountered acute surgical condition.

Neoadjuvant Short-Course Radiotherapy for Upper Third Rectal Tumors: Systematic Review and Individual Patient Data Metaanalysis of Randomized Controlled Trials.

BACKGROUND: There is no consensus on the use of neoadjuvant radiotherapy for tumors of the upper third of the rectum. Due to conflicting findings in high-quality trials and significant long-term side effects associated with neoadjuvant radiotherapy, the benefit of neoadjuvant radiotherapy for upper third rectal tumors is less certain than for lower two third rectal tumors. This metaanalysis compares oncological outcomes with neoadjuvant radiotherapy and surgery versus surgery alone for upper third rectal tumors. PATIENTS AND METHODS: PubMed, Embase, and the Cochrane library databases were searched. Randomized controlled trials (RCT) comparing neoadjuvant radiotherapy and surgery versus surgery alone for resectable rectal cancer were included. Individual patient data were sought from the principal investigator of each eligible trial for comparative data on patients with upper third rectal tumors. The main outcomes measured were survival outcomes, oncological outcomes, postoperative morbidity, and late toxicity. RESULTS: Individual patient data from two RCTs examining outcomes in 758 patients were obtained. Published data from one further RCT containing comparable data on upper third rectal tumors were included in analysis of local recurrence. In patients with curative surgery, there was no significant reduction in local recurrence or significant improvement in overall survival or disease-free survival with neoadjuvant radiotherapy (LR RR: 0.38, 95% CI 0.14-1.04, p = 0.06) (OS RR: 1.10, 95% CI 0.98-1.24, p = 0.11) (DFS RR: 1.11, 95% CI 0.97-1.26, p = 0.13). CONCLUSIONS: The benefit of neoadjuvant radiotherapy for upper third rectal tumors is not certain, and surgery alone for patients with potentially curative disease at preoperative staging may be sufficient.

Hybrid Systematic Review and Network Meta-Analysis of Randomized Controlled Trials of Interventions for Depressive Symptoms in Patients With Coronary Artery Disease.

OBJECTIVE: Depression is common in patients with coronary artery disease (CAD) and is associated with poor outcomes. Although different treatments are available, it is unclear which are best or most acceptable to patients, so we conducted a network meta-analysis of evidence from randomized controlled trials (RCTs) of different depression treatments to ascertain relative efficacy. METHODS: We searched for systematic reviews of RCTs of depression treatments in CAD and updated these with a comprehensive search for recent individual RCTs. RCTs comparing depression treatments (pharmacological, psychotherapeutic, combined pharmacological/psychotherapeutic, exercise, collaborative care) were included. Primary outcomes were acceptability (dropout rate) and change in depressive symptoms 8 week after treatment commencement. Change in 26-week depression and mortality were secondary outcomes. Frequentist, random-effects network meta-analysis was used to synthesize the evidence, and evidence quality was evaluated following Grading of Recommendations, Assessment, Development and Evaluations recommendations. RESULTS: Thirty-three RCTs (7240 participants) provided analyzable data. All treatments were equally acceptable. At 8 weeks, combination therapy (1 study), exercise (1 study), and antidepressants (10 studies) yielded the strongest effects versus comparators. At 26 weeks, antidepressants were consistently effective, but psychotherapy was only effective versus usual care. There were no differences in treatment groups for mortality. Grading of Recommendations, Assessment, Development and Evaluations ratings ranged from very low to low. CONCLUSIONS: Overall, the evidence was limited and biased. Although all treatments for post-CAD depression were equally acceptable, antidepressants have the most robust evidence base and should be the first-line treatment. Combinations of antidepressants and psychotherapy, along with exercise, could be more effective than antidepressants alone but require further rigorous, multiarm intervention trials.Systematic Review Registration: CRD42018108293 (International Prospective Register of Systematic Reviews).

Costing pressure ulcer care in an Irish acute care setting: a feasibility study.

OBJECTIVE: To test the feasibility of using a standardised data collection tool to estimate the cost of stage 2-4 pressure ulcer (PU) care within an acute care setting. METHOD: Data on resource use and cost were obtained through a retrospective survey of nursing and medical notes collecting cost data for individual patients who received care for stage 2-4 PUs. RESULTS: Data for 20 patients (12 male/8 female) were analysed. The average patient age was 69 years (range: 37-95 years). Of this sample, seven patients had hospital-acquired PUs (HAPUs) and 14 patients had community-acquired PUs (CAPU) (one patient had both-in different anatomical areas). Over half of the total sample (55%; n=11) had a stage 2 PU. The average length of stay was 31.8 days (range: 5-119 days). Most of the patients (70%; n=14) had a CAPU. The average cost per patient with PU care was €878 (range: €39-2393). The mean cost for patients with a HAPU was €866 (SD: €1313) versus €911 (SD: €567) for patients with a CAPU. The majority of the cost related to equipment and staff time for treatment. CONCLUSION: Overall, the application of the standardised data collection tool to obtain cost data from retrospective inspection of nursing and medical notes is feasible. The cost of PU care in this sample was high, indicating that these wounds may impose a substantial burden on health systems. The costs varied greatly between patients in the sample, reflecting the complexity of PU care. Furthermore, given that costs increased with the higher PU stages, there is a potential to reduce costs by preventing the development of higher stage PUs. Larger-scale studies are required to understand the cost variation and full economic impact of PU care. DECLARATION OF INTEREST: The authors have no conflicts of interest.

Systematic review and meta-analysis of factors which reduce the length of stay associated with elective laparoscopic cholecystectomy.

BACKGROUND: Laparoscopic cholecystectomy is a safe ambulatory procedure in appropriately selected patients; however, day case rates remain low. The objective of this systematic review and meta-analysis was to identify interventions which are effective in reducing the length of stay (LOS) or improving the day case rate for elective laparoscopic cholecystectomy. METHODS: Comparative English-language studies describing perioperative interventions applicable to elective laparoscopic cholecystectomy in adult patients and their impact on LOS or day case rate were included. RESULTS: Quantitative data were available for meta-analysis from 80 studies of 10,615 patients. There were an additional 17 studies included for systematic review. The included studies evaluated 14 peri-operative interventions. Implementation of a formal day case care pathway was associated with a significantly shorter LOS (MD = 24.9 h, 95% CI, 18.7-31.2, p < 0.001) and an improved day case rate (OR = 3.5; 95% CI, 1.5-8.1, p = 0.005). Use of non-steroidal anti-inflammatories, dexamethasone and prophylactic antibiotics were associated with smaller reductions in LOS. CONCLUSION: Care pathway implementation demonstrated a significant impact on LOS and day case rates. A limited effect was noted for smaller independent interventions. In order to achieve optimal day case targets, a greater understanding of the effective elements of a care pathway and local barriers to implementation is required.

"It means so much for me to have a choice": a qualitative study providing first-person perspectives on medication-free treatment in mental health care.

BACKGROUND: In 2016, the Western Norway Regional Health Authority started to integrate more evidence-based psychosocial interventions into the existing mental health care, emphasizing the right for persons with psychosis to choose medication-free treatment. This change emerged from the debate on the effectiveness and adverse effects of the use of antipsychotic medication. Aspects beyond symptom reduction, such as interpersonal relationships, increased understanding of one's own pattern of suffering, hope and motivation, are all considered important for the personal recovery process. METHODS: This study explores whether these aspects were present in users' descriptions of their recovery processes within the medication-free treatment programme in Bergen, Western Norway. We interviewed ten patients diagnosed with psychosis who were eligible for medication-free services about their treatment experiences. Data were analysed using Attride-Stirling's thematic network approach. RESULTS: The findings show a global theme relating to personal recovery processes facilitated by the provision of more psychosocial treatment options, with three organizing subthemes: interpersonal relationships between patients and therapists, the patient's understanding of personal patterns of suffering, and personal motivation for self-agency in the recovery process. Participants described an improved relationship with therapists compared to previous experiences. Integrating more evidence-based psychosocial interventions into existing mental health services facilitated learning experiences regarding the choice of treatment, particularly the discontinuation of medication, and appeared to support participants' increased self-agency and motivation in their personal recovery processes. CONCLUSION: Health care in Norway is perhaps one step closer to optimizing care for people with psychosis, allowing for more patient choice and improving the dialogue and hence the interpersonal relationship between the patient and the therapist. Personal patterns of suffering can be explored within a system aiming to support and have a higher level of acceptance for the discontinuation of medication. Such a system requires personal agency in the treatment regimen, with more focus on personal coping strategies and more personal responsibility for the recovery process.

Discharge outcomes among elderly patients undergoing emergency abdominal surgery: registry study of discharge data from Irish public hospitals.

BACKGROUND: Intra-abdominal emergency surgery is associated with high mortality risk and long length of hospital stay. The objective of this study was to explore variations in surgery rates, the relationship between admission source and discharge destination, and whether the postoperative length of stay was related to nursing home capacity in Irish counties. METHODS: Data on emergency hospital episodes for 2014-18 for patients aged over 65 years with a primary abdominal procedure code were obtained from the National Quality Assurance Improvement System. Data on population and nursing home capacity were obtained from the Central Statistics Office and the Health Information and Quality Authority. Episode rates per 100,000 were estimated for sex and age groups and compared between 26 Irish counties. The association between admission source and discharge destination was explored in terms episode numbers, length of stay and mortality. A negative binomial regression model estimated casemix adjusted excess post-operative length of stay. The correlation between excess post-operative length of stay and nursing home capacity was explored by linear regression. RESULTS: Overall, 4951 hospital episodes were included. The annual surgery rate ranged from 100 episodes per 100,000 65-69 years old to 250 per 100,000 85-89 year old men. 90% of the episodes were admitted from patients' home. Four in five of these patients returned to their home while 12.7% died at hospital. The proportion of episodes where patients returned to their home reduced to two in five for those aged 85-89 years. The post-operative length of stay was 13.6 days longer (p < 0.01) for episodes admitted from home and discharged to nursing home in comparison with episodes discharged home. A negative association (p = 0.08) was found between excess post-operative length of stay and county-level nursing home capacity. CONCLUSIONS: This study provides relevant information to support informed consent to surgery for patients and clinicians and to improve the provision of care to older patients presenting with intra-abdominal emergencies.

Unstimulated apheresis for chimeric antigen receptor manufacturing in pediatric/adolescent acute lymphoblastic leukemia patients.

Autologous unstimulated leukapheresis product serves as starting material for a variety of innovative cell therapy products, including chimeric antigen receptor (CAR)-modified T-cells. Although it may be reasonable to assume feasibility and efficiency of apheresis for CAR-T cell manufacture, several idiosyncrasies of these patients warrant their separate analysis: target cells (mononuclear cells [MNC] and T-cells) are relatively few which may instruct the selection of apheresis technology, low body weight, and, hence, low total blood volume (TBV) can restrict process and product volume, and patients may be in compromised health. We here report outcome data from 46 consecutive leukaphereses in 33 unique pediatric patients performed for the purpose of CD19-CAR-T-cell manufacturing. Apheresis targets of 2×109 MNC/1×109 T-cells were defined by marketing authorization holder specification. Patient weight was 8 to 84 kg; TBV was 0.6 to 5.1 L. Spectra Optia apheresis technology was used. For 23 patients, a single apheresis sufficed to generate enough cells and manufacture CAR-T-cells, the remainder required two aphereses to meet target dose and/or two apheresis series because of production failure. Aphereses were technically feasible and clinically tolerable without serious adverse effects. The median collection efficiencies for MNC and T-cells were 53% and 56%, respectively. In summary, CAR apheresis in pediatric patients, including the very young, is feasible, safe and efficient, but the specified cell dose targets can be challenging in smaller children. Continuous monitoring of apheresis outcomes is advocated in order to maintain quality.

A health inequality impact assessment from reduction in overweight and obesity.

BACKGROUND: In recent years, social differences in overweight and obesity (OWOB) have become more pronounced. Health impact assessments provide population-level scenario evaluations of changes in disease prevalence and risk factors. The objective of this study was to simulate the health effects of reducing the prevalence of overweight and obesity in populations with short and medium education. METHODS: The DYNAMO-HIA tool was used to conduct a health inequality impact assessment of the future reduced disease prevalence (ischemic heart disease (IHD), diabetes, stroke, and multi-morbidity) and changes in life expectancy for the 2040-population of Copenhagen, Denmark (n = 742,130). We simulated an equalized weight scenario where the prevalence of OWOB in the population with short and medium education was reduced to the levels of the population with long education. RESULTS: A higher proportion of the population with short and medium education were OWOB relative to the population with long education. They also had a higher prevalence of cardiometabolic diseases. In the equalized weight scenario, the prevalence of diabetes in the population with short education was reduced by 8-10% for men and 12-13% for women. Life expectancy increased by one year among women with short education. Only small changes in prevalence and life expectancy related to stroke and IHD were observed. CONCLUSION: Reducing the prevalence of OWOB in populations with short and medium education will reduce the future prevalence of cardiometabolic diseases, increase life expectancy, and reduce the social inequality in health. These simulations serve as reference points for public health debates.