Hospital Days Research Articles

Impact on healthcare costs of adding telemedicine to a multidisciplinary disease management program for heart failure: a sub-analysis of the iCOR trial

Abstract Background Impact of telemedicine on heart failure outcomes has shown conflicting results. Little is known about the effect of these programs on mid-term healthcare costs. Purpose To evaluate the cost-efficacy of a comprehensive telemonitoring program within the vulnerable post-discharge period after an acute heart failure admission. Methods The insuficiència cardiaca Optimizació Remota (iCOR) trial was a single-centre, randomized, open-label study designed to evaluate the efficacy of the addition of telemonitoring and teleintervention to a specialized multidisciplinary nurse-led heart failure (HF) program. Adult patients with a recent hospital admission for acute HF and an acceptable social support and cognitive ability were recruited. This sub-analysis evaluates the effect of telemedicine on mid-term healthcare costs, including clinical events, drugs and devices, technology purchase and maintenance, outpatient care, days of hospitalization, procedures and complementary tests. t-test via bootstrap estimation is used to compare differences between the telemedicine (TM) and the usual care (UC) groups. Results 81 patients were assigned to the TM group and 97 patients to the UC group. Mean age was 74 years, more than 50% had HF with preserved ejection fraction and 25% were frail. Baseline characteristics were well-balanced between groups. Among the TM subgroup, adherence was very high (< 1% of missed biometric daily transmissions). During 6 months of follow-up, mean total healthcare cost per patient was 7949 euros (€) in the UC cohort and 4383 € in the TM cohort (relative risk reduction [RRR] of 45%; between-group differences 3546 €, 95% confidence interval 627-6464 €, bootstrap achieved significance level 0.022). This result was consistent across several subgroups (age, sex, frailty, left ventricular ejection fraction, educational level) and mainly driven by a 63% RRR in costs of hospitalization (which accounted for two-thirds of the total costs) in the TM cohort. 20 patients required HF admissions in the TM group, compared to 51 patients in the TM group (p < 0.001). This was associated with a 59% RRR in the need for diagnostic procedures. Total number of days of hospitalization per patient decreased from 12.2 in the UC group to 4.2 days in the TM group (p = 0.003), impelled by a reduction in HF and cardiovascular days of hospital stay. On the contrary, ambulatory care costs increase two-fold in the TM group compared to UC group. Nevertheless, these costs only accounted for a 19% of the total costs. Cost of devices needed to implement TM supposed 698 € per patient. Use of TM was associated with a 355 € increase in the cost of ambulatory neurohormonal treatment for HF. Conclusions TM implementation during the vulnerable phase after an acute HF admission was associated to a 45% RR reduction in mean total healthcare cost per patient. This result was driven by an almost two-thirds decrease in costs of hospitalization.UC and TM total healthcare costs

Verification about the usefulness of early cardiac rehabilitation initiation in patients with congestive heart failure requiring hospitalization

Abstract Background It is a well-known fact that for patients with decompensated congestive heart failure (CHF) who require hospitalization, starting cardiac rehabilitation (CR) early after hospitalization has a positive impact on their clinical course. To maintain their activity and nutritional status through the early mobilization by efficient medical care, we have introduced our own clinical pathway(PATH) for CHF since August 2015. In PATH, the initiation of CR early after admission was stipulated. With PATH introduction, starting time of CR was significantly earlier and the average hospitalization period for CHF cases was also significantly reduced. However, there are still some cases applied PATH who are unable to start CR early after admission for various reasons. Purpose We examined whether the clinical course after admission differs depending on the timing of CR initiation even in CHF cases applied PATH. Methods We enrolled 933 patients admitted with CHF for the first time from August 2015 to July 2023, applied PATH, started physical therapy (PT) as CR, and discharged alive. We divided them into two groups based on when they started PT, Early-group (649 cases: Starting time is within the 3rd hospital day) and the Late-group (284 cases: Starting time is after the 4th hospital day). And we investigated patient background, clinical data at admission, and clinical course after admission for all cases, and examined the differences in each item between the two groups. Results There were no differences in patient characteristics or clinical data at admission between the two groups (Table 1). On the other hand, although there was no difference in the performance rate of each acute treatment between the two groups, the performance duration of each treatment in cases introduced was significantly shorter in Early-group. Furthermore, the average meal (side dish) intake rate on the 2nd to 4th hospital days after admission was significantly higher in Early-group, and the average length of hospitalization was significantly shorter in the Early-group (Figure 1). Conclusions For 8 years, we have strived to begin cardiac rehabilitation interventions early after hospitalization with introduction of our own clinical pathway. However, we found that even with the introduction of the clinical pathway, cardiac rehabilitation was started on or after the 4th hospital day in 30% of all cases. And we found that in these cases, each treatment during the acute phase was prolonged, nutritional intake was inadequate, and the length of hospitalization tended to be prolonged. The delay in initiation of rehabilitation was thought to be related to factors such as the timing of hospitalization (admission on holidays or public holidays) or the location of hospital management (ICU management in severe cases). It seemed necessary to create a system that would allow cardiac rehabilitation to be started flexibly even in such situations.Table1Figure 1

The cost-effectiveness of a digitally enabled telerehabilitation program delivered nationally to patients in Australia

Abstract Introduction Traditionally delivered cardiac rehabilitation (CR) programs have considerable benefits, yet access and participation remains low. Emerging digital health models offer promise in healthcare delivery, but their benefits and impact on healthcare utilization and cost-effectiveness are uncertain. We conducted a cost-effectiveness analysis of a telehealth program with a CR mobile app for post-hospitalization coronary heart disease (CHD) patients. Purpose To assess whether a digitally enabled CR program is cost-effective compared with a propensity matched usual care control group in the Australian health system. Methods Patients were recruited nationally, through a health insurer, following hospitalization for CHD. Participants received weekly telehealth consultations for up to 8 weeks, supplemented by use of an mHealth app. Using administrative private health insurance claims data, we assessed differences in hospital costs, mortality rates and bed days at 12-months post discharge. Incremental cost effectiveness ratios (ICERS) were calculated to determine the cost per deaths prevented and cost per bed days saved for the digital-CR group (n=133) compared with usual care (n=266). Results Among the cohort, 36% lived in regional/rural areas, 70% were male and the mean age was 68 years. The mean total hospital all cause readmission costs at 12-months were $1,488 AUD less in the digital-CR group ($16,411) compared to the usual care group ($17,899). Digital-CR had fewer total hospital days relative to the usual care group (median of 2 vs 3 days) and patients in the digital-CR group had a significantly lower mortality rate at 12-months post discharge. The ICERs were -$337 per 100 patient deaths prevented and -$3,033 per median bed days saved. Conclusion The implementation of a digital-CR program demonstrates cost-effectiveness for patients with CHD when compared to usual care. Thus, advocating for the widespread availability of digital-CR programs as an option for CHD patients following hospital discharge is warranted.

Baseline shock index-creatinine clearance score and long-term mortality after ACS. Results from 24 years of follow-up of the ABC study on heart disease

Abstract Background Shock Index-Creatinine Clearance score (SI-C) is an updated version of the shock index that includes renal function. Recent studies reported its potential as a novel and simple risk stratification tool for predicting in-hospital mortality in acute coronary syndrome (ACS) patients. Purpose To assess the long-term predictive value of baseline SI-C score in patients after ACS. Methods This preliminary prospective analysis included 589 patients with ACS admitted to three Italian hospitals and discharged alive. Baseline clinical and laboratory data were collected within the first 7 hospitalization days and baseline SI-C score was calculated as [(SI×100)-estimated creatinine clearance]. Patients were prospectively followed for 24 years or until death. Results Virtually all patients completed the follow-up, representing 7066 person-years. Patients' mean age was 66±12 years, 70% were males, and 482(82%) had died during follow-up. Compared to those who survived, deceased patients were significantly different in many of the baseline clinical characteristics. They also showed a significantly higher SI-C values ( -11± 25 vs. -36±23, p<0.0001). The predictive value of SI-C for 24-year mortality was very good (area under the curve= 0.783, 95% CI: 0.738-0.827, p<0.001). The cumulative risk was significantly higher in the upper SI-C tertile (log-rank = 162.1, p < 0.001). Unadjusted Cox regression survival analysis showed that the SI-C score was significantly associated with long-term all-cause mortality (HR: 2.1, 95%CI 1.8-2.3, p<0.0001). Similar results were obtained with the fully adjusted model. Conclusion Baseline SI-C seems to be an effective and independent predictor of long-term all-cause mortality after ACS.

Intensive lipid - lowering therapy is highly cost effective in patients with ST - elevation myocardial infarction: a two - year follow - up of Jena auf Ziel

Abstract Background Jena auf Ziel - "JaZ" - is a prospective cohort study in which early combination therapy with atorvastatin 80mg and ezetimibe 10mg was initiated on admission in all patients with ST - elevation myocardial infarction (STEMI). Lipid - lowering therapy (LLT) was escalated during follow – up with bempedoic (BA) acid and PCSK9 - inhibitors (PCSK9 - I) if serum LDL - C was not within the ESC / EAS goal of 1.4mmol/L or less. Methods and objectives We collected economic and clinical data, including in - hospital costs and length of stay. Costs related to LLT were derived from a pharmaceutical directory for Germany. Follow – ups were conducted either by the outpatient lipid clinic through scheduled appointments or through routine standard care provided by general practitioners (GPs), according to the patients' preferences. In this secondary analysis of "JaZ" we analyzed cost - effectiveness of intensive LLT therapy compared to a less effective LLT approach within the first 24 months after the index event. Results A total of 85 (85.9% men, age: 64.4 ± 13.1 years) consecutive patients were included in this study. Overall, 631 hospital days accumulated for these 85 STEMI - patients. Total cumulative costs of these stays were 802.185,13 EUR (Figure 1). 24 months after discharge, 96.3% of the patients were on statins (atorvastatin: 67.9%; rosuvastatin: 25.9%), 87.7% on ezetimibe, 17.3% on BA and 6.2% on PCSK9 - I with intermittent adjustments by the two outpatient clinics. A mean LDL - C serum reduction of 1.78 ± 1.42 mmol/L could be measured. During the 24 months of follow – up, the total costs for LLT amounted to: 35.495,78 EUR (average per case: 417,59 ± 100,49 EUR) for statins and ezetimibe; 19.983,87 EUR (average per case: 1.492,09 ± 480,97 EUR) for BA and 59.308,32 EUR (average per case: 11.861,66 ± 1.535,62 EUR) for PCSK9 - I (Figure 1). MACE occurred in 10 patients (12.3%) that required a second hospital treatment with additional costs of 73.411,17 EUR (Figure 1). Patients with MACE during follow - up exhibited a shorter duration within the target LDL - C range compared to those without MACE (58.1 ± 29.9% vs. 79.1 ± 28.1%; p < 0.05) (Figure 2). Additionally, their LDL - C levels after 24 - months were higher (2.04 ± 1.26 mmol/L vs. 1.27 ± 0.47 mmol/L; p < 0.001) (Figure 2). Patients with MACE had lower associated costs for LLT compared to patients without MACE (547.04 ± 475.93 EUR vs. 2.562,29 ± 3.170,20 EUR; p < 0.05). Incorporating the additional costs associated with MACE for the subsequent hospital stay, the overall costs for a more expensive LLT however proved to be less and thus highly cost - effective (2.562,29 ± 3.170,20 EUR vs. 7.921,25 ± 4.140,53 EUR; p < 0.01) (Figure 2). Conclusion Intensive lipid - lowering therapy within the first 24 months after STEMI is highly cost effective compared to a less effective lipid - lowering approach.

Reassess Hospital Costs and Mortality Between Myocardial Infarction With and Without ST-Segment Elevation in a Modern Context.

Patients with ST-segment elevation myocardial infarction (STEMI) may have higher hospitalization costs and poorer prognosis than non-ST-segment elevation myocardial infarction (NSTEMI). A single-center retrospective study was conducted on 758 STEMI patients and 386 NSTEMI patients from January 1, 2020 to May 30, 2023 aimed to investigate the differences in cost and mortality. STEMI patients had higher maximal troponin I (15,222.5 (27.18, 40,000.00) vs. 2731.5 (10.73, 27,857.25), p < 0.001) and lower left ventricular ejection fraction (LVEF) (56% (53%, 59%) vs. 57% (55%, 59%), p < 0.001) compared to NSTEMI patients. The clinical symptoms were mainly persistent or interrupted chest pain/distress in either STEMI or NSTEMI patients. STEMI patients had a significantly higher risk of combined hypotension than NSTEMI patients (8.97% vs. 3.89%, p = 0.002), and IABP was much more frequently used in the STEMI group with a statistical difference (2.90% vs. 0.52%, p = 0.015). STEMI patients have statistically higher hospitalization costs (RMB, ¥) (31,667 (25,337.79, 39,790) vs. 30,506.91 (21,405.96, 40,233.75), p = 0.006) and longer hospitalization days (10 (8, 11) vs. 9 (8, 11), p = 0.001) compared to NSTEMI patients. Although in-hospital mortality was higher in STEMI patients, the difference was not statistically significant (3.56% vs. 2.07%, p = 0.167). Multivariable logistic regression was performed and found that systolic blood pressure and NT-proBNP were risk factors for patient death (OR ≥ 1). STEMI patients are more likely comorbid cardiogenic shock, heart failure complications with higher hospitalization costs and longer hospitalization days. And relatively more use of acute mechanical circulatory support devices such as IABP. ChiCTR2300077885.

Ethical issues after the earthquake in Turkey: A qualitative study on nurses' perspectives.

After natural disasters, the urgent need for survival and rescue operations for those trapped in the rubble results in a heightened demand for healthcare services. Nurses are pivotal in addressing the consequences of such calamities. Nurses operating in critical conditions encounter numerous challenges, including safety issues and ethical quandaries. The ethical considerations primarily revolve around the limitations, duties, and modified norms of care administered by nurses during disasters, presenting both significant and complex challenges. The study was designed to elucidate the nature and essence of nurses' care experiences and to offer an in-depth depiction of the ethical dilemmas while attending to individuals injured in the earthquake. A descriptive phenomenological design was used in this research. A total of 16 nurses who worked for at least 7 days in field hospitals in any of the earthquake regions after the 2023 earthquake in Turkey participated in the research. The research was conducted between March 13 and March 20, 2023. Data were collected by face-to-face interview method with a semistructured form. The steps of Colaizzi's phenomenological method were used to analyze the qualitative data. The study involved a group of 16 Turkish nurses, aged between 20 and 36 years. Through data analysis, four primary themes, 14 subthemes, and 25 codes were identified. The principal themes derived from the interviews included "humanitarian duties," "non-adherence to ethical principles," "respect for the injured," and "medical errors." In this intricate process, it becomes paramount to enhance support for nurses in the domains of management, education, and psychosocial assistance, thereby nurturing their individual and professional acumen, commitment, and ethical sensitivity. Refining the guidelines and professional standards that encapsulate the principles to be adhered to by nurses in disaster scenarios, coupled with providing comprehensive training in both medical and ethical competencies, represents a significant avenue for advancement. Focused training on crisis management will enable nurses to render ethically informed decisions and bolster their professional proficiency. Natural disasters, including earthquakes, pose significant ethical challenges for healthcare professionals, especially nurses who play a pivotal role in delivering care during these emergencies. Issues such as resource allocation and triage, the duty of care and ensuring continuity of care, informed consent and communication, cultural sensitivity, and providing psychosocial support are critical ethical considerations for nursing policies in earthquake situations. Addressing these ethical issues in nursing policies related to earthquakes is crucial for maintaining the integrity of healthcare delivery, preserving public trust, and ensuring the well-being of both the injured and healthcare providers during times of crisis.

Early Hospital Discharge on Day Two Post-Robotic Lobectomy with Telehealth Home Monitoring.

Background: Despite the implementation of enhanced recovery programs, the reported average postoperative length of stay after robotic lobectomy remains as 4 days. In this prospective study, we present the outcomes of early discharge (on day 2) with telehealth home monitoring device after robotic lobectomy for lung cancer in selected patients. Methods: All patients with a caregiver were discharged on postoperative day 2 (POD 2) with a telemonitoring device provided they met the specific discharge criteria. Inclusion criteria: <75 years old, stage I-II NSCLC, with caregiver, ECOG 0-2, scheduled for lobectomy, logistic proximity to hospital (<60 km); intra-postoperative exclusion criteria: conversion to open surgery, early complications needing hospital monitoring or redo-operation, difficult pain management, <92 HbO2% saturation on room air or need for O2 supplementation, altered vital or laboratory parameters. Teleconsultations were scheduled as follows: the first one in afternoon of POD2, two on POD3, then once a day until chest tube removal. After discharge, patients recorded their vital signs at least four times a day using the device, which allowed two surgeons to monitor them via a mobile application. In the event of sudden changes in vital signs or the occurrence of adverse events, patients had access to a direct phone line and a dedicated re-hospitalization pathway. The primary outcome was safety, assessed by the occurrence of post-discharge complications or readmissions, as well as feasibility. Secondary outcomes: comparison of safety profile with a matched control group in which the standard of care and the evaluation of resource optimization were maintained and economic evaluation. Results: Between July 2022 and February 2024, 48 patients were enrolled in the present study. Six patients (12.5%) dropped out due to unsatisfied discharge criteria on POD2. Exclusion causes were: significant air leaks (n:2) requiring monitoring and the use of suction device, uncontrolled pain (n:2), atrial fibrillation, and occurrence of cerebral ischemia (n:1 each). The adherence rate to vital signs monitoring by patients was 100%. A mean number of four measurements per day was performed by each patient. During telehealth home monitoring, a total of 71/2163 (1.4%) vital sign measurements violated the established acceptable threshold in 22 (52%) patients. All critical violations were managed at home. During the surveillance period (defined as the time from POD 2 to the day of chest tube removal), a persistent air leak was recorded in one patient requiring readmission to the hospital (on POD 13) and re-intervention with placement of a second thoracic drainage due to unsatisfactory lung expansion. No other postoperative complication occurred nor was there any readmission needed. Compared to the control group, the discharge gain was 2.5 days, with an economic benefit of 528 €/day (55.440 € on the total enrolled population). Conclusions: Our results confirm that the adoption of telehealth home monitoring is feasible and allows a safe discharge on postoperative day two after robotic surgery for stage I-II NSCLC in selected patients. A potential economic benefit (141 days of hospitalizations avoided) for the healthcare system could result from the adoption of this protocol.

Association of inpatient and outpatient pediatric palliative care with healthcare utilization and end-of-life outcomes in pediatric oncology.

Pediatric palliative care (PPC) is associated with improved end-of-life (EOL) outcomes. Inpatient and outpatient PPC have unique roles during the disease course. Yet, it is unknown whether the location of PPC receipt (inpatient vs. outpatient) is associated with healthcare utilization and EOL outcomes for pediatric and adolescent and young adult oncology patients. A retrospective single-institution chart review of pediatric patients (age 0-28) with cancer who died between January 2015 and December 2022 was performed to compare EOL outcomes and healthcare utilization metrics among inpatient PPC, any outpatient PPC, and non-PPC recipients. Demographics and clinical factors were analyzed by PPC receipt location. Among 450 patients, 292 (64.9%) received PPC (inpatient only 35%, any outpatient 65%). Patients who died without receiving PPC dropped from 69% to 22% following development of an outpatient PPC clinic (p<.001). In the last 6months, 1month, and last week of life, inpatient PPC recipients spent more days admitted to the hospital and intensive care unit (all p<.001), and had more intensive medical interventions performed (p<.01). Outpatient PPC recipients were less likely to receive intravenous (IV) chemotherapy (p<.01) or intubation (p=.05), and more likely to receive hospice, die at home, and have an outpatient do-not-resuscitate order (all p<.001). PPC receipt substantially increased after the creation of an outpatient PPC clinic, suggesting that outpatient PPC is critical in the provision of PPC to children with cancer. Outpatient PPC was associated with fewer hospital days, IV chemotherapy, and intubation at EOL, while increasing hospice enrollment and home death.

Plan of Care Visits: Implementation During Hospitalization and Association With 30-Day Readmissions in a Large, Integrated Health Care System.

Plan of Care of Visits (POCV), including the patient, nurse, and hospital provider were implemented across an integrated health system to improve provider-patient communication during hospitalization and patient outcomes. To assess POCV adoption after implementation, patient characteristics assosites were classified as teachsites were classified as teachsites were classified as teachsites were classified as ciated with POCV completion, and association of POCV with 30-day readmissions. This retrospective cohort study utilized electronic medical record (EMR) data of 237,430 adult patients discharged to home from 11 hospitals from January 2020 to December 2022. POCV completion was a discrete EMR variable. POCV adoption was estimated monthly by hospital as proportion of patients with at least 1 POCV during hospitalization, with variation among hospitals measured using the Variance Partition Coefficient (VPC). Multivariable logistic regressions assessed factors associated with POCV completion and POCV association with 30-day readmission. POCV adoption increased from 69% to 94% (2020-2022) and varied by 50% across hospitals (VPC 0.50, 95% CI: 0.29-0.70). Odds of a discharge-day POCV were lower among older patients (≥65 vs. 18-34y, OR 0.81, CI: 0.79-0.83), and higher among female (OR 1.06; CI: 1.04-1.07), Asian (vs. White, OR 1.13; CI: 1.06-1.21), Hispanic (OR 1.09; CI: 1.05-1.13), and surgical patients (vs. medical, OR 1.33; CI: 1.30-1.35). Patients completing discharge-day POCV had lower 30-day readmission odds (2022 OR 0.76, CI: 0.73-0.79). Patients with POCV on ≥75% of hospital days had similar readmission odds trends. POCV implementation was successful, and POCV completion was associated with fewer 30-day readmissions. Future work should focus on increasing POCV adoption while reducing hospital variation.

First Pregnancy Abortion or Natural Pregnancy Loss: A Cohort Study of Mental Health Services Utilization.

While both induced abortion and natural pregnancy loss have been associated with subsequent mental health problems, population-based studies directly comparing these two pregnancy outcomes are rare. We sought to compare mental health morbidity after an induced abortion or natural loss. Continuously eligible Medicaid beneficiaries age 16 in 1999 were assigned to two cohorts based upon the first pregnancy outcome: abortion (n = 1,331) or natural loss (n = 605). Outcomes were mental health outpatient visits, inpatient hospital admissions and hospital days of stay per patient per year. Average exposure periods before and after the first pregnancy outcome for each cohort were used to adjust the mental health service rates. Prior to the first pregnancy outcome, all three utilization rates were significantly higher for the natural loss cohort compared to the abortion cohort. For the abortion cohort, the per-patient per-year increase from the pre- to post-pregnancy periods was significant for all three rates: 2.04 times for outpatient visits (p < 0.0001), 3.04 times for inpatient admissions (p = 0.0003), and 3.01 times for hospital days of stay (p = 0.0112). None of the pre-to-post rate increases were significant for the natural loss cohort. Higher pre-pregnancy use rates for women who experience a natural pregnancy loss indicate that increased mental health services use following abortion cannot be solely attributed to pre-existing mental illness. Only the abortion cohort, but not the natural loss cohort, experienced significant increases in mental health services use following the first pregnancy outcome.

Neurological Complications and Outcomes in Critically Ill Patients With COVID-19: Results From International Neurological Study Group From the COVID-19 Critical Care Consortium.

In this COVID-19 Critical Care Consortium (CCCC) sub-study, we qualified neurological complications associated with SARS-CoV2 infection. The CCCC is an international, multicenter study. Eligible patients were COVID-19 patients admitted to intensive care units (ICU) across 23 centers between 1/7/2020 to 6/23/2022. Incidence of neurological complications was estimated as number of events per hospital days and per admission using Poisson regression. Associations between neurological complications and risk factors were assessed using multivariable Poisson regression. 713 patients were included. Median age = 56years (interquartile range (IQR) = 45-65). Neurological complications reported in 61/480 patients (12.7%) with the majority being ischemic stroke (2.9%), intracranial hemorrhage (ICH) (2.8%), and seizures (2.6%). Multivariable analysis for neurological complications per admitted days showed comorbid neurological conditions (incidence rate ratio (IRR) = 6.35, 2.57-15.7) were an independent risk factor for ischemic stroke. Extracorporeal membrane oxygenation (IRR = 5.32, 1.52-18.6), low-middle income countries (LMIC) vs high income countries (HIC) (IRR = 4.70, 1.62-13.7), and age >55 (IRR = 3.66, 1.23-10.9) were independent risk factors for ICH. Co-morbid neurological conditions (IRR = 3.43, 1.11-10.6), LMIC vs HIC (IRR = 8.69, 2.15-35.2), July-December 2020 vs January-June 2020 (IRR = 0.17, 0.04-0.69) and age >55 (IRR = 4.05, 1.15-14.3) were independent risk factors for seizure. Decision-making should incorporate salient risk factors to inform management of SARS-CoV2 infection and avoid neurological complications.

Health shocks and households’ welfare in Ghana: does social assistance mitigate the effects?

PurposeHealth shocks are among the factors that have impeded households from experiencing better welfare. To mitigate the consequences of these shocks, individuals have sought to enrol in a formal insurance scheme or borrow from banks. This study estimates the effects of health shocks on households' welfare while examining the mitigating role of social assistance in Ghana.Design/methodology/approachThe study utilized the three-stage least squares and feasible generalized least squares to estimate the impact of health shocks on households' welfare.FindingsThe authors find that health shocks put households at risk, particularly disability and severe illness, which significantly limits individuals’ ability to smooth consumption to increase welfare. We further find that hospitalization due to illness significantly allows households to increase welfare through consumption. Finally, we find that social assistance has the potential to reduce these adverse effects of shocks conditioned on the type of shock and the outcome variable in question.Research limitations/implicationsFirst, we only used cross-sectional data for the two waves and therefore lacked panel data across time for analyses. Second, the data do not provide information on the exact amount of cash received by beneficiaries, so it was quite impossible to measure the exact effect of social assistance on welfare. We could only track whether or not having such assistance could mitigate the effect of a health shock.Practical implicationsThe practical implication of the findings is that Ghana needs to build a resilient health system in order to withstand the health shocks of individuals.Originality/valueNo study has attempted to investigate the differential effect of health shocks – hospitalization, disability and labour days lost due to illness in Ghana. Our choice is dependent on the fact that these shocks have been an issue for many households in Ghana, thus the need to examine their impact on individual well-being. Second, social assistance has been Ghana’s flagship social protection programme, but what is missing in the literature is whether this programme is capable of reducing the effect of health shocks faced by beneficiaries’ households in Ghana.

Impact of enhanced recovery after surgery (ERAS) on surgical site infection and postoperative recovery outcomes: a retrospective study of 1276 cases

This retrospective observational study aimed to evaluate the incidence of surgical site infection (SSI) in the era of enhanced recovery after surgery (ERAS) and the effect of ERAS on postoperative outcomes. Totally 1,276 patients (565 in ERAS group and 711 in non-ERAS group) who underwent operations at the department of general surgery during 2017–2021 were included. Risk factors were identified via logistic regression analysis and meta-analysis of all relevant published studies was performed. Subsequently, propensity score matching was used to match different risk factors. Overall, 40 patients were diagnosed with SSI, and the pooled incidence of SSI was 3.13%. In total, 14 (2.48%) and 26 (3.66%) patients in the ERAS and non-ERAS groups, respectively, were diagnosed with SSI (P = 0.230). Among patients for whom the ERAS protocol was adopted, 7 independent risk factors of SSI were identified. After propensity score matching, in patients without SSI, the number of hospital days was significantly lower in the ERAS group than in the non-ERAS group (2 [2, 5] vs. 3 [2, 7], P = 0.005), whereas in patients with SSI, the number of hospital days was similar between the ERAS and non-ERAS groups. ERAS had no effect on the incidence of SSI but could significantly accelerate the discharge of uninfected patients. In the era of ERAS, SSI incidence was affected by the type of surgery; number of postoperative hospital days; type of incision; serum hemoglobin, total protein, and albumin levels; and antibiotic prophylaxis. Furthermore, these results will significantly affect the implementation of the ERAS protocol and optimal preoperative management.

Incidental findings of borderline ovarian tumor or ovarian cancer - real-world data on surgical and oncological outcomes.

Centralization of ovarian cancer treatment is associated with higher rates of optimal surgery and longer survival. However, preoperative diagnosis of ovarian cancer is challenging and some diagnoses are made incidentally after surgery. This study investigated the surgical and oncological outcomes of patients with incidental findings of borderline ovarian tumors or ovarian cancer who were centralized postoperatively and treated with a two-stage surgical procedure, and compared these with those of patients with adnexal masses of suspected malignancy who were offered a single-stage surgical procedure with intraoperative frozen section in a tertiary hospital. A database of 390 patients with adnexal masses and surgical treatment at the Bern University Hospital, Switzerland was retrospectively reviewed to identify patients with borderline ovarian tumors or ovarian cancer between 2010 and 2020. Among 390 patients with adnexal masses, 223 were diagnosed with a borderline ovarian tumor or ovarian cancer. Compared with patients with suspected malignancy and a centralized single-stage surgical procedure, patients with an incidental postoperative malignancy diagnosis and a two-stage surgical procedure underwent more surgical interventions (1.3 vs. 2.1 p<.001) and had a longer time interval from diagnosis to initiation of chemotherapy (33.3 vs. 45.1 p=.005) and to completion of surgical cytoreduction (31.9 vs. 73.7 days, p<.001). However, there were no differences in the rates of complete cytoreduction (90.0% vs. 93.2%, p=.719), intraoperative (11.3% vs. 13.7%, p=.664) or postoperative (38.7% vs. 37.0%, p=.884) complication rates, and number of hospitalization days (11.1 vs. 12.0 days, p=.369). An incidental diagnosis of malignancy with postoperative referral was neither associated with an increased risk of recurrence (hazard ratio (HR) 0.8, 95% confidence interval (CI) 0.6-1.8, p=.839) nor death (HR 0.7, 95% CI 0.4-1.1, p=.113), and there was no difference in mean recurrence-free survival between the study subgroups. Although patients with incidental findings of borderline ovarian tumors or ovarian cancer treated with a two-stage surgical procedure had a longer time to completion of surgical staging and initiation of chemotherapy, our results showed no negative impact on oncological outcomes.

Traumatic Tension Pneumocephalus with mount Fuji sign and air bubble sign

Introduction: Tension Pneumocephalus is a rare but a life threatening neurosurgical emergency which may need urgent surgical intervention. For diagnosis Brain imaging preferably Brain CT scan is mandatory. Case presentation: We present a rare case case of post traumatic tension Pneumocephalus in 40 years old man who sustained a road traffic accident. Brain CT scan shows Mount Fuji sign and air bubble sign, which are the typical signs of tension Pneumocephalus. Emergency burr-hole evacuation was carried out and after the procedure the patient was followed by control lateral skull X-ray and then discharged after 10 days of hospital Stay with GCS of 15. Conclusion: Tension Pneumocephalus is a clinical diagnosis. History with Brain Imaging can easily diagnose it but invasive surgical intervention may be Mandatory to overcome the problem. Knowledge of risk factors ,radiographic findings and clinical signs/symptoms associated with Tension Pneumocephalus is crucial to its Prompt identification and treatment.

Early diaphragm dysfunction assessed by ultrasonography after cardiac surgery: a retrospective cohort study.

Approximately 10%-70% of patients may develop diaphragmatic dysfunction after cardiac surgery, which may lead to delayed weaning from mechanical ventilation, increased ICU stays, postoperative hospitalization stays, and respiratory complications. However, its impact on prognosis and risk factors remain controversy. Therefore, we conducted a retrospective cohort study in which we evaluated diaphragmatic dysfunction in patients who underwent cardiac surgery via bedside diaphragm ultrasound to investigate its prognosis and possible risk factors. Data from the electronic medical records system included case records and ultrasound images of the diaphragm for 177 consecutive patients admitted to the ICU following cardiac thoracotomy surgeries performed between June and September 2020. Diaphragmatic dysfunction was defined as a diaphragmatic excursion of less than 9 mm in women and less than 10 mm in men at rest, with an average thickening fraction of less than 20%. SPSS 25.0 software was used to analyse the relationships between patients' general information, intraoperative and postoperative factors and diaphragmatic dysfunction, as well as the impact on patients' hospitalization days, mechanical ventilation time and respiratory system complications. The incidence of early postoperative diaphragmatic dysfunction after cardiac surgery was 40.7%. Patients with diaphragmatic insufficiency were more likely to sequentially use noninvasive ventilation within 24 h after weaning off mechanical ventilation (3.8% vs. 12.5%, P = 0.029) and to require more oxygen support (23.8% vs. 40.3%, P = 0.019). Although there was no significant difference, the diaphragmatic dysfunction group tended to have longer ICU stays and postoperative hospital stays than did the normal diaphragmatic function group (P = 0.119, P = 0.073). Univariate and multivariate logistic regression analyses both revealed that chest tube drainage placed during surgery accompanied by bloody drainage fluid was an independent risk factor for diaphragmatic dysfunction (univariate analysis: 95% CI: 1.126-4.137, P = 0.021; multivariate analysis: 95% CI: 1.036-3.897, P = 0.039). Eearly diaphragmatic dysfunction after cardiac surgery increased the proportion of patients who underwent sequential noninvasive ventilation after weaning from mechanical ventilation and who required more oxygen. Chest tube drainage placed during surgery accompanied by bloody drainage fluid was an independent risk factor for diaphragmatic dysfunction, providing evidence-based guidance for respiratory rehabilitation after cardiac surgery.

Damage-associated molecular patterns in bacteraemic infection, including a comparative analysis with bacterial DNA, a pathogen-associated molecular pattern

Damage-associated molecular patterns (DAMPs) and pathogen-associated molecular patterns (PAMPs) are key triggers of inflammation in sepsis. However, they have rarely been studied simultaneously. Thus, in the present study of patients with bacteraemic infection, we aimed to study how DAMP dynamics are linked to disease severity and outcome and to compare diagnostic and prognostic properties of a DAMP and a previously analysed PAMP (16S rDNA). In a prospective study of adult patients hospitalized with culture-proven community-onset bacteraemic infection, caused by Streptococcus pneumonia (n = 30), Staphylococcus aureus (n = 27), or Escherichia coli (n = 26), dynamics of a PAMP, i.e. 16S rDNA, have previously been presented. For the present study, blood samples obtained on hospital days 1–2 (when blood culture was positive), 3–4, 7 ± 1, 14 ± 2, and 28 ± 4 were analysed for four different DAMPs, i.e., nuclear DNA (nDNA), mitochondrial DNA (mtDNA), heat shock protein 90 alpha (HSP90α), and extracellular high mobility group box 1 (HMGB1). Sepsis was defined according to the Sepsis-3 criteria. The study outcomes were sepsis at admission and negative outcome, defined as intensive care unit (ICU) admission and/or death within 60 days. Of 83 study patients, sepsis was noted in 41 patients (49%) and a negative outcome was noted in 17 patients (20%). nDNA had areas under the receiver operating characteristic (ROC) curves of 0.78 for sepsis and 0.76 for negative outcome, which were higher than those of the other DAMPs and additional biomarkers (CRP, IL-6, IL-8, and IL-10). The nDNA and positive 16S rDNA results on day 1–2 were correlated with each other (r = 0.68, p < 0.001). Multivariate analyses showed that high day 1–2 concentrations of both nDNA and 16S rDNA were independently associated with sepsis. In addition, high day 1–2 concentration of nDNA was independently associated with negative outcomes. While 16S rDNA dissipated from the circulation within days, nDNA concentrations remained elevated throughout the follow-up period in patients with negative outcome. In conclusion, nDNA outperformed the other DAMPs regarding sepsis detection and outcome prediction. Both nDNA (a DAMP) and 16S rDNA (a PAMP) were independently linked to sepsis; nDNA was also associated with negative outcomes and persisted elevated in such cases. This highlights nDNA as an interesting marker within sepsis pathogenesis and as a promising clinical biomarker, warranting further studies.

Particularities of Pyelonephritis With Multidrug-Resistant (MDR) Germs During Pregnancy: A Case-Control Study.

The aim of this study was to analyze the characteristics of pyelonephritis with multidrug-resistant (MDR) bacteria in pregnant women in comparison to pyelonephritis with multidrug-sensitive bacteria in this particular patient group. We conducted a retrospective study over a period of three years on a study group of 17 pregnant patients with pyelonephritis with MDR bacteria and on a control group of 52 pregnant patients with pyelonephritis with multidrug-sensitive bacteria. We analyzed the demographic data, the potential risk factors, aspects of the clinical picture, the incidence and type of bacteria involved, and their sensitivity spectrum. The patients in the study group had pyelonephritis on the right side (N=10, 58.83%), were in the second and third trimesters of pregnancy (N=16, 94.12%), and had a high percentage of anemia (N=9, 52.94%), as did the control group. Unlike the patients in the control group, the patients in the study group had a higher incidence of antibiotic treatment (N=17,100% vs. N=14, 29.92%, p<0.001), previous urological surgery, especially ureteral catheterization with insertion of double-J catheters (N=9, 52.94% vs. N=9, 17.30%, p=0.003), and an increased incidence of urosepsis on admission (N=11, 64.70% vs. N=11, 21.15%, p<0.001). E. coli (N=8, 47.05% vs. N=28, 53.85%, p=0.626) and Klebsiella pn. (N=5, 29.41% vs. N=12, 23.07%, p=0.598)were predominant in both study groups. Also, the hospitalization days were significantly higher in the study group compared with the control group (N=7.38±2,91 vs. N=5.02±1,87, p=0.002). The spectrum of microbial resistance was increased in favor of the study group for all antibiotics tested, with the exception of ampicillin, where resistance was increased in both groups. The Gram-negative bacteria responsible for the pyelonephritis in both groups retained 100% sensitivity to carbapenems and piperacillin/tazobactam. Pregnant women in the second and third trimesters of pregnancy who have undergone right-sided double-J catheter insertion during pregnancy and/or who have received antibiotic treatment in the past are at increased risk for pyelonephritis with MDR. E. coli and Klebsiella pn.,bacteria are most commonly involved and maintain susceptibility to carbapenems and reserve penicillins.

Comparing Closure Techniques for Pharyngeal Mucosa After Total Laryngectomy: Manual Suture, Linear Stapler, and Thyroid Gland Flap-A Retrospective Analysis.

Objective: This study aimed to compare the clinical effectiveness of manual suture (group A), linear stapler (group B), and thyroid gland flap (group C) for pharyngeal mucosal closure after total laryngectomy (TL) in laryngeal cancer patients. Methods: The data of laryngeal cancer patients who underwent TL between January 1, 2017, and December 1, 2021, were analyzed. Patients were categorized into group A, group B, and group C based on the closure technique. Various parameters, including general data, hospitalization days, total cost, pharyngeal closure time, pharyngeal fistula, pre- and post-surgical calcium levels, and thyroid function indexes, were compared. Results: The study included 81 patients (mean age: 64.09 ± 9.20 years), the general data of the 3 groups of patients were comparable. Tumor stage and primary tumor location varied significantly among the groups (P = .002 and P < .001, respectively). Group A was more commonly used for advanced-stage tumors with widespread invasion. Group B was primarily used for early-stage tumors localized to the larynx. Group C was preferred for cases with mucosal defects or extensive hypopharyngeal invasion. Group B presented a significantly shorter operation time and slightly lower total cost (P = .006). Pharyngeal fistula incidence was 17.28% (14/81), with comparable rates among the groups [12.35% (10/50) in group A, 12.5% (2/16) in group B, and 13.3% (2/15) in group C]. No dysphagia complications were observed during the 2-to-5-year follow-up. Blood calcium levels and thyroid function indicators showed no significant differences before and after surgery among the 3 groups (P > .05). Conclusion: Thyroid gland flap is a safe option that can be used to repair mucosal defects and close the pharyngeal cavity after TL surgery, but in the absence of mucosal defects and widespread tumor invasion, linear staplers are the most time-efficient method.