Acute hospital-community hospital care bundle for elderly orthopedic surgery patients:A propensity score-matched economic analysis

BACKGROUND While Singapore attains good health outcomes,Singapore’s healthcare system is confronted with bed shortages and prolonged stays for elderly people recovering from surgery in acute hospitals.An Acute Hospital-Community Hospital(AHCH)care bundle has been developed to assist patients in postoperative rehabilitation.The core concept is to transfer patients out of AHs when clinically recommended and into CHs,where they can receive more beneficial dedicated care to aid in their recovery,while freeing up bed capacities in AHs.AIM To analyze the AH length of stay(LOS),costs,and savings associated with the AH-CH care bundle intervention initiated and implemented in elderly patients aged 75 years and above undergoing elective orthopedic surgery.METHODS A total of 8621:1 propensity score-matched patients aged 75 years and above who underwent elective orthopedic surgery in Singapore General Hospital(SGH)before(2017-2018)and after(2019-2021)the care bundle intervention period was analyzed.Outcome measures were AH LOS,CH LOS,hospitalization metrics,postoperative 30-d mortality,and modified Barthel Index(MBI)scores.The costs of AH inpatient hospital stay in the matched cohorts were compared using cost data in Singapore dollars.RESULTS Of the 862 matched elderly patients undergoing elective orthopedic surgery before and after the care bundle intervention,the age distribution,sex,American Society of Anesthesiologists classification,Charlson Comorbidity Index,and surgical approach were comparable between both groups.Patients transferred to CHs after the surgery had a shorter median AH LOS(7 d vs 9 d,P<0.001).The mean total AH inpatient cost per patient was 14.9%less for the elderly group transferred to CHs(S$24497.3 vs S$28772.8,P<0.001).The overall AH U-turn rates for elderly patients within the care bundle were low,with a 0%mortality rate following orthopedic surgery.When elderly patients were discharged from CHs,their MBI scores increased significantly(50.9 vs 71.9,P<0.001).CONCLUSION The AH-CH care bundle initiated and implemented in the Department of Orthopedic Surgery appears to be effective and cost-saving for SGH.Our results indicate that transitioning care between acute and community hospitals using this care bundle effectively reduces AH LOS in elderly patients receiving orthopedic surgery.Collaboration between acute and community care providers can assist in closing the care delivery gap and enhancing service quality.

Determinants of Maternal Mortality at the Community University Hospital of Bangui: Central African Republic

Introduction: Pregnancy is a physiological condition that can sometimes end in death. The death of a woman is a constant concern for the obstetrician and is considered a major public health problem in our developing countries. Objective: To identify the determinants that contribute to maternal morbidity and mortality in the Gynaecology and Obstetrics Department of the University Community Hospital. Methodology: We conducted a retrospective study from 1 January 2015 to 31 December 2019 (5 years) in the obstetrics and gynaecology department of the Centre Hospitalier Universitaire Communautaire (CHUC). It focused on the determinants of maternal mortality. Our study population consisted of all women who died during the period and met the World Health Organization (WHO) definition of maternal mortality (MOMA). We used non-probability sampling with the exhaustive choice technique. Results: The study revealed that the number of deaths recorded was 98, while 17,172 live births were registered during the same period. The maternal mortality ratio was 570 per 100,000 live births. The most common age group was 20 to 24, with an average age of 26. The frequency of death among primiparous women was 37.74%, pauciparous women 28.30% and multiparous women 26.42%. Direct causes were dominated by abortion complications (22.41%), followed by infections (9.30%) and haemorrhage (8.19%). Indirect causes were dominated by anaemia with a proportion of 45.16%. The majority of maternal deaths occurred in the post-partum period (34.71%). Most maternal deaths occurred after vaginal delivery, 19 cases (63.33%), while 11 deaths (36.66%) occurred after caesarean section. The occurrence of direct causes was associated with age less than or equal to 25 years, abortion complications and primiparity, with a statistically significant difference. Conclusion: At the end of this study, complications of unsafe abortion and poverty are all factors contributing to the rise in the maternal mortality rate. Emphasis should be placed on promoting family planning, as this would make a major contribution to reducing maternal mortality.

Hospital community benefits and the effect of Schedule H: A difference-in-difference approach

Since 1969 private, nonprofit hospitals have qualified for tax exemption as charitable institutions and in exchange for the preferential tax treatment were required to provide community benefits. However, in the absence of mandatory reporting of community benefits at the federal level and in the absence of a clear definition of community benefits, the previous literature provides but ambiguous evidence regarding hospitals’ supply of community benefits. Responding to policymakers’ concerns, the Internal Revenue Service (IRS) mandates all private, non-profit hospitals to report charity care at cost as well as unreimbursed Medicaid costs starting with the tax year 2008. Using data from hospitals in California before and after tax year 2008 (2009 filing), this study examines whether changes in the IRS 990 Schedule H had a significant effect on the supply of community benefits by non-profit hospitals relative to for-profit hospitals. Empirical results suggest that nonprofit hospitals do not supply more community benefits relative to for-profit hospitals for both definitions of community benefits reported in Schedule H. Although the supply of community benefits increased for all hospitals after 2008, the increase was not higher for nonprofits. Moreover, nonprofits supplied significantly less community benefits according to some definitions. Thus, minimum charity care standard is justified.

Positioning and function of secondary general hospital in community rehabilitation of disabled persons-a case study of a secondary general hospital in Changsha city

Objective:the positioning of secondary hospitals in the community rehabilitation work system and the status of community medical rehabilitation ser-vices for the disabled in Changsha were clarified through investigation and study of the 2019 income of a second-ary general hospital in Changsha.Suggestions from var-ious parties were integrated to provide feasible ideas for expanding the role of secondary hospitals in community rehabilitation.Methods:the 2019 income of a secondary general hospital in Changsha was statistically analyzed,a community rehabilitation questionnaire was designed,and a field survey was carried out focusing on 19 issues including rehabilitation service items,rehabilitation facil-ities and equipment,and the satisfaction of rehabilitation practitioners.Results:in the total hospitalization expenses of a secondary general hospital in Changsha city in 2019,rehabilitation physiotherapy expenses accounted for 7%,and drug treatment expenses accounted for 25%.In addi-tion,in the survey of community rehabilitation service sat-isfaction for the disabled,the difference between the very dissatisfied and very satisfied groups was statistically sig-nificant(P<0.05).Conclusion:taking a secondary gener-al hospital in Changsha city as an example,the treatment methods in secondary general hospitals are still dominated by traditional drug therapy,and the disabled are not sat-isfied with community rehabilitation services.Therefore,rehabilitation treatment projects to meet the rehabilitation needs of the disabled should be promoted in hospitals.

Comprehensive therapeutic effect of the stroke rehabilitation unit in a medium-sized comprehensive community hospital

BACKGROUND： Acute stroke unit （stroke care unit） is developing in some domestic large-sized hospitals, but most stroke patients need stroke rehabilitation unit therapy, so setting stroke rehabilitation unit in medium-sized comprehensive community hospital （secondary hospital）, where medical facility is relatively insufficient, is a new pathway to satisfy stroke patients. OBJECTIVE： To observe the comprehensive effect of developing stroke rehabilitation unit based on the facility of secondary hospital and its feasibility. DESIGN： Non-randomized concurrent controlled observation SETTING： Department of Neurology, Beijing Longfu Hospital PARTICIPANTS： Totally 264 stroke reconvalescents who suffered stroke for 7 days and received treatment in the Department of Neurology, Beijing Longfu Hospital during June 2003 to June 2005 were involved in the study. All the involved patients were confirmed by CT or MRI. The patients were scored by using Modified Edinbergh-Scandinavia stroke scale （SSS） 〉 16 points. Written informed consents were obtained from all the patients. The patients were assigned into 2 groups according to the willing of patients and their relatives： （1）treatment group, in which, there were 134 patients, 76 males and 58 females, aged 43 to 74 years; cerebral infarction was found in 116 cases and cerebral hemorrhage in 18 cases;（2） control group, in which, there were 130 patients, 66 males and 64 females, aged 45 to 77 years, cerebral infarction was found in 115 cases and cerebral hemorrhage in 15 cases. There were significant differences in baseline data of the patients between two groups. METHODS： A same basic treatment was conducted in the patients of the two groups. （1） Patients in the treatment group admitted to stroke rehabilitation unit and received comprehensive rehabilitation treatment. The rehabilitation flow-sheet： randomization-letting the patients of treatment group go into the unit-making comprehensive assessment in the initial stage-making therapy plan-talking with patients and their other family members-general rehabilitation-making metaphase assessment-adjusting therapy plan-making final assessment-letting the patients discharge and doing follow-up visits. （2） The patients in the control group admitted to common wards, and they were encouraged to do activities by themselves in the early stage, but did not receive rehabilitation training under the instructions from professional physicians. MAIN OUTCOME MEASURES： The following assessments were conducted on admission and 7 and 28 days after admission： （1） Severity of stroke and motor function： scored as 0 to 45 points by SSS, the higher points, the severer damage. （2）Activities of daily living： Evaluated by Barthel index, 110 points in total, 110 points meant normal, 0 point meant extremely poor. （3）Mental status： evaluated by Hopkin＇s symptom scale with a 5-point scoring. The symptom was scored with low to high points. （4）Cognitive function： Quantification measurement was conducted with LOTCA method. The higher points, the better therapeutic effects. RESULTS： （1） Three cases dropped out and one died in the treatment group, 11 cases dropped out and 4 died in the control group. （2）The neurologic impairment points on 7 and 28 days after therapy in the treatment group were lower than those in the control group separately [7 days：（9.73±6.43） points vs. （12.63± 7.87） points, t =2.28, P〈 0.05;28 days：（7.88±4.81） points vs. （9.84±7.03）points, t =2.04, P〈 0.05]. Barthel index on 7 and 28 days after therapy in the treatment group were higher than those in the control group separately [7 days：（54.28±8.38） points vs. （39.76±7.31） points, t =2.206, P 〈 0.05; 28 days： （89.72±7.94） points vs. （67.34±8.63） points, t =2.812, P 〈 0.01]. （4） Patients were allocated into different age groups based on age and evaluated with LOTCA. Results showed that there were no significant differences among different age groups （P 〉 0.05）. （5） Totally 160 patients in the two groups accomplished the Hopkin＇s test, among them, 94 （58.7%） had different mental disorders; Among the patients with mental disorder, depression, obsessive-compulsive and anxiety were found mostly, being 53.8%, 52.5% and 46.2%, respectively. CONCLUSION： （1） Developing stroke rehabilitation unit therapy in the secondary hospital can obviously improve the motor function and activities of daily living of stroke reconvalescents. （2） More than half of the stroke reconvalescents accompany the symptoms of depression, obsessive-compulsive, anxiety and other mental disorders. （3） The cognitive function of stroke reconvalescents is not related to age.

Prevalence of Opportunistic Pathogens and Diversity of Microbial Communities in the Water System of a Pulmonary Hospital

Objective Our objective was to investigate the occurrence of opportunistic pathogens and characterize the bacterial community structures in the water system of a pulmonary hospital.Methods The water samples were collected from automatic and manual faucets in the consulting room,treatment room,dressing room,respiratory ward,and other non-medical rooms in three buildings of the hospital.Quantitative polymerase chain reaction was used to quantify the load of several waterborne opportunistic pathogens and related microorganisms,including Legionella spp.,Mycobacterium spp.,and M.avium.Illumina sequencing targeting 16 S r RNA genes was performed to profile bacterial communities.Results The occurrence rates of Legionella spp.,Mycobacterium spp.,and M.avium were 100%,100%,and 76%,respectively in all samples.Higher occurrence rates of M.avium were observed in the outpatient service building(building 1,91.7%)and respiration department and wards(building 2,80%)than in the office building(building 3),where no M.avium was found.M.avium were more abundant in automatic faucets(average 2.21×10~4 gene copies/L)than in manual faucets(average 1.03×10~4 gene copies/m L)(P<0.01).Proteobacteria,Actinobacteria,Bacteroidetes,Cyanobacteria,Firmicutes,and Acidobacteria were the dominant bacterial phyla.Disinfectant residuals,nitrate,and temperature were found to be the key environmental factors driving microbial community structure shifts in water systems.Conclusion This study revealed a high level of colonization of water faucets by opportunistic pathogens and provided insight into the characteristics of microbial communities in a hospital water system and approaches to reduce risks of microbial contamination.

Clinical presentation and endoscopic management of Dieulafoy's lesions in an urban community hospital

AIM:To identify rates of occurrence,common clinical and endoscopic features,and to review the outcome of endoscopic management of Dieulafoy's lesions in the upper gastrointestinal (GI) tract in an urban community hospital setting. METHODS:Endoscopic data from esophagogastroduo denoscopies (EGDs),done at Wyckoff Heights Medical Center,Brooklyn,NY between 2000 and 2006 were reviewed to identify patients with Dieulafoy's lesions. Demographic data,medical history,examination findings,lab data,endoscopic findings and details of therapy for patients treated for Dieulafoy's lesions were reviewed retrospectively. RESULTS:Dieulafoy's lesions were documented to be the cause of bleeding in approximately 1% of patients presenting with upper gastrointestinal bleeding,while they were detected in only 2 patients when the indications for EGDs were different from active GI bleeding. When we analyzed EGDs performed in patients above age 65 years presenting with gastrointestinal bleeding,prevalence of Dieulafoy's lesions approached 10 percent. The most common location of the lesion was the body of stomach (7),followed by the cardia (4) and the esophagus (2). One patient had this lesion in the fundus and one patient in the duodenal apex. All patients were initially treated endoscopically with epinephrine injection,in eight cases heater probe was applied following epinephrine and endoscopic clips were applied in two cases. All but one of the patients did well in near and intermediate term follow-up (average follow-up period of 18 mo). One patient died of multi-organ failure during the same hospital stay. Average length hospital stay was 7 d.CONCLUSION:Community hospital gastroenterologists and endoscopists should be aware that Dieulafoy's lesions are an uncommon cause of upper GI bleeding among elderly patients. Early accurate diagnosis through emergent endoscopy and endoscopic therapy,especially in patients with multiple co-morbid conditions,can be very effective and life saving.

Rate of Inappropriate Imaging Utilization by the Emergency Department in Community Hospitals

Objective: To retrospectively analyse the use of imaging studies in the Emergency Department of community hospitals using evidence based guidelines and clinical judgement. Methods: Medical records of 661 patients who visited the Emergency Department (ED) in 2015 and underwent imaging studies were reviewed. The Canadian Association of Radiologists, American College of Radiologists and Choosing Wisely Canada guidelines were used to determine the appropriateness of imaging studies. The use of prior patient imaging, the rate at which studies were repeated and the respective impacts on patient management of the imaging studies were also examined. Results: Of the 1056 imaging studies reviewed, 228 (22%) were found to be clinical situations where no imaging study was indicated while 168 (16%) were considered a suboptimal choice of imaging study or modality. When no study was recommended, a positive impact on the diagnosis was noted in 105 (46%) cases and on patient management 83 (36%) times. Notably, 219 (21%) patients had a relevant examination performed in the last 30 days, and 147 (14%) reports noted that the results of the prior study also concurred with the imaging study evaluated. Conclusion: In this study, 228 (22%) radiographs and CT studies, excluding MVC related imaging and extremity imaging, were not indicated based on appropriateness criteria and consequently had a limited impact on patient management. This supports the need for increased clinical decision support for ED physicians, regional health information exchanges and consideration of Computerized Physician Order Entry in the ED with embedded appropriateness criteria at the point of ordering.

The HIV’s Transmission from the Mother to the Child at the Community Hospital Center of Bangui (Central African Republic)

Objective: Assess the impact of B + option on mother-to-child HIV’s transmission at the community university hospital center after 4 years of use. Patients and methods: This was a retrospective and analytical study from January 1st 2015 to December 31st 2018 i.e. 4 years. The population’s study was on HIV-positive mothers and their infants care in the service. Results: A total of 323 files of infants born from HIV-positive mothers were selected and having performed the PCR. 9 of them were HIV positive representing a rate of 2.79% mother-to-child HIV’s transmission. This prevalence was 1.1% for women who started ART before and during pregnancy. The average age of newborns was 29 years. Mothers were literally rating in 24.15% during the period of starting antiretroviral therapy, 63% during pregnancy and 19% before pregnancy. For the delivery’s way 295 delivered vaginally;they represented 91.33%. Cesarean delivery was 8.67%. Exclusive breastfeeding represented 87.31% of the diet. Mothers who started ARV therapy during the labor and after delivery were more likely to transmit HIV to their infants than mothers who started ART before and during pregnancy (p = 0.01). The other risk factors were represented by premature rupture of the membranes (p = 0.0001), hours of labor (p = 0.0001), use of suction cup (p = 0.0005), birth weight less than 2500 g (p = 0.00). Conclusion: Mother-to-child HIV’s transmission still remains a public health problem at the Community University Hospital.

Surgery for Acute Stanford Type A Aortic Dissection in an Inner City Community Hospital: Single Surgeon’s Experience

Objective: An inverse relationship between volume and mortality in some cardiothoracic surgical procedures has been previously established, leading to suggestions that acute aortic dissection should not be operated in community or low volume heart centers. We therefore reviewed our experience to compare with published data. Methods: Retrospective review of 27 patients who underwent proximal aortic surgery by a single surgeon at an inner city community hospital between May 2004 and April 2015. 16 patients, mean age 51.7 ± 13.6 years old, 75.0% males underwent emergency surgery for acute Stanford type A aortic dissection, while 9 with root or ascending aortic aneurysm, mean age 50.3 ± 15.0 years old, 88.9% males had elective proximal aortic surgery. 2 patients with arch aneurysm were excluded. Results: Four (25.0%) patients with acute dissection were in Penn class A, 3 (18.7%) Penn B, 3 (18.7%) Penn C and 6 (37.5%) Penn B+C. 10 (62.5%) patients underwent emergency root replacement with 60.0% (6/10) mortality all related to malperfusion including 2 patients with bloody stools, while 6 (37.5%) underwent supracoronary graft replacement with 16.6% (1/6) mortality from cardiac tamponade. The 5-year survival was 89.0%. In patients with aortic aneurysm, 8 (88.9%) underwent elective root replacement and 1 (11.1%) supracoronary graft replacement with zero mortality. Conclusion: Supracoronary graft replacement is performed for the majority of uncomplicated acute type A dissections and can be undertaken by the average general cardiac surgeon with acceptable results. Visceral malperfusion especially when associated with bloody stools portends a poor prognosis, and aortic dissection should be excluded in any Marfan patient presenting with acute abdomen. Delaying intervention in attempting transfer to a tertiary hospital can potentially increase preoperative mortality, known to rise with each passing hour from onset of acute dissection. Patients presenting therefore to community hospitals should probably undergo surgery there to avoid complications associated with delay.

Epidemio-Clinical, Therapeutic and Evolutive Aspects of Pulmonary Embolism in Young Subject in the Cardiology Department in Point “G” Hospital University Center Bamako

Objective: The purpose of this work was to determine the epidemiological, clinical and evolutionary aspects of the pulmonary embolism of the young person in the cardiology department of the University Hospital Center (CHU) Point G in Bamako-Mali. Methodology: This was an analytical study from January 01, 2018 to December 31, 2018 in the CHU Point G cardiology department, including all patients hospitalized during this period. Results: Of 1379 hospitalized patients, 19 patients were concerned by pulmonary embolism of the young person. The prevalence of pulmonary embolism of the young person was 1.37%. The most affected age group was 21 - 30 (47.4%) of patients. The predominance was female (89.47%) with a gender ratio of 0.11 in favour of women. The average age in the series was 29.79 years with extremes of 16 years and 40 years. Factors predisposing to pulmonary embolism were dominated by peri partum, cardiomyopathy and obesity with 47.3%, 31.57% and 21.1%, respectively. The dominant signs were chest pain and dyspnea in 94.7% and 89.5% of cases respectively. Pulmonary embolism was unlikely in 60.52% according to the Geneva and Wells score simplified. At the thoracic angioscanner, the embolism was bilateral in 52.6% of cases and distal in 36.8% of patients;in 10 patients who performed cardiac ultrasound, pulmonary arterial hypertension (70%), dilation of the right ventricle (20%) and left ventricular dilation (40%). Hyper leucocytosis (47.4%), anemia and low prothrombin rate (TP) (22.2%) were the most found biological abnormalities. More than 2/3 (68.5%) our patients had an intermediate mortality risk according to the PESI (Pulmonary Embolism Severity Index) score. The average hospital stay was 10 days. Hospital mortality was 10.5%. Conclusion: The pulmonary embolism of the young person is a frequent, serious and multifactorial pathology and the female sex is most affected especially during peri partum periods, hence the need for preventive measures. Clinical signs are not specific and based on the assessment of clinical probability. Pulmonary angioscanner remains the confirmation review in our context.

Factors Predicting Progression to Severe COVID-19: A Competing Risk Survival Analysis of 1753 Patients in Community Isolation in Wuhan, China

Most studies of coronavirus disease 2019(COVID-19)progression have focused on the transfer of patients within secondary or tertiary care hospitals from regular wards to intensive care units.Little is known about the risk factors predicting the progression to severe COVID-19 among patients in community iso-lation,who are either asymptomatic or suffer from only mild to moderate symptoms.Using a multivari-able competing risk survival analysis,we identify several important predictors of progression to severe COVID-19—rather than to recovery—among patients in the largest community isolation center in Wuhan,China from 6 February 2020(when the center opened)to 9 March 2020(when it closed).All patients in community isolation in Wuhan were either asymptomatic or suffered from mild to moderate COVID-19 symptoms.We performed competing risk survival analysis on time-to-event data from a cohort study of all COVID-19 patients(n=1753)in the isolation center.The potential predictors we inves-tigated were the routine patient data collected upon admission to the isolation center:age,sex,respira-tory symptoms,gastrointestinal symptoms,general symptoms,and computed tomography(CT)scan signs.The main outcomes were time to severe COVID-19 or recovery.The factors predicting progression to severe COVID-19 were:male sex(hazard ratio(HR)=1.29,95%confidence interval(CI)1.04–1.58,p=0.018),young and old age,dyspnea(HR=1.58,95%CI 1.24–2.01,p<0.001),and CT signs of ground-glass opacity(HR=1.39,95%CI 1.04–1.86,p=0.024)and infiltrating shadows(HR=1.84,95%CI 1.22–2.78,p=0.004).The risk of progression was found to be lower among patients with nausea or vomiting(HR=0.53,95%CI 0.30–0.96,p=0.036)and headaches(HR=0.54,95%CI 0.29–0.99,p=0.046).Our results suggest that several factors that can be easily measured even in resource-poor set-tings(dyspnea,sex,and age)can be used to identify mild COVID-19 patients who are at increased risk of disease progression.Looking for CT signs of ground-glass opacity and infiltrating shadows may be an affordable option to support triage decisions in resource-rich settings.Common and unspecific symptoms(headaches,nausea,and vomiting)are likely to have led to the identification and subsequent community isolation of COVID-19 patients who were relatively unlikely to deteriorate.Future public health and clinical guidelines should build on this evidence to improve the screening,triage,and monitoring of COVID-19 patients who are asymtomatic or suffer from mild to moderate symptoms.

Situational Analysis of Low-density Lipoprotein Cholesterol Control and the Use of Statin Therapy in Diabetes Patients Treated in Community Hospitals in Nanjing, China

Background：Comprehensive management of diabetes should include management of its comorbid conditions,especially cardiovascular complications,which are the leading cause of morbidity and mortality among patients with diabetes.Dyslipidemia is a comorbid condition of diabetes and a risk factor for cardiovascular complications.Therefore,lipid level management is a key of managing patients with diabetes successfully.However,it is not clear that how well dyslipidemia is managed in patients with diabetes in local Chinese health-care communities.This study aimed to assess how well low-density lipoprotein cholesterol （LDL-C） was managed in Nanjing community hospitals,China.Methods：We reviewed clinical records of 7364 diabetic patients who were treated in eleven community hospitals in Nanjing from October 2005 to October 2014.Information regarding LDL-C level,cardiovascular risk factors,and use of lipid-lowering agents were collected.Results：In patients without history of cardiovascular disease （CVD）,92.1% had one or more CVD risk factors,and the most common CVD risk factor was dyslipidemia.The overall average LDL-C level was 2.80 ± 0.88 mmol/L,which was 2.62 ± 0.90 mmol/L and 2.82 ± 0.87 mmol/L in patients with and without CVD history respectively.Only 38% of all patients met the target goal and 37.3% of patients who took lipid-lowering agents met target goal.Overall,24.5% of all patients were on lipid-lowering medication,and 36.3% of patients with a CVD history and 20.9% of patients without CVD history took statins for LDL-C management.The mean statin dosage was 13.9 ± 8.9 mg.Conclusions：Only a small portion of patients achieved target LDL-C level,and the rate of using statins to control LDL-C was low.Managing LDL-C with statins in patients with diabetes should be promoted,especially in patients without a CVD history and with one or more CVD risk factors.

Dose surgical sub-specialization influence survival in patients with colorectal cancer?

AIM:To perform a review of patients with colorectal cancer to a community hospital and to compare the risk-adjusted survival between patients managed in general surgical units versus a colorectal unit. METHODS:The study evaluated all patients with colorectal cancer referred to either general surgical units or a colorectal unit from 1/1996 to 6/2001.These results were compared to a historical control group treated within general surgical units at the same hospital from 1/1989 to 12/1994.A Kaplan- Meier survival analysis compared the overall survivals (all- cause mortality) between the groups.A Cox proportional hazards model was used to determine the influence of a number of independent variables on survival.These variables included age,ASA score,disease stage,emergency surgery, adjuvant chemotherapy and/or radiotherapy,disease location,and surgical unit. RESULTS:There were 974 patients involved in this study. There were no significant differences in the demographic details for thethree groups.Patients in the colorectal group were more likely to have rectal cancer and Stage Ⅰ cancers, and less likely to have Stage Ⅱ cancers.Patients treated in the colorectal group had a significantly higher overall 5-year survival when compared with the general surgical group and the historical control group (56 % versus 45 % and 40 % respectively,P<0.01).Survival regression analysis identified age,ASA score,disease stage,adjuvant chemotherapy,and treatment in a colorectal unit (Hazards ratio:0.67;95 % CI:0.53 to 0.84,P =0.0005),as significant independent predictors of survival. CONCLUSION:The results suggest that there may be a survival advantage for patients with colon and rectal cancers being treated within a specialist colorectal surgical unit.

Characteristics of abnormal menstrual cycle and polycystic ovary syndrome in community and hospital populations

Background Polycystic ovary syndrome （PCOS） is considered to be the most common endocrine disorder in women of reproductive age.The involvement of an abnormal menstrual cycle in the etiology of PCOS remains unclear.We aimed to analyze the characteristics of abnormal menstrual cycles and their association with PCOS in community and hospital patient populations.Methods Women with PCOS identified from 2111 permanent female residents in the community of Beijing and 506 outpatients obtained from the reproductive clinic of Peking University Third Hospital were recruited for this study,comprising the PCOS community group and the PCOS hospital group, respectively.Each group was further divided into four subgroups according to the length of menstrual cycles： 〈21 days; 21-34 days; 35-60 days; and 〉60 days.Women in each group were interviewed using a questionnaire to assess factors including age, age of menarche, menstrual cycle history, related family history, and modified Ferriman-Gallwey （mF-G） score.All women received transvaginal ultrasound scan and had fasting blood samples taken for endocrine evaluation.A two-tailed P value of 〈0.05 was considered significant.Results In the community population, the prevalence of abnormal menstrual cycle was 27.19% （574/2111）.The prevalence of PCOS in the community was 6.11% （129/2111） according to Rotterdam criteria.In the community group,the most common menstrual cycle length was 35-60 days, whereas for the hospital group, it was 〉60 days.In both the community and hospital groups, the most common phenotype of PCOS was that of Oligo/amenorrhea＋PCO＋hyperandrogenism （HA） （O＋P＋H） （P=0.000）.With increasing cycle length of 35-60 days to 〉60 days, the percentages of Oligo/amenorrhea＋PCO （O＋P） and O＋P＋H were found to significantly decrease in the community group and significantly increase in the hospital group （P=0.000 for each）.In the hospital group, as the menstrual cycle length increased from 35-60 days to 〉60 days, the rate of spontaneous abortion increased significantly （P=0.000）, meanwhile the rate of poorly-secreted endometrium and abnormal endometrial hyperplasia increased significantly （P=0.000）.Conclusions The prevalence of PCOS in the Beijing community of women was 6.11%.Oligo/arnenorrhea was the most common type of abnormal menstrual cycle and may be an indicator for PCOS and endometrial lesions.Gynecologists should seek relevant medical information from women in the community to promptly diagnose PCOS and then follow up patients for potential development of subsequent complications.

Urinary Tract Infections in a Tunisian Orthopedic Institute: Major Strain Microbiological Profile

Background: Urinary Tract Infection (UTI) detected in the hospital and in the community is one of the most common reasons for consultation in everyday practice;it represents a major source of antibiotic consumption. This study’s objectives were to outline the microbiological profile of Tunisian patients with UTI and assess antibiotic resistance over the course of three years at the Orthopedic Institute. Methods: All strains identified in urine samples between January 1st, 2019, and December 31st, 2021, were included. Standard laboratory procedures were used to identify the bacterium. The Microscan Walkway 40 Plus was used to do biochemical assays and antibiotic susceptibility testing. The EUCAST criteria were used to interpret the findings. Results: A total of 1313 strains were isolated. The bacteriological study showed the predominance of enterobacteria (96.8%), especially E. coli (52.2%) and K. pneumoniae (19.3%). Overall resistance rates to antimicrobial agents were as follows: for hospital, E. coli strains were in descending order amoxicillin (73.05%), trimeth/sulfamethoxazole (46.9%), ofloxacin (40.3%), amoxicillin/clavulanic acid (35.05%) and gentamicin (20.5%). Our results showed low resistance to fosfomycin for E. coli 2.6% in hospitals while ≥12.1% for K. pneumoniae. Amikacin resistance remains medium-low for E. coli being ≥20% and 10% for K. pneumonia. Nitrofuran resistance has affected 1.06% of E. coli strains in hospital settings and 21.5% of K. pneumoniae. Extended Spectrum Beta-Lactamases (ESBLs) production was present in a number of enterobacteria (19.3% of K. pneumoniae and 14.4% of E. coli). Conclusion: The prevalence of E. coli and K. pneumoniae producers ESBLs in UTI is increasing. Rigorous surveillance of resistance rate is necessary to determine appropriate empirical treatment and limit the spread of multiresistant strains.

Kant： The Sweet Dream of Perpetual Peace

This essay is a survey upon Kant＇s Sweet Dream of Perpetual Peace. According to Kant, a permanent peace could be achieved under the condition of the creation of a Federation of States. This Federation of States will be rest upon three fundamental requirements--i.e., democracy, reason, universal hospitality. Kant＇s idea of global Federation of States should not be confused with existing nowadays Unions of States, such as European Union, which depend heavily upon a central authority and a complicated bureaucracy.

Patronage and Community in Medieval China:The Xiangyang Garrison,400-600 CE.(Andrew Chittick,New York:State of New York Press,2009)

Andrew Chittick先生的Patronage and Community in Medieval China:The Xiangyang Garison,400-600 CE.(《中古中國的庇護制與共同體:公元4-6世紀的襄陽地區》)一書,出版於2009年,是英文學界第一部系統研究4—6世紀南朝史的著作。~①作者並不諱言自己在理論上的野心。

Implementation of International Society Guidelines on Chorionicity Determination in Twins:A Multi-Center Cohort Study in China's Mainland

Objective:Ultrasound determination of chorionicity is poor in early pregnancy in China.In an effort to increase the accuracy rate of prompt chorionicity determination,clinical training was provided to primary care physicians.This study assesses the effects of implementing clinical guidelines on chorionicity determination.Methods:A multi-centered cohort study was conducted between January 2014 and June 2017 in 12 hospitals without fetal medicine centers.In 2014,the obstetricians and ultrasound physicians were trained in clinical practice and ultrasound examination relating to chorionicity determination.Linear and binary regression analyses were conducted to identify the effects of introducing the new protocols,including the diagnosis rate of chorionicty and perinatal outcomes,taking the data from 2014 as a baseline.Pregnancy outcomes were additionally adjusted for maternal age.Results:During the period of this study,3,599 twin pregnancies from 12 centers were enrolled,and a total of 2,998 twin pregnancies were extracted.The rate of overall chorionicity determination,including antenatal and postpartum diagnosis,increased successively from 49.5% in 2014 to 93.5% in 2017(P<0.0001).The rate of ultrasonic chorionicity diagnosis before 14 weeks increased from 25.2% in 2014 to 65.0% in 2017(P<0.0001).These changes were associated with decreasing incidence of preterm birth,a lower risk of stillbirth,whether for one(P=0.0456 in 2016)or two fetuses(P=0.0470 in 2016;P=0.0042 in 2017)and a decreased rate of admission to neonatal intensive care unit(43.0% in 2014,37.4% in 2017;P=0.0032).Conclusions:The implementation of a clinical practice guideline improved both overall and early chorionicity determinations.Regular training workshops of antenatal care are recommended to further promote capability in clinical diagnosis and treatment.