Impact of exercise-based cardiac rehabilitation in patients with heart failure (ExTraMATCH II) on mortality and hospitalisation:an individual-patient data meta-analysis of randomised trials

This is the author accepted manuscript. The final version is available from Wiley via the DOI in this recordAIMS: To undertake an individual patient data (IPD) meta-analysis to assess the impact of exercise-based cardiac rehabilitation (ExCR) in patients with heart failure (HF) on mortality and hospitalisation, and differential effects of ExCR according to patient characteristics: age, sex, ethnicity, New York Heart Association functional class, ischaemic aetiology, ejection fraction, and exercise capacity. METHODS AND RESULTS: Randomised trials of exercise training for at least 3 weeks compared with no exercise control with 6-month follow-up or longer, providing IPD time to event on mortality or hospitalisation (all-cause or HF-specific). IPD were combined into a single dataset. We used Cox proportional hazards models to investigate the effect of ExCR and the interactions between ExCR and participant characteristics. We used both two-stage random effects and one-stage fixed effect models. IPD were obtained from 18 trials including 3912 patients with HF with reduced ejection fraction. Compared to control, there was no statistically significant difference in pooled time to event estimates in favour of ExCR although confidence intervals (CIs) were wide [all-cause mortality: hazard ratio (HR) 0.83, 95% CI 0.67-1.04; HF-specific mortality: HR 0.84, 95% CI 0.49-1.46; all-cause hospitalisation: HR 0.90, 95% CI 0.76-1.06; and HF-specific hospitalisation: HR 0.98, 95% CI 0.72-1.35]. No strong evidence was found of differential intervention effects across patient characteristics. CONCLUSION: Exercise-based cardiac rehabilitation did not have a significant effect on the risk of mortality and hospitalisation in HF with reduced ejection fraction. However, uncertainty around effect estimates precludes drawing definitive conclusions.This work is supported by UK National Institute for Health Research funding (HTA 15/80/30)

Utilisation of an operative difficulty grading scale for laparoscopic cholecystectomy

Background A reliable system for grading operative difficulty of laparoscopic cholecystectomy would standardise description of findings and reporting of outcomes. The aim of this study was to validate a difficulty grading system (Nassar scale), testing its applicability and consistency in two large prospective datasets. Methods Patient and disease-related variables and 30-day outcomes were identified in two prospective cholecystectomy databases: the multi-centre prospective cohort of 8820 patients from the recent CholeS Study and the single-surgeon series containing 4089 patients. Operative data and patient outcomes were correlated with Nassar operative difficultly scale, using Kendall’s tau for dichotomous variables, or Jonckheere–Terpstra tests for continuous variables. A ROC curve analysis was performed, to quantify the predictive accuracy of the scale for each outcome, with continuous outcomes dichotomised, prior to analysis. Results A higher operative difficulty grade was consistently associated with worse outcomes for the patients in both the reference and CholeS cohorts. The median length of stay increased from 0 to 4 days, and the 30-day complication rate from 7.6 to 24.4% as the difficulty grade increased from 1 to 4/5 (both p < 0.001). In the CholeS cohort, a higher difficulty grade was found to be most strongly associated with conversion to open and 30-day mortality (AUROC = 0.903, 0.822, respectively). On multivariable analysis, the Nassar operative difficultly scale was found to be a significant independent predictor of operative duration, conversion to open surgery, 30-day complications and 30-day reintervention (all p < 0.001). Conclusion We have shown that an operative difficulty scale can standardise the description of operative findings by multiple grades of surgeons to facilitate audit, training assessment and research. It provides a tool for reporting operative findings, disease severity and technical difficulty and can be utilised in future research to reliably compare outcomes according to case mix and intra-operative difficulty

Population‐based cohort study of outcomes following cholecystectomy for benign gallbladder diseases

Background The aim was to describe the management of benign gallbladder disease and identify characteristics associated with all‐cause 30‐day readmissions and complications in a prospective population‐based cohort. Methods Data were collected on consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing all‐cause 30‐day readmissions and complications were analysed by means of multilevel, multivariable logistic regression modelling using a two‐level hierarchical structure with patients (level 1) nested within hospitals (level 2). Results Data were collected on 8909 patients undergoing cholecystectomy from 167 hospitals. Some 1451 cholecystectomies (16·3 per cent) were performed as an emergency, 4165 (46·8 per cent) as elective operations, and 3293 patients (37·0 per cent) had had at least one previous emergency admission, but had surgery on a delayed basis. The readmission and complication rates at 30 days were 7·1 per cent (633 of 8909) and 10·8 per cent (962 of 8909) respectively. Both readmissions and complications were independently associated with increasing ASA fitness grade, duration of surgery, and increasing numbers of emergency admissions with gallbladder disease before cholecystectomy. No identifiable hospital characteristics were linked to readmissions and complications. Conclusion Readmissions and complications following cholecystectomy are common and associated with patient and disease characteristics

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

Interest Rate Consequences of Targeting Money (Conséquences de la fixation d'objectifs monétaires sur les taux d'intérêt) (Efecto de las metas monetarias en los tipos de interés)

This paper examines the implications of pursuing monetary targets for the behavior of interest rates in the vastly differing economic and political environments found among countries. This behavior depends on the economic environment in which the policy is undertaken. The simultaneous pursuit of interest rate and monetary targets (by means of monetary policy alone) is not generally possible, except in a limited way, even in the most isolated, financially undeveloped economies. For this reason the major interest rate issue associated with targeting money for those countries with developed financial markets is its consequence for the volatility of rates. In examining the underlying relationships that link monetary and interest rate behavior in an effort to assess the magnitude of the impact of monetary targeting on interest rate volatility, several shortcomings of the existing literature are presented. When these shortcomings are taken into account (or are corrected), the earlier assessments that interest rates would be "much" more volatile are "greatly" attentuated. The paper concludes that while monetary targets may increase interest rate volatility somewhat, that increase should be modest. /// La présente étude examine les implications que peut avoir la fixation d'objectifs monétaires quantitatifs sur le comportement des taux d'intérêt compte tenu des conditions économiques et politiques extrêmement différentes qui existent d'un pays à l'autre. Ce comportement dépend de la situation économique dans laquelle se trouve le pays lorsque les autorités appliquent leur politique. La poursuite simultanée d'objectifs en matière de taux d'intérêt et d'objectifs monétaires (seulement au moyen de la politique monétaire) n'est généralement pas possible, excepté de façon limitée, même dans les économies les plus isolées et financièrement peu développées. C'est pourquoi, le problème majeur que pose pour les taux d'intérêt la fixation d'objectifs monétaires dans les pays pourvus de marchés financiers développés est l'incidence de ces objectifs sur la stabilité des taux d'intérêt. L'examen des relations fondamentales entre l'évolution des agrégats monétaires et le comportement des taux d'intérêt entrepris dans le souci d'évaluer l'ampleur des effets de la fixation d'objectifs monétaires sur la stabilité des taux d'intérêt, fait apparaître plusieurs lacunes dans les travaux consacrés à ce sujet. Si l'on tient compte de ces lacunes (ou si l'on y remédie), les assertions initiales selon lesquelles les taux d'intérêt seraient "nettement" plus instables, se trouvent "fortement" atténuées. L'étude conclut que si les objectifs monétaires peuvent quelque peu accroître l'instabilité des taux d'intérêt, cet accroissement devrait être faible. /// En este estudio se analiza la repercusión de la fijación de metas monetarias en el comportamiento de los tipos de interés dentro de la gran variedad de contextos económicos y políticos de los diversos países. Dicho comportamiento depende del marco económico en al cual se aplican las medidas monetarias. En general, aun en las economías más aisladas y financieramente subdesarrolladas, no es posible fijar simultáneamente metas para los tipos de interés y la oferta monetaria (valiéndose únicamente de la política monetaria). Por esta razón el principal problema de los tipos de interés vinculado con las metas monetarias en los países que cuentan con un mercado financiero desarrollado es la repercusión de dichas metas en lo que se refiere a la volatilidad de los tipos de interés. Al examinar la relación fundamental que vincula el comportamiento monetario con el de los tipos de interés en un esfuerzo por evaluar la magnitud de la repercusión de la fijación de metas monetarias en la volatilidad de los tipos de interés, se hacen notar varias deficiencias de los estudios existentes. Al tener en cuenta (o corregir) estas deficiencias, la conclusión tradicional de que los tipos de interés serían "mucho" más volátiles se ve "notablemente" atenuada. Finalmente, se concluye an el estudio que, si bien es posible que las metas monetarias aumenten en cierta medida la volatilidad de los tipos de interés, este aumento sería moderado.

The SDR as a Means of Payment (Le DTS en tant que moyen de paiement) (El DEG como medio de pago)

Before the special drawing right (SDR) can make much progress toward becoming an important reserve asset, it needs to be more readily and widely used as a means of payment. The development of arrangements for settling SDR-denominated payment instructions between commercial banks is an important ingredient in that wider use. Clearing arrangements take many forms, and over time the market tends to evolve several interconnected arrangements simultaneously, such that payments are cleared in the most economical manner. Thus, there is the coexistence of correspondent clearing banks, citywide or regional clearinghouses, and central bank clearing accounts. For the SDR, it is possible if not likely that market participants will evolve a role for the Fund's official SDR in the clearing process similar to that played by central banks' reserve or clearing accounts in settling domestic currency payments. This paper explores one such possible arrangement; it would utilize movements of official SDRs between central banks as a means of making transfers of private SDRs between commercial banks in different countries. (In this context, official and private SDRs refer to SDRs allocated by the Fund and to SDR-denominated claims created by commercial banks, respectively.) The arrangement would require that central banks accept SDR-denominated clearing accounts from the commercial banks operating in their jurisdictions. These private SDR accounts of paying and receiving banks would be appropriately debited and credited with the counterpart in the Fund's official SDRs moving from one central bank to another on the books of the Fund's Special Drawing Rights Department. /// Pour que le droit de tirage spécial (DTS) puisse devenir un actif de réserve important, il faut que son utilisation comme moyen de paiement devienne plus facile et se généralise. La mise au point d'arrangements permettant de régler entre les banques commerciales les ordres de paiement libellés en DTS est une des conditions de cette utilisation élargie. Les systèmes de compensation se présentent sous différentes formes et, avec le temps, le marché tend à mettre en place plusieurs dispositifs qui sont simultanément interconnectés entre eux, afin que les paiements puissent être compensés de la façon la plus économique. C'est ainsi qu'on trouve à côté des banques de clearing, les chambres de compensation opérant à l'échelon d'une ville ou d'une région et les comptes de compensation de la banque centrale. Dans le cas du DTS, il est possible, sinon probable, que les participants au marché mettront au point pour le DTS officiel du Fonds un rôle dans le processus de compensation analogue à celui que les comptes de réserve ou de compensation auprès des banques centrales jouent dans le règlement des paiements intérieurs en monnaie. La présente étude examine l'un des dispositifs possibles. Celui-ci utiliserait les mouvements de DTS officiels entre les banques centrales comme moyen pour effectuer les transferts de DTS privés entre des banques commerciales situées dans des pays différents. (A cet égard, on entend par DTS officiels et DTS privés, les DTS alloués par le Fonds et les titres de créance libellés en DTS créés par les banques commerciales, respectivement.) Dans ce dispositif, les banques centrales seraient tenues d'accepter l'ouverture de comptes de compensation libellés en DTS par les banques commerciales qui relèvent de leur autorité. Ces comptes en DTS privés des banques qui effectuent ou reçoivent des paiements seraient convenablement débités et crédités de la contrepartie constituée par les DTS officiels qui passent d'une banque centrale à l'autre dans les livres du Département des droits de tirage spéciaux du Fonds. /// Para que el derecho especial de giro (DEG) pueda avanzar realmente hacia el objetivo de convertirse en un activo de reserva importante, es necesario facilitar y ampliar su uso como medio de pago. A fin de ampliar este uso es importante establecer mecanismos institucionales para liquidar órdenes de pago denominadas en DEG entre bancos comerciales. El mecanismo de compensación puede adoptar numerosas modalidades, y con el tiempo el mercado tiende a producir simultáneamente varios mecanismos interrelacionados de manera que tales pagos se liquiden del modo más económico. Esto explica la coexistencia de bancos corresponsales de compensación, cámaras de compensación regionales o limitadas al ámbito de una ciudad, y cuentas de compensación de los bancos centrales. Es posible, incluso probable, que los participantes en el mercado vayan definiendo un papel concreto para los DEG oficiales del Fondo en el proceso de compensación, similar al que desempeñan las reservas que los bancos comerciales mantienen en los bancos centrales para la liquidación de los pagos en moneda nacional. En este estudio se considera la posibilidad de un mecanismo de este tipo que utilizara las transacciones de DEG oficiales entre bancos centrales como medio de efectuar transferencias de DEG privados entre bancos comerciales de diferentes países. (En este contexto son DEG oficiales los asignados por el Fondo, y DEG privados, los títulos denominados en DEG creados por bancos comerciales.) Este mecanismo requeriría que los bancos centrales abrieran cuentas de compensación denominadas en DEG para los bancos comerciales que operan en sus jurisdicciones. Estas cuentas de DEG privados de los bancos pagadores y receptores se debitarían y acreditarían como correspondiese, asentándose la contrapartida en DEG oficiales del Fondo que pasan de un banco central a otro en los libros del Departamento de Derechos Especiales de Giro del Fondo.