How do time trends in inhospital mortality compare? A retrospective study of England and Scotland over 17 years using administrative data

Objectives To examine the trends in inhospital mortality for England and Scotland over a 17-year period to determine whether and if so to what extent the time trends differ after controlling for differences in the patients treated. Design Analysis of retrospective administrative hospital data using descriptive aggregate statistics of trends in inhospital mortality and estimates of a logistic regression model of individual patient-level inhospital mortality accounting for patient characteristics, case-mix, and country-specific and year-specific intercepts. Setting Secondary care across all hospitals in England and Scotland from 1997 to 2013. Population Over 190 million inpatient admissions, either electively or emergency, in England or Scotland from 1997 to 2013. Data Hospital Episode Statistics for England and the Scottish Morbidity Record 01 for Scotland. Main outcome measures Separately for two admission pathways (elective and emergency), we examine aggregate time trends of the proportion of patients who die in hospital and a binary variable indicating whether an individual patient died in hospital or survived, and how that indicator is influenced by the patient’s characteristics, the year and the country (England or Scotland) in which they were admitted. Results Inhospital mortality has declined in both countries over the period studied, for both elective and emergency admissions, but has declined more in England than Scotland. The difference in trend reduction is greater for elective admissions. These differences persist after controlling for patient characteristics and case-mix. Conclusions Comparing data at country level suggests questions about the roles performed by or functioning of their healthcare systems. We found substantial differences between Scotland and England in regard to the trend reductions in inhospital mortality. Hospital resources are therefore being deployed increasingly differently over time in these two countries for reasons that have yet to be explained

Bitten to the bone: A case of anxiety-induced osteomyelitis

Background: Onychophagia is a habitual nail-biting disorder, usually associated with mental or emotional diseases. It affects 20–30% of the population in all age groups. Human bites have the potential to become serious injuries due to high virulence in the human oral flora and may often require hospital admission, antibiotics and even debridement in the operating room. Thus, repetitive nail biting has the potential to be limb-threatening if not treated early and appropriately. Case Presentation: Patient is a 49-year-old gentleman with a past medical history of severe refractory anxiety treated with hydroxyzine and scheduled alprazolam, after failing multiple other treatments, who was admitted to the hospital due to cellulitis of the right third digit after failing outpatient antibiotic therapy. On the initial physical exam, the patient had a lack of fingernails and multiple wounds at various stages of healing across all digits. The distal and middle phalanges of the 3rd right digit showing increased erythema and swelling and band tightening. Patient was started on broad spectrum antibiotics. Initial Xray of the right hand was concerning for osteomyelitis which was later confirmed with Magnetic Resonance Imaging (MRI). Infectious disease agreed on a course of cefepime, vancomycin and metronidazole. Hand surgery did not see a need for amputation initially though patient did require fasciotomy of the flexor compartment of the right middle finger at day 6 of admission due to slow recovery. Hand surgery however was not convinced patient would make meaningful recovery and advocated for amputation of finger, but patient decided to continue non operative treatment. He was discharged to a skilled nursing facility where he was to continue intravenous antibiotics for 4 more weeks. Conclusion:The vulnerable patient population of south Texas is predominately Hispanic, Spanish-speaking and uninsured. It is imperative to treat psychiatric disorders early to prevent complications, however, given the few numbers of psychiatrist in the Rio Grande Valley and even fewer who speak Spanish it is not unusual find an appointment in more than 6 months out. In this case, we observe the limb-threatening complications a simple “bad habit” can lead to if not treated early and appropriately

Trends in and drivers of Healthcare Expenditure in the English NHS : a retrospective analysis

Background: In England, rises in healthcare expenditure consistently outpace growth in both GDP and total public expenditure. To ensure the National Health Service (NHS) remains financially sustainable, relevant data on healthcare expenditure are needed to inform decisions about which services should be delivered, by whom and in which settings. Methods: We analyse routine data on NHS expenditure in England over 9 years (2008/09 to 2016/17). To quantify the relative contribution of the different care settings to overall healthcare expenditure, we analyse trends in 14 healthcare settings under three broad categories: Hospital Based Care (HBC), Diagnostics and Therapeutics (D&T) and Community Care (CC). We exclude primary care and community mental health services settings due to a lack of consistent data. We employ a set of indices to aggregate diverse outputs and to disentangle growth in healthcare expenditure that is driven by activity from that due to cost pressures. We identify potential drivers of the observed trends from published studies. Results: Over the 9-year study period, combined NHS expenditure on HBC, D&T and CC rose by 50.2%. Expenditure on HBC rose by 54.1%, corresponding to increases in both activity (29.2%) and cost (15.7%). Rises in expenditure in inpatient (38.5%), outpatient (57.2%), and A&E (59.5%) settings were driven predominately by higher activity. Emergency admissions rose for both short-stay (45.6%) and long-stay cases (26.2%). There was a switch away from inpatient elective care (which fell by 5.1%) and towards day case care (34.8% rise), likely reflecting financial incentives for same-day discharges. Growth in expenditure on D&T (155.2%) was driven by rises in the volume of high cost drugs (270.5%) and chemotherapy (110.2%). Community prescribing grew by 45.2%, with costs falling by 24.4%. Evidence on the relationship between new technologies and healthcare expenditure is mixed, but the fall in drug costs could reflect low generic prices, and the use of health technology assessment or commercial arrangements to inform pricing of new medicines

Reading under the Common Core: Latinx Students’ Agency and Meaning-Making Practices in Peer Discussions about Text

The widespread adoption of the Common Core State Standards (CCSS), since 2010, has led to a growing concern among education scholars and practitioners about how the new standards will impact the educational trajectories of students from minoritized linguistic, ethnic, and racial backgrounds (Bunch, Walqui, & Pearson, 2014; Hakuta, Santos, & Fang, 2013; Lee, Quinn, & Valdés, 2013). In the area of English Language Arts (ELA), the close reading of texts, particularly informational texts, is identified as one of the primary reading skills students are expected to acquire, and is presented as central to students’ academic success in school and beyond. The CCSS narrowly define close reading as the practice of extracting knowledge and evidence from texts, paying limited attention to students’ broader learning contexts and existing funds of knowledge (Moll et al., 1992). The CCSS’s conceptualization of close reading contrasts with a sociocultural orientation to literacy (Castanheira, Crawford, Dixon, & Green, 2001; Hull & Moje, 2012) in which students’ language and literacy practices are viewed as socially situated and constructed. Drawing on the latter perspective, as well as on Neo-Vygotskian sociocultural theory (Rogoff, 1990) and a sociocultural linguistic framework (Bucholtz & Hall, 2005), the present study examines student interactions within and across instructional activities designed to support the acquisition of literacy skills required for close reading and analysis of complex texts. This dissertation presents a discourse analysis of classroom interaction in a 6th grade public school classroom in Southern California that was documented over the course of five months using video and audio recordings, participant observation, field notes, and samples of students’ work. The observations and analysis focus on peer discussions involving emergent bilinguals (García, 2009) from Latinx immigrant backgrounds, several of whom had been recently transitioned out of the school’s English Language Development (ELD) program. Findings suggest that students fluidly employed a range of linguistic and cultural resources, such as the use of their funds of knowledge and various linguistic registers, to make meaning and co-construct their understanding of texts with others. Students often used academic language as part of these interactions and demonstrated strong awareness of their language choices—particularly how they were connected to discourses about “standard” and “academic” language. Lastly, students’ engagement in different literacy tasks was locally constructed and influenced by factors such as the characteristics of specific texts and students’ affective responses to those texts. These finding have implications for how teaching practices associated with reading can be designed to leverage students’ knowledge and interests and expand learning opportunities for linguistically and racially marginalized students. Based on the findings, I propose an integrative and dynamic sociocultural approach to conceptualizing, teaching, and assessing students’ literacy practices in the classroom

Publicly funded hospital care : expenditure growth and its determinants

Understanding the drivers of growth in health care expenditure is crucial for forecasting future health care requirements and for the efficient use of resources. We consider total hospital admitted care expenditure in England between 2009/10 and 2016/17. Decomposition techniques are used to separate changes in expenditure into elements due to changes in the distribution of characteristics, of both individuals and the services they receive, and due to changes in the impact of characteristics on expenditures. Growth in aggregate expenditure was due to increases in total patient admissions together with a substantial shift towards episodes of non-elective care, particularly the use of long-stay care. Decomposition of patient level expenditure suggests efficiency gains in treatment across the full distribution of expenditures, but that these were outweighed by structural changes towards a greater proportion of patients presenting with high-dimensional comorbidities. This is particularly relevant at the top end of the expenditure distribution and accounts for a large proportion of the total expenditure growth

The determinants of health care expenditure growth

Understanding the drivers of growth in health care expenditure is crucial for forecasting future health care requirements and to ameliorate inefficient expenditure. This paper considers the detailed breakdown of hospital inpatient expenditures across the period 2007/08 to 2014/15. Decomposition techniques are used to unpick the observed rise in expenditure into a component due to a change in the distribution of characteristics, for example, greater prevalence of morbidity, and a component due to structural changes in the impact of such characteristics on expenditures (coefficient effects, for example, due to technological change). This is undertaken at the mean using standard decomposition techniques, but also across the full distribution of expenditures to gain an understanding of where in the distribution growth and its determinants are most relevant. Decomposition at the mean indicates a larger role for a structural change in characteristics rather than a change in coefficients. A key driver is an increased prevalence of comorbidities. When considering the full distribution we observe a decrease in expenditure at the bottom of the distribution (bottom two quintiles) but increasing expenditure thereafter. The largest increases are observed at the top of the expenditure distribution. Where changes in structural characteristics dominate changes in coefficients in explaining the rise in expenditure. Increases in comorbidities (and the average number of first diagnoses) across the two periods, together with increases in non-elective long stay episodes and non-elective bed days are important drivers of expenditure increases

Understanding the differences in in-hospital mortality between Scotland and England

Aims: We describe differences in in-hospital mortality between Scotland and England and test whether these differences are robust to controlling for the case-mix of patients. In spite of Scotland and England having much in common in regard to their hospital systems and populations we observe trends in-hospital mortality – the percentage of elective and emergency Continuous Inpatient Spells (CIS) that ended in death – that are different: England’s in-hospital mortality rates have decreased faster than Scotland’s for both types of admissions. Data: Individual patient data from England (HES) and Scotland (SMR01) for the period 2003/04 – 2011/12. Episode data is linked into CIS. Sample: Elective and emergency admissions, including day cases and excluding maternity. Methods: Logit regression of in-hospital death on country and financial year dummies, and their interaction, controlling for age group, gender, deprivation decile, and HRG of the first episode; separately for elective and emergency admissions. Results: For elective admissions, England has a lower initial in-hospital mortality rate than Scotland, and this rate decreases in both countries but the decrease has been faster in England. For emergency admissions, England starts with a slightly higher in-hospital mortality rate and both countries in-hospital mortality rates reduce throughout the period but England’s does so faster. Conclusions: There are differences in in-hospital mortality between Scotland and England; these differences increase over time and persist when we account for patient characteristics. It is important to understand the causes and consequences of these differences and we make a number of suggestions for future research on this issue

DETERMINACION DE LA UTILIDAD Y EFICACIA DEL PERFIL BIOFISICO FETAL Y DEL TEST DE APGAR EN PERINATOS DEL HOSPITAL DE QUILLABAMBA

BIENESTAR FETAL ECOGRAFÍA EDAD GESTACIONAL FETO FRECUENCIA CARDIACA HIPERCAPNIA HIPEROXIA HIPOCAPNIA HIPOXIA LÍQUIDO AMNIÓTICO MECONIO MORBILIDAD MORTALIDAD MUERTE PERINATAL NEONATO PARTO POR CESÁREA PARTO VAGINAL PERFIL BIOFÍSICO PERINATO SUFRIMIENTO FETAL VALOR PREDICTIVO POSITIVO VALOR PREDICTIVO NEGATIV

Culture-Negative Endocarditis Complicated with Mycotic Aneurysm and Intracranial Bleed - A Case Report

Background: Blood culture-negative infective endocarditis (IE) requires at least three independent blood samples with negative cultures after seven days of incubation. Ischemic events are the most frequent neurologic complication of IE with intracranial mycotic aneurysms being the consequence of displacement of septic emboli from valvular vegetations. In this case report, we describe a young gentleman who initially presented with neurologic deficit and was later found to have mycotic aneurysms and culture negative infective endocarditis. Case Presentation: A 34-year-old man with a past medical history of Tourette Syndrome presented to the Emergency department (ED) due to acute change in mental status. In the ED, the patient was found to have a Glasgow Coma Scale of 4 and was immediately intubated. Initial computed tomography (CT) of the head without contrast showed a large intraparenchymal hematoma within the left frontal lobe with internal hypoechoic densities suggesting active bleeding and a left-to-right midline shift. A subarachnoid hemorrhage was also noted on the left. The patient was taken to the operating room for emergent right ventriculostomy placement. Subsequent CT angiography of the head revealed a focal lobulated area of contrast density suspicious for a ruptured aneurysm. An additional peripheral aneurysm was found within the peripheral aspect of the right parietal lobe. Due to peripheral location of the aneurysms, they were deemed to be mycotic and patient underwent embolization of the left frontal and right parietal aneurysms. Patient was initially treated with vancomycin and piperacillin-tazobactam for the first 24 hours and was later switched to vancomycin, ceftriaxone, and tobramycin by the infectious disease specialist. Due to patient having recurrent fevers despite antibiotic therapy, a transesophageal echocardiogram (TEE) was performed showing a small mobile echodensity on the anterior leaflet of the mitral valve, highly suspicious of vegetation and endocarditis. The anaerobic bottle of the initial blood culture grew anaerobic gram-positive cocci, identified as Finegoldia magna suspected to be a contaminant. Subsequent cultures were negative. Conclusion: Currently, there are no randomized trials to guide the management of infected aneurysms. Management strategies are based upon clinical experience usually with antibiotic therapy combined with surgical debridement and revascularization