Regional Variation In Hospitalization Rates: Causes And Implications

Regional Variation in Hospitalization Rates: Causes and Implications Sachin J. Shah, Harlan M. Krumholz. Section of Cardiology, Department of Internal Medicine, Yale University, School of Medicine, New Haven, CT. Background: Admission rates vary by regions and states, but the extent by which variation in regional admission rates are related to variation in the medical need of populations and the association with hospital outcomes is unknown. To address these issues, we examine two cardiovascular conditions that differ in physician discretion to admit, acute myocardial infarction (AMI), less discretionary, and heart failure (HF), more discretionary. We first determined whether regional cardiovascular risk factors predict admission rates and then examined whether regional admission rates were related to 30-day risk-standardized mortality and readmission rates (RSMRs and RSRRs). Methods: We used 2006-2008 Medicare ICD-9-CM claims data and the Medicare Denominator file to determine AMI and HF admission rates. The statewide prevalence of cardiovascular risk factors were obtained from the 2007 Behavioral Risk Factor Surveillance System. First, the relationship between statewide AMI and HF admission rates and cardiovascular risk factors was determined by a multivariate, least squares linear regression model. Second, hierarchical logistic models were used to estimate hospital RSMRs and RSRRs and then were aggregated to the level of hospital referral regions (HRRs). The correlation (R2) was obtained by linear regression to characterize the relationship between both AMI and HF admission rates and regional RSMRs and RSRRs. Where significant relationships were observed, cross condition analyses were performed comparing admission rates of one condition against the RSMR or RSRR of the other in an effort identify potentially confounded relationships. Results: In the first analysis, cardiovascular risk factors explained 49% of the variation observed in statewide AMI admission rates and 50% of the variation in HF admission rates. In the second analysis, regional AMI admission rate was not correlated with AMI RSMR (R2 0.01, 95% CI 0.00-0.04). Regional HF admission rate was inversely correlated with HR RSMR (R2 0.13, 95% CI 0.07-0.21). Regional AMI hospitalization rate was weakly correlated with AMI RSRR (R2 0.05, 95% CI 0.02-0.11). Regional HF admission rate was modestly correlated with HF RSRR (R2 0.25, 95% CI 0.17-0.34). In the cross condition analyses, regional HF admission rate was not associated with AMI RSMR (R2 0.00, 95% CI 0.00-0.02) but was associated with AMI RSRR (R2 0.25, 95% CI 0.17-0.34). Conclusion: Cardiovascular risk factors explain part, but not all, of the variation in AMI and HF admission rates. The modest association between regional HF admission rate, a more discretionary admission condition, and both AMI and HF RSRRs suggests a system propensity to patients. The same was not seen true of AMI a less discretionary admission condition. The modest inverse relationship between regional HF admission rate and HF RSMR, which was not observed with AMI RSMR, suggests an unmeasured confounder affecting the HF RSMR model

Enhanced external counterpulsation for management of symptoms associated with long COVID

Study objective: Enhanced external counterpulsation (EECP) as a possible therapy for Long COVID. Design: Retrospective analysis of a contemporary, consecutive patient cohort. Setting: 7 outpatient treatment centers. Participants: Long COVID patients. Intervention: 15–35 EECP treatments. Main outcome measures: The change from baseline in 1) Patient Reported Outcome Measurement Information System (PROMIS) Fatigue; 2) Seattle Angina Questionnaire (SAQ); 3) Duke Activity Status Index (DASI); 4) 6-Minute Walk Test (6MWT); 5) Canadian Cardiovascular Society (CCS) Angina Grade; 6) Rose Dyspnea Scale (RDS); and 7) Patient Health Questionnaire (PHQ-9). Results: Compared to baseline, the PROMIS Fatigue, SAQ, DASI, and 6MWT improved by 4.63 ± 3.42 (p \u3c 0.001), 21.44 ± 16.54 (p \u3c 0.001), 18.08 ± 13.82 (p \u3c 0.001), and 200.00 ± 180.14 (p = 0.002), respectively. CCS and RDS improved in 63% and 44% of patients, respectively. All patients unable to work prior to EECP were able to return post-therapy. Conclusions and relevance: EECP significantly improved validated fatigue and cardiovascular-related markers in patients with Long COVID

A comparative study of in clinico-pathological profile in dengue shock syndrome versus other types children's at tertiary health care center

Background: Dengue a mosquito borne arboviral disease is caused by one of the serotypes of dengue virus (DEN-1, DEN-2, Den-3, DEN-4) belonging to the family Flaviviridae. The objective of this study was to study clinco-pathological profile of Dengue shock syndrome versus Other types children's at tertiary health care center.Methods: This was Cross sectional observational study was conducted in a tertiary care hospital in the Department of Pediatrics after obtaining approval from the institutional Ethical Committee. The study was carried out over a period of one & half years from January 2015 to June 2016 Statistical analysis done by Chi-square, ANOVA, Paired t test SPSS version 22 (IBM SPSS Statistics, Somers NY, USA) was used to analyze data.Results: Mean age of patients were 8.08±2.72 years, majority of cases were females (51.9%) and 48.1% were males, the clinical features like hepatomegaly, Ascites Pleural Effusion significantly present in DSS (P<0.001). In the study, there was no significant difference in symptoms and severity of dengue fever except for convulsion Thrombocytopenia (platelet<1lakh/cmm) was observed in 74% of cases, leucopenia (total leukocyte count <4000/cmm) was observed in 56% of cases, haemocrit more than 40 was observed in 21.27% cases. Dengue shock syndrome had acute kidney injury, CCF and encephalopathy. This observation of complications between dengue severity was statistically significant. There was significant difference in haematocrit values between three diagnoses of dengue fever from day 1 till day 4. Initially higher haematocrit was observed in Dengue shock syndrome, later goes on decreasing.Conclusions: It can be concluded from our study that significantly dengue shock syndrome had acute kidney injury, CCF and encephalopathy. There was significant difference in hematocrit values between three diagnoses of dengue fever from day 1 till day 4. Initially higher hematocrit was observed in dengue shock syndrome

Development and validation of dissolution method for carvedilol compression-coated tablets

The present study describes the development and validation of a dissolution method for carvedilol compression-coated tablets. Dissolution test was performed using a TDT-06T dissolution apparatus. Based on the physiological conditions of the body, 0.1N hydrochloric acid was used as dissolution medium and release was monitored for 2 hours to verify the immediate release pattern of the drug in acidic pH, followed by pH 6.8 in citric-phosphate buffer for 22 hours, to simulate a sustained release pattern in the intestine. Influences of rotation speed and surfactant concentration in medium were evaluated. Samples were analysed by validated UV visible spectrophotometric method at 286 nm. 1% sodium lauryl sulphate (SLS) was found to be optimum for improving carvedilol solubility in pH 6.8 citric-phosphate buffer. Analysis of variance showed no significant difference between the results obtained at 50 and 100 rpm. The discriminating dissolution method was successfully developed for carvedilol compression-coated tablets. The conditions that allowed dissolution determination were USP type I apparatus at 100 rpm, containing 1000 ml of 0.1N HCl for 2 hours, followed by pH 6.8 citric-phosphate buffer with 1% SLS for 22 hours at 37.0 ± 0.5 ºC. Samples were analysed by UV spectrophotometric method and validated as per ICH guidelines.O presente estudo descreve o desenvolvimento e a validação de método de dissolução para comprimidos revestidos de carvedilol. O teste de dissolução foi efetuado utilizando-se o aparelho para dissolução TDT-06T. Com base nas condições fisiológicas do organismo, utilizou-se ácido clorídrico 0,1 N como meio de dissolução e a liberação foi monitorada por 2 horas para se verificar o padrão de liberação imediata do fármaco em condições de pH baixo, seguidas por pH 6,8 em tampão cítrico-fosfato por 22 horas, para simular o padrão de liberação controlada no intestino. Avaliou-se a influência da velocidade de rotação e a concentração de tensoativo no meio. As amostras foram analisadas por método espectrofotométrico UV-visível validado, em 286 nm. O laurilsulfato sódico a 1% (SLS) mostrou-se ótimo para aumentar a solubilidade do carvedilol em pH 6,8 em tampão cítrico-fosfato. A análise da variância não mostrou diferença significativa entre os resultados obtidos a 50 e a 100 rpm. O método da dissolução discriminante foi desenvolvido com sucesso para os comprimidos revestidos de carvedilol. As condições que permitiram a determinação da dissolução foram: aparelho USP tipo I a 100 rpm, contendo 1000 mL de HCL 0,1 N por 2 horas, seguido de pH 6,8 com tampão cítrico-fosfato, com 1% de SLS por 22 horas a 37,0 ± 0,5 ºC. Amostras foram analisadas por método espectrofotométrico e validadas pelas normas ICH

EFFICACY OF ‘MADHUSIKTHADI LEPA’ IN PADADARI

Padadari is one of the commonest & most negligible diseases. It is observed that people are least bothered about their feet than their face. The feet bear the whole body weight. In India 80 % of population live in rural area. Most of them work in farms in wet soil and water also. So incidence of cracking the skin of the foot is very common. Poor people ignore this problem due to lack of consciousness about foot care or may be due to costly drugs. In Ayurveda, Padadari is described in Kshudra roga by Sushruta, Madhavanidana, Bhavaprakasha, Yogaratnakara etc. The signs, symptoms, pathogenesis and treatment of Padadari are mentioned in details which indicate that this disease was affecting the people since ancient times. It is mentioned that Padadari is caused due to Vataprakopaka hetu such as Aticankramana (i.e. excessive walking especially barefooted). In the initial stage of disease patient does not have any complaint. But as the disease progresses, it can lead to severe symptoms as acute pain, burning sensation, itching and even bleeding from cracks. Study was a small scale trial including 50 patients with a small duration of 11days. But after studying 15 patients for one more week (total 14 days), it was observed that 12 patients (80%) were totally symptom free. So we concluded that Madhusikthadi lepa gives better effects in long duration with proper Pathyapalana

Implementation and Design of Customer Relationship Management for Openbravo

Customer Relationship management is the strongest and the most efficient approach in maintaining and creating relationships with customers.CRM systems are designed to com-pile information on customers across different channels which could include the company?s website, telephone, live chat, direct mail, marketing materials and social media. The purpose of the system is to capture the potential customer details using CRM Openbravo

Management of complete dislocation of tarsal scaphoid without fracture

Background: Injuries to the mid tarsal joints usually occur in the form of various combinations such as fracture, fracture subluxation, and fracture dislocation. Dislocations of navicular without fracture are rare injuries, minimal literatures exist, which describe the probable mechanism of injury and optimal treatment.Methods: Four patients with complete dislocation of navicular without fracture presented to us following a history of trauma. The diagnosis was confirmed by radiology and further details were studied by CT scans. One injury was open and the rest were closed. One had associated fracture of talus and two had metatarsal fracture and one was purely isolated navicular dislocation without any associated injury. All were initially stabilized in a below knee plaster of paris slab and foot end elevated. All were successfully treated surgically under spinal anesthesia with open reduction and internal fixation with Kirschner wires through a dorsomedial approach. Postoperative immobilization was continued for twelve weeks then gradual mobilization begun followed by physiotherapy.Results: All patients had good clinical results with two patients resuming their work within twelve weeks and the one with open wound took twenty weeks for resuming his original work. One with associated talar fracture later had to undergo subtalar arthrodesis for pain in the foot while weight bearing after one year of surgery for navicular dislocation. Conclusions: Open reduction and internal fixation with Kirschner wire is an effective way of managing patients with complete dislocation of tarsal navicular for early resuming of the functions and return to work

Doppler predictors of perinatal outcome in intra-uterine growth retarded foetuses

Background: The study aims at early detection of intrauterine growth retarded fetuses which are at high risk of perinatal complications. It can help obstetricians take appropriate preventive steps and prevent serious perinatal complications.Methods: The study undertaken over 100 pregnant women with pregnancy induced hypertension between 28-36 weeks subjected to umbilical artery and uterine artery doppler. The outcome data including gestational age at birth, birth height, APGAR score, admission to NICU, need for positive pressure ventilation and neonatal mortality.Results: The study shows that 58% mothers with IUGR foetuses were primigravida; gestational age at delivery is 34.2 weeks and 82% of IUGR foetuses were delivered by C-section. Average birth weight of foetus with abnormal doppler was significantly lower and there was high incidence of NICU admission. The study also shows that oligohydroamnios was common with abnormal doppler group.Conclusions: Umbilical artery doppler velocity in addition to uterine artery velocity doppler should be considered as a primary tool for foetal surveillance in pregnancy induced hypertension patients and for planning management of IUGR foetuses