Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Civil-military realitions in south asia : Pakistan, Bangladesh and India/ Kukreja

306 hal; 21 cm

Democracy, Development and Discontent in South Asia

The volume deals with the issues of democracy and development in major South Asian countries. In a comprehensive manner, it draws attention to various aspects like ethnicity, multiculturalism, authoritarianism, economic reforms, trade, armed rebellion, democracy movements, and federal pressures.While examining the many facets of democracy and development in the region, the various contributors to the volume capture: the discontent in the political sphere within each country; how states navigate a maze of ethnic claims, multicultural compulsions, and separatist insurgencies; and; the region's optimism in economic reforms for development, peace-building processes for security, and democratization.340 hlm.; 23 cm

Curing and thermal behaviour of epoxy resin in the presence of aromatic imide-amines

259-264The paper describes the synthesis and characterization of aromatic imide-amines obtained by reacting pyromellitic dianhydride (P)/or benzophenone 3,3′, 4,4′-tetracarboxylic dianhydride (B) (1 mol) with excess of 4,4'-diaminodiphenyl ether [E]/or 4,4′-diaminodiphenyl methane [M]/or 4,4′-diaminodiphenyl sulfone [S] and their use as curing agents for diglycidyl ether of bisphenol-A (DGEBA). Structural characterization of imide-amines was done using FTIR, 1H-NMR,13C-NMR spectroscopy and elemental analysis. These aromatic imide-amines were used as curing agents in order to investigate the effect of structure on the curing and thermal behaviour of diglycidyl ether of bisphenol-A (DGEBA). Curing behaviour of DGEBA in the presence of stoichiometric amounts of aromatic imide-amines was investigated by differential scanning calorimetry (DSC). A broad exothermic transition in the temperature range of 180-230°C was observed in all the samples. The peak exotherm temperature (Tp) was lowest in case of imide-amines based on B and M and highest in case of imide-amines based on P/or B and S. Thermal stability of the isothermally cured resins was investigated using dynamic thermogravimetry in nitrogen atmosphere. The char yield was highest for resin cured with imide-amines based on B and E