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Haemodialysis centres have conventionally provided maintenance haemodialysis using a standard dialysate temperature (eg, 36·5°C) for all patients. Many centres now use cooler dialysate (eg, 36·0°C or lower) for potential cardiovascular benefits. We aimed to assess whether personalised cooler dialysate, implemented as centre-wide policy, reduced the risk of cardiovascular-related death or hospital admission compared with standard temperature dialysate.MyTEMP was a pragmatic, two-arm, parallel-group, registry-based, open-label, cluster-randomised, superiority trial done at haemodialysis centres in Ontario, Canada. Eligible centres provided maintenance haemodialysis to at least 15 patients a week, and the medical director of each centre had to confirm that their centre would deliver the assigned intervention. Using covariate-constrained randomisation, we allocated 84 centres (1:1) to use either personalised cooler dialysate (nurses set the dialysate temperature 0·5-0·9°C below each patient's measured pre-dialysis body temperature, with a lowest recommended dialysate temperature of 35·5°C), or standard temperature dialysate (36·5°C for all patients and treatments). Patients and health-care providers were not masked to the group assignment; however, the primary outcome was recorded in provincial databases by medical coders who were unaware of the trial or the centres' group assignment. The primary composite outcome was cardiovascular-related death or hospital admission with myocardial infarction, ischaemic stroke, or congestive heart failure during the 4-year trial period. Analysis was by intention to treat. The study is registered at ClinicalTrials.gov, NCT02628366.We assessed all of Ontario's 97 centres for inclusion into the study. Nine centres had less than 15 patients and one director requested that four of their seven centres not participate. 84 centres were recruited and on Feb 1, 2017, these centres were randomly assigned to administer personalised cooler dialysate (42 centres) or standard temperature dialysate (42 centres). The intervention period was from April 3, 2017, to March 31, 2021, and during this time the trial centres provided outpatient maintenance haemodialysis to 15 413 patients (about 4·3 million haemodialysis treatments). The mean dialysate temperature was 35·8°C in the cooler dialysate group and 36·4°C in the standard temperature group. The primary outcome occurred in 1711 (21·4%) of 8000 patients in the cooler dialysate group versus 1658 (22·4%) of 7413 patients in the standard temperature group (adjusted hazard ratio 1·00, 96% CI 0·89 to 1·11; p=0·93). The mean drop in intradialytic systolic blood pressure was 26·6 mm Hg in the cooler dialysate group and 27·1 mm Hg in the standard temperature group (mean difference -0·5 mm Hg, 99% CI -1·4 to 0·4; p=0·14).Centre-wide delivery of personalised cooler dialysate did not significantly reduce the risk of major cardiovascular events compared with standard temperature dialysate. The rising popularity of cooler dialysate is called into question by this study, and the risks and benefits of cooler dialysate in some patient populations should be clarified in future trials.Canadian Institutes of Health Research, Heart and Stroke Foundation of Canada, Ontario Renal Network, Ontario Strategy for Patient-Oriented Research Support Unit, Dialysis Clinic, Inc., ICES (formerly known as the Institute for Clinical Evaluative Sciences), Lawson Health Research Institute, and Western University.

Hidradenitis suppurativa is a chronic inflammatory dermatologic condition occurring most commonly in areas with large numbers of apocrine sweat glands. Surgical excision and wound reconstruction are indicated for severe or refractory disease. This study aims to explore institutional reconstructive outcomes following hidradenitis suppurativa excision and compare these to the nationally recognized Tracking Operations and Outcomes for Plastic Surgeons (TOPS) database to determine best-practice guidelines.A retrospective chart review of all patients with surgically treated hidradenitis suppurativa from January of 2004 to January of 2016 was performed. Data on patient characteristics, reconstructive methods, and outcomes were collected. Outcomes for each reconstructive method were analyzed and associations between reconstruction and complications were determined. These results were compared to TOPS data.A total of 382 operative sites for 101 individual patients were reviewed. Overall complication rates were 80, 68.3, and 59.6 percent for simple, intermediate, and complex closure, respectively; 68.3 percent for adjacent soft-tissue rearrangement; and 100 percent for split-thickness skin grafts and perforator flaps. Statistical significance was identified between superficial wound dehiscence and adjacent tissue rearrangement compared to intermediate and complex closure (p = 0.0132). TOPS data revealed similar wound breakdown rates for primary closure methods but much lower rates with negative-pressure wound therapy, split-thickness skin grafts, and muscle flaps.Primary closure techniques for hidradenitis suppurativa wound reconstruction possess high complication rates, whereas improved outcomes are observed with negative-pressure wound therapy, split-thickness skin grafts, and muscle flaps. The correlation in outcomes between our experience and that reported in the TOPS database provides a level of validation to this national database.

OBJECTIVETo evaluate the long-term outcomes of an antimicrobial stewardship program (ASP) implemented in a hospital with low baseline antibiotic use.DESIGNQuasi-experimental, interrupted time-series study.SETTINGPublic safety net hospital with 525 beds.INTERVENTIONImplementation of a formal ASP in July 2008.METHODSWe conducted a time-series analysis to evaluate the impact of the ASP over a 6.25-year period (July 1, 2008–September 30, 2014) while controlling for trends during a 3-year preintervention period (July 1, 2005–June 30, 2008). The primary outcome measures were total antibacterial and antipseudomonal use in days of therapy (DOT) per 1,000 patient-days (PD). Secondary outcomes included antimicrobial costs and resistance, hospital-onset Clostridium difficile infection, and other patient-centered measures.RESULTSDuring the preintervention period, total antibacterial and antipseudomonal use were declining (−9.2 and −5.5 DOT/1,000 PD per quarter, respectively). During the stewardship period, both continued to decline, although at lower rates (−3.7 and −2.2 DOT/1,000 PD, respectively), resulting in a slope change of 5.5 DOT/1,000 PD per quarter for total antibacterial use (P=.10) and 3.3 DOT/1,000 PD per quarter for antipseudomonal use (P=.01). Antibiotic expenditures declined markedly during the stewardship period (−$295.42/1,000 PD per quarter, P=.002). There were variable changes in antimicrobial resistance and few apparent changes in C. difficile infection and other patient-centered outcomes.CONCLUSIONIn a hospital with low baseline antibiotic use, implementation of an ASP was associated with sustained reductions in total antibacterial and antipseudomonal use and declining antibiotic expenditures. Common ASP outcome measures have limitations.Infect Control Hosp Epidemiol 2015;00(0): 1–9

Management information systems are an essential tool for health care managers. Denver Health, an integrated safety net institution, upgraded its financial management information system during 1997 and experienced almost an 18 percent or $23 million increase in cash collections from 1997 to 1998 and a 17 percent or over $25 million increase from 1998 to 1999. Cash collections continued to increase in 2000 with a $12.0 million (6.8%) ncrease over 1999. This article explains the information system factors that have contributed to this increase and describes the continued management efforts that are expected to continue to improve cash collections.

More common than anorexia and less easily detected, bulimia typically begins as an effort to control weight. Although the prognosis is better than that for anorexia nervosa, a number of medical complications can arise related to the mode of purging. Some of these complications can have profound deleterious sequelae if not diagnosed and treated.