Emergency Medicine

Σκοπός της παρούσας πτυχιακής εργασίας είναι η βιβλιογραφική ανασκόπηση σχετικά με τη σπαστικότητα που προκύπτει μετά το Αγγειακό Εγκεφαλικό Επεισόδιο (ΑΕΕ) καθώς και τις θεραπευτικές επιλογές που διαθέτει ο ασθενής (φαρμακευτική αγωγή, φυσικοθεραπεία, εργοθεραπεία και λογοθεραπεία). Η αντιμετώπιση της σπαστικότητας απαιτεί μια διεπιστημονική προσέγγιση για τα μέγιστα αποτελέσματα. Για την αναζήτηση των πληροφοριών χρησιμοποιήθηκαν οι εξής βάσεις δεδομένων: PubMed, Google Scholar, Scopus, PeDro. Επιλέχθηκαν άρθρα με βάση τη βαθμολογία PeDro (>7/10). Ακόμη χρησιμοποιήθηκαν βιβλία ανατομίας, νευροφυσιολογίας, φυσικοθεραπείας, λογοθεραπείας και ψυχιατρικής. Στο γενικό μέρος δίνεται ο ορισμός του ΑΕΕ και βασικά στοιχεία όπως επιδημιολογία κ.α. Επιπλέον, στο γενικό μέρος εξετάζεται ο μυϊκός τόνος και η ρύθμισή του, για την κατανόηση της σπαστικότητας μετά από ΑΕΕ, που έγκειται σε διαταραχή του μυϊκού τόνου. Μελετάται η εξέταση του ασθενή με σπαστικότητα, οι αλλοιώσεις στα μαλακά μόρια...

Local de defesa: Sala 01, Bloco 126, campus da Universidade Estadual de Maringá. Aos meus filhos Ana Caroline e Bruno, que por tantas vezes, sacrificaram os poucos momentos de convivência comigo, para que eu pudesse me dedicar a este trabalho, obrigado por me acompanharem nesta jornada. E em especial a minha esposa Eliane, por sua tão grande paciência e compreensão comigo durantes estes anos, sempre comigo nos momentos mais difíceis. Só eu sei o tamanho da importância de vocês na minha vida. Amo vocês... A DEUS, por me proteger nas viagens a Maringá e também ao meu tempo em Durham (Carolina do Norte) nos Estados Unidos, dando força e sabedoria para enfrentar e superar os contratempos na realização dos trabalhos neste período de qualificação. Ao meu Pai Benedito Luciano (in memorian) e a minha mãe Maria Aparecida "Dona Cida" por mostrar o verdadeiro sentido de família em minha vida. Ao meu irmão Lucino "Dedé" (in memorian) minha referência de dedicação aos estudos, e às minhas irmãs e meus sobrinhos pelo carinho de sempre. Ao meu grande amigo Professor Oscar kenji Nihei pela contribuição valiosa que vem dando a mim nestes últimos anos, me ensinando lições de pesquisa, mas principalmente lições de humildade.

Department. The decision rule achieved a sensitivity of 99.5% (95% CI: 98.1% to 99.9%) and specificity of 7.4% (95% CI: 6% to 9.1%) to the primary outcome. The BIG criteria achieved the same sensitivity but lower specificity (5%). Our empirical models showed good predictive performance and outperformed the BIG criteria. This would potentially allow ED discharge of one in twenty patients currently admitted for observation. However prospective external validation and economic evaluation is required.

One of the most helpful strategies to deal with ongoing coronavirus pandemics is to use some prudence when treating patients infected with SARS-CoV-2. We aimed to evaluate the clinical, demographic, and laboratory parameters that might have predictive value for in-hospital mortality and the need for intensive care and build a model based on them. This study was a prospective, observational, single-center study including non-critical patients admitted to COVID-19 wards. Besides classical clinic-demographic features, basic laboratory parameters obtained on admission were tested, and then new models for each outcome were developed built on the most significant variables. Receiver operating characteristics (ROC) analyses were performed by calculating each model's probability. A total of 368 non-critical hospitalized patients were recruited, the need for ICU care was observed in 70 patients (19%). The total number of patients who died in either ICU or wards was 39 (10.6%). The first two models (based on clinical features and demographics) were developed to predict ICU and death, respectively; older age, male sex, active cancer, and low baseline saturation were noted to be independent predictors. The area under the curve values of the first two models were noted 0.878 and 0.882 (p < .001; confidence interval [CI] 95% [0.837-0.919], p < .001; CI 95% [0.844-0.922]). Following two models, the third and fourth were based on laboratory parameters with clinicdemographic features. Initial lower sodium and lower albumin levels were determined as independent factors in predicting the need for ICU care; higher blood urea nitrogen and lower albumin were independent factors in predicting in-hospital mortality. The area under the curve values of the third and fourth model was noted 0.938 and 0.929, respectively (p < .001; CI 95% [0.912-0.965], p < .001; CI 95% [0.895-962]). By integrating the widely available blood tests results with simple clinic demographic data, non-critical patients can be stratified according to their risk level. Such stratification is essential to filter the patients' non-critical underlying diseases and conditions that can obfuscate the physician's predictive capacity.

Background The 30-day readmission rate is an important indicator of patient safety and hospital’s quality performance. In this study, we aimed to find out the 30-day readmission rate of mild and moderate severity coronavirus disease of 2019 (COVID-19) patients discharged from a tertiary care university hospital and to demonstrate the possible factors associated with readmission. Methods This is an observational, single-center study. Epidemiological and clinical data of patients who were hospitalized with a diagnosis of COVID-19 were retrieved from a research database where patient information was recorded prospectively. Readmission data were sought from the hospital information management system and the National Health Information System to detect if the patients were readmitted to any hospital within 30 days of discharge. Adult patients (≥18 years old) hospitalized in COVID-19 wards with a diagnosis of mild or moderate COVID-19 between 20 March 2020 (when the first case was admitte...

Background French Guiana (FG) is a French territory located in South America with the highest rate of armed assaults. FG presents a poorly developed road system and a young and precarious population that makes the geographical and sociodemographic characteristics specific. No data concerning the firearm injury management are available in this country. Studying thesis trauma could permit to improve the management of victims. The objective of this study is to investigate the epidemiology of firearm injuries in FG, to define characteristics of the victims, and to assess factors associated with death. These identified factors could enable target primary prevention and intensification of medical management. Methods From January 2016 to December 2019, we conducted a retrospective study at the Cayenne General Hospital (CGH), including all patients admitted for firearm injuries in the emergency department, the medical emergency and resuscitation service, and the forensic service. A bivariate analysis was performed to assess relevant clinical data that were entered into a logistic regression model to assess factors associated with death. Results A total of 871 files were analyzed concerning 340 patients included after cross-checking. Victims were mainly males (90%) and young (30 ± 11 years old). The injury occurred mainly at night (60%), in a context of assaults (83%) and with long-barreled guns (82%). Among the 290 patients managed at the CGH, 60% were hospitalized including 12% that were in the intensive care unit, 41% that required surgical treatment, and 7% that died in hospital. The overall average length of stay was 10 ± 18 days. Overall mortality (n = 71, 21%) is statistically associated with male gender (p = 0.007) and suicide context (p < 0.001). In multivariate analysis, the sites of wounds (head and neck, thorax; p < 0.001) as well as induced organ injuries (neurological, respiratory, and vascular; p < 0.005) were independent factors associated to mortality. Conclusions This work underlines the high incidence of ballistic trauma in FG. This mainly involves a young and male population linked to the use of long arms and assaults. Despite the geographical difficulties of the territory and the technical platform deficits (no neurosurgery, no cardiothoracic surgery, no interventional radiology), the mortality is comparable to other studies, but remains more than twice as high as in mainland France. Finally, despite a change in legislation restricting access to firearms, our results show that gunshot firearm injuries remain a major public health concern requiring greater political actions.

Introduction: Prediction of complications is an essential part of risk management in surgery. Knowing which patient to operate and those at high risk of developing complications contributes significantly to the quality of surgical care and cost reduction. The postoperative complications of patients who underwent Laparotomy in Mulago Hospital were studied using POSSUM scoring system. The main objective of this study was to determine the postoperative complications of Laparotomy in Mulago Hospital, between September 2003 and February 2004. Methods: Consecutive patients, who underwent Laparotomy in Mulago, were studied using POSSUM system for development of complications. For each patient operated, they were followed up in wards until discharge. When the postoperative complications were reported, they were reexamined by the surgeons, treated and followed up for 30 days postoperatively. Phone contacts were used for the follow up. Surgical reviews were conducted once a week in Mulago Hos...

Little is known of the incidence of adverse events in the paediatric intensive care unit (PICU). Perceived incidence may be dependent on data-collection methods. To determine the incidence of adverse events by voluntary reporting and systematic enquiry. Adverse events in PICU were recorded contemporaneously by systematic enquiry with bedside nurses and attending doctors, and compared with data submitted voluntarily to the hospital&#39;s quality and safety unit. Events were classified as insignificant, minor, moderate, major and catastrophic or lethal, and assigned origins as medical/surgical diagnosis or management, medical/surgical procedures, medication or miscellaneous. Among 740 patients, 524 adverse events (mean 0.71 per patient) occurred in 193 patients (26.1%). Systematic enquiry detected 405 (80%) among 165 patients and were classified by one investigator as insignificant 30 (7%); minor 100 (25%); moderate 160 (37%); major 103(25%) and catastrophic 12 (3%). The coefficient o...

Little is known of the incidence of adverse events in the paediatric intensive care unit (PICU). Perceived incidence may be dependent on data-collection methods. To determine the incidence of adverse events by voluntary reporting and systematic enquiry. Adverse events in PICU were recorded contemporaneously by systematic enquiry with bedside nurses and attending doctors, and compared with data submitted voluntarily to the hospital&#39;s quality and safety unit. Events were classified as insignificant, minor, moderate, major and catastrophic or lethal, and assigned origins as medical/surgical diagnosis or management, medical/surgical procedures, medication or miscellaneous. Among 740 patients, 524 adverse events (mean 0.71 per patient) occurred in 193 patients (26.1%). Systematic enquiry detected 405 (80%) among 165 patients and were classified by one investigator as insignificant 30 (7%); minor 100 (25%); moderate 160 (37%); major 103(25%) and catastrophic 12 (3%). The coefficient o...

To reduce in-hospital intervals by developing a prehospital notification (PHN) protocol which directly notifies a neurologist to prepare for possible treatment. Methods: A 24/7 connection was established between emergency medical services dispatch and the on-call neurologist. A database of all patients with in-hospital stroke code activation was developed, door-to-computed tomography (CT) time and door-toneedle time was recorded from January 2013 to December 2016. The statistical results were considered significant at p < 0.05. Result: PHN resulted in a significant reduction in door-to-CT time (median 14 vs 20; p < 0.001). Among patients who were treated with intravenous thrombolysis, door-to-needle time was significantly shorter in patients with PHN compared with non-PHN group (median 42 vs 70; p < 0.001). Conclusion: PHN effectively reduced door-to-CT and door-to-needle times.

Background and ObjectivesDeclines in stroke admission, IV thrombolysis (IVT), and mechanical thrombectomy volumes were reported during the first wave of the COVID-19 pandemic. There is a paucity of data on the longer-term effect of the pandemic on stroke volumes over the course of a year and through the second wave of the pandemic. We sought to measure the effect of the COVID-19 pandemic on the volumes of stroke admissions, intracranial hemorrhage (ICH), IVT, and mechanical thrombectomy over a 1-year period at the onset of the pandemic (March 1, 2020, to February 28, 2021) compared with the immediately preceding year (March 1, 2019, to February 29, 2020).MethodsWe conducted a longitudinal retrospective study across 6 continents, 56 countries, and 275 stroke centers. We collected volume data for COVID-19 admissions and 4 stroke metrics: ischemic stroke admissions, ICH admissions, IVT treatments, and mechanical thrombectomy procedures. Diagnoses were identified by theirICD-10codes or ...

Background It has been reported that acute stroke services were compromised during COVID-19 due to various pandemic-related issues. We aimed to investigate these changes by recruiting centers from different countries. Methods Eight countries participated in this cross-sectional, observational, retrospective study by providing data from their stroke data base. We compared 1 year before to 1 year during COVID-19 as regards onset to door (OTD), door to needle (DTN), door to groin (DTG), duration of hospital stay, National Institute of Health Stroke Scale (NIHSS) at baseline, 24 h, and at discharge as well as modified Rankin score (mRS) on discharge and at 3 months follow-up. Results During the pandemic year, there was a reduction in the number of patients, median age was significantly lower, admission NIHSS was higher, hemorrhagic stroke increased, and OTD and DTG showed no difference, while DTN time was longer, rtPA administration was decreased, thrombectomy was more frequent, and hos...

Background: Intravenous thrombolysis is an approved treatment method for patients with acute ischemic stroke (AIS) and is recommended by multiple guidelines. However, it seems that it is less frequently used in the developing countries compared to the developed countries. Objectives: The purpose of this study was to estimate the percentage of patients with AIS, eligible for intravenous thrombolytic therapy, at the main referral center in Northwest Iran and to determine the main barriers for implementation of this method. Patients and Methods: Over one year, 647 patients who were admitted to the emergency department and met the Cincinnati Stroke Scale were enrolled into the study. The center to which patients were admitted, is a tertiary university hospital that has the required infrastructure for thrombolytic therapy in AIS. Factors recorded were neurological examinations and time between onset of symptoms and hospital arrival, hospital arrival and performance of brain computed tomography (CT) scanning, and hospital arrival to complete the investigations. Patients eligible for intravenous thrombolytic therapy were identified according to the American Heart Association (AHA) guidelines. Results: Mean time interval between hospital arrival and completion of brain CT scanning was 91 minutes (range: 20-378 minutes) and mean time from hospital arrival to completion of investigations was 150 minutes (range: 30-540 minutes). A total of 159 (31.3%) patients arrived at hospital within 3 hours of the onset of symptoms (early enough for intravenous thrombolytic therapy). However, 81.7% (130/159) of these patients missed thrombolytic therapy due to delayed performance of brain CT scanning and laboratory tests and 38.3% (61/159) had contraindications. The remaining 16 patients (10% of those who arrived within 3 hours and 3.1% of all cases) were eligible for thrombolytic therapy. Conclusions: The major barriers for thrombolytic therapy for patients with AIS in this setting were delays in the provision of in-hospital services, like initial patient assessment, CT scans or laboratory studies. These results were in contrast with previous reports.

Tuberculosis or TB is a global problem because of it high number globally. The 2021 WHO report shows that in 2020 there were around 9.9 million TB cases of which 1.2 million died. Of the total cases, 465,000 were MDR/RR-TB case. In Indonesia, TB RO is estimated to reach 2.4% of the total new TB patients and 13% of TB patients who have been treated previously. In the Global Tuberculosis Report issued by WHO in 2023, there were 28,000 cases of MDR-TB in Indonesia. TB patients with Diabetes Mellitus (DM) also have a 6.8x risk of being infected with secondary MDR-TB. This research is an observational study conducted retrospectively using medical records obtained from the MDR-TB polyclinic in Dr Soetomo General Academic Hospital during the period January 2019 to January 2023. The result of the highest comorbid was DM with 29.3% MDR-TB Patients are found with DM with 47.7% cause of infection are treatment failure.

The delivery of electricity to widely dispersed communities across the open steppe grasslands of Mongolia depends on medium-voltage (10–35 kV) distribution lines, often carrying power over substantial distances. Previously utilizing wooden supports, upgraded and new distribution lines are now designed to be cheaper, using steel-reinforced concrete poles with galvanized steel crossarms that can carry an electrical charge to the ground. Consequently, any bird that perches on these poles and simultaneously touches a conducting cable can be electrocuted, which is a significant risk for medium to large-sized birds at 10 kV and 15 kV lines utilizing pin-insulators. Surveys and monitoring of these dangerous power lines revealed that raptor electrocution rates were high, especially in areas with abundant prey, and widespread across steppe habitats. With around 3,500 km of hazardous lines in the Mongolian steppe zone, it was estimated around 18,000 raptors, including 4,000 Saker Falcons, wer...

To evaluate whether a clinical aid providing precalculated medication doses decreases prescribing errors among residents during pediatric simulated cardiopulmonary arrest and anaphylaxis. METHODS: A crossover randomized trial was conducted in a tertiary care hospital simulation center with residents rotating in the pediatric emergency department. The intervention was a reference book providing weight-based precalculated doses. The control group used a card providing milligram-per-kilogram doses. The primary outcome was the presence of a prescribing error, defined as a dose varying by ≥20% from the recommended dose or by incorrect route. Residents were involved in 2 sets of paired scenarios and were their own control group. Primary analysis was the difference in mean prescribing error proportions between both groups. RESULTS: Forty residents prescribed 1507 medications or defibrillations during 160 scenarios. The numbers of prescribing errors per 100 bolus medications or defibrillations were 5.1 (39 out of 762) and 7.5 (56 out of 745) for the intervention and control, respectively, a difference of 2.4 (95% confidence interval [CI], -0.1 to 5.0). However, the intervention was highly associated with lower risk of 10-fold error for bolus medications (odds ratio 0.27; 95% CI, 0.10 to 0.70). For medications administered by infusion, prescribing errors occurred in 3 out of 76 (4%) scenarios in the intervention group and 13 out of 76 (22.4%) in the control group, a difference of 13% (95% CI, 3 to 23). A clinical aid providing precalculated medication doses was not associated with a decrease in overall prescribing error rates but was highly associated with a lower risk of 10-fold error for bolus medications and for medications administered by continuous infusion.

Baclofen, a derivative of γ-aminobutyric acid, is used for symptomatic relief of skeletal muscle spasm and spasticity. Overdose of this drug can cause profound central nervous system depression, including coma, hypotonia, respiratory depression, seizures, and cardiovascular effects. In this paper, we reported a case of 19 year-old female with baclofen overdose presenting to the emergency department with coma. She recovered and discharged after supportive care including mechanical ventilation. An acutely confused or comatose patient is admitted to emergency department, baclofen intoxicitation should be kept in mind in the differential diagnosis.

Reactive oxygen species may play a role in the mediation of acetaminophen (APAP) hepatotoxicity. N-acetylcysteine (NAC) is the standard therapy for treatment of the APAP overdose patient. The suspected mechanism of hepatic injury appears to be similar to that of APAP and the empiric use of NAC may be justified, especially in significant endosulfan poisoning. An 18-year-old male presented to the emergency department because of unconsciousness and seizure that developed after acute intentional ingestion of endosulfan. Severe diaphoresis was noted and he had a Glasgow Coma Score of 7 (E1M4V2). Within 8 hours of his arrival in the emergency department, progressive elevation of transaminases was detected and NAC was administered via the intravenous route. Within the next 5 days the serum levels of transaminases returned to normal and he was discharged in good condition. We suggest that in patients with endosulfan poisoning who have primarily hepatotoxicity, NAC administration might be considered. NAC therapy was well tolerated and there were no serious adverse effects. Nevertheless, further data are required to demonstrate the efficacy of NAC therapy in endosulfan poisoning, and guidelines for dosing regimens have to be provided.

Background: Intensive care units (ICUs) around the world are in high demand due to patients with COVID-19 requiring hospitalization. As researchers at the University of Bristol, we were approached to develop a bespoke data visualization dashboard to assist two local ICUs during the pandemic that will centralize disparate data sources in the ICU to help reduce the cognitive load on busy ICU staff in the ever-evolving pandemic. The aim of this study was to conduct interviews with ICU staff in University Hospitals Bristol and Weston National Health Service Foundation Trust to elicit requirements for a bespoke dashboard to monitor the high volume of patients, particularly during the COVID-19 pandemic. We conducted six semistructured interviews with clinical staff to obtain an overview of their requirements for the dashboard and to ensure its ultimate suitability for end users. Interview questions aimed to understand the job roles undertaken in the ICU, potential uses of the dashboard, specific issues associated with managing COVID-19 patients, key data of interest, and any concerns about the introduction of a dashboard into the ICU. Results: From our interviews, we found the following design requirements: (1) a flexible dashboard, where the functionality can be updated quickly and effectively to respond to emerging information about the management of this new disease; (2) a mobile dashboard, which allows staff to move around on wards with a dashboard, thus potentially replacing paper forms to enable detailed and consistent data entry; (3) a customizable and intuitive dashboard, where individual users would be able to customize the appearance of the dashboard to suit their role; (4) real-time data and trend analysis via informative data visualizations that help busy ICU staff to understand a patient's clinical trajectory; and (5) the ability to manage tasks and staff, tracking both staff and patient movements, handovers, and task monitoring to ensure the highest quality of care. The findings of this study confirm that digital solutions for ICU use would potentially reduce the cognitive load of ICU staff and reduce clinical errors at a time of notably high demand of intensive health care.

Objective: To assess knowledge and practice trends in managing acute pain in patients infected with human immunodeficiency virus (HIV+) or having acquired immunodeficiency syndrome (AIDS) among emergency physicians of four tertiary care hospitals. Acute pain management in such patients is complex because of multiple concomitant painful conditions related to their disease. After obtaining ethical approval and written informed consent, emergency physicians were requested to fill out a questionnaire. Results: Out of 84 physicians who participated, 49 had managed HIV+/AIDS patients during the preceding year. Out of the 49, 30 (61.2%) physicians stated that they used a combination of analgesics for acute pain in these patients. Forty-two (50%) out of the 84 participants believed that routine doses of opioids were adequate for pain relief, while 42 (50%) agreed that pain management was more complex in these patients mainly due to presence of multiple coexisting problems and psychological issues. Only 26 (31%) respondents considered that pain was under-reported and under-treated in these patients, mainly because physicians were more focused on patients' other disease related complications and issues. Formulation of guidelines are recommended for effective acute pain management in these patients encompassing associated issues, including concomitant painful conditions, opioid dependence, psychiatric problems, etc.

Dedicated outpatient vascular access centers (VAC) specializing in percutaneous interventions (angiography, thrombectomy, angioplasty and catheter placement) provide outpatient therapy that can obviate the need for hospitalization. This paper reports the impact of one VAC staffed by interventional nephrologists on vascular access-related hospitalization and missed outpatient dialysis treatments. We performed a retrospective analysis of vascular access-related hospitalized days and missed vascular access-related outpatient dialysis treatments from 1995 to 2002 in 21 Phoenix Arizona Facilities (5928 cumulative patients) and 1275 cumulative Fresenius Medical Care North America (FMCNA) facilities (289 454 cumulative patients) to evaluate the impact of the introduction of a VAC in Phoenix. Vascular access-related hospitalized days/patient year and missed dialysis treatments/patient year declined from 1997 to 2002 across all access types. The decline was greater in Phoenix and coincided with the creation of a VAC in 1998. By 2002, there were 0.57 fewer hospitalized days/patient year and 0.29 fewer missed treatments/patient year than in the national sample (Po0.01). In 2002, the relative risk for vascular access hospitalized days was 0.38 (95% confidence interval (CI) 0.27-0.5) (Po0.01) and for vascular access-related missed outpatient dialysis treatments was 0.34 (95% CI 0.24-0.49) (Po0.01) in Phoenix vs FMCNA after adjustment for age, gender, diabetic status duration of dialysis and access type. VAC development was associated with a significant decrease in vascular access-related hospitalization and missed outpatient dialysis treatments. Further studies are necessary to demonstrate this effect in other communities.

Sepsis hospitalisations with subsequent skilled nursing facility (SNF) admissions have had an annual cost of $41 billion in the United States. There has been a limited amount of literature on early interventions for sepsis in long-term care. Objective: To assess the impact of a pilot sepsis quality improvement program (SQIP) aimed at early identification and intervention in 10 partnering SNFs in New York City. Methods: Obtained baseline data of sepsis hospitalisations in 2017 among 10 SNFs. A SQIP was implemented utilizing the systemic inflammatory response syndrome criteria with a modified threshold temperature of 37.2°C (99.0°F). Sepsis hospitalisations were reported and validated for the intervention period in 2018 and compared to the baseline. A cost savings analysis was completed by utilizing local hospital billing records. Findings: Overall, there was a reduction of 54 sepsis hospitalisations when comparing the intervention period (183 sepsis hospitalisations) to the baseline (237 sepsis hospitalisations), a 22.8% decrease (p < 0.001). The initial SQIP costs were $45,000 USD. The SQIP had an estimated cost savings between $1,039,662-$3,188,430 USD. Limitations: Implementation at each facility was voluntary, so there may have been varying degrees of SQIP implementation. However, the hospital primary diagnosis of sepsis and cost were accurately reported. Implications: A SQIP in a long-term care setting could reduce avoidable hospitalisations and offer cost savings. The SQIP reported is a complex intervention and needs to be methodologically understood as such. The intervention shows promise and important insights into its implementation and evaluation have been developed which would be helpful in further evaluation.

Sepsis hospitalisations with subsequent skilled nursing facility (SNF) admissions have had an annual cost of $41 billion in the United States. There has been a limited amount of literature on early interventions for sepsis in long-term care. Objective: To assess the impact of a pilot sepsis quality improvement program (SQIP) aimed at early identification and intervention in 10 partnering SNFs in New York City. Methods: Obtained baseline data of sepsis hospitalisations in 2017 among 10 SNFs. A SQIP was implemented utilizing the systemic inflammatory response syndrome criteria with a modified threshold temperature of 37.2°C (99.0°F). Sepsis hospitalisations were reported and validated for the intervention period in 2018 and compared to the baseline. A cost savings analysis was completed by utilizing local hospital billing records. Findings: Overall, there was a reduction of 54 sepsis hospitalisations when comparing the intervention period (183 sepsis hospitalisations) to the baseline (237 sepsis hospitalisations), a 22.8% decrease (p < 0.001). The initial SQIP costs were $45,000 USD. The SQIP had an estimated cost savings between $1,039,662-$3,188,430 USD. Limitations: Implementation at each facility was voluntary, so there may have been varying degrees of SQIP implementation. However, the hospital primary diagnosis of sepsis and cost were accurately reported. Implications: A SQIP in a long-term care setting could reduce avoidable hospitalisations and offer cost savings. The SQIP reported is a complex intervention and needs to be methodologically understood as such. The intervention shows promise and important insights into its implementation and evaluation have been developed which would be helpful in further evaluation.

Monkeypox (Mpox) is an emerging zoonotic disease with the potential for severe complications. Early identification and diagnosis are essential to prompt treatment, control its spread, and reduce the risk of human-to-human transmission. This study aimed to develop a clinical diagnostic tool and describe the clinical and sociodemographic features of 19 PCR-confirmed Mpox cases during an outbreak in a nonendemic region of northwestern Mexico. The median age of patients was 35 years, and most were male. Mpox-positive patients commonly reported symptoms such as fever, lumbago, and asthenia, in addition to experiencing painful ulcers and a high frequency of HIV infection among people living with HIV (PLWH). Two diagnostic models using logistic regression were devised, with the best model exhibiting a prediction accuracy of 0.92 (95% CI: 0.8–1), a sensitivity of 0.86, and a specificity of 0.93. The high predictive values and accuracy of the top-performing model highlight its potential to s...

Background Hospitalization for Acute Heart Failure (AHF) remains an important turning point for patients and families, presenting itself as an index event after which the rate of readmission and mortality are particularly high. Hospitalization for Heart Failure (HF) also has a considerable cost impact on healthcare systems. Strategies that reduce the risk of readmission for HF are, therefore, crucial for patients and healthcare systems. A possible strategy to reduce HF readmissions currently recomended by the European Society of Cardiology is guaranteeing an outpatient follow-up visit carried out by a multidisciplinary HF team (combining specialized medical and nurse care) shortly after discharge. Our goal was to describe and demonstrate the feasibility of an early follow-up visit carried out by a multidisciplinary HF team in the transition care of HF patients, after hospital discharge, and to evaluate its association with early HF readmission and all-cause mortality. Methods This w...

Background Cannabis-related medical consultations are increasing worldwide, a non-negligible public health issue; patients presenting to acute care traditionally complain of abdominal pain and vomiting. Often recurrent, these frequent consultations add to the congestion of already chronically saturated emergency department(s) (ED). In order to curb this phenomenon, a specific approach for these patients is key, to enable appropriate treatment and long-term follow-up. Objectives This study reviews cannabinoid hyperemesis syndrome (CHS) and cannabis withdrawal syndrome (CWS), in a bid to help promote better understanding and handling of pathologies associated with chronic cannabis use. Following a literature review, we present a novel therapeutic algorithm aimed at guiding clinicians, in a bid to improve long-term outcomes and prevent recurrences. Methods Using the keywords “Cannabis,” “Hyperemesis,” “Syndrome,” “Withdrawal,” and “Emergency Medicine,” we completed a literature review ...

Cancellation of planned surgery impacts substantially on patients and health systems. This study describes the incidence and reasons for cancellation of inpatient surgery in the UK NHS. We conducted a prospective observational cohort study over 7 consecutive days in March 2017 in 245 NHS hospitals. Occurrences and reasons for previous surgical cancellations were recorded. Using multilevel logistic regression, we identified patient- and hospital-level factors associated with cancellation due to inadequate bed capacity. We analysed data from 14 936 patients undergoing planned surgery. A total of 1499 patients (10.0%) reported previous cancellation for the same procedure; contemporaneous hospital census data indicated that 13.9% patients attending inpatient operations were cancelled on the day of surgery. Non-clinical reasons, predominantly inadequate bed capacity, accounted for a large proportion of previous cancellations. Independent risk factors for cancellation due to inadequate be...

Physical activity (PA) has been shown to be beneficial for patients with cardiovascular disease (CVD), but some studies showed that many patients do not enhance their PA after hospital discharge. A cross-sectional study was conducted to investigate PA and to identify the predictive factors of PA among new coronary artery disease (CAD) patients. Participants were recruited from 10 tertiary hospitals, selected by proportional randomized sampling of all regions of Thailand. Data were collected by using self-reported questionnaires, i.e. demographic, symptom frequency and symptom distress scale (SFSDS), subjective PA experiences scale (SPAES), family and friend support for PA scale (FFSPAS), self-efficacy for PA scale (SEPAS), and international PA long form (IPAQ_L form). Data were analyzed by descriptive and inferential statistics, i.e. range, median, interquartile range (IQR), and the LISREL with robust maximum likelihood estimation. The results revealed that among 160 participants re...

Background: Signs of serious clinical events overlap with those of sepsis. We hypothesised that any education on severe sepsis/septic shock may affect the outcome of all hospital patients. We designed this study to assess the trend of the mortality rate of adults admitted to hospital for at least one night in relationship with a hospital staff educational program dedicated to severe sepsis/septic shock. Methods: This study was performed in six Italian hospitals in the same region. Multidisciplinary Sepsis Teams members were selected by each hospital management among senior staff. The education included the following steps: i) the Teams were taught about adult learning, problem based learning, and Surviving Sepsis guidelines, and provided with educational material (literature, electronic presentations, scenarios of clinical cases for training and booklets); ii) they started delivering courses and seminars each to their own hospital staff in the last quarter of 2007. To analyse mortality, we selected adult patients, admitted for at least one night to the wards or units present in all the study hospitals and responsible for 80% of hospital deaths. We fitted a Poisson model with monthly hospital mortality rates from December 2003 to August 2009 as dependent variable. The effect of the educational program on hospital mortality was measured as two dummy variables identifying a first (November 2007 to December 2008) and a second (January to August 2009) education period. The analysis was adjusted for a linear time trend, seasonality and monthly average values of age, Charlson score, length of stay in hospital and urgent/non-urgent admission. Results: The hospital staff educated reached 30.6% at the end of June 2009. In comparison with the pre-education period, the Relative Risk of death of the patient population considered was 0.93 (95% confidence interval [CI] 0.87-0.99; p 0.025) for in-patients in the first, and 0.89 (95% CI 0.81-0.98; p 0.012) for those in the second period after education. Conclusion: Our hypothesis that a program educating hospital staff to early detection and treatment of severe sepsis/septic shock may affect the outcome of all hospital patients is original, but it has to be corroborated by other experiences.

Pediatric comas are particular situations of terrestrial or aerial medical intervention, requiring knowledge of specific protocols and prioritization and hierarchy of emergency interventions. The reactivity of the comatose child is modified according to multiple biological, physiological parameters and generating pathologies. The study aims to analyze the specific elements of aerial medical interventions with helicopter, HEMS (Helicopter Emergency Medical Service) at comatose child that influences the emergency path, but especially the medium and long term prognosis of these cases. The transfer of comatose children at Galati aeromedical base, both primary and secondary interventions, were studied. The study was a prospective randomized study involving pediatric comas transferred over a 4-year course (2014-2017) according to the criteria in force. A total of 24 children between the ages of 0-18 years were transferred, with primary and secondary interventions. In the study lot, the co...

The aim of this study was to assess the delays that can potentially occur in the emergency transfer of patients with ST-elevation myocardial infarction (STEMI) to percutaneous coronary intervention (PCI) centers. We conducted a retrospective study using the medical reports pertaining to 97 patients who presented to the Emergency Department of the Emergency County Hospital of Galati during the year of 2018 with the diagnosis of STEMI and meeting eligibility criteria for PCI, thus warranting transfer to a hospital with PCI facilities. The pick-up time of patients diagnosed with acute myocardial infarction from the emergency department by the transfer crew is significantly shorter (p &lt; 0.05) than those transferred by air, regardless of the PCI center to which the transfer was performed, Iasi or Bucharest, when compared to the time required to process the patients transferred by land to the same PCI centers. The results of the study shows that the helicopter use for transferring acut...

Background: Data collected in clinical trials have been used to develop scoring systems that identify adults with malaria at greatest risk of death. One of these, the RCAM score, can be simply determined by measuring a patient's Glasgow Coma Score and respiratory rate on admission to hospital. However the safety of using the RCAM score to define high-risk patients has not been assessed outside of the clinical trial setting. Methods: A retrospective audit of medical records of all adults admitted with a diagnosis of malaria to two tertiary referral hospitals in Lower Myanmar in 2013 was undertaken. An RCAM score was calculated in all patients and related to their subsequent clinical course. The recent decline in malaria hospitalizations at both sites continued in 2013. During the year 90 adults were hospitalized with malaria; 62 (69%) had Plasmodium falciparum mono-infection, 11 (12%) had Plasmodium vivax mono-infection, 17 (19%) had mixed infection. All seven (7.7%) deaths occurred in patients infected with P. falciparum. An admission RCAM score <2 identified all the patients that would survive to discharge (positive predictive value (95% confidence interval (CI)) 100% (94.9-100%) and also predicted a requirement for less supportive care: 9/70 (13%) patients with an admission RCAM score <2 required supportive care (blood transfusion, vasopressor support or oxygen supplementation) during their hospitalization compared with 12/20 (60%) patients with an admission RCAM score ≥2 (p < 0.0001). No patient with P. vivax mono-infection required supportive care during their hospitalization. Patients with an oxygen saturation ≤95% on room air on admission were more likely to die before discharge (odds ratio 17.3 (95% CI: 2.9-101.2) than patients with a higher oxygen saturation (p = 0.002). Conclusions: Even outside a clinical trial setting the RCAM score reliably identifies adults with malaria who are at greatest risk of death and can be safely used in the initial triage and management of these patients.

We are presenting our initial experience with the utilization of the scalp as a donor for split thickness skin grafting in the treatment of massive thermal injuries. Rapid donor reepithelization, absence of hypertrophic scarring in the donor area, inconspicuous donor area and a large area for the procurement of grafts in the pediatric population are the advantages that are emphasized in the literature. The outcome in a 3-year-old boy who suffered a burn injury from an open fire in the family house on the 57% of his total body surface area (48% full thickness burn) showed that the “take rate”, in the absence of a massive local infection, was around 80% and that the scalp can be utilized again as a donor area after a period of 14 days. Folliculitis and alopecia are complications that should be kept in mind when using this technique.

Sažetak. Prikazujemo svoje inicijalno iskustvo u uporabi vlasišta kao davatelja presatka djelomične debljine kože pri liječenju masivnih opeklinskih ozljeda. Brzina cijeljenja donora, odsutnost razvoja hipertrofi čnih ožiljaka na davateljskim regijama, nezamjetne donorske regije te velika površina koja se, posebice u dječjoj dobi, može iskoristiti kao donor prednosti su ove tehnike koje se navodi u literaturi. Ishod kod trogodišnjeg dječaka s opeklinskom ozljedom nastalom u plamenu u obiteljskoj kući pri čemu mu je opečeno 57% tjelesne površine (48% tjelesne površine opeklina pune debljine kože) pokazao je da je prihvat transplantata u odsutnosti masivne lokalne infekcije bio oko 80% te da se vlasište može ponovo iskoristiti kao donorska regija nakon perioda od 14 dana. Folikulitis i alopecija jesu komplikacije o kojima treba voditi računa pri uporabi ove tehnike.

Background No guideline for percutaneous cholecystostomy exists at Dorset County Hospital, nor has an audit looking into patient outcomes after percutaneous cholecystostomy previously been carried out. This audit aims to identify the indications for cholecystostomy insertion, timing of insertion, complications thereafter, timing of any tubograms, and follow-up of patients after cholecystostomy. No universal management guidelines for percutaneous cholecystostomy currently exist, though studies have proposed treatment algorithms. Methods Retrospective cohort audit of all patients who underwent cholecystostomy insertion at Dorset County Hospital over 6 years from January 2017 – December 2022. Data was provided by the local radiology department of all abdominal drains inserted in this period, with further information collected from discharge summaries, clinic letters and tubogram data on local clinical systems. Data was inputted to and analysed on Microsoft excel. Results Between 2017 –...

The nursing systemwas defined or structured based on self-care needs and the client&#39;s ability to perform self- care, so nursing was formed when nurses use their ability to define, design and provide care to clients, both individuals and groups. The application of triage consists of rapidly classifying cases of injury cases based on the severity of their injuries and their survival opportunities through immediate medical intervention. The purpose of this study was to determine the level of dependence of patient based on the triage classification in the Emergency Instalation of RSK Mojowarno. Method of this study was analytic description with cross- sectional study. The population of all patients hospitalized through the Emergency Instalation, sample counted 63 patients. Sampling technique using purposive sampling. The results of study revealed that from 63 respondents there were 9 respondents (14%) at first priority with total care dependency level, and there were 18 respondents ...

Drug expenditures are responsible for an increasing proportion of health costs, accounting for $1.1 trillion in annual expenditure worldwide. As hundreds of billions of dollars are being spent each year on overtreatment with prescribed medications that are either unnecessary or are in excess of lowest cost-effective therapy, programs are needed that optimize fiscally appropriate use. We evaluated whether providing physicians with information on the patient out-of-pocket payment consequences of prescribing decisions that were in excess of lowest cost-effective therapy would alter prescribing decisions using the treatment of uncomplicated hypertension as an exemplar. A single-blind cluster randomized trial was conducted over a 60-month follow-up period in 76 primary care physicians in Quebec, Canada, and their patients with uncomplicated hypertension who were using the MOXXI integrated electronic health record for drug and health problem management. Physicians were randomized to an ou...

Background: Adverse drug events are responsible for up to 7% of all admissions to acute care hospitals. At least 58% of these are preventable, resulting from incomplete drug information, prescribing or dispensing errors, and overuse or underuse of medications. Effective implementation of medication reconciliation is considered essential to reduce preventable adverse drug events occurring at transitions between community and hospital care. An electronically enabled discharge reconciliation process represents an innovative approach to this problem. Methods/Design: Participants will be recruited in Quebec and are eligible for inclusion if they are using prescription medication at admission, covered by the Quebec drug insurance plan, admitted from the community, 18 years or older, admitted to a general or intensive care medical or surgical unit, and discharged alive. A sample size of 3,714 will be required to detect a 5% reduction in adverse drug events. The intervention will comprise electronic retrieval of the community drug list, combined with an electronic discharge reconciliation module and an electronic discharge communication module. The primary outcomes will be adverse drug events occurring 30 days post-discharge, identified by a combination of patient self-report and chart abstraction. All emergency room visits and hospital readmission during this period will be measured as secondary outcomes. A cluster randomization approach will be used to allocate 16 medical and 10 surgical units to electronic discharge reconciliation and communication versus usual care. An intention-to-treat approach will be used to analyse data. Logistic regression will be undertaken within a generalized estimating equation framework to account for clustering within units. Discussion: The goal of this prospective trial is to determine if electronically enabled discharge reconciliation will reduce the risk of adverse drug events, emergency room visits and readmissions 30 days post-discharge compared with usual care. We expect that this intervention will improve adherence to medication reconciliation at discharge, the accuracy of the community-based drug history and effective communication of hospital-based treatment changes to community care providers. The results may support policy-directed investments in computerizing and training of hospital staff, generate key requirements for future hospital accreditation standards, and highlight functional requirements for software vendors.

Patients with chronic illness often require ongoing support postdischarge. This study evaluated a simple-touse, mobile health-based program designed to improve postdischarge follow-up via (1) tailored communication to patients using automated calls, (2) structured feedback to informal caregivers, and (3) automated alerts to clinicians about urgent problems. Methods: A total of 283 patients with common medical diagnoses, including chronic obstructive pulmonary disease, coronar y arter y disease, pneumonia, and diabetes, were recruited from a university hospital, a community hospital, and a US Department of Veterans Affairs hospital. All patients identified an informal caregiver or "care partner" (CP) to participate in their postdischarge support. Patient-CP dyads were randomized to the intervention or usual care. Intervention patients received weekly automated assessment and behavior change calls. CPs received structured e-mail feedback. Outpatient clinicians received fax alerts about serious problems. Primary outcomes were 30-day readmission rate and the combined outcome of readmission/emergency department (ED) use. Information about postdischarge outpatient visits, rehospitalizations, and ED encounters was obtained from medical records. Results: Overall, 11.4% of intervention patients and 17.9% of controls were rehospitalized within 30 days postdischarge (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.31-1.11; p = 0.102). Compared to intervention patients with other illnesses, those with pulmonary diagnoses generated the most clinical alerts ( p = 0.004). Pulmonary patients in the intervention group showed significantly reduced 30-day risk of rehospitalization relative to controls (HR: 0.31; 95% CI: 0.11-0.87; p = 0.026). The CP intervention did not improve 30-day readmission rates overall, although post hoc analyses suggested that it may be promising among patients with pulmonary diagnoses. B etween 20% and 30% of hospitalized medical patients are readmitted within 30 days postdischarge. 1-3 Adverse outcomes often result from patients' difficulty managing their complex self-care regimens. 4 , 5 Nurse telephone calls postdischarge are labor intensive, 6 , 7 and evidence is mixed that postdischarge clinician follow-up alone improves outcomes. Informal caregivers often play an important role in supporting chronically ill patients' efforts to follow self-management plans, identify early warning signs of acute illness, and cope emotionally. 16 , 17 However, health care professionals often do not communicate with family caregivers in effective ways to engage them in the care of the patient, and this can contribute to preventable rehospitalization, emergency care visits, and higher health care costs. In this trial, we used simple automated telephone calls (interactive voice response [IVR]) as a tool for increasing communication between patients, informal caregivers, and

Patients with chronic illness often require ongoing support postdischarge. This study evaluated a simple-touse, mobile health-based program designed to improve postdischarge follow-up via (1) tailored communication to patients using automated calls, (2) structured feedback to informal caregivers, and (3) automated alerts to clinicians about urgent problems. Methods: A total of 283 patients with common medical diagnoses, including chronic obstructive pulmonary disease, coronar y arter y disease, pneumonia, and diabetes, were recruited from a university hospital, a community hospital, and a US Department of Veterans Affairs hospital. All patients identified an informal caregiver or "care partner" (CP) to participate in their postdischarge support. Patient-CP dyads were randomized to the intervention or usual care. Intervention patients received weekly automated assessment and behavior change calls. CPs received structured e-mail feedback. Outpatient clinicians received fax alerts about serious problems. Primary outcomes were 30-day readmission rate and the combined outcome of readmission/emergency department (ED) use. Information about postdischarge outpatient visits, rehospitalizations, and ED encounters was obtained from medical records. Results: Overall, 11.4% of intervention patients and 17.9% of controls were rehospitalized within 30 days postdischarge (hazard ratio [HR]: 0.59; 95% confidence interval [CI]: 0.31-1.11; p = 0.102). Compared to intervention patients with other illnesses, those with pulmonary diagnoses generated the most clinical alerts ( p = 0.004). Pulmonary patients in the intervention group showed significantly reduced 30-day risk of rehospitalization relative to controls (HR: 0.31; 95% CI: 0.11-0.87; p = 0.026). The CP intervention did not improve 30-day readmission rates overall, although post hoc analyses suggested that it may be promising among patients with pulmonary diagnoses. B etween 20% and 30% of hospitalized medical patients are readmitted within 30 days postdischarge. 1-3 Adverse outcomes often result from patients' difficulty managing their complex self-care regimens. 4 , 5 Nurse telephone calls postdischarge are labor intensive, 6 , 7 and evidence is mixed that postdischarge clinician follow-up alone improves outcomes. Informal caregivers often play an important role in supporting chronically ill patients' efforts to follow self-management plans, identify early warning signs of acute illness, and cope emotionally. 16 , 17 However, health care professionals often do not communicate with family caregivers in effective ways to engage them in the care of the patient, and this can contribute to preventable rehospitalization, emergency care visits, and higher health care costs. In this trial, we used simple automated telephone calls (interactive voice response [IVR]) as a tool for increasing communication between patients, informal caregivers, and

Objective: To compare usage patterns and outcomes of a nurse practitioner–staffed medical ICU and a resident-staffed physician medical ICU. Design: Retrospective chart review of 1,157 medical ICU admissions from March 2012 to February 2013. Setting: Large urban academic university hospital. Subjects: One thousand one hundred fifty-seven consecutive medical ICU admissions including 221 nurse practitioner-staffed medical ICU admissions (19.1%) and 936 resident-staffed medical ICU admissions (80.9%). Interventions: None. Measurements and Main Results: Data obtained included age, gender, race, medical ICU admitting diagnosis, location at time of ICU transfer, code status at ICU admission, and severity of illness using both Acute Physiology and Chronic Health Evaluation II scores and a model for relative expected mortality. Primary outcomes compared included ICU mortality, in-hospital mortality, medical ICU length of stay, and post-ICU discharge hospital length of stay. Patients admitted...

Posters / Paediatric Respiratory Reviews 14S2 (2013) S55-S85 disease. It is universally recommended but rarely implemented in TB endemic settings. A symptom based screening approach could improve implementation at the primary care level but has not been prospectively evaluated. Objective: To evaluate the performance of symptom based approach for screening and management of child TB contact. Methods: We performed clinical assessment, tuberculin skin test and chest X-ray in all eligible children exposed to a TB patient, irrespective of symptoms at baseline. Sputum smear and culture was performed only in children with suspected TB. Following assessment, children were treated appropriately, as guidelines. All children were prospectively followed up for 12 months. Results: A total of 269 child contacts of 140 TB cases were evaluated. At baseline, 21 (8%) children had TB disease and 93 (35%) were identified as infected with Mycobacterium tuberculosis. The proportion of TB disease in symptomatic children was 21% compared to none in asymptomatic children (p = 0.000). Only two (1.2%) of 171 asymptomatic children developed TB disease at follow up, and 2.6% of 77 symptomatic children. The cost incurred from the symptom based screening approach was half of that incurred by complete investigation. Symptom based screening provides a simple, safe and low cost approach to child TB contact management, that can be implemented at the primary health care setting.

Calidad; Requisitos arquitectónicos; funcionales y de personal; Cuestionario de autoevaluación Introducción: La medicina de urgencias pediátrica en España se practica en servicios de distinta configuración. Nuestro objetivo es conocer su situación y adaptación a los requisitos del Cuerpo Doctrinal de la Sociedad Española de Urgencias Pediátricas. Método: Se envió por correo electrónico una encuesta con el cuestionario de Autoevaluación del Cuerpo Doctrinal a los responsables de 47 servicios. Consta de 101 ítems, 69 considerados de cumplimiento obligatorio. Se establecieron 4 grupos de servicios según el cumplimiento de esos 69 ítems: I o situación óptima (cumplen 69); II o que precisan cambios mínimos (cumplen 62-68); III o que precisan cambios mayores (cumplen 41-61); IV o que precisan grandes modificaciones (cumplen menos de 41). Resultados: Contestaron 39 servicios, que atienden una media de 35.310 urgencias anuales (5.000-115.000). Ninguno ha quedado incluido en el grupo I, 6 en el II, 27 en el III y 6 en el IV. Hay una tendencia a un mayor cumplimiento en los servicios más frecuentados, pero sin relación significativa entre el número de urgencias y los ítems cumplimentados. Conclusiones: 1) Muchos servicios de urgencias pediátricos en España tienen problemas estructurales y funcionales que pueden dificultar dar una asistencia de calidad, sin relación significativa con el volumen de urgencias atendidas; 2) los puntos de mejora afectan principalmente a cuestiones funcionales, que deben ser acometidas por sus responsables; 3) un número significativo tienen serios problemas arquitectónicos y de dotación, que precisarían medidas económicas por parte de sus órganos directivos, y 4) nuestro cuestionario de autoevaluación permite identificar acciones de mejora.