Accident And Emergency Department Research Articles

(De)construction of the meanings of work: experiences of suffering in hospital emergency wards

Objective: To investigate the experiences of suffering in the work of nurses in a hospital emergency service. Methods: Qualitative study with 15 nurses from a public hospital emergency unit in a municipality in Bahia, Brazil. Data were obtained through in-depth interviews, analyzed by the Collective Subject Discourse and anchored in the theoretical framework of Work Psychodynamics. Results: There is professional suffering in the work of nurses in the Hospital Emergency Unit and it is permeated by the (de)construction of the meanings of work, the way work is organized, professional recognition, psychological illness, and the coping strategies developed and available to them. Final considerations: The suffering that emerges from work relationships presents specificities of the organization and professional practice in nursing in the emergency sector, which makes up the context, causes and consequences of the phenomenon and impacts on the different dimensions of life.

Frequency of Reversibility of Complete Heart Block in Acute Myocardial Infarction

Objective The aim of current study was to evaluate the frequency of reversibility of complete heart block in patients of acute myocardial infarction. Methods Total one hundred and thirty eight patients with complaint of syncope and atypical chest pain presented at emergency ward of Punjab Institute of Cardiology, Lahore. All patients underwent conventional coronary angiogram to roll out the ischemic etiology of underlying bradyarrhythmias. Among them more than 90% patients have mild coronary artery disease and they were kept on medical management. But all patients remained TPM dependant for two weeks which were then treated with permanent pacemakers. Results Results of the current study revealed that the mean age of patients was 51.48 ± 15.46 with minimum age 18 and maximum was 65 years. Out of 138 patients, 84(61%) were male while 54(39%) were female., 52(37.7%) patients diagnosed of diabetes mellitus, 75(54.3%) patients of hypertension and 58(42.03%) patients were smoker, 41(29.7%) have family history, 47(34.1%) patients have dyslipidemia and only 50(36.2%) obese patients. Patients divided into two groups; patients with complete heart block in the age grouped between 16-35 years, only 6(4.3%) as compare with age grouped 36-65 years only 10(7.2%) have complete heart block, male 8(5.8%), only 5(3.6%) hypertensive patients and 4(2.9%) diabetic patients suffering complete heart block, 2(1.4%) patients presented during 1-12 hours compare with 7(5.1%) presented between 13-24 hours, results showed statistically insignificant as p-value > 0.05. 2nd Degree AV Block and complete heart block showed significant difference between troponin level as p-value <0.05 in patients diagnosed with ACS. Conclusion Atrioventricular block is frequently reversible in people with AMI. As a result, in situations with AMI permanent pacemaker installation should be postponed.

Correlation of delta shock index and lactate clearance in shock patients treated in pediatric intensive care unit at Prof Dr. I.G.N.G Ngoerah Hospital

Introduction: Lactate was an examination done in patients with shock as a predictor of mortality. The delta shock index (DSI) is one of the parameters that are easy to do but very limited studies related to the benefits of DSI have been found. This study aimed at determining the correlation of DSI and lactate clearance levels in pediatric shock patients treated at the Pediatric Intensive Care Unit (PICU) of Prof Dr. I.G.N.G Ngoerah Hospital. Method: This was a prospective cohort study of children diagnosed with shock in a pediatric emergency ward or PICU Prof Dr. I.G.N.G Ngoerah Hospital. A Spearman correlation test was done since the data distribution was abnormal. Multivariate analysis with multiple regression tests was carried out to assess the pure effect of lactate clearance with DSI. The level of significance was determined based on p <0.05. The general linear model analysis is done on variables that are repeated measurements. Result: There were 39 subjects obtained in this study, with 34 subjects surviving and 5 subjects not surviving. The median lactate clearance was 28.5 (-95 - 77.7), with a median DSI of 0.45 (0.04-1.3). There were significant differences in the decrease of shock index over time (p = 0.034). The correlation test results showed a weak positive between lactate clearance with DSI (r = +0.351) and p = 0.028. Multivariate analysis test results obtained a value of â 0.002 with p = 0.071. Conclusion: There was a weak positive correlation between lactate clearance and DSI. There were significant differences in the decrease of shock index over time between survivors and non-survivors.

The Study of Lactate/Albumin Ratio as a Predictor of In-Hospital Mortality in Patients with Sepsis and Septic Shock in a Tertiary Care Hospital

Abstract Background: Sepsis is a common and deadly disease that is characterized by elevated levels of acute phase reactants such as high-sensitivity C-reactive protein, lactate dehydrogenase, ferritin, procalcitonin, interleukin (IL-6), tumor necrosis factor, and IL-1. These markers are often used for early diagnosis, management, and risk stratification in patients with septic shock, but they may not be accessible in resource-poor settings with financial constraints. This study aimed to investigate the potential use of the ratio between serum lactate and negative acute phase reactant serum albumin level as a prognostic marker for the outcome of sepsis in resource-poor and -constrained settings. Materials and Methods: The study was a prospective observational study that included 122 patients admitted to the intensive care unit and emergency ward with sepsis or septic shock. Ethical clearance was obtained from the Ethics Committee of Mysore Medical College and Research Institute, and informed consent was obtained from the patients and their attendants. Blood samples for analysis of arterial blood gases, albumin, and other biochemical parameters were collected on the 1st and 3rd days of admission. The outcome of the disease was compared to these parameters using statistical methods such as ANOVA and Chi-square tests with multivariate analysis. Results: The study population consisted of 54.09% males, with one-third of the patients belonging to the age group of 61–70 years. The mortality rate was 27%. The mean serum lactate level on day 1 was 1.7 ± 0.15 mmol/L and on day 3 was 2.65 ± 0.32 mmol/L. The mean serum albumin level on day 1 was 3.14 ± 0.14 g/dL and on day 3 was 3.03 ± 0.13 g/dL. The lactate/albumin ratio on day 1 was 0.49 ± 0.12 and on day 3 was 0.89 ± 0.1 and was positively correlated with the severity of sepsis and septic shock (P < 0.001) and showed a greater significance than lactate or albumin alone. Conclusion: The serum lactate/albumin ratio is a highly sensitive marker that is noninferior to other high-cost biomarkers in assessing the daily prognosis of patients with sepsis in resource-poor and -constrained settings. This study suggests that the lactate/albumin ratio may be a cost-effective, novel, easily feasible, and relevant investigation for assessing the severity and mortality of sepsis and septic shock in rural resource-limited and financially poor hospital settings.

An Innovative Mobile Hospital for the Management of a Massive Flow of Victims.

Introduction:In order to deal with disastrous situations needing massive healthcare support, a new tool, financed by FEDER European funds (Interreg POCTEFA program) has been designed: the multipurpose mobile hospital Europe Occitanie (UMPEO). It is a projectable, foldable, versatile and autonomous truck with an interchangeable function from advanced medical post to operational command center, for acute events involving mass gathering or during multiple victims disasters. This study aims to show the usefulness of this structure during the COVID-19 health crisis.Method:The UMPEO is a shelter deployable in an emergency ward or intensive care unit, mobilizable in one hour, projectable by truck and autonomous for the first two hours. A descriptive, transversal, European study was carried out to describe its use in the cross-border countries of the Pyrenees (France, Spain and Andorra). When applicable, demographic data were gathered and/or a satisfaction questionnaire was given to the caregivers involved.Results:Between September 8, 2020 andFebruary 25, 2021, UMPEO was mobilized as a COVID-19 testing center, emergency department, vaccination center or as a command center at a political summit. Thus, 1322 screening tests were carried out over the screening three weeks deployment and 91% of the volunteers considered the screening operation useful. Used as a hospitalization ward, UMPEO was able to accommodate 266 patients over a period of four weeks. Eight hundred people were able to benefit from two doses of vaccines during the six weeks of the mobile vaccination campaign.Conclusion:This tool, initially designed to be used in the event of a catastrophic event of an accidental or terrorist type or as a help station during mass gathering, has been diverted without any modification of its structure to meet the challenges of the global health crisis and provide a solution adapted to the population of countries bordering the Pyrenees.

A case of sclerochoroidal calcification masquerading as a retained intraocular foreign body

A 41-year-old, New Zealand European male, was seen in the acute eye clinic as an in-patient from the trauma ward with multiple comorbidities including an orbital fracture from injuries sustained in a road traffic accident. It is not uncommon in emergency settings for emergency physicians to review polytrauma patients prior to Ophthalmologists, with Computerized Tomography being the imaging modality of choice. A hyper-dense lesion within the right globe was noted by radiology at the time and concerns were raised about the possibility of a retained intraocular foreign body. Upon Ophthalmic examination, a clinical diagnosis of sclerochoroidal calcification was made. This case highlights a rare case of sclerochoroidal calcification manifesting as a hyperdense lesion on computerized tomography masquerading as an intraocular foreign body.

Regularity of ventilator-associated pneumonia induced by three common pathogens

To investigate the incidence and infection regularity of ventilator-associated pneumonia (VAP) in patients undergoing tracheal intubation and to provide reference for the prevention and treatment of VAP infection in the future. A retrospective study was conducted to collect the microbial data of airway secretion cultures from 72 patients with endotracheal intubation admitted to the emergency ward of Shanghai Fifth People's Hospital from May 2020 to February 2021, and the species of microorganisms and intubation time were statistically analyzed. Among 72 patients with endotracheal intubation, males were more than females (58.33% vs. 41.67%); Patients over 60 years old accounted for 90.28%; pneumonia was the main primary disease, accounting for 58.33%. Pathogenic tests showed that: (1) 72 patients were infected with Acinetobacter baumannii (AB), Klebsiella pneumoniae (KP), and Pseudomonas aeruginosa (PA) 48 hours after intubation, 51.39% (37/72), 27.78% (20/72), and 26.39% (19/72), respectively. The infection rate of AB was significantly higher than that of KP and PA. Within 48 hours of intubation, the infection rates of AB, KP, and PA were 20.83% (15/72), 13.89% (10/72), and 4.17% (3/72), respectively. Of the 42 patients with primary pneumonia, 61.90% (26/42) were infected with one or more of the three pathogenic bacteria AB, KP, and PA 48 hours after intubation, indicating a change in the etiology of the pathogenic bacteria, with the main pathogenic bacteria transitioning from other pathogenic bacteria to AB, KP, and PA. (2) AB, KP, and PA were prone to cause late onset VAP (i.e., intubation ≥ 5 days). Respectively, among VAP patients infected with AB, late onset VAP accounted for 59.46% (22/37). Among patients infected with KP, 75.00% (15/20) had late onset VAP. Among patients infected with PA, late onset VAP accounted for 94.74% (18/19), indicating a higher proportion of late onset VAP caused by PA and KP. (3) Infection was closely related to intubation time, and the pipeline can be replaced according to the peak period of infection. AB and KP infections peaked within 4 days after intubation, reaching 57.69% (30/52) and 50.00% (15/30), respectively. It is recommended to replace the tubes or undergo sensitive antimicrobial therapy around 3-4 days after starting the machine. The proportion of PA infection after 7 days of intubation was 72.73% (16/22), and it was considered to replace the pipeline after 7 days. (4) Most of the three pathogenic bacteria, AB, KP, and PA were carbapenem resistant pathogens with multiple drug resistance. Except for PA, the infection rate of carbapenem resistant bacteria (CRAB, CRKP) was significantly higher than that of non-carbapenem resistant bacteria (AB, KP), accounting for 86.54% (45/52) and 66.67% (20/30) of the corresponding infection cases, respectively, while CRPA only accounts for 18.18% (4/22). The main differences in VAP infection caused by AB, KP, and PA pathogens are infection time, infection probability, and carbapenem resistance. Targeted prevention and treatment measures can be implemented for patients with intubation.

Comparison of Serum Procalcitonin Levels between Patients with Acute Exacerbation of Chronic Obstructive Pulmonary Disease (AECOPD) and Patients with Chronic Obstructive Pulmonary Disease

Background: This study aimed to compare the serum levels of procalcitonin in the pa-tients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) and the patients with chronic obstructive pulmonary disease (COPD) in the emergency ward of Afzalipour Hospital in Kerman. Methods: This cross-sectional study was conducted on 45 patients with stable COPD and 45 pa-tients with AECOPD. Patients were divided into four groups based on COPD severity assessment. Serum procalcitonin levels were measured using an ELISA kit.. Results: The mean age of patients in the exacerbation and the stable group was 60.97 ± 12.61 and 62.53 ± 11.04 years, respectively. Serum procalcitonin levels in two exacerbation groups (215.22 ± 19.84) were higher than stable groups (127.92 ± 8.97) (P = 0.001). The accuracy of this test for diagnosing acute attack in terms of AECOPD was 77%, and the serum procalcitonin level of 132.6 was found to be the best cut-off point to diagnose acute disease. The mean serum procalcitonin le-vels of stage D patients in the acute attack group were substantially higher than those of stages D and B patients in the stable group (P = 0.001). Serum procalcitonin levels were related to body mass index (P = 0.01), post-bronchodilator FEV1/FVC (P = 0.028), and the number of hospitalizations per year (P = 0.001). By increasing the serum procalcitonin levels, BMI and number of admissions per year increase, and post-bronchodilator FEV1/FVC decreases. Conclusion: The mean serum levels of procalcitonin in the group with attacks due to COPD was significantly higher than the stable group.

Role of General Practice Led Observation Ward to Support Emergency Ward to Improve Health Outcomes at a Major Kathmandu Hospital in Nepal

Introduction:Tribhuvan University Teaching Hospital (TUTH) is a tertiary care hospital in Kathmandu. The emergency department sees between 130 to 140 cases per day. These patients get initial evaluation and basic investigation for acute emergency management and treatment. Those requiring further treatment are then admitted to the department of General Practice for post emergency care which acts as an observation ward. This step allows for the patients to be observed on a short-term basis and permits patient monitoring and/or treatment for an initial 24-48 hour period and up to a maximum of five days. These steps allow for focused follow up, improved efficiency and minimizes inappropriate admissions to other hospital inpatient wards. This paper evaluates functionality, admission criteria, patient categorization and subspeciality referral to specialty patient care, discharge criteria and cost effectiveness.Method:A descriptive observational study was carried out of the patients admitted to the observational ward between 2020-2021.Results:Most articles suggest these wards improve patient satisfaction and clinical care, decrease length of stay, reduce unnecessary inpatient hospital admissions and are useful in fever under evaluations, COPD, poisoning, pneumonia, mild head injuries, high sugar, hypertension, gastroenteritis etc. Around 14% of patients were sent to the observation ward after acute emergency care. 84% were discharged from observation ward with a mean stay of three days and were followed up in community care or GP OPD. Nine percent were admitted to hospital wards, and 7% transferred to yellow/red area emergencies for derange vitals.Conclusion:Observation wards seem to have advantages, excluding those who will inevitably need longer treatment, reduces cost savings and unnecessary burden of hospital admission.

Computerised cognitive assessment in patients with traumatic brain injury: an observational study of feasibility and sensitivity relative to established clinical scales.

Online technology could potentially revolutionise how patients are cognitively assessed and monitored. However, it remains unclear whether assessments conducted remotely can match established pen-and-paper neuropsychological tests in terms of sensitivity and specificity. This observational study aimed to optimise an online cognitive assessment for use in traumatic brain injury (TBI) clinics. The tertiary referral clinic in which this tool has been clinically implemented typically sees patients a minimum of 6 months post-injury in the chronic phase. Between March and August 2019, we conducted a cross-group, cross-device and factor analyses at the St. Mary's Hospital TBI clinic and major trauma wards at Imperial College NHS trust and St. George's Hospital in London (UK), to identify a battery of tasks that assess aspects of cognition affected by TBI. Between September 2019 and February 2020, we evaluated the online battery against standard face-to-face neuropsychological tests at the Imperial College London research centre. Canonical Correlation Analysis (CCA) determined the shared variance between the online battery and standard neuropsychological tests. Finally, between October 2020 and December 2021, the tests were integrated into a framework that automatically generates a results report where patients' performance is compared to a large normative dataset. We piloted this as a practical tool to be used under supervised and unsupervised conditions at the St. Mary's Hospital TBI clinic in London (UK). The online assessment discriminated processing-speed, visual-attention, working-memory, and executive-function deficits in TBI. CCA identified two significant modes indicating shared variance with standard neuropsychological tests (r=0.86, p<0.001 and r=0.81, p=0.02). Sensitivity to cognitive deficits after TBI was evident in the TBI clinic setting under supervised and unsupervised conditions (F (15,555)=3.99; p<0.001). Online cognitive assessment of TBI patients is feasible, sensitive, and efficient. When combined with normative sociodemographic models and autogenerated reports, it has the potential to transform cognitive assessment in the healthcare setting. This work was funded by a National Institute for Health Research (NIHR) Invention for Innovation (i4i) grant awarded to DJS and AH (II-LB-0715-20006).

Knowledge and Practice of Injection Safety among Nurses Working in Tertiary Health Science Institute of Eastern Nepal

Background: Injections are among the nursing procedures which are commonly performed worldwide. Unsafe injections occur routinely in most developing world regions, implying a significant potential for the transmission of blood borne pathogen. Unsafe injections currently account for a significant proportion of all new hepatitis B and C infections. This study was done to explore the factors affecting knowledge and practices and to carry out observation in selected sample. Material and Methods: A descriptive cross-sectional study design was used to conduct the study among 143 nurses working at selected wards of BPKIHS using self-administered questionnaire. The Medical, Surgical, Emergency, Orthopedic, ICU, SICU, Gynecology, Antenatal and Postnatal wards were selected purposively and the nurses were selected using population proportionate stratified random sampling. Observation of the 30 injection procedure was carried out .Collected data was analyzed using various descriptive and inferential statistics. Results: The mean age of the respondents was 25.48±3.66 years. Poor knowledge was seen among 33.6% and good knowledge was seen among 66.4% of the respondents. Similarly, good practice was observed among 11.2% and excellent practice was observed among 88.6% of the respondents. Significant association was found between knowledge and socio-demographic variables i.e. total work experience (p 0.023), vaccination against hepatitis B (p&lt;0.001) Conclusion: The study concluded that one third of the nurses had good knowledge regarding injection safety and majority of the nurses had excellent practice. The major lacking was seen related to the steps to be taken immediate after needle stick injury, practices of recapping of the syringes and coverage of the Hepatitis B vaccination. We recommend the authority of the study setting to prioritize these components. Further participatory observation studies are required to explore factors related to the knowledge and practices of safe injection practices.

Optimizing sepsis care through heuristics methods in process mining: A trajectory analysis

Process mining can help acquire insightful knowledge and heighten the system’s performance. In this study, we surveyed the trajectories of 1050 sepsis patients in a regional hospital in the Netherlands from the registration to the discharge phase. Based on this real-world case study, the event log comprises events and activities related to the emergency ward, admission to hospital wards, and discharge enriched with data from lab experiments and triage checklists. At first, We aim to discover this process through Heuristics Miner (HM) and Inductive Miner (IM) methods that can deal with noise and can be used to express the main behavior recorded in an event log. Then, we analyze a systematic process model based on organizational information and knowledge. Besides, we address conformance checking given medical guidelines for these patients and monitor the related flows on the systematic process model. The results show that HM and IM are inadequate in identifying the relevant process. However, using a systematic process model based on expert knowledge and organizational information resulted in an average fitness of 97.8%, a simplicity of 77.7%, and a generalization of 80.2%. The analyses demonstrate that process mining can shed light on the patient flow in the hospital and inspect the day-to-day clinical performance versus medical guidelines. Also, the process models obtained by the HM and IM methods cannot provide a concrete comprehension of the process structure for stakeholders compared to the systematic process model. The implications of our findings include the potential for process mining to improve the quality of healthcare services, optimize resource allocation, and reduce costs. Our study also highlights the importance of considering expert knowledge and organizational information in developing effective process models.

Third dose mRNA vaccination against SARS-CoV-2 reduces medical complaints seen in primary care: a matched cohort study

BackgroundSARS-CoV-2 mRNA vaccination has been associated with both side effects and a reduction in COVID-related complaints due to the decrease in COVID-19 incidence. We aimed to investigate if individuals who received three doses of SARS-CoV-2 mRNA vaccines had a lower incidence of (a) medical complaints and (b) COVID-19-related medical complaints, both as seen in primary care, when compared to individuals who received two doses.MethodsWe conducted a daily longitudinal exact one-to-one matching study based on a set of covariates. We obtained a matched sample of 315,650 individuals aged 18–70 years who received the 3rd dose at 20–30 weeks after the 2nd dose and an equally large control group who did not. Outcome variables were diagnostic codes as reported by general practitioners or emergency wards, both alone and in combination with diagnostic codes of confirmed COVID-19. For each outcome, we estimated cumulative incidence functions with hospitalization and death as competing events.ResultsWe found that the number of medical complaints was lower in individuals aged 18–44 years who received three doses compared to those who received two doses. The differences in estimates per 100,000 vaccinated were as follows: fatigue 458 less (95% confidence interval: 355–539), musculoskeletal pain 171 less (48–292), cough 118 less (65–173), heart palpitations 57 less (22–98), shortness of breath 118 less (81–149), and brain fog 31 less (8–55). We also found a lower number of COVID-19-related medical complaints: per 100,000 individuals aged 18–44 years vaccinated with three doses, there were 102 (76–125) fewer individuals with fatigue, 32 (18–45) fewer with musculoskeletal pain, 30 (14–45) fewer with cough, and 36 (22–48) fewer with shortness of breath. There were no or fewer differences in heart palpitations (8 (1–16)) or brain fog (0 (− 1–8)). We observed similar results, though more uncertain, for individuals aged 45–70 years, both for medical complaints and for medical complaints that were COVID-19 related.ConclusionsOur findings suggest that a 3rd dose of SARS-CoV-2 mRNA vaccine administered 20–30 weeks after the 2nd dose may reduce the incidence of medical complaints. It may also reduce the COVID-19-related burden on primary healthcare services.

Comparative study of CT-scan modality with MRI modality findings in patients suspected of COVID-19

BackgroundCT-scan and MRI are both best of radiologic modalities with different advantages and disadvantages. In this study, we aimed to evaluate and compare the features of COVID-19 pneumonia in these two modalities. Fifty-three suspected COVID-19 patients who presented to our emergency ward underwent chest CT and, once various features of COVID-19 pneumonia were identified, a dedicated multi-sequence chest MRI was performed on the same day with an institutional protocol. Demographic data and the morphology, laterality and location of the lesions were recorded for each case.ResultsThirty-seven males and sixteen females with the mean age of 47.49 ± 13.86 years old were present in this case series. Fifty-one cases had typical CT features with ground glass opacities and consolidations, readily visible on different MRI sequences. Thirteen cases had atelectasis which were also easily seen on MRI. The comprehensive review of MRI features for each case and representative images has been illustrated.ConclusionWe can suggest MRI as an alternative choice of CT-scan for diagnosis COVID-19 pneumonia according to the revealed results, it can be a logical choice in the suspected cases.

Physician scheduling for emergency telemedicine across multiple facilities

Telemedicine has emerged as an effective means to connect health service providers with patients remotely. In the context of emergency care, telemedicine typically involves a telemedicine service hub (TSH) that matches remote physicians with patients in emergency wards. Effective operation of such systems requires careful and continuous coordination between physicians and local providers and as such, physician staffing and scheduling is a major managerial challenge that a TSH has to overcome. In this context, our paper studies a setting, where the TSH must respond to an arriving emergency case by assigning a physician within a considerably short time window. An emergency case at a facility can be matched only with a physician who is credentialed at that facility. Since care is urgent, queuing patients is not an option when there is no available on-shift physician. In such cases, the system must invoke the off-shift physicians, which is referred to as “blast.” The telemedicine company tries to avoid this option due to high costs. We propose a novel integer programming model for generating physician schedules with optimal mix of credentials and coverage across multiple hospitals. The proposed model aims to minimize total costs under a chance constraint that limits the blast probabilities and other tactical constraints that are unique to this setting. Two fast acting heuristic-based solution approaches are developed for real-life size problems and their computational performances were demonstrated via numerical analyses.

Safety and efficacy of intravenous thrombolysis for ischemic stroke in an elderly patient with thrombocytopenia

Background: Strokes remain as one of the diseases with high mortality and morbidity, which can be prevented through prompt and concise treatment. Intravenous thrombolysis (IV-rTPA) is the mainstay treatment for hyperacute ischemic stroke with onsets of less than 4.5 hours. However, it has several contraindications that should be monitored, one of them being thrombocytopenia. Objectives: This case report details the use of IV-rTPA in a geriatric patient with thrombocytopenia to highlight its efficacy and safety. Case: An 85-year-old woman was admitted to the emergency ward with weakness in the left extremities, slurred speech, and upward-right gaze one hour prior to ER admission. She had a significant history of hypertension and type II diabetes mellitus. A physical examination revealed a muscle strength of +5/+1, palsy in the left 7th and 12th cranial nerves, an NIHSS score of 15, and a RACE score of 7. The laboratory result was positive for thrombocytopenia (96,000/μl). IV-rTPA was administered, and two hours later, the patient's NIHSS score raised to 11. During the IV-RTPA administration, there was minor gum bleeding, which was considered insignificant. The patient was admitted to the ICU and observed for the next 72 hours. No signs of bleeding or clinical deterioration were observed during that period. Numerous studies have confirmed IV-rTPA's efficacy in acute ischemic stroke treatment if administered before 4.5 hours of onset. Thrombocytopenia is known as a contraindication of IV-rTPA, which may increase the risk of bleeding. In this case, IV-rTPA was administered due to hyperacute onset and no known history of bleeding despite low platelet count. Conclusion: IV-rTPA may be considered if the benefits outweigh the risks, coupled with thorough monitoring of the patient's condition.

Emergency Medicine Specialists’ Knowledge of Hospital Emergency Department Indicators and Their Role in Patient Treatment: A Qualitative Study

Background: National indicators have been defined for the satisfaction and efficiency of emergency services and for evaluating their functionality. These indicators enlighten strengths and areas where improvements can help improve emergency ward quality. Objectives: This study assessed the knowledge of medical specialists and their experiences, especially concerning the effects of these protocols. Methods: This qualitative study was conducted in 2019 in the emergency departments of hospitals affiliated with the Iran University of Medical Sciences. During semi-structured interviews with 20 professors of emergency medicine in 2019, their experiences regarding the effects of these indicators on providing emergency services were evaluated. The data were collected until saturation. All interviews were recorded with the participant’s permission and then transcribed verbatim and analyzed by content analysis method, and their semantic codes were extracted. Results: By analyzing the interviews, 14 subcategories, and four main categories were obtained. Categories and subcategories consisted of providing services to patients (with three subcategories: Improving the quality of medical services, waiting time reduction, and increasing satisfaction), improving emergency efficiency and performance (with five subcategories: Improving conditions, services, communication improvement, resource management, and facilities and equipment), accreditation (with three subcategories: Performance improvement, management and planning, and service quality improvement), and proposed indicators (with three subcategories: Time, capacity, and resources). Conclusions: The recognition of emergency medicine specialists in hospital emergencies is below average, which can affect the manner of providing health services and upgrading national indicators. With more and more familiarity of emergency medicine specialists with the indicators, a step can be taken to improve the status of hospital emergencies, thus determining patients’ tasks faster, reducing the length of stay in the emergency department, increasing patient satisfaction, and improving the performance of the emergency department.

Pulmonary tumor thrombotic microangiopathy during good response to immuno-chemotherapy for advanced non-small cell lung cancer: a case report

BackgroundPulmonary tumor thrombotic microangiopathy is a rapidly progressive and fatal disease in which tumor cells embolize to the pulmonary microvasculature. This condition is characterized by severe dyspnea and right heart failure. Although pulmonary tumor thrombotic microangiopathy typically occurs in patients with untreated and/or advanced cancer, its occurrence in patients who are responding well to medical therapy is poorly documented.Case presentationA 68-year-old Japanese woman who had received four cycles of immuno-chemotherapy (pembrolizumab, carboplatin, and pemetrexed) followed by three cycles of maintenance therapy (pembrolizumab and pemetrexed) for advanced non-small cell lung cancer and had achieved a partial response with a stable clinical course was admitted to the emergency ward because of worsening breathlessness and general fatigue for 1 week. Chest computed tomography showed no evidence of tumor progression or any new lung lesion. Two-dimensional transthoracic echocardiography demonstrated right atrial and ventricular dilatation, tricuspid regurgitation, and a high trans-tricuspid pressure gradient of 65 mmHg. Despite her percutaneous oxygen saturation being 96% on room air at the time of admission, it worsened rapidly; the patient requiring 8 L/min of oxygen within 4 h. Repeat computed tomography with contrast medium revealed no evidence of pulmonary embolism. The patient developed progressive respiratory failure that was unresponsive to optimal cardio-pulmonary supportive therapy. An autopsy revealed tumorous clusters in pre-capillary lung vessels, whereas the primary lesion had shrunk to the point of almost complete resolution.ConclusionPulmonary tumor thrombotic microangiopathy occurs not only in patients with advanced and/or uncontrolled cancer but also in those whose primary lesion seems to have been well controlled by medical treatment.

The study on association of elevated cardiac biomarker in patients of acute exacerbation of chronic obstructive pulmonary disease

Chronic obstructive pulmonary disease (COPD) is the third leading cause of death worldwide, and also resulting in economic and social burden which is substantial and is significantly increasing with time. Chronic obstructive pulmonary disease is frequently associated with right ventricular loading and pulmonary hypertension. Study aimed to evaluate a possible association between cardiac biomarker levels and adverse events in hospitalized patients with Acute exacerbations of chronic obstructive pulmonary disease comorbidities are important determinants of outcome and quality of life of patients with chronic obstructive pulmonary disease. An observational, cross-sectional study was conducted on 89 patients with AECOPD admitted in the medicine emergency ward of Baba Raghav Das medical college and Nehru Hospital Gorakhpur India. Acute exacerbations of chronic obstructive pulmonary disease were diagnosed according to Global Initiative for chronic obstructive lung disease guidelines. cTnI levels were estimated at the time of admission by method based on chemiluminescence with other investigations. Levels ≥ 0.01ng/ml was taken as positive. Tabulation and statistical analysis were performed using Microsoft Excel and SPSS v.17.0 software. p –value&amp;#60; 0.05 at 95% confidence intervals taken as statistically significant. 89 patients with AECOPD were enrolled, among them mean age was 59.59±8.72. We found that cardiac biomarker elevation (cTnI≥0.01ng/ml) is significantly associated with increased mortality, duration of hospitalization, need of ventilation (both invasive or non-invasive) &amp; cardiovascular morbidity. cTnI positivity predicted increased need of ICU admission and significantly increased duration of hospital stay (P=0.0001). cTnI positivity can prognosticate need of NIV or ventilator support. It was found in our study that ventilator support necessity &amp; mortality was more in cTnI positive patients which shows statical significance (P=0.006).cTnI in AECOPD has close relation with exacerbation od disease, right ventricular dysfunction, so it can be used as prognostic marker for mechanical ventilation requirement in future.

Prevalence of gastrointestinal bleeding and frequency of selected predictors of mortality on the medical emergency ward at Mulago hospital.

There was no data on the prevalence of Gastrointestinal bleeding (GI) among patients admitted on the emergency ward at Mulago hospital. This was partly because the medical records were not adequately completed as designed. To estimate the prevalence of gastrointestinal bleeding and the frequency of selected predictors of mortality on the emergency ward. This was a chart review incorporating quality improvement methods in the process of data collection. The health care team was educated on documentation of gastrointestinal bleeding while being assessed weekly for knowledge and practice of completion of the Casualty Assessment form (CAF) from which a documented diagnosis of GI bleeding and selected predictors of mortality were looked for. Of the 1881 CAF assessed, 278 had a documented diagnosis of GI bleeding, resulting in a prevalence of 6.8%. Of the patients with GI bleeding, 14.1% had age greater than 60 years, 24.0% had a systolic blood pressure less than 100mmHg and 44.5% had a heart rate greater than 100 beats per minute. The prevalence of GI bleeding on the medical emergency ward of Mulago hospital is high. This calls for strategies for resuscitative management of this life-threatening medical emergency. Among the selected predictors of mortality, tachycardia was most frequent followed by hypotension. These should always be assessed in a patient with GI bleeding and resuscitative measures with blood transfusion and intravenous fluids undertaken to correct them.