Chronic Care Hospital Research Articles

Exploring the effect of wound related pain on psychological stress, inflammatory response, and wound healing.

The relationship between pain and poor healing is intricate, potentially mediated by psychological stress and aberrations in inflammatory response. The purpose of this study was to examine the biopsychosocial model of pain by assessing the relationships between pain, stress, inflammation and healing in people with chronic wounds. This was a 4-week prospective observational study to explore the relationship of pain, stress, inflammation and wound healing in a convenience sample of patients with chronic wounds in a chronic care hospital in Canada. Only subjects over 18 with chronic wounds were recruited into the study. Chronic wounds were defined by the duration of wounds for more than 4 weeks of various aetiologies including wounds caused by pressure injuries, venous disease, arterial insufficiency, surgery or trauma and diabetic neuropathy. Participants were evaluated for pain by responding to the Brief Pain Inventory-Short Form, the McGill Pain Questionnaire-Short Form and the Leeds Assessment of Neuropathic Symptoms and Signs scale. Stress was measured by the Perceived Stress Scale (PSS). All wounds were assessed with the Pressure Ulcer Scale for Healing tool. The levels of matrix metalloproteinases were analysis by obtaining wound fluid from all participants. A total of 32 individuals with chronic wounds participated in the study. Correlation analysis indicated pain severity was positively and significantly related to pain interference, McGill Pain Questionnaire scores, neuropathic pain and matrix metalloproteinase levels. Logistic regression was used to determine the predictors for high or low perceived stress. The only significant variable that contributed to the stress levels was BPI-I. Results suggested that participants who experienced higher levels of pain interference also had an increased odds to report high level of stress by 1.6 times controlling for all other factor in the model. Pain is a complex biopsychosocial phenomenon affecting quality of life in people with chronic wounds. Results of this study identified a significant relationship between pain, stress and wound healing.

The Administration of Lemborexant at Admission is Not Associated with Inpatient Falls: A Multicenter Retrospective Observational Study.

There has been no large-scale investigation into the association between the use of lemborexant, suvorexant, and ramelteon and falls in a large population. This study, serving as a pilot investigation, was aimed at examining the relationship between inpatient falls and various prescribed hypnotic medications at admission. This study was a sub-analysis of a multicenter retrospective observational study conducted over a period of 3 years. The target population comprised patients aged 20 years or above admitted to eight hospitals, including chronic care, acute care, and tertiary hospitals. We extracted data on the types of hypnotic medications prescribed at admission, including lemborexant, suvorexant, ramelteon, benzodiazepines, Z-drugs, and other hypnotics; the occurrence of inpatient falls during the hospital stay; and patients' background information. To determine the outcome of inpatient falls, items with low collinearity were selected and included as covariates in a forced-entry binary logistic regression analysis. Overall, 150,278 patients were included in the analysis, among whom 3,458 experienced falls. The median age of the entire cohort was 70 years, with men constituting 53.1%. Binary logistic regression analysis revealed that the prescription of lemborexant, suvorexant, and ramelteon at admission was not significantly associated with inpatient falls. The administration of lemborexant, suvorexant, and ramelteon at admission may not be associated with inpatient falls.

Validation of the Saga Fall Injury Risk Model.

Background: Predicting fall injuries can mitigate the sequelae of falls and potentially utilize medical resources effectively. This study aimed to externally validate the accuracy of the Saga Fall Injury Risk Model (SFIRM), consisting of six factors including age, sex, emergency transport, medical referral letter, Bedriddenness Rank, and history of falls, assessed upon admission. Methods: This was a two-center, prospective, observational study. We included inpatients aged 20 years or older in two hospitals, an acute and a chronic care hospital, from October 2018 to September 2019. The predictive performance of the model was evaluated by calculating the area under the curve (AUC), 95% confidence interval (CI), and shrinkage coefficient of the entire study population. The minimum sample size of this study was 2,235 cases. Results: A total of 3,549 patients, with a median age of 78 years, were included in the analysis, and men accounted for 47.9% of all the patients. Among these, 35 (0.99%) had fall injuries. The performance of the SFIRM, as measured by the AUC, was 0.721 (95% CI: 0.662-0.781). The observed fall incidence closely aligned with the predicted incidence calculated using the SFIRM, with a shrinkage coefficient of 0.867. Conclusions: The external validation of the SFIRM in this two-center, prospective study showed good discrimination and calibration. This model can be easily applied upon admission and is valuable for fall injury prediction.

Description of care pathways for benzodiazepine and sedative hypnotic discontinuation in older adults: protocol of a multicentre qualitative study

Introduction: Benzodiazepines and sedative hypnotics (BSHs) may represent a threat to patient safety, especially among older adults. The project BE-SAFE (Implementing a patient-centred and evidence-based intervention to reduce BEnzodiazepine and sedative-hypnotic use to improve patient SAFEty and quality of care) is a 5-year research project funded through the Horizon Europe Research Programme (Grant agreement n° 101057123). Its goal is to improve patient safety by addressing knowledge and practice gaps related to the reduction of BSHs used for sleep problems in older adults. Within the project, a patient-centred and evidence-based intervention will be developed to reduce the use of BSHs for sleep problems in older adults. This intervention will be tested in a cluster randomized controlled trial in different hospitals of six European countries (Belgium, Greece, Norway, Poland, Spain and Switzerland). Understanding current care pathways and healthcare systems in relation to BSH discontinuation should help tailor the BE-SAFE intervention to target contexts. This understanding should also shed light on the conditions for patient involvement in shared-decision making and interprofessional and interorganisational collaboration. These elements are expected to be key to the success of the intervention.
 
 Objective: To describe care pathways, including interprofessional and interorganisational collaborations, and healthcare systems in relation to BSH discontinuation in the six countries participating in the BE-SAFE trial, from the perspective of healthcare professionals and patients.
 Methods: A qualitative study will be conducted in the hospitals where the trial will take place and in other healthcare settings that are part of the care pathway, such as primary care. This study will follow four phases: 1) exploring healthcare systems, 2) mapping a typical care pathway for BSH discontinuation, including stakeholder analysis with patients, healthcare professionals and managers, 3) characterising healthcare systems in relation to BSH discontinuation, and 4) validation of results with stakeholders. Participants will be healthcare professionals, especially those involved in BSH discontinuation, managers and patients over 65 years of age either taking BSHs for sleep problems or who have undergone BSH discontinuation in the last three months. Data will be collected through self-administered questionnaires, semi-structured interviews and focus groups. The “6 W” multidimensional model of care trajectories (1) and the “Context and Capabilities for Integrating Care” framework (2) will be used to guide data collection and analyses.
 Expected results: We will obtain an in-depth description of care pathways and healthcare systems in relation to BSH discontinuation in each of the six countries participating in the BE-SAFE trial. These results will help to inform intervention development through the creation of logic models and to fit the BE-SAFE intervention to target contexts. By May 2023, we will have an initial version of the description of care pathways in each country.
 1.Vanasse A, Courteau M, Ethier JF. The ‘6W’ multidimensional model of care trajectories for patients with chronic ambulatory care sensitive conditions and hospital readmissions. Public Health. 2018 Apr 1;157:53–61.
 2.Evans JM, Grudniewicz A, Baker GR, Wodchis WP. Organizational context and capabilities for integrating care: A framework for improvement. Int J Integr Care. 2016 Jun 24;16(3):1–14.
 

Measures to Contain the Transmission of Hepatitis C in a Chronic Kidney Care Hospital Unit in the Triângulo Mineiro in Brazil: A Case Study.

Objectives: Hepatitis C virus elimination is complex. The objective was to analyze measures to eliminate virus transmission in a hemodialysis unit. Methods: Case study composed of multiple units of analysis. The scenario is the hemodialysis unit of a Brazilian public hospital. Population composed of health service records. Descriptive analyzes were performed and the beginning of the event was considered as the moment of increased incidence of HCV. The intentional and purposeful collection of information for understanding the event and implementing interventions. Results: The subunits of analysis were related to: clinical-epidemiological profile, active search, transmission routes, management protocol and results achieved. In August 2019, out of 45 patients, six were reactive for anti-HCV. All received treatment. Patients had exposure to contaminated medical equipment, objects or hands of professionals. Preventive measures were adopted and routine techniques were corrected. Situational Analysis Committee guided the management of the event. No new cases were detected. Conclusions: Strategies for the microelimination of the C virus in a dialysis environment are demonstrated and it shows the multidisciplinary efforts in conducting the event.

Lessons from the COVID-19 pandemic: strategies and challenges for an aging society in Japan

PurposeThis article analyzes the challenges of infectious disease control under a super-aged society through Japan’s experience with COVID-19.Design/methodology/approachThis article provides an overview of Japan’s COVID-19 measures and their characteristics, discusses their successes and failures, and identifies future challenges.FindingsJapan’s basic strategy for COVID-19 consists of three parts: the border defense (Stage 1), slowing down the spread (Stage 2), and damage control (Stage 3). One key policy feature in Stage 2 and Stage 3 is based on “voluntary restriction”. It had a certain effect, but it was prolonged with each recurring “wave of infection”, resulting in economic exhaustion and people’s dissatisfaction. Thus, the effect of the voluntary restriction has weakened, while the percentage of people who have been vaccinated is improving, making it difficult to predict the damage of the next “wave”. Under the hyper-aged society, it was necessary to identify and protect particularly vulnerable areas, i.e., psychiatry hospitals, chronic care hospitals, and long term care (LTC) facilities. On the other hand, secondary impacts extend to young people. The most serious one is the decrease in births which further accelerates the aging of society.Originality/valueThis study is original as it investigated why Japan’s unique countermeasures against COVID-19 without mandatory lockdown worked well for a considerable period. It also revealed that secondary impacts of the COVID-19 epidemic are broader and more significant than the direct loss of life, and that the social system, especially super-aged society with many vulnerable areas should be reformed in consideration of the threat of infectious diseases. Lessons from the Japanese case may contribute to other countries.

Negative impact of behavior restriction amidst a clustered COVID-19 infection on immobility syndrome in older patients negative for COVID-19: report from a chronic care hospital in Japan.

Previous studies have reported on associations between immobility syndrome and the COVID-19 pandemic. However, little is known about the aggravation of this syndrome in older patients negative for COVID-19 infection amidst behavior restriction due to a clustered COVID-19 infection. Patients hospitalized one month before a clustered COVID-19 infection occurred in our hospital were recruited. Rehabilitation therapy was suspended for 25 days during behavior restriction. The ability of daily living of the patients was evaluated with the functional independence measure and Barthel index. Chronological changes in the functional independence measure and Barthel index scores were evaluated monthly, beginning one month before the clustered COVID-19 infection to one month after re-initiation of rehabilitation therapy. Patients with minimum scores in the functional independence measure (18) and Barthel index (0) prior to the clustered COVID-19 infection were excluded. Functional independence measure scores of 73 older patients and the Barthel index scores of 48 patients were analyzed. The mean total functional independence measure score amidst the behavior restriction significantly changed from 36.3 to 35.1 (p = 0.019), while statistical significance was not detected in the mean motor subtotal (from 21.6 to 20.9 with p = 0.247) or cognitive subtotal functional independence measure scores (from 14.6 to 14.2 with p = 0.478). During the behavior restriction, the mean Barthel index scores declined from 25.8 to 23.2 without statistical significance (p = 0.059). Behavior restriction due to a clustered COVID-19 infection may aggravate immobility syndrome in older patients who are negative for COVID-19.

Risk for primary cephalosporin resistance in Gram-negative bacteremia.

This study aimed to examine the clinical risk factors for cephalosporin resistance in patients with Gram-negative bacteremia caused by Escherichia coli (EC), Klebsiella pneumoniae (KP), Enterobacter cloacae (ENC), and Pseudomonas aeruginosa (PS). This retrospective cohort study included 400 adults with Gram-negative bacteremia. The goal was to review 100 cases involving each species and approximately half resistant and half susceptible to first-line cephalosporins, ceftriaxone (EC or KP), or cefepime (ENC or PS). Logistic regression was used to identify factors predictive of resistance. A total of 378 cases of Gram-negative bacteremia were included in the analysis. Multivariate analysis identified significant risk factors for resistance, including admission from a chronic care hospital, skilled nursing facility, or having a history of infection within the prior 6 months (OR 3.00, P < .0001), requirement for mechanical ventilation (OR 3.76, P < .0001), presence of hemiplegia (OR 3.54, P = .0304), and presence of a connective tissue disease (OR 3.77, P = .0291). Patients without the identified risk factors should be strongly considered for receiving ceftriaxone or cefepime rather than carbapenems and newer broad-spectrum agents.

Indicators Predicting Inpatient Mortality in Post-Stroke Patients Admitted to a Chronic Care Hospital: A Retrospective Pilot Study.

Evidence concerning the mortality of post-stroke patients admitted to a chronic-phase hospital seems to be lacking. This pilot study aimed to identify mortality-related clinical variables in the admission of post-stroke patients from a retrospective perspective. A group of 38 non-survival stroke patients and another group of 46 survival stroke patients in a chronic-phase ward of the single center were recruited. Clinical variables including age, sex, stroke type, and Barthel index (BI) score were collected. The difference in the age and BI scores on admission were statistically significant between the two groups (p < 0.01). Polytomous logistic regression analysis revealed that age (odds ratio = 1.09, p = 0.03, and 95% confidence interval: 1.01–1.07), male sex (odds ratio = 5.04, p = 0.01, and 95% confidence interval: 1.39–18.27), and BI scores on admission (odds ratio = 0.90, p = 0.01, and 95% confidence interval: 0.83–0.97) could be prognostic variables. The percentage of correct classification was 83.3%. Age, male sex, and BI scores on admission may be prognostic indicators. The result of this study could lay the groundwork for palliative care for such a clinical population.

External validation of a new predictive model for falls among inpatients using the official Japanese ADL scale, Bedriddenness ranks: a double-centered prospective cohort study

BackgroundSeveral reliable predictive models for falls have been reported, but are too complicated and time-consuming to evaluate. We recently developed a new predictive model using just eight easily-available parameters including the official Japanese activities of daily living scale, Bedriddenness ranks, from the Ministry of Health, Labour and Welfare. This model has not yet been prospectively validated. This study aims to prospectively validate our new predictive model for falls among inpatients admitted to two different hospitals.MethodsA double-centered prospective cohort study was performed from October 1, 2018, to September 30, 2019 in an acute care hospital and a chronic care hospital. We analyzed data from all adult inpatients, for whom all data required by the predictive model were evaluated and recorded. The eight items required by the predictive model were age, gender, emergency admission, department of admission, use of hypnotic medications, previous falls, independence of eating, and Bedriddenness ranks. The main outcome is in-hospital falls among adult inpatients, and the model was assessed by area under the curve.ResultsA total of 3,551 adult participants were available, who experienced 125 falls (3.5%). The median age (interquartile range) was 78 (66–87) years, 1,701 (47.9%) were men, and the incidence of falls was 2.25 per 1,000 patient-days and 2.06 per 1,000 occupied bed days. The area under the curve of the model was 0.793 (95% confidence interval: 0.761–0.825). The cutoff value was set as − 2.18, making the specificity 90% with the positive predictive value and negative predictive value at 11.4% and 97%.ConclusionsThis double-centered prospective cohort external validation study showed that the new predictive model had excellent validity for falls among inpatients. This reliable and easy-to-use model is therefore recommended for prediction of falls among inpatients, to improve preventive interventions.Trial registrationUMIN000040103 (2020/04/08)

In-hospital ventricular arrhythmia in heart failure patients: 7year follow-up of the multi-centric HEARTS registry.

AimsThe aim of this study was to determine the incidence, predictors, and short‐term and long‐term outcomes associated with in‐hospital sustained ventricular tachycardia (VT) and ventricular fibrillation (VF) collectively termed ventricular arrhythmia (VA) in the heart failure (HF) patients.Methods and resultsThe HEart function Assessment Registry Trial in Saudi Arabia (HEARTS registry) is a prospective national registry of patients with chronic HF from18 tertiary care hospitals across Saudi Arabia. Diagnosis of HF was in accordance with American Heart Association/European Society of Cardiology definition criteria. The registry had enrolled 2610 HF patients during the 14 month recruitment period between October 2009 and December 2010. Occurrence of in‐hospital cardiac events, prognosis, and outcome were monitored during the 7 year follow‐up period. The incidence of in‐hospital VA in HF was 4.2%. VA was more common among men, and mean age was lesser than non‐VA patients (58.5 ± 16: 61.5 ± 15 years; P = 0.042). Smoking and family history of cardiomyopathy were significant risk factors of VA. Previous history of arrhythmia, ST elevated myocardial infarction, infections, and hypotension remained significant predictors of in‐hospital VA associated with three to seven times more risk. Patients with VA had higher rates of in‐hospital events like recurrent HF, haemodialysis, shock, sepsis, major bleeding, intra‐aortic balloon pump, and stroke compared with those without VA, all being highly significant (P < 0.001). After adjustment for age, gender, and co‐morbidities, in‐hospital VA increased the risk of cardiogenic shock by 24 times, dialysis and major bleeding by 10 times, and recurrent congestive HF and pacing by five times. Survival analysis showed that all‐cause mortality was significantly higher in the VA patients (P < 0.001). Presence of VA increased in‐hospital and 1 month mortality to 23 and 17 times, respectively.ConclusionsLower mean age of VA complicated HF patients is a matter of concern in the Saudi population. HF associated with VA increased in‐hospital events and all‐cause mortality indicating poor prognosis and survival. These findings enable risk stratification and reflect on the importance of early recognition of the clinical markers and predictors of VA prompting immediate management.

Patient characteristics, ICU-specific supports, complications, and outcomes of persistent critical illness

ObjectivesThe primary objective was to identify the proportion of patients on mechanical ventilation (MV) beyond day 10, the recently defined time of onset of Persistent Critical Illness (PerCI). The secondary objective was to identify underlying diagnoses, intensive care unit (ICU) based therapies, relevant complications, and outcomes of patients with PerCI. Subjects100 PerCI patients and 100 age, sex, mechanical ventilation for >24 h, acute physiology and chronic health score (APACHE III) and co-morbidity score-matched controls. Main resultsThe maximum proportion of PerCI patients requiring invasive MV beyond day 10 was 66%. PerCI patients were more likely to have respiratory, septic, or neurosurgical admission diagnoses (p = .01). In the first 10 ICU days, they received multiple types of ICU-based treatments for longer duration and had a higher incidence rate of ventilator-associated pneumonia (VAP) (p = .008). Hospital discharge destination differed significantly (p≤.001), with greater mortality (34% vs. 22%) and discharge to chronic care facility (11% vs. 0%). ConclusionsMechanical ventilation beyond day 10 affected only two thirds of PerCI patients. However, VAP was a key complication in such patients. Discharge to chronic care facilities and hospital mortality were more common in PerCI patients.

Structural Changes in the Hungarian Healthcare System Between 2000 and 2017

BackgroundThe rigid and old-fashioned structure of the Hungarian healthcare system has been discussed since the mid-1990s and is at the center of professional and policy debates. It is characterized by the too high number of acute care hospital beds in international comparison; access is regionally unequal; levels of progressive care are mixed; and there is a nonuniform emergency service system with unequal access to the emergency room, heterogeneous quality of care, and unexploited opportunities of modern health technology (eg, 1-day surgery, minimally invasive procedures, telemedicine). ObjectivesThe aim of this study is to analyze the indicators of ongoing structural changes of the Hungarian healthcare system between 2000 and 2017. MethodsData are derived from the Organisation for Economic Co-operation and Development Heath Statistics, Hungarian National Statistical Office, National Health Insurance Fund Administration and the database of the European Structural Funds. The methods used for the analysis are descriptive statistics, trend analysis, and longitudinal data. ResultsThe total number of hospitals beds showed a 32% reduction between 2005 and 2017. Parallel with this subsequent reduction of hospital bed capacities, we can see a moderate reduction (22.3%) in the number of discharged patients from hospitals: from 2005 to 2017, 2.55 million to 1.95 million. The average length of stay in acute hospital care has decreased from 6.3 to 5.1 days. About 25 to 27 small local hospitals lost their acute or short-term care profile (mainly intensive care units, internal medicine, surgery, and pediatric care wards) and became long-term care, chronic care, or rehabilitation profile hospitals. ConclusionStructural change is in progress in the Hungarian healthcare system, and some efficiency gains have been reached. Nevertheless, still there are significant potential efficiency gains in the better organization and management of health services in addition to the dissemination and better incorporation of modern healthcare technologies.

Cost of establishing a general dentistry department in a small or medium-sized hospital.

To contribute to future dental healthcare policies, this study compiled data on hospital expenses and follow-ups conducted after a hospital dentistry department was established. In addition, the management status and reports on the utility and challenges of establishing a dentistry department were analyzed. The dentistry department was established through fund raising and inaugurated in May 2009. The depreciation period was set at 7 years, and income and expenditure during the 7 years 8 months after opening were compiled. In total, 17.22 million yen was needed for the dentistry department. The average income from dental care was 21.59 million yen per year, and expenditure amounted to 21.54 million yen per year. The findings indicated that a general dentist able to systemically manage patients was essential in a chronic-care hospital. Moreover, the present findings indicate that if general dentistry consultations were performed without excessive investments, after adjusting for personnel expenses, such an initiative would neither yield considerable income nor produce a substantial deficit. Finally, it is imperative to develop staff who are familiar with the costs and management of hospital dentistry and to increase medical fees for consultations with elderly patients.

Serum lipid profile among non diabetic patients with chronic kidney disease attending tertiary care hospital in West Bengal, India

Background: Chronic kidney disease (CKD) is a major health deteriorating factor worldwide as well as in India. It encompasses various pathophysiological processes involving abnormal kidney function and thereby declination in glomerular filtration rate (GFR). CKD is known risk factor for dyslipidemia. Due to lack of studies of association between different lipid parameters and its association with severity of CKD in non-diabetic patients in Indian population, we designed a study aimed to describe the serum lipid profile in non-diabetic CKD patients.Methods: This hospital based observational analytical was carried out in 60 subjects with CKD and non-diabetic. They were investigated for blood sugar parameters, lipid profile and renal function tests. Lipid profile was associated with different stages of CKD. Data was expressed as percentage and mean±SD.Results: Mean BMI was found to be 21.6±2.7kg/m2. Most common symptom encountered was H/o edema in 98% subjects. Out of total sixty subjects’ maximum subjects were found to be in stage 4 (22 subjects, 36.7%). Significantly higher levels of serum creatinine (p &lt;0.0001), and serum urea (p &lt;0.0001) was observed in higher grade CKD stages in study subjects.Conclusions: Total cholesterol (TC) and LDL were found to be significantly different amongst CKD stages having higher mean values in non-diabetic subjects. Serum TC, TG, LDL and VLDL were found to be significantly higher in subjects with advanced CKD (stage 3, stage 4). TC/HDL and LDL/HDL ratio were significantly higher in subjects with advanced CKD compared to initial stages of CKD in non-diabetic subjects.

Comparative effectiveness of fragility fracture integrated rehabilitation management for elderly individuals after hip fracture surgery: A study protocol for a multicenter randomized controlled trial.

Introduction:Although it is essential to provide comprehensive rehabilitation after hip fracture to restore the patient to preoperative physical functioning, feasibility issues remain. Here, we describe a protocol for a randomized controlled trial (RCT) to evaluate the effectiveness of fragility fracture integrated rehabilitation management (FIRM) for elderly individuals after hip fracture surgery. We also examine the feasibility of applying FIRM in a chronic-care hospital or community-based setting.Methods and analysis:Elderly patients will be randomly assigned to either the FIRM, conventional, or control group for a 2-week intervention period following hip fracture surgery. The primary outcome of this study is Koval walking ability. All functional outcomes will be measured 1 and 3 weeks, 3, 6, and 12 months after the surgical intervention. Researchers will be blind to group allocation, and participants will be blind to outcome. A sample size of 282 participants will be necessary to demonstrate the effect of the FIRM program. After the RCT has been conducted in 3 core hospitals, FIRM will be applied in 6 community-based local hospitals to investigate the feasibility of the program. The data will be analyzed using the intention-to-treat principle.Trial registration number:NCT03430193.

Burnout in the staff of a chronic care hospital.

ABSTRACTOBJECTIVETo estimate the prevalence of Burnout in a medium or long-stay hospital, to monitor its evolution and to highlight the importance of cut-off points used to avoid distortions in the interpretation of the results.METHODSTwo cross-sectional studies (2013–2016) were carried out, applying the Spanish version of the Maslach Burnout Inventory to the staff of a chronic care hospital (n = 323). Result variables were: Burnout prevalence and a high degree of affectation of the subscales and predictor variables: sociodemographic characteristics and factors that trigger and modulate the syndrome. The association between variables was quantified using odds ratio.RESULTSThe participation rate went from 31.5% to 39.3%. The professionals presented a mean level of Burnout in both moments, observing a lower degree of affectation of the depersonalization subscales and personal accomplishment in the 2016 cut-off. The average score of the subscales in 2016 was 21.5 for emotional fatigue, 4.7 for depersonalization and 41.7 for personal fulfillment, compared to the values of emotional fatigue = 21.6, depersonalization = 6.9 and personal fulfillment = 36.3 obtained in 2013. The emotional fatigue score was slightly higher than the mean value of the national studies (19.9), while the rest of the values were similar to the mean values of the studies considered. The prevalence of Burnout and the interpretation of the results varied significantly according to the cut-off points considered. In both studies, sociodemographic variables showed little significance, while social support and interpersonal relationships were associated with the degree of burnout among professionals.CONCLUSIONSOur prevalence of Burnout was similar to that of other studies consulted, although the emotional component is more marked in our environment. The interpretation of the results varied significantly according to the cut-off points applied, due to the cross-cultural differences.

Fever of Unknown Origin: Don't Forget Kala-Azar Even in Europe.

We present the case of a 70-year-old male patient with fever of unknown origin after a long period of convalescence from a previous admission to a chronic care hospital. During the admission, multiple combinations of antibiotic and antifungal treatments were prescribed, but with persistent fever and, eventually, neutropenia (200 lymphocytes, 0 neutrophils). Given the suspicion of infection at bone marrow level, a biopsy was performed as was serology of Leishmania, both diagnostic determinations. Treatment with amphotericin B liposomal resulted in a good outcome.LEARNING POINTSVisceral leishmaniasis is a rare aetiology of neutropenia, which causes an important constitutional syndrome and long-standing fever.However, this pathology is endemic in areas of the Mediterranean Sea, which is well known for migratory flows.High clinical suspicion of leishmaniasis is necessary in patients with fever of long evolution, hepatomegaly or splenomegaly, fever and constitutional syndrome, and from endemic areas.

Human resources estimates and funding for antibiotic stewardship teams are urgently needed

Human resources estimates and funding for antibiotic stewardship teams are urgently needed

FROM RESEARCH TO POLICY TO IMPLEMENTATION: THE CASE OF THE ISRAELI NATIONAL STRATEGIC PLAN TO ADDRESS ALZHEIMER'S AND OTHER TYPES OF DEMENTIA

In 2013, Israel developed and adopted a National Strategic Plan to Address Alzheimer's and Other Types of Dementia based on the work of a multidisciplinary group of experts from the Ministries of Health, Social Affairs, Senior Citizens, and the National Insurance Institute. In addition professional societies, the Israel Alzheimer's Association (EMDA), public foundations, the health funds, and non-governmental agencies, as well as members of academia were represented. The plan has 7 objectives: raising professional and public awareness of dementia, developing health services targeting people with dementia, developing social services, family and caregiver support, improving long term care institutional services, professional training, and research. The Ministry of Health is leading the Strategic Plan through an implementation committee including representatives of all stakeholders. Major initiatives and accomplishments to date include Three media campaigns that have increased public and professional awareness of dementia A “Dementia Friends” program in partnership with local municipalities and EMDA also to increase public awareness Financial support to the health funds to develop programs of primary care team training, and case management for people with dementia. Competitive financial support for acute and chronic care hospitals to develop programs that train professional staff; and identify, treat and discharge people with dementia using innovative care pathways. A national dementia registry is being built in cooperation with the health funds to provide a tool for policy development, planning, and research. Caregiver support and education have been a major focus with funding provided for different models of group and individual programs. The Israel National Strategic Plan to Address Alzheimer's and Other Types of Dementia has led to cooperation between governmental ministries and across public and private agencies. The major initiatives described have resulted in an increased awareness of dementia, not only among professionals and the public, but also among policy makers. Our goal is to continue to promote care for people with dementia and their families as a public health priority.