Day Hospital Care Research Articles

Applying Value Stream Mapping to Improve the Delivery of Patient Care in the Oncology Day Hospital.

Improving the delivery of patient care is an ongoing challenge in the National Health Service (NHS). This challenge is not insignificant in the process of chemotherapy administration for oncology patients. The present research is motivated by a public Spanish hospital in which oncology patients receive medical care in the Oncology Day Hospital (ODH). At the ODH, oncology patients receive different health services by different specialists on a single day. Any discoordination in patient flow will contribute to longer waiting times and stays in the ODH. As oncology patients tend to have special health conditions, any extra time in the hospital is a source of risk and discomfort. This study applies value stream mapping methodology in a Spanish ODH to improve this situation, reducing hospital waiting times and shorting the length of stay. For that purpose, the path of the oncology patients is mapped and the current state of the system is analyzed. Working at takt time and levelling the workload are proposed for improving the working conditions for healthcare personnel. As a result, the quality of service for oncology patients who need a well-defined care profile is improved. The singular characteristics of the Spanish NHS make it challenging to implement new ways of working, so this study has significant theoretical and managerial implications offering directions in which improvement is possible.

COVID-19 and atherosclerosis: looking beyond the acute crisis

COVID-19 and atherosclerosis: looking beyond the acute crisis

P210 Assessment of disease specific knowledge and quality of life among patients with Inflammatory Bowel Disease

Abstract Background Inflammatory bowel disease (IBD) is a chronic inflammatory condition affecting the gastrointestinal tract that leads to a marked decrease in quality of life. Patients should develop coping strategies. Higher levels of IBD-related knowledge are associated with lower disease-related helthcare costs and less need for a step-up strategy. Aims To determine individual factors influencing the level of patient knowledge and whether this has an impact on therapeutic adherence and quality of life. Methods The IBD-KNOW, Short Inflammatory Bowel Disease Questionnaire (SIBDQ) and Morisky Medication Adherence Scale (MMAS-8) questionnaires were applied to IBD patients who were consecutively assessed at outpatient consultation or day-care hospital. Factors associated with higher levels of knowledge about IBD were analysed Results We included 74 patients (male: 51%; median age: 46 years [interquartile range (IQR): 25–67]), 54% (n=40) had Crohn’s Disease. The median duration of IBD was 5 years (IQR: 1–16 years). Physicians/nurses (n=67) and the internet (n=26) were considered the main sources of knowledge. Median IBD-KNOW score was 13 (IQR: 7–19), the percentage of correct answers was highest in the areas of vaccination (78%), epidemiology (43%) and anatomy (27%) and lowest in knowledge regarding reproduction (21%), lifestyle (21%), physiology (14%) and surgery (14%). Most patients (68%, n= 53) know that IBD with several years of evolution is a risk factor for colorectal cancer and recognize the importance of screening. The IBD-KNOW median score was statistically significantly higher in patients with previous hospitalisation (p=0.01), bowel surgery (p=0.04) and disease with more than 5 years of evolution (p=0.04). No differences were identified according to educational level. Patients adherent to therapy (MMAS-8=8) did not present higher scores (p=0.09) and no positive correlation was found between IBD-KNOW score and SIBDQ (p=0.415). Conclusion A longer duration of disease and previous hospitalisation/surgery related to the disease were associated with a higher level of knowledge. There was no association between quality of life and therapeutic adherence and level of knowledge. The authors intend to use this analysis to target future promotion of health education programmes to address the areas with the greatest knowledge deficits.

The quality of mental health care-clinic Veldre pilot study results

Background The practice of the assessment of mental health care quality is currently under development in Latvia. Clinic ‘Veldre’ (2012) is one of the only two community – based mental health care centers in Latvia. The quality of clinic ‘Veldre’ has never been assessed. To assess the quality of care for patients with schizophrenia of the ‘Veldre’ clinic’s outpatient department. Methods The retrospective, descriptive, real-life pilot study was performed. Medical chart analysis was performed and the following indicators were assessed in 30 randomly selected schizophrenia outpatients (aged 21–65; 15 male (50%, mean age 45), 15 female (50%, mean age 50): rehospitalization, frequent hospitalization (more than once per year), long-stayers rate (more than 28 days of hospital care), received outpatient care; suicide and mortality rate. Statistical data analysis was performed, correlations were found. Results Results demonstrate weak positive correlations between male gender and (a) rehospitalisation rate (Sperman's rank correlation (rs) −0.27) and (b) long term hospitalisation (Spearmans's rank correlation (rs) 0.27). Conclusions Future research is needed to explore the gender differences in mental health care quality indicators.

Spinal Anesthesia in Patient with Congestive Heart Failure due to Congenital Atrial Septal Defect, and Pulmonary Hypertension Undergoing Cesarean Section Procedure: A Case Report

Introduction. In patients suffering from heart disease, pregnancy is a risk factor for mortality. Heart disease in pregnant women can be in form of rheumatic heart disease, cardiomyopathy, or congenital heart disease. This case report is about the successful spinal anesthesia technique in cesarean section (C-section) patients with congestive heart failure due to congenital atrial septal defect, and pulmonary hypertension (PH).
 Case presentation. A pregnant woman, 24 years old, planned to have an emergency C-section. She complained about shortness of breath for 2 days before admission. Three months ago, the patient started to feel shortness of breath during activity and also complained her legs swelled. She has a history of congenital heart i.e. atrial septal defect (ASD), but not routinely been treated. Her examination showed tachypnea, murmur, bibasilar fine crackles lung sound, and pretibial pitting edema. Echocardiography showed ASD with pulmonary hypertension. Spinal Anesthesia using 0.5% isobaric bupivacaine 7.5 mg and fentanyl 25 µcg was given before surgery. Drugs was injected in L3-L4 level with the upper target was as high as T6. the head position is raised 30 degrees. Procedure went well and the APGAR score was 8/9, Patient was admitted to the ICU for one day and discharged from hospital at the 5 days of hospital care.
 Conclusion. Spinal single-shot spinal anesthesia with small doses of bupivacaine and adjuvant can be used as an alternative technique in emergency C-section for patients with congestive heart failure due to congenital atrial septal defect, and pulmonary hypertension.

Implementation of a hospital-at-home (HAH) unit for hematological patients during the COVID-19 pandemic: safety and feasibility.

Background“Hospital-at-home” (HAH) programs have been shown to optimize resource utilization, shorten hospitalization and prevent nosocomial infection.MethodsWe retrospectively analysed data regarding implementation of an HAH unit for caring patients with hematological malignancies in our center, during the COVID-19 pandemic.ResultsBetween January and November 2020, 105 patients were treated in the HAH unit for a total of 204 episodes. Nine patients with multiple myeloma (MM) received autologous HSCT (auto-HSCT). Three patients with acute myeloid leukemia (AML) received consolidation therapy, 32 patients underwent clinical and analytical monitoring, 20 were transplant recipients early discharged (5 auto-HSCT and 15 allo-HSCT) and 2 had received CART cells therapy. Azacitidine, bortezomib and carfilzomib were administered at home to 54 patients with AML, myelodysplastic syndrome (MDS) or MM. A median of 17 (IQR 13–19) days of admission per patient and a total of 239 visits to the Hematology day-care hospital were avoided. Overall, 28 patients (14% of all episodes) needed admission to the hospital, 4 of them due to COVID-19.ConclusionsImplementation of a Hematology HAH unit was feasible and safe, and provided thorough advanced care to a high-risk population. Advanced care-at-home strategies can be crucial during times of COVID-19 to minimize treatment interruptions and reduce the risk of cross-infections.

Atypical presentation acute appendicitis, a diagnostic challenge. Case report and literature review

BACKGROUND: Atypical appendicitis corresponds to approximately 39.3% of all appendicitis cases. Typically located appendicitis begins with acute pain around the belly button, which will later migrate to the right iliac fossa; however, the patient’s condition must be oriented in details that arise from a meticulous anamnesis, considering the patients history and the development of the symptoms. CASE REPORTS: 17-year-old male patient with history of right hepatectomy 15 years ago. He presented with five day evolution continuous abdominal pain, located in the right upper quadrant, nausea, vomiting and fever. Complementary laboratory tests evidenced: leukocytosis, neutrophilia, elevated procalcitonin and CRP. Tomography was suggestive of an inflammatory process in the lower right thoracic region and the right upper quadrant. A diagnostic laparoscopy was performed, it was converted into an exploratory laparotomy, showing purulent fluid in the right parietocolic gutter, adhesions, appendicular plastron in the right sub and retrohepatic region formed by the cecum, distal ileum, omentum and appendix. Retrohepatic appendix with perforation in the middle third, appendicular base and poor quality cecum. An appendectomy, cavity lavage was performed, with placement of a drain. EVOLUTION: During the postoperative period, the patient had a poor clinical evolution, with health care associated pneumonia, in addition to the need for a second surgical intervention due to the formation of a sub-hepatic collection. After 13 days of hospital care, after the second surgical intervention, he presented an adequate recovery and was discharged from the hospital. CONCLUSION: Physicians must have a high clinical suspicion of atypical location appendicitis in the presence of acute abdomen; since a late diagnosis of this cases increases the risk of complications, with perforation and peritonitis and prolonged hospital stay. The first-line treatment for complicated appendicitis is surgical intervention.

P-OT025. A rare case of dengue encephalopathy in pregnant woman

Introduction . Dengue fever has been known for more than two decades as a tropical endemic infection caused by the dengue virus that affected from Aedes aegypti . Complications of dengue fever are common and usually related to renal and hepatic dysfunction. Encephalopathy is a rare complication. Here we report an unusual case of pregnant woman with dengue encephalopathy. Results . A 28-year-old female, G1P0A0, consulted by the anesthetic division with loss of consciousness. Prior to that, she had acute fever with history of acute progressive cephalgia and positive results of IgG and IgM dengue antibody. She was 20 weeks of pregnancy. On examination she was stuporous (E2V2M5). Lateralization, pathological reflex, and meningeal signs were not found. Laboratory examination showed thrombocytopenia 23 × 10 3 /µl, increased transaminase enzyme, hypokalemia 2.53 mmol/L, and hypoalbuminemia 2.35 gr/dL. Head CT Scan showed cerebral edema. During hospital care, she was monitored closely. Careful fluid management was carried out with additional treatment consisted of thiamine 100 mg/12 h, piracetam 800 mg/12 h, folic acid 2 × 1 mg, and transfusion of albumin and premix KCL. Patient condition was improved after 7 days of hospital care. The encephalopathy lasted for 5 days. Patient was discharged with full of consciousness and the baby was safe. Conclusion . Encephalopathy is a rare manifestation of DHF. However, it is a significant diagnostic challenge when it presents in atypical form, especially during pregnancy. It was first reported in 1976, and worldwide literature search shows the various incidence of dengue encephalopathy from 0.5% to 6.2% with a mortality rate up to 40%. The complications of dengue in pregnancy have been scarcely studied. There are increased risks of maternal hemorrhage, preterm labor and stillbirths. Dengue should be the differential diagnosis even a pregnant women presents with fever and altered sensorium especially in endemic areas like Indonesia.

Efficacy of oral tolerance induction to raw apple using an ultra-rush protocol in 28 patients allergic to rosaceae fruits: RAAP study

BackgroundThe aim of this study was to describe an ultra-rush (UR) protocol of Raw Golden Apple (RGA) in 28 patients with Oral Allergy Syndrome (OAS) which resulted in avoidance of raw rosaceaes fruits, in order to demonstrate the safety of the protocol and follow-up of patients at 2 months and 1 year. MethodsThe UR protocol was administered with RGA in a daycare hospital starting with 1 gram (g) of RGA, then by regularly doubling the dose until 128g, to reach a 255g cumulative dose in a 3-hours’ period. During the post-hospitalization period, patients had to eat half of a RGA a day during one month, then 1 RGA a day during one month. An assessment consultation was performed at two months follow-up and a telephone interview at one year. ResultsDuration of OAS to raw rosacea ranged from 6 months to 20 years. All 28 patients received the 255g cumulative dose. Tolerance was very good in 25 of the 28 patients. No major allergic incident was recorded. After two months, all the patients were eating a RGA. After one year, 21 patients continued eating all types of raw rosacea fruits. ConclusionThis study shows that resumption of RGA intake by patients with OAS to raw rosacea fruits, part of a cross-allergy with birch pollen is possible within 3 hours’ after use of an UR protocol. This protocol is simple, safe and easy to administer. Follow-up at 2 months and at one year was positive.

Unraveling the Mystery of Polyvalent Immunoglobulins in Belgium: Do We Have an Indication?

Introduction: Worldwide, polyvalent immunoglobulin (Ig) use is rising. Together with the limited supply, this puts pressure on Ig availability. A clear overview on a country’s usage pattern helps in forecasting future needs. This research aims to provide an overview of Ig use in Belgium on the different indications, including an estimation of off-label use. Methods: Multiple data sources were used. Existing claims data were explored for reimbursed Ig use between 2010 and 2018. General 2018 sales data from the firms were compared to the reimbursed use to serve as a proxy for off-label use. Indication-specific information was retrieved via a proxy: diagnostic codes available during day-care and inpatient hospitalization. Results: In 2018, 7,556 patients had reimbursed Ig. The most prevalent indication, both in terms of patient numbers and volume, was primary immunodeficiency (PID). In Belgian hospitals, the currently reimbursed indications represented 84.4% of patients (PID [≈35%], secondary immunodeficiency [SID] [≈21%], primary immune thrombocytopenia [≈10%], chronic inflammatory demyelinating neuropathy [CIDP] [≈8%], Guillain-Barre syndrome [≈6%], Kawasaki [≈2%], streptococcal toxic shock [≈2%] and multiple motor neuropathy [≈1%]), and 82.4% of Ig use (predominantly PID [≈33%] and CIDP [≈21%]). Although no direct data on off-label use were available, crude estimates derived from indirect sources showed a proportion of around 15.4%. Conclusion: Our research offers the first comprehensive overview on Ig use in Belgium, including a detailed description of reimbursed use, as well as approximations to off-label use. In view of increasing pressure on Ig availability, better understanding Ig needs and trends, would benefit from an effective indication-specific national registry system (ideally covering both reimbursed and nonreimbursed use).

Costs and effects of comprehensive geriatric assessment in primary care for older adults with high risk for hospitalisation

BackgroundThe healthcare system needs effective strategies to identify the most vulnerable group of older patients, assess their needs and plan their care proactively. To evaluate the effectiveness of comprehensive geriatric assessment (CGA) of older adults with a high risk of hospitalisation we conducted a prospective, pragmatic, matched-control multicentre trial at 19 primary care practices in Sweden.MethodsWe identified 1604 individuals aged 75 years and older using a new, validated algorithm that calculates a risk score for hospitalisation from electronic medical records. After a nine-month run-in period for CGA in the intervention group, 74% of the available 646 participants had accepted and received CGA, and 662 participants remained in the control group. Participants at intervention practices were invited to CGA performed by a nurse together with a physician. The CGA was adapted to the primary care context. The participants thereafter received actions according to individual needs during a two-year follow-up period. Participants at control practices received care as usual. The primary outcome was hospital care days. Secondary outcomes were number of hospital care episodes, number of outpatient visits, health care costs and mortality. Outcomes were analysed according to intention to treat and adjusted for age, gender and risk score. We used generalised linear mixed models to compare the intervention group and control group regarding all outcomes.ResultsMean age was 83.2 years, 51% of the 1308 participants were female. Relative risk reduction for hospital care days was − 22% (− 35% to − 4%, p = 0.02) during the two-year follow-up. Relative risk reduction for hospital care episodes was − 17% (− 30% to − 2%, p = 0.03). There were no significant differences in outpatient visits or mortality.Health care costs were significantly lower in the intervention group, adjusted mean difference was € − 4324 (€ − 7962 to − 686, p = 0.02).Conclusions and relevanceOur findings indicate that CGA in primary care can reduce the need for hospital care days in a high-risk population of older adults. This could be of great importance in order to manage increasing prevalence of frailty and multimorbidity.Trial registrationclinicaltrials.gov Identifier: NCT03180606, first posted 08/06/2017.

Ambulatory anal self-sampling in MSM living with HIV, an acceptable and reliable screening method

ObjectivesAnal cancer, usually driven by an oncogenic Human Papillomavirus, remains a leading cause of morbidity in men who have sex with men (MSM) living with HIV, despite combined antiretroviral therapy. Various recommendations advocate to perform regular examination and proctologist-performed samples to anticipate this risk and treat locally before cancer occurrence, an efficient strategy which has the drawback of requiring the proctologist’s availability. This study evaluates the acceptability, feasibility, and efficiency of self-performed samples to screen for HPV-infection and HPV-related anal dysplasia among MSM living with HIV followed in Hôtel-Dieu Hospital.MethodsBetween February 2015 and June 2015, MSM living with HIV and referred to the day-care hospital were offered to perform an anal self-sampling for cytologic and virologic evaluation. A self-sampling kit was provided, and a tutorial video was shown. A subset of participants had a proctology appointment after they did the self-sampling, and thus had a clinical examination and an anal swab sampling performed by the proctologist, using the same sampling material.ResultsAnal self-sampling was offered to 103 patients, and 100 accepted. Sixty-three samples were interpretable, of which 36 (57%) were normal and 27 (43%) showed abnormal results. Virologic analysis was performed for 60 (95%) interpretable samples: 50/60 (83%) of them were positive for HPV. Among HPV-carrier patients, 42/50 (84%) were infected with at least one HR-HPV. Twenty patients had a proctologist consultation. All clinician-performed samples were interpretable and 14 (70%) self-samples were interpretable.ConclusionsThis study highlights the acceptable accuracy of self-sampling screening method among MSM living with HIV and try out its acceptability and feasibility as a secondary prevention device. Although it cannot replace a proctologist consultation for high risk patients, self-sampling should be studied further as one of the ways of screening for anal cancer among low-risk outpatients.

Effectiveness of the Close Collaboration with Parents intervention on parent-infant closeness in NICU

BackgroundParent-infant closeness during hospital care of newborns has many benefits for both infants and parents. We developed an educational intervention for neonatal staff, Close Collaboration with Parents, to increase parent-infant closeness during hospital care. The aim of this study was to evaluate the effectiveness of the intervention on parent-infant closeness in nine hospitals in Finland.MethodsParents of hospitalized infants were recruited in the hospitals during 3-month periods before and after the Close Collaboration with Parents intervention. The data were collected using daily Closeness diaries. Mothers and fathers separately filled in the time they spent in the hospital and the time of skin-to-skin contact with their infant during each hospital care day until discharge. Statistical analyses were done using a linear model with covariates.ResultsDiaries were kept before and after the intervention by a total of 170 and 129 mothers and 126 and 84 fathers, respectively. Either parent was present on average 453 min per day before the intervention and 620 min after the intervention in the neonatal unit. In the adjusted model, the increase was 99 min per day (p = 0.0007). The infants were in skin-to-skin contact on average 76 min per day before the intervention and 114 min after the intervention. In the adjusted model, skin-to-skin contact increased by 24 min per day (p = 0.0405).ConclusionThe Close Collaboration with Parents intervention increased parents’ presence and skin-to-skin contact in nine hospitals. This study suggests that parent-infant closeness may be one mediating factor explaining benefits of parenting interventions.Trial registrationClinicalTrials.govNCT04635150. Retrospectively registered.

Dados da vida real de uma enfermaria de oncologia em um hospital universitário brasileiro

OBJECTIVE: Analyze data regarding patients in need of hospital care admitted in our oncology in?rmary aiming for better clinical practices, clinical support and scope for ?nancial and structural needs for institutions. METHODS: A prospective study of 191 patients admitted for in-hospital care during a year, who were strati?ed by diagnosis, age, sex, admission reason, duration of stay, re-admission rate and outcomes. RESULTS: 97 male and 94 female patients were admitted, with a 61-year-old mean age; the mean stay was 13,4 days; and a re-admission rate of 9,4%. Main admission causes: terminality [de?ned by PSECOG=4, with a 30 day or less estimated life expectancy]: 30 patients (15,7%); total pain: 23 (12,0%); oncological emergencies [febrile neutropenia, malignant hypercalcemia, medullar compression, superior vena cava syndrome]: 20 (10,4%); clinical deterioration [de?ned as worsening of patients performance or malnutrition]: 15 (7,8%); abdominal pain [without acute abdomen]: 14 (7,3%). Most common primary tumor sites were: colorectal=30 (15,7%), breast=28 (14,6%), stomach=20 (10,4%), lung=14 (7,3%), ovary=12 (6,2%) and prostate=10 (5,2%). RESULTS: 99 deaths (mortality rate 52,1%). Patients in terminality presented a 90% ratio of mortality within an average of 6,6 days of hospital care. Febrile neutropenia (42,8%) and abdominal pain (35,7%) both achieved above expected mortality rates. 91 patients were discharged from the hospital and went back to ambulatory care. CONCLUSION: Our analysis pointed at an admission rate of 1,2%, pointing at good clinical ambulatory practices. The mean in-hospital stay comparison between patients who were discharged and those who died, not considered terminal ill, was unexpectedly similar, 11,7 versus 13,4 days, respectively, suggesting that in-hospital care should be focused on symptoms - not outcomes. Patients with febrile neutropenia and gastrointestinal cancer should be evaluated with caution due to higher than expected mortality rates

Differences between psychiatric disorders in the clinical and functional effectiveness of an acute psychiatric day hospital, for acutely ill psychiatric patients

IntroductionIntensive treatment in acute day-care psychiatric units may represent an efficient alternative to inpatient care. However, there is evidence suggesting that this clinical resource may not be equally effective for every psychiatric disorder.The primary aim of this study was to explore differences between main psychiatric diagnostic groups, in the effectiveness of an acute partial hospitalization program. And, to identify predictors of treatment response. Material and methodsThe study was conducted at an acute psychiatric day hospital. Clinical severity was assessed using BPRS, CGI, and the HoNOS scales. Main socio-demographic variables were also recorded. Patients were clustered into 4wide diagnostic groups (i.e.: non-affective psychosis; bipolar; depressive; and personality disorders) to facilitate statistical analyses. ResultsA total of 331 participants were recruited, 115 of whom (34.7%) were diagnosed with non-affective psychosis, 97 (28.3%) with bipolar disorder, 92 (27.8%) with affective disorder, and 27 (8.2%) with personality disorder. Patients with a diagnosis of bipolar disorder showed greater improvement in BPRS (F=5.30; P=0.001) and CGI (F=8.78; P<0.001) than those suffering from psychosis or depressive disorder. Longer length of stay in the day-hospital, and greater baseline BPRS severity, were identified as predictors of good clinical response. Thirty-day readmission rate was 3%; at long-term (6 months after discharge) only 11.8% (N=39) of patients were re-admitted to a psychiatric hospitalization unit, and no differences were observed between diagnostic groups. ConclusionsIntensive care in an acute psychiatric day hospital is feasible and effective for patients suffering from an acute mental disorder. However, this effectiveness differs between diagnostic groups.

National sample surveys show poor households face catastrophic expenditure for oral healthcare services in India.

Introduction:Globally people pay out-of-pocket (OOP) to access Oral healthcare services. In India, there is limited evidence on estimates of OOP expenditure. We undertook an analysis of national sample survey data on household health care expenditure to understand the expenditure pattern for Oral healthcare services and the catastrophic burden.Method:The expenditure reported for Oral healthcare services from two surveys: 71st round and 75th round, published by National Sample Survey Office (NSSO) was extracted. Based on monthly household consumption expenditure three economic groups were made: poor, middle- and rich-income groups. The OOP expenditure pattern while accessing day-care services and hospitalization and in public and private sector and the catastrophic expenditure were analysed.Results:A total of 204 and 155 households from two national surveys reported to have accessed day-care Oral services respectively. The median OOP expenditure in public sector remained same at US $ 4 in both surveys. Over 35% of 78 households in 71st round and 42% of 167 in 75th round used public sector hospitalization services. The median expenditure of hospitalization doubled from US$ 58 (IQR 21–263) in 71st round to US $ 125 (IQR 45-363) in 75th round. Households from poor income groups spent seven times more for Oral healthcare services during the recent survey and faced catastrophic expenditure.Conclusion:The OOP expenditure for Oral healthcare has significant catastrophic household expenditure among the poor. There is a need to increase investment in public sector and insurance to protect poor against hospitalization expenditure in private sector.

Spinal Anesthesia in Patient with Congestive Heart Failure due to Congenital Atrial Septal Defect, and Pulmonary Hypertension Undergoing Cesarean Section Procedure: A Case Report

Introduction. In patients suffering from heart disease, pregnancy is a risk factor for mortality. Heart disease in pregnant women can be in form of rheumatic heart disease, cardiomyopathy, or congenital heart disease. This case report is about the successful spinal anesthesia technique in cesarean section (C-section) patients with congestive heart failure due to congenital atrial septal defect, and pulmonary hypertension (PH).&#x0D; Case presentation. A pregnant woman, 24 years old, planned to have an emergency C-section. She complained about shortness of breath for 2 days before admission. Three months ago, the patient started to feel shortness of breath during activity and also complained her legs swelled. She has a history of congenital heart i.e. atrial septal defect (ASD), but not routinely been treated. Her examination showed tachypnea, murmur, bibasilar fine crackles lung sound, and pretibial pitting edema. Echocardiography showed ASD with pulmonary hypertension. Spinal Anesthesia using 0.5% isobaric bupivacaine 7.5 mg and fentanyl 25 µcg was given before surgery. Drugs was injected in L3-L4 level with the upper target was as high as T6. the head position is raised 30 degrees. Procedure went well and the APGAR score was 8/9, Patient was admitted to the ICU for one day and discharged from hospital at the 5 days of hospital care.&#x0D; Conclusion. Spinal single-shot spinal anesthesia with small doses of bupivacaine and adjuvant can be used as an alternative technique in emergency C-section for patients with congestive heart failure due to congenital atrial septal defect, and pulmonary hypertension.

Immunological Evaluation on Potential Treatment Window for Hospitalized COVID-19 Patients.

PurposeNovel coronavirus disease has become such an escalating epidemic that the exponential growth of infected patients has overloaded the health-care systems in many countries. Determination of early assessments for patients with a risk of clinical deterioration would benefit the management of COVID-19 outbreaks.Patients and MethodsA total of 214 confirmed COVID-19 patients were enrolled from January 11th to February 11th 2020. Medical records including laboratory parameters, clinical outcomes and other characteristics of the admitted patients were analyzed retrospectively.ResultsThe critical patients experienced a significantly prolonged onset–admission interval and presented with lymphopenia (r=−0.547, p=0.015) and lower albumin level (p<0.001) 6 days after symptom onset. Early admission of critical patients significantly reduced the duration of hormone therapy. Starting from 9 days of hospital stay, the reduced lymphocyte counts exhibited linear growth. Furthermore, on days 9 and 12, significant correlations were demonstrated between immunological manifestations and duration of hormone therapy in critical patients, and length of hospital stay in severe patients. In addition, the virus negative conversion rate was more significantly correlated with increased lymphocytes in critical patients.ConclusionEarly intervention, within 6 days of symptom onset, benefited patients’ recovery from critical illness. The 9–12 days of hospital care represented a valuable window during which to evaluate the therapeutic effects on physical recovery and virus clearance.

Narrative Inquiry on Experience of Mentally Ill Patients in Psychiatric Day Hospital Care

Narrative Inquiry on Experience of Mentally Ill Patients in Psychiatric Day Hospital Care

P1467Ambulatory implantation of cardiac rhythm management devices: a retrospective safety and cost-minimization analysis in a developing country

Abstract Introduction The monetary costs and safety of ambulatory implantation of cardiac rhythm management devices (CRMD) has been previously studied in many developed countries, but few of these analyses come from developing countries. Here we present a summary of complications and comparative costs of ambulatory implantation of CRMDs sourced from a set of cases logged in a large database of a public facility from a developing country, over a period of 6 years. Purpose To determine the number and type of complications in ambulatory implantation of CRMDs and to perform a cost-minimization analysis of the outpatient versus the implantation with hospital admission. Methods We performed a retrospective study using the database of CRMDs that included implantation procedures of unicameral (UNI) and bicameral (BI) pacemakers, implantable cardiac defibrillators (ICD) and generator replacements (RPL) from September 2012 to December 2018, in order to determine the number of patients that received the device in ambulatory and hospitalization regimens. Then, we reviewed the medical records to determine the complication rate during the first month in both modalities. Finally, we compared the ambulatory implant costs, including hospital day-care, against the costs of a two-day hospitalization, one of these being spent in an intermediate-care unit and the other in general hospitalization. Results We identified a total of 541 procedures; mean age 70 ± 14 years; 227 (42%) female patients. From these, 361 were ambulatory (66,7%), 45% being BI implantation, 38% RPL, 9% UNI implantation and 8% ICD implantation. Of this, 81% of the procedures were for AV block, 7% for sinus node dysfunction and 12% for sudden death prevention (primary or secondary). There were a significant lower number of complications in the ambulatory group (3,9%, n = 14) compared with the hospitalization group (11,6%, n = 15) p = 0,006 (X²) , with no CRMDs emergencies, fatal complications or emergency readmissions in either group. Complications included pneumothorax, deep venous thrombosis, endocarditis, lead displacement and local hematoma. The cost of an ambulatory CRMD implantation was 65 USD whereas the same procedure with hospital admission was 675 USD, according with the payment units valid for our country. Conclusion Ambulatory implantation of all CRMDS is feasible and safe. This modality implies a significant monetary saving that directly benefits the patients and the social security system. It can be done in a tertiary level hospital that can reach the whole quality standards for these interventions.