Department Of Medicine Research Articles

Optimizing a mentorship program from the perspective of academic medicine leadership – a qualitative study

BackgroundEffective mentorship is an important contributor to academic success. Given the critical role of leadership in fostering mentorship, this study sought to explore the perspectives of departmental leadership regarding 1) current departmental mentorship processes; and 2) crucial components of a mentorship program that would enhance the effectiveness of mentorship.MethodsDepartment Division Directors (DDDs), Vice-Chairs, and Mentorship Facilitators from the Department of Medicine at the University of Toronto Temerty Faculty of Medicine were interviewed between April and December 2021 using a semi-structured guide. Interviews were audio-recorded and transcribed verbatim, then coded. Analysis occurred in 2 steps: 1) codes were organized to identify emergent themes; then 2) the Social Ecological Model (SEM) was applied to interpret the findings.ResultsNineteen interviews (14 DDDs, 3 Vice-Chairs, and 2 Mentorship Facilitator) were completed. Analysis revealed three themes: (1) a culture of mentorship permeated the department as evidenced by rigorous mentorship processes, divisional mentorship innovations, and faculty that were keen to mentor; (2) barriers to the establishment of effective mentoring relationships existed at 3 levels: departmental, interpersonal (mentee-mentor relationships), and mentee; and (3) strengthening the culture of mentorship could entail scaling up pre-existing mentorship processes and promoting faculty engagement. Application of SEM highlighted critical program features and determined that two components of interventions (creating tools to measure mentorship outcomes and systems for mentor recognition) were potential enablers of success.ConclusionsEstablishing ‘mentorship outcome measures’ can incentivize and maintain relationships. By tangibly delineating departmental expectations for mentorship and creating systems that recognize mentors, these measures can contribute to a culture of mentorship.

Low inter-rater reliability and reproducibility of Neck Reflex / "Adler-Langer" Points in Neural Therapy Diagnostics but increased pressure-pain threshold after therapy - results of a randomized controlled observer-blind trial.

Neck reflex points or Adler-Langer Points are commonly used in neural therapy to detect so-called interference fields. Chronic irritations or inflammations in the sinuses, teeth, tonsils or ears are supposed to induce tension and tenderness of the soft tissues and short muscles in the upper cervical spine. The individual treatment strategy is based on the results of diagnostic Adler-Langer Points palpation. This study investigated the inter- and intra-rater reliability and explored treatment effects. We performed a randomized-controlled trial with 104 inpatients (80.8% female, 51.812.74 yrs) of a German department for internal and integrative medicine. Patients were randomized to individual neural therapy according to the pathological findings (n=48) or no treatment (n=56). In each patient, three experienced raters (20-45y experience in neural therapy) and two novice raters (medical students) rated Adler-Langer Points rigidity on a standardized rating scale ("strong", "weak", "none"). The patients independently evaluated the tenderness on palpation of the eight points using the same scale. Pressure pain thresholds were assessed at the eight Adler-Langer Points. All patients were retested after 30 minutes. The five raters were blinded to treatment allocation and assessments of the other raters. Video recordings were obtained to assess the consistency of the areas tested by the different raters. Agreement between patients and raters (Cohen's Kappa=.161-.400) and inter-rater reliability were low (Fleiss-Kappa=.132-.150). Moreover, the individual agreement (pre-post comparisons in untreated patients) was similarly low even in experienced raters (Cohen's Kappa=.099-.173). Video documentation suggests that raters do not place their fingers in the correct segments (percentage of correct position 42.0-60.6%). Pressure pain thresholds at five of the eight Adler-Langer Points showed significant changes after treatment compared to none in the control group. Under this artificial experimental setting, this method of Adler-Langer Point palpation has not proven to be a reliable diagnostic tool. But it could be shown, that as claimed by the method, the tenderness in five of eight Adler-Langer Points decreased after neural therapy.

Efficacy of Bedside Index for Severity In Acute Pancreatitis (Bisap) Score As Predictor of In-Hospital Outcome in Acute Pancreatitis

Background: Acute pancreatitis is a potentially life-threatening condition characterized by inflammation of the pancreas. Early identification of patients at risk of severe disease is crucial for devising appropriate management strategies and improving outcomes. The aim of the study was to investigate the efficacy of BISAP score as predictor of in-hospital outcome in patients with acute pancreatitis. Methods: This was a longitudinal study conducted in Department of Medicine, Sir Salimullah Medical College Mitford Hospital, Dhaka from January 2023 to December 2023. After ethical approval, a total 107 subjects were included in this study based on inclusion and exclusion criteria. Severity of the disease was assessed by BISAP score. Theoutcome determinants were length of hospital stay, complete recovery, partial recovery with complication, transfer to ICU and mortality. Chi Square test, Binominal Regression analysis and Receiver operator characteristic (ROC) curve analysis were performed as applicable. p value <0.05 was considered as the level of significance. Results: The mean BISAP score among 107 study participants was 2.00 ± 0.76. Patients with BISAP score ³3 had significantly increased odds of prolonged hospital stay (OR: 11.226; 95% CI: 2.985- 42.222; p<0.001), higher rate of partial recovery with complications (OR: 7.302; 95.325% CI: -20.997; p<0.001). <0.001), and greater likelihood of intensive care unit (ICU) transfer (OR: 1.136; 95% CI: 0.968-1.333; p=0.004). A BISAP score cutoff value of ³3 was associated with increased length of hospital stay (sensitivity 91.3%, specificity 97.6%, AUC=0.945), partial recovery with complications (sensitivity 83.3%, specificity 96.4%, AUC=0.899), and ICU transfer (sensitivity 75%, specificity 80.6%, AUC=0.778).Conclusion: It can be concluded that increased BISAP score can be served as an independent predictor of in-hospital in patients with acute pancreatitis (AP). Bangladesh J Medicine 2024; 35: 88-92

Quality Improvement Intervention Using Social Prescribing at Discharge in a University Hospital in France: Quasi-Experimental Study.

Social prescription is seen as a public health intervention tool with the potential to mitigate social determinants of health. On one side, social prescription is not yet well developed in France, where social workers usually attend to social needs, and historically, there is a deep divide between the health and social sectors. On the other side, discharge coordination is gaining attention in France as a critical tool to improve the quality of care, assessed indirectly using unplanned rehospitalization rates. This study aims to combine social prescription and discharge coordination to assess the need for social prescription and its effect on unplanned rehospitalization rates. We conducted a quasi-experimental study in two departments of medicine in a French university hospital in a disadvantaged suburb of Paris over 2 years (October 2019-October 2021). A discharge coordinator screened patients for social prescribing needs and provided services on the spot or referred the patient to the appropriate service when needed. The primary outcome was the description of the services delivered by the discharge coordinator and of its process, as well as the characteristics of the patients in terms of social needs. The secondary outcome was the comparison of unplanned rehospitalization rates after data chaining. A total of 223 patients were included in the intervention arm, with recruitment being disrupted by the COVID-19 pandemic. More than two-thirds of patients (n=154, 69.1%) needed help understanding discharge information. Slightly less than half of the patients (n=98, 43.9%) seen by the discharge coordinator needed social prescribing, encompassing language, housing, health literacy, and financial issues. The social prescribing covered a large range of services, categorized into finding a general practitioner or private sector nurse, including language-matching; referral to a social worker; referral to nongovernmental organization or group activities; support for transportation issues; support for health-related administrative procedures; and support for additional appointments with nonmedical clinicians. All supports were delivered in a highly personalized way. Ethnic data collection was not legally permitted, but for 81% (n=182) of the patients, French was not the mother tongue. After data chaining, rehospitalization rates were compared between 203 patients who received the intervention (n=5, 3.1%) versus 2095 patients who did not (n=51, 2.6%), and there was no statistical difference. First, our study revealed the breadth of patient's unmet social needs in our university hospital, which caters to an area where the immigrant population is high. The study also revealed the complexity of the discharge coordinator's work, who provided highly personalized support and managed to gain trust. Hospital discharge could be used in France as an opportunity in disadvantaged settings. Eventually, indicators other than the rehospitalization rate should be devised to evaluate the effect of social prescribing and discharge coordination.

Clinical Profile and In-hospital Outcome of Acute Household Substances Poisoning in a Tertiary Care Hospital

Background: Poisoning is an acute medical emergency. Among the thousands of harmless products available for household, very few are hazardous. Still, self-poisoning with these substances is one of the commonest mode of poisoning. This study was carried out to get information related to clinical profile and inhospital outcome of household substances poisoning in a particular area of Bangladesh. Methods: This cross-sectional type of descriptive study was carried out in the department of Medicine, Sylhet M.A.G. Osmani Medical College Hospital, Sylhet, Bangladesh during the period of June 2022 to November 2022.Purposive convenient sampling was applied to recruit sample from study population. Calculated sample size was 64. Detailed history including nature of poisoning (unintentional/ intentional), route of poisoning, type of poison, symptoms and signs with relevant laboratory findings were documented in a structured data collection sheet through interview from the patient or their guardians after obtaining informed written consent. In-hospital outcome in terms of survival (discharged, discharge without advice/absconded) and mortality were recorded.Results:Among 64 participants majority 65.63% (n=42) were female and most 56.25% (n=36) were of 18-20 years age group.Regarding educational status 96.87 %(n=62) participants were educated. All of the poisoning were intentional and by oral route. Harpic was the most common agents 59.38% (n=38) used by the victims.Vomiting was the most common 81.25% (n=52) symptomand oral ulcer was the commonest 40.63% (n=26) sign. No significant abnormality of vital signs and laboratory investigations were found. Majority of the respondents 43.75 % (n=28) stayed 2 days in hospital for treatment purpose. Total 85.94% (n=55) respondents were discharged with advice and 14.06% (n=9) respondents left hospital without medical advice. No death was documented in this study. Conclusion: Young teenaged female patients were the majority of victims in our study reflecting the degree of powerlessness and hopelessness of young, educated people with unemployment and difficulties in coping with life stressors. Bangladesh J Medicine 2024; 35: 70-75

Estimating Time Since Death From Post Mortem Lividity: An Autopsy Study Conducted in Government Medical College and Ssg Hospital ofCentral Gujarat State of India

Background: Evaluation and estimation of time since death is a fundamental part of medico-legal investigations. Post mortem lividity or post-mortem staining is a bluish or reddish-purple discoloration due to capillo-venous distension with blood, at the under surface of the skin on the dependant parts of the body, as a result of settling of blood in those areas following pulling by gravity, after circulation of the blood in motion ceases. A study was conducted in the department of forensic medicine, GovernmentMedical College and SSG hospital, Vadodara to evaluate time since death by method of studying post mortem lividity. This was prospective and observational study conducted on 256 dead bodies brought for post mortem examination from November 2021 to August 2022. It was observed that the Post mortem Lividity starts appearing as a patchy form by 1-7 hours and well develops by 7-13 hours. Post mortem Lividity gets fixed by 8-18 hours following death. It was concluded that compared to other methods, the post mortem lividity assessment can be used as the most conventional, easy and quicker method for estimating time since death

Comparison Of Outcome Between Conventional And Video Laryngoscope In Predicted Difficult Intubation

Background: Endotracheal intubation is the mainstay of airway management in general anaesthesia. Failure to intubate the trachea, often known as difficult intubation, is always a possibility. To overcome difficult intubation, different methods of instrumental support were developed. Some authors. Methods: From March 2018 to September 2019, a comparative cross-sectional study was conducted at BSMMU, Dhaka in the department of anesthesia, analgesia, and intensive care medicine. A total of 60 patients with predicted difficult intubation who were scheduled for elective surgery under general anaesthesia with endotracheal intubation were selected for the study. Prediction of difficult intubation was assessed by modified Mallampati class III and IV or thyromental height. Results: Time taken from visualization of glottis for insertion of ETT was 12.8±2.3 sec in conventional laryngoscope which was significantly lower in video laryngoscope (15.0±3.6) (p =0.006). Time taken to visualize the glottis was 13.2±1.7 sec in conventional laryngoscope and 13.2±4.0 sec in video laryngoscope (p>0.05). Total time for tracheal intubation was 49.0±6.4 sec in conventional laryngoscope and 53.2±9.9 sec in video laryngoscope (p>0.05). Intubation with first attempt by video laryngoscope was (30/30; 100%) as compared with conventional laryngoscope (27/30; 90%) (p>0.05). Conclusion: It is evident from the study that intubation with video laryngoscope in comparison to conventional laryngoscope might provide better outcome in terms of ease of intubation and number of attempts during intubation for patients undergoing elective surgery under general anaesthesia. Bangladesh Armed Forces Med J Vol 56 No (1) June 2023, pp 7-13

Analysis of interventional treatment options of the common femoral artery - a retrospective single center experience.

Background: Due to the rapid development of treatment techniques of peripheral arterial disease (PAD) treatment is nowadays predominantly interventional. An exception are lesions of the common femoral artery (CFA), which should be treated surgically according to vascular guidelines. However, recent evidence has shown that endovascular techniques, e.g. stenting, have comparable clinical outcomes while causing fewer complications. The aim of the present analysis was to evaluate the therapeutic success of endovascular therapy of CFA lesions in a single center, all - comers registry. Patients and methods: All patients who were treated for a CFA lesion at the Department of Internal Medicine I of the University Hospital Jena in the period from 01/2017 to 12/2020 were included. Treatment success was determined by evaluating the ankle-brachial-index (ABI) pre- and post-interventional as well as after follow-up (FU), measuring walking distance (WD) and by target revascularization rate (TLR) and primary patency rate (PPR). Results: The analysis included 109 patients with a mean age of 73.4 years, with 67% (73) of those being men. 72 patients received interventional treatment, whereas 33 were treated surgically and 4 conservatively. Resting ABI in the overall cohort showed an increase from 0.5 to 0.7 post intervention (p=<0.05; mean FU-time: 6.5 months). In the interventional cohort ABI increases from 0.6 to 0.8 (p=<0.05; mean FU-time: 5,8 months) at FU and from 0.3 to 0.6 (p=<0.05; mean FU-time: 8,8 month) in the surgically treated group. The WD improved in the whole collective from 116.5 meter (m) to 152.5 m (p=<0.05). The TLR showed no significant difference with 8.1% after interventional treatment and 6.1% after vascular surgery in the present analysis (p=0.72) as well as PPR with 89.8% after EVT and 90.9% after surgical approach (p=0.87). The intra-/postinterventional complication rate was 5.5% in the intervention group, compared to postoperative complication rate of 15.2% in the surgically treated group. Conclusions: The present analysis demonstrates that even in a real-world, all-comers collective, interventional therapy for CFA lesions was safe and equally effective as the surgically treated patient cohort. Continuing to generate registry data is important to eventually initiate a paradigm shift.

Clinical epidemiology of cardiovascular disease in advanced chronic kidney disease prior to dialysis to a tertiary care centre in Bangladesh

Background: Patients with advanced CKD stages exhibit a markedly elevated risk of cardiovascular disease. Patients with chronic kidney disease (CKD) exhibit an elevated cardiovascular risk manifesting as coronary artery disease, heart failure, arrhythmias, and sudden cardiac death .The main objective of this study was to observe the clinical epidemiology of cardiovascular disease in advanced stages of CKD prior to dialysis to a tertiary care centre in Bangladesh. Methods: This was a cross-sectional observational study on 150 cases of diagnosed advanced stages (4&amp;5) of CKD patients in the indoor Department of Medicine of Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh from July 2022to January2023 for 6 months. Data was analyzed SPSS 25. Results: Out of the total group, 62.0% are male, 38.0% are female, and the average (mean) age of the entire group was 55.2 ±10.3. Patients are compared in terms of their relative percentages and the associated cardiovascular disease (CVD) risk, with the hypothesis that lower hemoglobin levels (&lt;9 mg/dL), common in advanced CKD, may be associated with higher CVD risk. A statistically significant P-value (0.036) indicates a significant association between lower hemoglobin levels and increased risk of CVD. Hypertension is the most common risk factor in both stages showing (80%) in stage 4 and 86.6% in Stage -5 of CKD respectively that increasing prevalence as stages of CKD increases . Other factors like diabetes 50.6%) and 53.3% , dyslipidemia 61.3% and 66.7% , and family history of cardiovascular disease (CVD) 40% and 46.6% also in prevalence from Stage 4 to Stage 5. However, the differences in the prevalence of these risk factors between the two stages are not statistically significant, as indicated by the P-values. The prevalence of Congestive Heart Failure rises from 44% in Stage 4 to 52% in Stage 5, and a similar trend is observed in Coronary Artery Disease from 40% in Stage 4 to 48% in Stage 5 and for other diseases, albeit with lesser increments. The provided pvalues, which assess statistical significance, indicate that the differences in disease prevalence between the two stages are not statistically significant, suggesting that the progression from Stage 4 to Stage 5. Conclusion: This study stated that increased prevalence and progression of cardiovascular risks in advanced CKD stages. Bangladesh J Medicine 2024; 35: 96-100

From Emergency Department to clinic center: management of patients with Heart Failure with Reduced Ejection Fraction

Aims: primary outcomes - cardiovascular and all-cause mortality evaluation within 1 year in elderly patients enrolled with Angiotensin Receptor Inhibitor (ARNI) and/or Sodium Glucose Co-Transporter Type 2 Inhibitors (SGLT2-i) in an Internal Medicine Department; recurrent hospitalization assessment for acute Heart Failure with Reduced Ejection Fraction (HFrEF); length of hospitalization analysis compared to not-enrolled patients. Secondary endpoints - to identify any parameters predicting the length of hospitalization; safety assessment through the incidence of complications and treatment interruption. Materials and Methods: prospective observational real-life cohort study that analyzes the recruitment during hospitalization and follow-up 3-6-12 months after discharge. Several clinical parameters were recorded for each patient of any ethnicity, considering a diagnosis of acute HFrEF with NT-proBNP and chest x-ray. Results: the enrolled group (34 patients) showed a hospitalization period lower than the not-enrolled one. The rehospitalizations percentage was inferior to Randomized Clinical Trials (RCTs) for ARNI. Cardiovascular-cause mortality, symptomatic hypotension, and Urinary Tract Infections (UTI) were lower than RCTs data. Age, eGFR, NT-proBNP, Cumulative Illness Rating Scale (CIRS), and severe comorbidities, except for EF, predicted the lengthening of hospitalization. Hypoglycemia wasn’t recorded. Conclusions: ARNI/SGLT2-i are effective and safe in elderly patients. Comorbidities and bio-humoral features influence HFrEF and quality of life. The future aim is to confirm the results obtained so far.

The use of antibiotics in the early stage of acute exacerbation of chronic obstructive pulmonary disease in patients without obvious signs of infection: a multicenter, randomized, parallel-controlled study

IntroductionChronic obstructive pulmonary disease (COPD) is a chronic respiratory disease with high prevalence and mortality. In some acute exacerbations of COPD (AECOPD) in patients with no obvious signs of infection, early antibiotic treatment seems to clinically improve the disease, but more studies are needed to determine the prognostic impact of antibiotic treatment in AECOPD patients with no obvious signs of infection.PurposeTo clarify the impact of antibiotic treatment on the short-term and long-term prognoses of AECOPD patients without obvious signs of infection.MethodsThe impact of the two treatment methods on the prognosis of patients was compared at 30, 90, 180, and 360 days after discharge. A multicenter, randomized, parallel-controlled clinical trial was conducted in a department of respiratory and critical care medicine in Central China. All patients met the inclusion criteria for AECOPD, and the patients were randomly assigned to the antibiotic group or the nonantibiotic group at a 1:1 ratio. Patients in the antibiotic group were given moxifloxacin 400 mg/day intravenously for 7 days. Patients in the nonantibiotic group were intravenously injected with the same amount of normal saline as the amount of moxifloxacin given to those in the antibiotic group for 7 days.ResultsThere were 406 patients in the antibiotic group and 410 patients in the nonantibiotic group. During the short-term and long-term follow-ups, the acute exacerbation frequency, intensive care unit (ICU) treatment rate, mortality, and mMRC and CAT scores were not significantly different between the two groups (p &amp;gt; 0.05). At the 180- and 360-day follow-ups, the forced expiratory volume in 1 s (FEV1%) and peak expiratory flow (PEF) were not significantly different between the two groups (p &amp;gt; 0.05). The 30-day readmission rate was significantly lower in the antibiotic group than in the nonantibiotic group (p &amp;lt; 0.05). The time from discharge to the first acute exacerbation was not significantly different between the two groups (p &amp;gt; 0.05). The length of the first hospital stay after discharge was significantly lower in the antibiotic group (5.84 days) than in the nonantibiotic group (6.75 days) (p &amp;lt; 0.05). At the 30-day follow-up, the acute exacerbation frequency, age, C-reactive protein (CRP) level, and sputum viscosity were significantly greater in the nonantibiotic group than in the antibiotic group (p &amp;lt; 0.05). In addition, according to the receiver operating characteristic (ROC) analysis, the frequency of acute exacerbations at the 30-day follow-up was significantly greater in COPD patients aged &amp;gt;62.5 years, with a CRP level &amp;gt;12.56 mg/L or with a sputum viscosity &amp;gt;III, in the nonantibiotic group than in those in the antibiotic group, suggesting that the short-term prognosis was poor.ConclusionPatients who are &amp;gt;62.5 years of age, have a CRP concentration &amp;gt;12.56 mg/L, or have a sputum viscosity &amp;gt;III without obvious signs of infection should be treated with antibiotics to improve their short-term prognosis.Clinical Trial Registration:(https://www.chictr.org.cn), (ChiCTR1800018921)

Clinical effectiveness of internet-based cognitive behavioral therapy for insomnia in routine secondary care: results of a randomized controlled trial

IntroductionDelivering cognitive behavioral therapy for insomnia over the internet bears the advantage of accessibility and uptake to many patients suffering from chronic insomnia. In the current study, we aimed to investigate the effectiveness of internet-based cognitive behavioral therapy for insomnia (iCBT-I) in routine care.Materials and methodsWe conducted a two-arm non-blinded randomized controlled trial with care as usual (CAU) as a control condition. Participants were recruited in a specialized outpatient sleep medicine department. Both arms had access to other healthcare resources, and the intervention group had access to the iCBT-I program for 2 months. The primary outcome was insomnia severity, measured by the Insomnia Severity Index (ISI). Secondary outcomes were fatigue severity, daytime sleepiness, affective symptoms, dysfunctional beliefs and attitudes about sleep, sleep locus of control, sleep hygiene, sleep efficiency (SE), sleep onset latency, wake time after sleep onset (WASO), and total sleep time (TST). Linear mixed models for repeated measures were used to analyze the longitudinal data at baseline, post-treatment, and after 3 months of follow-up. The trial was registered at www.clinicaltrials.gov (NCT04300218 21.04.2020).ResultsThe results showed a significant time*group interaction effect (p = 0.001) at post-treatment with between-group effect size (d = 0.51), indicating that the ISI decreased by a score of 3.8-fold in the iCBT-I group than in the CAU group. There was no significant difference in ISI between groups at follow-up. Regarding secondary outcomes, dysfunctional beliefs about sleep, SE, and WASO decreased significantly during treatment in the intervention group with between-group effect sizes d = 0.35, d = −0.51, and d = 0.47, respectively. At the follow-up, between-group effects on DBAS and SE remained significant: d = 0.36 and d = −0.63, respectively. For TST, we observed a significant time*group effect of d = −0.38 only after follow-up.ConclusionOur findings suggest that iCBT-I has a significant effect on insomnia severity at post-treatment compared to CAU. iCBT-I further improved dysfunctional beliefs about sleep and improved subjective sleep characteristics, such as SE, WASO, and TST during 3 months after treatment.Clinical trial registrationwww.clinicaltrials.gov, identifier (NCT04300218).

Risk Assessment Models for Venous Thromboembolism in Medical Inpatients

Thromboprophylaxis is recommended for medical inpatients at risk of venous thromboembolism (VTE). Risk assessment models (RAMs) have been developed to stratify VTE risk, but a prospective head-to-head comparison of validated RAMs is lacking. To prospectively validate an easy-to-use RAM, the simplified Geneva score, and compare its prognostic performance with previously validated RAMs. This prospective cohort study was conducted from June 18, 2020, to January 4, 2022, with a 90-day follow-up. A total of 4205 consecutive adults admitted to the general internal medicine departments of 3 Swiss university hospitals for hospitalization for more than 24 hours due to acute illness were screened for eligibility; 1352 without therapeutic anticoagulation were included. At admission, items of 4 RAMs (ie, the simplified and original Geneva score, the Padua score, and the IMPROVE [International Medical Prevention Registry on Venous Thromboembolism] score) were collected. Patients were stratified into high and low VTE risk groups according to each RAM. Symptomatic VTE within 90 days. Of 1352 medical inpatients (median age, 67 years [IQR, 54-77 years]; 762 men [55.4%]), 28 (2.1%) experienced VTE. Based on the simplified Geneva score, 854 patients (63.2%) were classified as high risk, with a 90-day VTE risk of 2.6% (n = 22; 95% CI, 1.7%-3.9%), and 498 patients (36.8%) were classified as low risk, with a 90-day VTE risk of 1.2% (n = 6; 95% CI, 0.6%-2.6%). Sensitivity of the simplified Geneva score was 78.6% (95% CI, 60.5%-89.8%) and specificity was 37.2% (95% CI, 34.6%-39.8%); the positive likelihood ratio of the simplified Geneva score was 1.25 (95% CI, 1.03-1.52) and the negative likelihood ratio was 0.58 (95% CI, 0.28-1.18). In head-to-head comparisons, sensitivity was highest for the original Geneva score (82.1%; 95% CI, 64.4%-92.1%), while specificity was highest for the IMPROVE score (70.4%; 95% CI, 67.9%-72.8%). After adjusting the VTE risk for thromboprophylaxis use and site, there was no significant difference between the high-risk and low-risk groups based on the simplified Geneva score (subhazard ratio, 2.04 [95% CI, 0.83-5.05]; P = .12) and other RAMs. Discriminative performance was poor for all RAMs, with an area under the receiver operating characteristic curve ranging from 53.8% (95% CI, 51.1%-56.5%) for the original Geneva score to 58.1% (95% CI, 55.4%-60.7%) for the simplified Geneva score. This head-to-head comparison of validated RAMs found suboptimal accuracy and prognostic performance of the simplified Geneva score and other RAMs to predict hospital-acquired VTE in medical inpatients. Clinical usefulness of existing RAMs is questionable, highlighting the need for more accurate VTE prediction strategies.

Retrospective analysis of thyroid incidentalomas detected by [68Ga]Ga-PSMA-11 PET/CT.

Prostate cancer patients, undergo imaging procedures, with [68Ga]Ga-PSMA-11 PET/CT (prostate-specific membrane antigen based positron emission tomography/computed tomography) utilized for primary and secondary staging. PSMA thyroid incidentalomas (PTI) are discovered in the thyroid gland while imaging prostate cancer patients with [68Ga]Ga-PSMA-11 PET/CT. The aim of the study was to determine the clinical significance of PTIs detected on [68Ga]Ga-PSMA-11 PET/CT. Another goal was to identify a possible threshold for the maximum standardized uptake value (SUVmax), above which a malignant growth could be suspected. A retrospective cross-sectional study. 769 patients with prostat cancer who underwent [68Ga]Ga-PSMA-11 PET/CT scans in the nuclear medicine department of a tertiary care hospital between January 2020 and December 2022 were retrospectively screened in this study. We analyzed 67 patients in whom PTI was detected. Patients who exceeded the inclusion criteria had their thyroid ultrasonography and ultrasonography -guided fine needle aspiration findings analyzed. PTI was discovered in 67 patients (8%). 42 patients who met the inclusion and exclusion criteria were included in the study. Of the 4 malignant patients (9.5%) in the study population, 2 were classified as TIRADS 3 and 2 were classified as TIRADS 4. The cut-off SUVmax value was found to be 5.6. With 100% sensitivity and 47.37% specificity, a cutoff SUVmax of 5.3 was determined through receiver-operator characteristic analysis in order to predict malignant cytology. PTI is a significant clinical finding; most of diffuse and focal uptakes are frequently related to benign diseases. Each center should establish its own a possible SUVmax cut-off over which a malignant lesion should be suspected.

Bone turnover markers and muscle decay indicator in patients with proximal femur fracture – a case-control study

IntroductionFracture of the proximal femur is common in elderly patients, in fact threatening their lives. Age-related sarcopenia may be involved in the imbalance resulting in the injury. Handy and readily accessible biochemical tests would be useful to assess the musculoskeletal system condition in daily practice. The aim of the study was to determine whether there is any relation between muscle decay and fracture of the proximal femur and to assess bone quality in elderly patients.Material and methodsIn the study 22 patients who represented the treatment group were hospitalized due to proximal femur fracture. Eighteen patients from the control group with no fracture in their history were admitted to the Internal Medicine Department. Anyone treated for osteoporosis, immune disease affecting protein balance, neoplasm, mental illness, heart failure, or myocardial infarction was excluded from the study. In every case a blood sample from an elbow vein was drawn, collected in EDTA-K2 tubes, and then centrifuged to separate plasma from the whole blood. Subsequently, the concentrations of C-terminal cross-linked telopeptide of type I collagen (CTX-I), sex hormone binding globulin (SHBG) and creatine kinase (CK) in plasma were determined using commercial enzyme-linked immunosorbent assays.ResultsThe CK plasma concentration differed between the patient groups (p = 0.011). The SHBG plasma concentration was significantly higher in the treatment group (p = 0.006), whereas a slight difference in CTX-I plasma concentration between the groups was found (p = 0.038). No significant correlations between plasma CK, SHBG or CTX-I were found (p &gt; 0.05).ConclusionsCreatine kinase is actually not an appropriate marker for the clinical assessment of muscle tissue quality in patients with or at risk of proximal femur fracture. Analyzing the quality of bone tissue, we can conclude it was poorer in patients with proximal femur fracture than in the control group.

Vitamin B12 Deficiency among Cases of Helicobacter Pylori Gastritis: A Cross Sectional Study

Background: Helicobacter pylori (H. pylori) is a gram-negative bacterium associated with various gastrointestinal diseases, including peptic ulcer disease, gastric cancer, and vitamin B12 deficiency. Recent research has highlighted a potential link between chronic H. pylori infection and significant malabsorption of vitamin B12, particularly in populations with high prevalence rates of infection. Objective: This study aims to investigate the frequency of vitamin B12 deficiency among patients with H. pylori gastritis and to explore the association between H. pylori infection and vitamin B12 levels. Methods: A cross-sectional study was conducted from September 2023 to March 2024 at the Department of Medicine, Ayub Teaching Hospital, Abbottabad. A total of 120 patients presenting with symptoms of gastritis were enrolled after obtaining ethical approval from the hospital’s review board. Exclusion criteria included patients already on vitamin B12 supplementation. Diagnostic testing for H. pylori was performed using stool antigen tests, and vitamin B12 levels were assessed through serum measurements. Data analysis was conducted using IBM SPSS Statistics version 23, with the Chi Square test applied to examine the association between H. pylori infection and vitamin B12 deficiency, setting the level of significance at p ≤ 0.05. Results: Out of the 120 patients studied, 49 (40.8%) tested positive for H. pylori. Vitamin B12 deficiency was observed in 35 (29.2%) patients. Among those infected with H. pylori, 51.0% (25 patients) also had vitamin B12 deficiency, compared to 14.1% (10 patients) among those not infected (p = 0.0001). Conclusion: The findings indicate a significant association between H. pylori infection and vitamin B12 deficiency. This study suggests that H. pylori is a potential risk factor for vitamin B12 deficiency, underscoring the need for screening and appropriate management of H. pylori in patients presenting with vitamin B12 deficiency.

Assessment of High Serum Cystatin C as an Early Marker of Renal Impairment in Pre Eclampsia

Introduction: Preeclampsia is the most common medical complication during pregnancy and one of the leading causes of maternal and perinatal morbidity and mortality in Bangladesh. Kidney has role in both adaptive physiology of normal pregnancy and in pathophysiology of preeclampsia. Among the new biomarkers, serum Cystatin C can reliably reflect the GFR in both healthy and hypertensive pregnant women. It is important to evaluate the diagnostic efficiency of Cystatin C as a marker of renal function in preeclampsia. Aim: To assess high serum Cystatin C level as an early marker of renal impairment in pre-eclamptic patients. Materials and Methods: From March, 2021 to February, 2022 (A total of 12 months) a cohort study was conducted among 66 pregnant women, aged 18 to 40 years with pre-eclampsia and normal serum creatinine (0.5-0.8mg/dl) at their 20-28 weeks of gestation attending the antenatal clinic and admitted in the Department of Feto maternal Medicine, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, selected by non random purposive and convenient sampling. Results: Out of 66 respondents, final analysis was done with 62 patients. Among 62 study samples, 76% patients had “High Cystatin C” level that was greater than 0.84 and renal impairment developed in 15% pregnant women. Majority of the participants were in 25-30 age groups (46.8%). The mean serum creatinine level of the pregnant women increased throughout follow up and it was statistically significant (p&lt;0.05) in both cases. No significant difference was found between serum Cystatin C in renal impaired and normal renal function pre eclampsia patients at a cut off value of 0.84. ROC analysis of serum Cystatin C level for detection of renal impairment among Pre eclamptic patients found a cut-off value of ≥1.49 showed the highest Youden index of 0.721. The sensitivity, specificity, PPV, NPV and accuracy of serum Cystatin C were 77.78%, 94.34%, 70.00%, 96.15% and 91.94%. Conclusion: Higher Cystatin C level in pre-eclampsia reflected renal impairment at an early stage even before conventional marker like serum creatinine raise. The diagnostic efficiency of Cystatin C as a marker of renal function in pre eclampsia can be used to reduce maternal morbidity and mortality of Bangladesh. Medicine Today 2023 Vol.36 (1): 12-16

Dentist Involvement in the Treatment of Radiation-Induced Oral Mucositis—A Pilot Cross-Sectional Study

Oral mucositis (OM) occurs in more than 95% of patients irradiated in the head and neck area. This paper aims to determine the occurrence and characteristics of OM in patients with head and neck cancer (HNC), as well as the involvement of dentists/oral medicine specialists in treating such patients. Methods: This study was conducted at the Department of Otorhinolaryngology and Department of Oral Medicine, University Hospital Center Zagreb, from April to August 2022, on patients irradiated in the head and neck area. A unique OM questionnaire was created on the incidence, characteristics, oral care, and involvement of dentists in the overall care. Results: Thirty patients filled out the questionnaire. Of the 22 patients who had developed OM, 14 had grade-three OM. Ten patients were treated for OM in line with the instructions of an oral medicine specialist, eight based on the instructions of a specialist responsible for monitoring of the underlying disease, and four were not treated at all. Sixteen patients had not been referred to a dentist before the start of RT. Conclusions: These results showed insufficient care and treatment of OM, as well as insufficient involvement of dentists in the oncology team.

Pattern of Pesticide and Herbicide Poisoning Among People Admitted to Medicine Wards of a Tertiary Care Hospital

Introduction: Acute poisoning has become a major public health problem accounting for significant morbidity and mortality around the globe2. According to WHO data, an estimated 193,460 people died worldwide in 2012 from unintentional acute poisoning. 84% of these deaths occurred in resource-lacking low- and middle income countries3. The toxicity of accessible poisons and the scarcity of adequate medical facilities for poisoning management is responsible for a such a high mortality rate in this region4. Acute pesticide poisoning usually occurs during agricultural use either by accidental exposure or by suicidal attempt, rarely as homicidal2,5&amp;8. This study is designed to assess the patterns of pesticide &amp; herbicide poisoning among rural &amp; urban peoples admitted to medicine ward of a tertiary level hospital and to find out the sociodemographic characteristics of the respondents. So that the supply of these agents be properly regulated to prevent easy accessibility and misuse. Materials and Methods: It was a hospital based cross-sectional observational study conducted at indoor Department of Medicine, Chittagong Medical College Hospital for six months period from 01/01/2019 to 31/06/2019. Ethical clearance was taken from ethical review committee of Chittagong Medical College and informed consent was obtained from each participants. Hundred patients above 12 years of age with a relevant history and clinical signs and symptoms of any type of pesticides and herbicides poisoning who fulfilled the selection criteria were selected consecutively for the study. Data was collected using a pretested, multi-structured questionnaire which comprised of questions to identify demographic data, type and circumstances of poisoning. Results: Regarding motive of poisoning in our study 81% patient took pesticide &amp; herbicide poisoning for suicide and 19% admitted with accidental case. This result is consistent with the study where most common reason of pesticide &amp; herbicide poisoning was suicide (93.3%) 20. A study performed at Rajshahi Medical College from January 1991 to December 1994 showed that out of those 405 cases of OPC poisoning 310 were suicidal (76.54%) and 95 were homicidal (23.45%) poisoning28. The present study revealed that factors responsible for the suicidal attempt were familial disharmony in 46% of cases, marital problems in 19%, financial problem in 16%, mental disorder in 3% and 11% due to other reasons. Shadequl-Islam et al. reported the motive of pesticide poisoning in their study that 45% of cases were due to familial disharmony, 15% unknown, 13.3% depression, 8.3% marital problems, 5% financial problems and 13.3% due to other reasons26. In most cases, the patient could access to the poison by self-purchasing from poison retailers. Conclusion: This study has indicated that young adults, males and socially underprivileged people are at a higher risk of pesticides and herbicides poisoning. This study showed pesticides &amp; herbicides poisoning is the most common modes of suicidal deaths. Pesticides are mostly misused purposefully as an easy means for committing suicide. Early diagnosis and treatment is mandatory in order to minimize mortality from these potentially lethal compounds. It is recommended that the supply of pesticides be properly regulated to prevent easy accessibility and misuse. Medicine Today 2023 Vol.36 (1): 36-40

The Pattern of Motorcyclists' Death Due to Accidents and a Three-year Forecast in East Azerbaijan Province, Iran: A Time Series Study

Introduction: In low- and middle-income countries, a large proportion of road users include pedestrians, cyclists, and motorcyclists, and nearly half of road traffic fatalities occur among motorcyclists. This study aimed to examine the pattern of motorcyclists' death due to accidents in East Azerbaijan, Iran between 2006 and 2021 and present a forecast. Methods: We used death data due to motorcycle accidents of Legal Medicine Department between 2006 and 2021. For time series analysis, the Box-Jenkins model was used and three stages of identification, estimation, and diagnosis were successively performed and repeated several times to achieve the best prediction model. The Box-cox transformation method was used to stabilize the variance, and the first-order seasonal differential method with a period of 12 was used to control the seasonality. Due to seasonal variations, the Seasonality Auto-Regressive Integrated Moving Average model: SARIMA (p, d, q) (P, D, Q)s was employed and the death trend was predicted for 36 months. The candidate models were compared based on Log-likelihood, AIC, and BIC indices. STATA 17 was used for data analysis. Results: About 18.6% of all accident deaths are attributed to motorcycle accidents. The death rate for all causes of accidents and motorcycle accidents were 23.13 and 4.30 per 100,000 population, respectively. Seven models were considered as candidates. The SARIMA (0, 0, 0) (1, 1, 1)12 model was selected as the best model due to better fit and used to predict the number and trend of motorcycle accident deaths. Motorcycle accident deaths are predicted to decrease gradually in the next 36 months, from June 2021 to May 2024, affected by seasonal changes. Conclusion: The trend of death due to motorcycle accidents from 2006 to 2021 in East Azerbaijan was declining, and it is predicted to decrease slightly in the next three years as well. As this reduction may be attributed to many factors, it is recommended to investigate effective factors in future studies.