Foundation Hospital Research Articles

Diagnoses supported by a computerised diagnostic decision support system versus conventional diagnoses in emergency patients (DDX-BRO): a multicentre, multiple-period, double-blind, cluster-randomised, crossover superiority trial.

Diagnostic error is a frequent and clinically relevant health-care problem. Whether computerised diagnostic decision support systems (CDDSSs) improve diagnoses is controversial, and prospective randomised trials investigating their effectiveness in routine clinical practice are scarce. We hypothesised that diagnoses made with a CDDSS in the emergency department setting would be superior to unsupported diagnoses. This multicentre, multiple-period, double-blind, cluster-randomised, crossover superiority trial was done in four emergency departments in Switzerland. Eligible patients were adults (aged ≥18 years) presenting with abdominal pain, fever of unknown origin, syncope, or non-specific symptoms. Emergency departments were randomly assigned (1:1) to one of two predefined sequences of six alternating periods of intervention or control. Patients presenting during an intervention period were diagnosed with the aid of a CDDSS, whereas patients presenting during a control period were diagnosed without a CDDSS (usual care). Patients and personnel assessing outcomes were masked to group allocation; treating physicians were not. The primary binary outcome (false or true) was a composite score indicating a risk of reduced diagnostic quality, which was deemed to be present if any of the following occurred within 14 days: unscheduled medical care, a change in diagnosis, an unexpected intensive care unit admission within 24 h if initially admitted to hospital, or death. We assessed superiority of supported versus unsupported diagnoses in all consenting patients using a generalised linear mixed effects model. All participants who received any study treatment (including control) and completed the study were included in the safety analysis. This trial is registered with ClinicalTrials.gov (NCT05346523) and is closed to accrual. Between June 9, 2022, and June 23, 2023, 15 845 patients were screened and 1204 (591 [49·1%] female and 613 [50·9%] male) were included in the primary efficacy analysis. The median age of participants was 53 years (IQR 34-69). Diagnostic quality risk was observed in 100 (18%) of 559 patients with CDDSS-supported diagnoses and 119 (18%) of 645 with unsupported diagnoses (adjusted odds ratio 0·96 [95% CI 0·71-1·3]). 94 (7·8%) patients suffered a serious adverse event, none related to the study. Use of a CDDSS did not reduce the occurrence of diagnostic quality risk compared with the usual diagnostic process in adults presenting to emergency departments. Future research should aim to identify specific contexts in which CDDSSs are effective and how existing CDDSSs can be adapted to improve patient outcomes. Swiss National Science Foundation and University Hospital Bern.

Harmful metabolic acidosis in children treated by ketogenic diet during prolonged general anesthesia for epilepsy surgery: A single center experience.

Management of ketogenic diet (KD) in case of prolonged anesthesia in children. We conducted a retrospective study in the pediatric neurosurgery department of Rothschild Hospital Foundation in France. All the children who underwent long term anesthesia (>4h) in case of neurosurgery for drug resistant pediatric epilepsy surgery between September 2020 and January 2024 were included, excluding patients with suspected metabolic disorder or without blood sample. Children were analyzed in three subgroups: Children under regular diet before surgery constituted the Non-KD group; strict maintenance of KD with no carbohydrate intake during surgery constituted the KD-S group (stringent); carbohydrate intravenous intake during surgery in a patient treated by KD represented the KD-B group (broken). 22 patients were included, among whom 6 under ketogenic diet (KD). After 4h of anesthesia, children maintained in strict ketogenic diet (KD-S, n=3) exhibited non-lactic metabolic acidosis (pH 7.13 vs 7.34, p=1.38x10-9) associated with an increased anionic gap (17.1mM vs 9.6mM, p=1.58 x10-4). Current recommendations for anesthesia during long term anesthesia (>4h) with strict no-carbohydrate intake during anesthesia in case ok KD may be at risk of life-threatening metabolic acidosis, in a context of absence of protocolized monitoring of variations in hyperketosis throughout a prolonged fast. A KD-management protocol, including routine monitoring of ketosis in addition to usual monitoring (lactacidemia, kaliemia and glycemia), and low carbohydrates intravenous perfusion throughout prolonged general anesthesia, should be implemented throughout prolonged general anesthesia, especially for infants younger than 2 years.

P1177 Factors Driving Persistence to First-Line Advanced Therapies in Inflammatory Bowel Disease – A Real-World Study

Abstract Background Advanced therapies, including biologics and small oral molecules, are the mainstay of inflammatory bowel disease (IBD) management. Nonetheless, factors driving drug persistence - defined as the duration from initiation to discontinuation of a therapy- remain unclear. This study aimed to evaluate the persistence of first-line advanced therapies in a real-word IBD cohort and identify factors influencing it. Methods Demographic and clinical data from IBD patients who initiated first-line advanced therapies after 2010 at the San Matteo Hospital Foundation were retrospectively collected in September 2024. Persistence and discontinuation, due to failure or other reasons, were recorded. Differences in persistence probability between therapies were analysed using the log-rank test. Univariate (Fisher’s exact test for categorical variables and t-test or Mann-Whitney for continuous variables) and multivariate (logistic regression) analyses were conducted to assess factors influencing persistence versus discontinuation due to failure. Results Among the 274 recruited patients (median age 42.5 years; F/M 119/155; 146 with Crohn’s disease (CD) and 128 with ulcerative colitis), 159 (58%) started infliximab, 76 (28%) adalimumab, 26 (9.5%) vedolizumab, 3 (1%) ustekinumab, 3 (1%) Janus-kinase inhibitors and 7 (2.5%) other advanced therapies as first-line treatment. Persistence was observed in 141 patients (51.5%), while 70 (26%) discontinued due to failure, 19 (6.9%) due to allergy/intolerance, 18 (6.6%) due to remission, 2 (0.7%) due to immunogenicity, and 24 (8.8%) for other/unknown reasons. No significant difference in drug persistence was observed between therapies (p=0.11). Univariate analysis identified CD phenotype (p<0.01), disease duration (p=0.01), concomitant mesalamine (p<0.01) or steroids (p<0.01), and therapy optimisation (p<0.01) as factors influencing persistence. A trend toward higher faecal calprotectin levels was observed in the discontinuation group (550 vs 385 mg/kg, p=0.09), while subcutaneous administration showed a slightly higher persistence rate (45% vs 33%, p=0.11). Multivariate analysis confirmed the CD phenotype as factor associated with higher persistence, while therapy optimisation was identified as a risk factor for discontinuation. Conclusion While persistence rates were similar across therapies, multiple factors influence persistence or discontinuation, offering potential guidance for optimising IBD management.

COMPARISION BETWEEN EARLY AND DELAYED CHOLECYSTECTOMY IN ACUTE BILIARY PANCREATITIS

Background: Acute biliary pancreatitis is a common surgical emergency requiring inpatient conservative management. Cholecystectomy is critical in preventing recurrent episodes and minimizing additional biliary complications. However, the optimal timing for cholecystectomy remains a matter of ongoing debate. Early laparoscopic cholecystectomy has been suggested to improve outcomes, but further evidence is required to validate its benefits compared to delayed surgery in patients with mild to moderate acute biliary pancreatitis. Objective: This study aimed to compare the outcomes of early versus delayed laparoscopic cholecystectomy for acute biliary pancreatitis in a tertiary care hospital setting. Methods: A randomized controlled trial was conducted in the General Surgery Department of Fauji Foundation Hospital, Rawalpindi, from July 2024 to December 2024. A total of 100 patients, aged 20–60 years, with mild to moderate acute biliary pancreatitis (ASA grades I or II), were enrolled and randomized into two groups. Group A (early cholecystectomy) underwent surgery within 7 days of symptom onset, whereas Group B (delayed cholecystectomy) underwent surgery between 8 days and 6 weeks after symptom onset. Cholecystectomy was performed following a standardized laparoscopic technique. Data were analyzed using SPSS version 17, with Chi-square tests applied to compare outcomes such as intraoperative bleeding, postoperative fever, severe abdominal pain, and atelectasis. A p-value ≤0.05 was considered statistically significant. Results: The mean age of patients in the early cholecystectomy group was 43.94 ± 11.26 years, while it was 46.38 ± 9.23 years in the delayed group. Females predominated in both groups (72% in early and 70% in delayed groups). Intraoperative bleeding occurred in 20% of early cholecystectomy patients compared to 34% in the delayed group (p=0.115). Postoperative severe abdominal pain was significantly lower in the early group (18% vs. 36%; p=0.043), as was postoperative fever (22% vs. 48%; p=0.006). Atelectasis occurred in 12% of early group patients and 22% of delayed group patients, with a statistically significant difference between the groups (p=0.183). Conclusion: Early laparoscopic cholecystectomy significantly reduces postoperative complications such as severe abdominal pain and fever in patients with acute biliary pancreatitis. The findings particularly highlight the benefits for patients with elevated BMI and advanced age, advocating for individualized treatment strategies. Future studies with larger sample sizes and longer follow-up periods are recommended to confirm these results and optimize management protocols.

Tracking the course of depressive and anxiety symptoms across adolescence (the CATS study): a population-based cohort study in Australia

Adolescent mental health appears to be in crisis, yet few studies have comprehensively charted the course of common mental disorders (CMDs; depression and anxiety) across this key life stage. We aimed to describe the course of CMD symptoms in adolescence by summarising annual prevalence, cumulative incidence, and course for depression and anxiety, both separately and as comorbid CMDs, by sex assigned at birth in a contemporary Australian cohort. The Child to Adult Transition Study (CATS) was established in 2012 to form a representative cohort of adolescents in Melbourne, VIC, Australia. 43 schools were recruited using a stratified sampling approach, and all 2289 students aged 8-9 years were invited to participate. 1239 (54·1%) students obtained parental written informed consent and were followed up annually from 2012 to 2019 for a total of ten waves. Data from waves 3-10 (ages 10 to 18 years) were used for the current study and analysed to describe the course of symptoms of CMDs across adolescence. Primary measures of interest were clinically relevant depressive symptoms, clinically relevant anxiety symptoms, and any CMD (clinically relevant depressive or anxiety symptoms) at waves 3-10. A secondary measure of interest was comorbid CMDs (concurrent reporting of clinically significant anxiety and depressive symptoms) at waves 3-10. Depressive symptoms in the past 2 weeks were self-reported using the 13-item validated Short Mood and Feelings Questionnaire (SMFQ) at each wave, with a threshold score of 12 or more indicating clinically relevant symptoms. Anxiety symptoms in the past two weeks were self-reported using an 8-item shortened version of the Spence Children's Anxiety Scale (SCAS) at each wave, with a threshold score of 11 or higher indicating clinically relevant symptoms. The course of CMDs was described using annual prevalence, cumulative incidence for depression and anxiety, separately and combined. Missing data were handled via multiple imputation. An author with lived experience was involved in the research and writing process. Of the 1239 adolescents who participated in the study, 667 (53·8%) were female and 572 (46·2%) were male. 769 (62·1%) of 1239 were classified as socioeconomically advantaged, 675 (66·4%) of the 1016 with available data had a mother whose highest level of education was vocational or tertiary, and 579 (70·7%) of the 819 participants with ethnicity data identified as Anglo-Celtic or European. Overall, incidence of any clinically significant CMD symptoms during adolescence was 74% (95% CI 70-77; 84% [81-88] for females and 61% [55-66] for males). Independently, incidences of clinically significant depressive symptoms and anxiety symptoms were 65% (62-68) and 58% (55-62), respectively. Incidence of comorbid CMD was 48% (45-52). The estimated mean ages of first report in adolescence for both sexes were 14·1 years (95% CI 13·9-14·4) and 13·6 years (3·3-13·9) for depressive and anxiety symptoms, respectively. Of those who reached the threshold score for any CMD between ages 10 and 18 years, over half had a chronic (three or more waves) course (depression 54% [49-60]; anxiety 52% [47-58]), and a third met criteria for full remission at any subsequent wave (depression 30% [25-35]; anxiety 33% [27-39]). Females were consistently estimated to have a worse course of adolescent CMDs compared with males (eg, 64% [58-70] of females had a chronic course of depressive symptoms vs 37% [26-48] of males). In this contemporary multi-wave cohort study, almost three-quarters of adolescents reported CMD symptoms. The likelihood of chronicity of CMD symptoms (ie, recurrence) was high. Universal responses are urgently required to address this considerable public health problem. National Health and Medical Research Council of Australia and the Royal Children's Hospital Foundation.

Prevalence and the associated factors of burnout among the critical healthcare professionals during the post-pandemic era: a multi-institutional survey in Taiwan with a systematic review of the Asian literatures

Background & AimsBurnout is a global concern, and critical healthcare professionals have been identified as a high-risk population of burnout. Early identification is crucial, but the prevalence of burnout and its risk factors demonstrate significant geographical variations. This study aims to investigate the prevalence of burnout among critical healthcare professionals and explore potential risk factors during the post-pandemic era in Taiwan.MethodsA web-based questionnaire survey was conducted from December 1, 2023, to January 31, 2024, targeting critical healthcare professionals employed in selected medical institutions affiliated with the Chang Gung Memorial Hospital Foundation, one of Taiwan’s largest healthcare organizations. Demographic information, the Subjective Happiness Scale (SHS), current work stressors and self-reported general health data were collected. The study utilized the Maslach Burnout Inventory Human Services Survey for Medical Personnel (MBI-MP). Univariate and multivariate logistic regression were employed to investigate the association between risk factors and each burnout subscales. A systematic review of Asian literature concerning burnout among critical care practitioners was also conducted.ResultsIn our study, 254 participants were enrolled, with an overall burnout rate of 35.4%. The prevalence of high emotional exhaustion (EE) was 70.9%, high depersonalization (DP) was 56.3%, and low personal accomplishment (PA) was 60.6%. Young, unmarried populations, individuals with limited work experience, longer working hours, and night shifts are potential vulnerable groups susceptible to burnout. The top three stressors identified were excessive workload, the burden of administrative tasks, and a shortage of vacation time. Our systematic review included 20 Asian studies on the same issue, with variable burnout prevalence ranging from 16.3 to 82.1%.ConclusionThe prevalence of burnout was high among critical healthcare professionals in post-pandemic Taiwan, particularly affecting younger, unmarried populations and individuals with limited work experience, longer hours, and more night shifts. The influence of pandemic-related factors has decreased. Regional variations in burnout have been observed across Asia, highlighting the need for further research to identify local risk factors and protect the well-being of professionals and healthcare quality.

Association of Coronary Artery Disease with Carotid Intima-Media Thickness in Women Population Presenting to Fauji Foundation Hospital, Rawalpindi

bstract Objective: To determine the association of coronary artery disease (CAD) with carotid intima-media thickness (CIMT) in women population presenting to Fauji Foundation Hospital, Rawalpindi. Methodology: With ethical approval, a descriptive, cross-sectional study was carried out from June 2023 to November 2023 at the Fauji Foundation Hospital, Rawalpindi. After obtaining informed consent, 200 female patients with CAD were included using nonprobability convenient sampling. These patients then underwent primary percutaneous coronary intervention to diagnose CAD and also determine its severity. The SYNTAX score and the number of diseased vessels were used to determine the disease’s severity. The CIMT of the patients was estimated using the B-mode ultrasound. Version 25 of the Statistical Package for the Social Sciences (SPSS) was used to carry out the analysis. Results: The participants had a mean CIMT of 0.85+0.14 mm. The mean CIMT was significantly higher in triple vessel disease (0.97+0.16 mm) versus double vessel disease (0.85+0.11 mm) and single vessel disease (0.78+0.10 mm). The CIMT value was much higher in patients with SYNTAX score >33 (0.96+0.14 mm) compared to score 23-32 (0.85+0.15 mm) and <22 (0.80+0.10 mm). The CIMT was higher in patients with increased age and those with diabetes mellitus and hypertension, with statistical significance. However, the association between CIMT and smoking was insignificant. Conclusion: According to the SYNTAX score and the number of diseased vessels, patients with severe CAD had higher CIMT in our study. Thus, an authentic, safe and noninvasive way of determining the severity of CAD is the carotid intima-media thickness.

Molecular imaging in experimental pulmonary fibrosis reveals that nintedanib unexpectedly modulates CCR2 immune cell infiltration

Pulmonary fibrosis is a challenging clinical problem with lung pathology featuring immune cell infiltrates, fibroblast expansion, and matrix deposition. Molecular analysis of diseased lungs and preclinical models have uncovered C-C chemokine receptor type 2 (CCR2)+monocyte egress from the bone marrow into the lung, where they acquire profibrotic activities. Current drug treatment is focused on fibroblast activity. Alternatively, therapeutic targeting and monitoring CCR2+ cells may be an effective patient management strategy. Inhibition of CCR2+ cells and, as a benchmark, the clinical antifibrotic agent, nintedanib, were used in mouse lung fibrosis models. Lungs were evaluated directly for CCR2+ cell infiltration and by non-invasive CCR2+ positron emission tomography imaging (CCR2-PET). Lung CCR2+ cells were significantly elevated in the bleomycin model as determined by tissue evaluation and CCR2-PET imaging. A protective treatment protocol with an oral CCR2 inhibitor was compared to oral nintedanib. While we expected disparate effects on CCR2+ cells, each drug similarly decreased lung CCR2+ cells and fibrosis. Chemotaxis assays showed nintedanib indirectly inhibited C-C motif chemokine 2 (CCL2)-mediated migration of CCR2+ cells. Even delayed therapeutic administration of nintedanib in bleomycin and the silicosis progressive fibrosis models decreased the accumulation of CCR2+ lung cells. In these treatments early CCR2-PET imaging predicted the later development of fibrosis. The inhibition of CCR2+ cell egress is likely a critical controller for stabilising lung fibrosis, as provided by nintedanib. Imaging with CCR2-PET may be useful to monitor nintedanib treatment responses, guide decision-making in the treatment of patients with progressive pulmonary fibrosis, and as a biomarker for drug development. National Institutes of Health (NIH), R01HL131908 (SLB), R35HL145212 (YL), P41EB025815 (YL), K01DK133670 (DHK); Barnes Jewish Hospital Foundation (SLB).

Association of Chronic Urticaria With Hepatitis C Infection In Female Patients Visiting Tertiary Care Hospital In Pakistan

Objective: To evaluate association of chronic urticaria with hepatitis C infection in female patients. Study Design: comparative cross-sectional study. Place and Duration of Study: Fauji Foundation Hospital Rawalpindi. One-year duration (Jan 2020-Jan 2021). Methodology: One Hundred female patients (group 1) of age 60 years or less with chronic urticaria were enrolled in this study. Patients with chronic liver disease or signs of hepatic decompensation were excluded. Equal number of age and gender matched patients not having urticarial symptoms were selected as group 2. Anti-Hepatitis C Virus Antibody (HCV ab) was evaluated by Enzyme linked immunosorbent assay (ELISA). Disease severity was calculated by Urticaria activity score 7(UAS 7). Association of HCV infection with chronic urticaria and its severity was analyzed by applying appropriate statistical tests. Results: Anti HCV antibody positivity frequency was 14/100(14%) in group 1 and 4/100(4%) in group 2 (p value: 0.013; significant). Mean ages in group 1 and 2 were 39.88+1.38 and 38.79+1.35 years respectively (p value: 0.57; insignificant). Mean UAS 7 calculated in the HCV negative Urticaria cases was 6.73+2.94 while it was significantly higher in HCV positive group i.e. 8.78+6.459 (p value 0.01). Frequency of HCV positivity in patients with well controlled urticaria and mild urticaria was 6/59(10.0%) and 5/36(13.8%) respectively while in moderate urticaria was 3/5(60%) which was significantly higher (p value 0.04). Conclusion: There is a significant association of chronic urticaria with anti HCV antibody positivity. HCV positive patients have more severe disease as compared to HCV negative patients.

Correlation between MRI and conventional radiographic findings in evaluation of osteoarthritis.

Objective: To evaluate the diagnostic accuracy of X-rays in detecting osteoarthritis (OA) in comparison to MRI. Study Design: Cross-sectional study. Setting: The Fauji Foundation Hospital, Rawalpindi. Period: August, 2023 to March, 2024. Methods: Total 350 patients consented to clinical interviews, physical examinations, standing radiographs, and MRIs. Standing, semi-flexed posteroanterior radiographs of the knees were obtained with proper alignment to accurately detect joint space narrowing. Manual measurements of joint space width were conducted by a blinded orthopedic surgeon using the Kellgren-Lawrence grading system. Data analysis was performed using SPSS 23, with frequencies, percentages, means, and standard deviations calculated for relevant variables. Diagnostic accuracy was assessed using a 2x2 table. Results: Of the 350 patients, 61.1% were up to 60 years old, and 38.9% were over 60 years old. Among those with positive MRI results, 70.1% also had a positive X-ray, while 29.6% did not. Cohen's Kappa was 0.377, indicating fair to moderate agreement. Sensitivity was 54.3%, specificity 82.4%, positive predictive value 70.1%, and negative predictive value 70.4%, with an overall diagnostic accuracy of 70.3%. Conclusion: X-rays demonstrated high specificity and moderate predictive values, but low sensitivity, suggesting that some OA cases may be missed if relying solely on X-rays.

Evaluating mobile health interventions for HIV patients in Nigeria: Healthcare policy implications from a simulation study

ObjectivesPeople living with HIV/AIDS (PLWHA) benefit from mobile health (mHealth) technologies through self-managing and monitoring their disease with enhanced patient experience and health outcomes. However, the efficiency and cost-effectiveness of these interventions are yet to be studied. The study aims to assess the impact of mHealth on operational and cost metrics relevant to PLWHA and HIV service delivery. Data SourcesData were a mixture of primary and secondary data from the hospital setting, experts’ opinions, reports, and the literature. MethodUsing a web-based simulation platform, SmartHIV Manager™, for the management of HIV services, we tested scenarios based on four possible reductions in the number of clinic visits and four groups of PLWHA who can be offered a mobile device free of charge (16 scenarios in total). The study was conducted in collaboration with Faith Alive Foundation Hospital (Nigeria) using a mHealth app (BSmart Chart). ResultsIn the worst-case scenario, the hospital anticipates a 14 % decrease in the number of visits from stable patients, nine fewer doctors to operate their service, and a 3 % savings in total cost after accounting for mHealth intervention expenses and mobile phone acquisition. With the service currently running at 161 % doctor capacity, this intervention alleviates staff pressure and ensures quality care. ConclusionThe study shows significant system efficiency gains, fewer visits, better health outcomes, economic benefits for stable patients, and increased capacity. These findings apply to most HIV services worldwide, especially in times of limited resources. Public Interest SummaryMobile health (mHealth) technologies support people living with HIV/AIDS by helping them manage their health and receive remote monitoring. This study examines the impact of mHealth apps on the costs and operations of HIV services. Conducted in a rural HIV setting in Nigeria, where many patients face financial challenges, the research used a simulation-based decision support tool (known as SmartHIV Manager) to test the scenario of providing free mobile devices and reducing clinic visits for stable patients. Results indicated that this approach could reduce patient visits and healthcare costs while easing the workload of overburdened doctors. Globally, introducing mHealth apps could be impactful, given the constraints of limited healthcare staff and budgets.

A cluster randomized trial of xylitol chewing gum for prevention of preterm birth: The PPaX trial.

Maternal periodontal disease is associated with preterm and low-birthweight deliveries, but randomized trials of likely efficacious treatments (e.g., dental scaling and root planing) during pregnancy have not reduced these adverse outcomes. As an alternative, we hypothesized that periconception initiation of xylitol chewing gum would reduce the occurrence of preterm or low-birthweight deliveries among a historical high-prevalence population in Malawi. We conducted an open-label, parallel-enrollment, matched-pair, cluster-randomized, controlled clinical trial across eight health centers (sites) in and around Lilongwe, Malawi. Sites were paired by anticipated delivery volume and randomized to prenatal and oral health education alone (active control) or with twice-daily xylitol chewing gum (intervention) throughout the periconception and antenatal periods. Forthe primary prevention of preterm (<37weeks) and low-birthweight (<2,500 g) deliveries (co-primary outcomes), comparison by allocation group was performed using generalized linear mixed models for each outcome as a fixed factor and the site(s) as a random factor. 10,069 participants were enrolled (n= 4,549 at intervention sites, n= 5,520 at active control sites), with >95% available for analyses. Initiation of xylitol chewing gum resulted in significant reductions in the co-primary outcomes: preterm birth (12.6% [549/4,349] vs. 16.5% [878/5,321]; relative risk [RR] 0.76, 95% confidence interval [CI] 0.57-0.99) and <2,500-g neonates (8.9% [385/4,305] vs. 12.9% [679/5,260]; RR 0.70, 95% CI 0.49-0.99). Xylitol chewing gum use also led to fewer neonatal demises (0.2% [8/4,305] vs. 0.4% [22/5,260]; RR 0.41, 95% CI 0.19-0.89). Periconception initiation and ongoing use of xylitol chewing gum significantly reduced the occurrence of preterm and low-birthweight deliveries in Malawi. E.W. Al Thrasher Foundation (to K.A.) and USAID Saving Lives at Birth Grand Challenges Grant AID-OAA-G-11-00062 (to K.A.). Additional financial and in-kind support was graciously provided by Texas Children's Hospital and Baylor Foundation Malawi.

P01 Adult-onset chronic recurrent multifocal osteomyelitis – case series of four adult patients in Liverpool University Teaching Hospitals Foundation Trust

Abstract Introduction Chronic recurrent multifocal osteomyelitis (CRMO) is a rare inflammatory bone disorder. Classically known as a childhood disorder and diagnosis of exclusion, it characteristically presents with relapsing sterile bone inflammation affecting the metaphysis of lung tubular bones, shoulder girdle, clavicle, vertebral column or bony pelvis. Links with autoimmune conditions have been suggested. Evidence of adult-onset cases (age &amp;gt;18 at diagnosis) remains sparse and sporadic, with mostly individual case reports on searches. We present a case series of four patients with adult-onset CRMO in Liverpool, with varying responses to bisphosphonate treatment and no clinical features of SAPHO. Case description We list four cases of adult patients with CRMO. Case 1: 53-year-old female presented in 2023 with a 10 year history of on-off chest pain isolated to her sternum, and back pain since 2021. MRI confirmation of bone marrow oedema. Bone biopsy normal. Treated with zoledronate. MRI following treatment suggested some improvement but patient remained in pain. Case 2: 24-year-old female presented in 2019 to services with a 10 year history of worsening back pain. Medical background of asthma, type 1 diabetes mellitus, primary biliary cirrhosis and psoriasis. MRI suggestive of persistent pre-sacral soft tissue and sacral oedema since 2015. ANA, Anti-CCP, ENA and dsDNA were negative. Bone biopsy done was positive for inflammation. Pain improved with pamidronate. Case 3: 31-year-old male presented in 2022 with 14 years of relapsing pains and swelling in left clavicle and improvement with NSAIDs. Initially presented via orthopaedic services who arranged an MRI scan that demonstrated oedema of his left clavicle. Received zoledronate infusion with improvement in pain. Case 4: 45-year old-female presented in 2024 with eight year history of chronic right hip and right sacroiliac joint pain. Persistent lower back pain, central right sided with radiation down right knee to her knee. Examination showed tenderness over her lumbar spine and sacroiliac joints. PET-CT done showed avid uptake in L3/4, with subtle lucencies in left frontal bone, right femur and right sacrum. Treated as CRMO with pamidronate with a positive response. All patients received bisphosphonate therapy and varied response to treatment was seen. Two of the four patients had an excellent response with complete resolution of symptoms. One patient has had initial positive response to treatment with resolution of pain but is still planned for more bisphosphonate cycles. One patient had no response to treatment. Discussion Current literature searches describe CRMO mostly in the paediatric populace, with peak incidence aged 10. Most cases of CRMO are diagnoses of exclusion, hence leading to diagnostic delays as differentials such as malignancy, infection, and histiocytosis are first excluded. The Bristol review study suggested a mean time of 15 months to diagnosis in the paediatric populace. We highlight here our findings that CRMO can also present within the adult populace. Typically in adults when similar symptoms arise, SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis and osteitis) is considered as a differential. Our patients, whilst having features on imaging suggestive of bone inflammation, did not have any features of SAPHO syndrome. Our findings are corroborated by the Eurofever International Registry study that enrolled 485 patients and showed adult-onset disease in 6.3% of their cohort, accounting for 31 cases. Our patients were all treated with bisphosphonate therapies. Currently, bisphosphonate therapies are often agreed as a first line treatment approach. Some reports exist of beneficial effects in the use of corticosteroids, DMARDS - particularly sulfasalazine and methotrexate - and biologic treatments (anti-TNF agents), though no common consensus guideline for treatment of CRMO within the UK exist at the moment to our knowledge. We feel the varied clinical response of our patients highlights a need for more research to be targeted towards this area. Key learning points Learning points are as follows: • Few cases of adult-onset CRMO are reported in the UK. Most are single site case reports or case series of paediatric patients. • This cases series is the largest adult-onset cohort in Europe from a single hospital site. • Bisphosphonates are used first line - typically pamidronate. • Corticosteroids, DMARDs (SLZ/MTX) and biologic treatments (anti-TNF agents) have been reported to be effective in some single case reports. • Additional research is required for a national consensus guideline for the treatment of CRMO, including additional management options for those patients that fail first line treatment (bisphosphonate).

Efficacy of Suprachoroidal versus Intravitreal Triamcinolone Acetonide in Refractory Macular Edema; A Quasi-experimental study

Objective: To compare the efficacy of suprachoroidal vs intravitreal triamcinolone acetonide in management of refractory macular edema. Study Design: Quasi-experimental study Place and Duration of Study: Ophthalmology Department, Fauji Foundation Hospital, Rawalpindi Pakistan, from Jun to Nov 2022. Methodology: A total of three hundred and seventy-eight eyes of 189 patients were selected after approval from the Institutional Ethics Review Board. In this study, individuals were divided into two Groups using lottery method: Group-A, received suprachoroidal triamcinolone acetonide and Group-B, received intravitreal triamcinolone acetonide. After intervention, both Groups were followed up at 1 and 3 months. Baseline central macular thickness was noted in each Group. Patients were also observed for complications. Statistical Package for Social Sciences version 23 was utilized for data analysis. Results: No significant differences were noted between both Groups at baseline Central Macular Thickness (p-value =0.29), However, significant difference was noted at 3-month Central Macular Thickness (p-value as &lt;0.001). Very few compli-cations were observed in both Groups. Conclusion: This study revealed that both suprachoroidal and intravitreal routes of administering triamcinolone acetonide were equally effective. Significant reduction in Central Macular Thickness and no increase in Intraocular Pressure along with better tolerance for treatment were seen in suprachoroidal route in our research which indicated its safety.

Assessing the Predictive Capabilities of Autoregressive Integrated Moving Average and Linear Regression Models for Acute Changes in Clinical and Selected Laboratory Parameters in Children After Cardiac Surgery in the ICU.

(1) Background: The main objective of this research was to assess the clinical factors related to the condition of pediatric patients with congenital heart defects after they underwent intensive care unit surgery. The information was gathered from the Congenital Heart Disease Surgery Unit at the National Heart Foundation Hospital and Research Institute in Dhaka, Bangladesh. We gathered and examined data from 288 ICU patients. Patients under the age of twelve who required more than a 24-h ICU stay were selected. (2) Methods: The dependent and independent variables were chosen in advance based on expert opinion. The relationships between these pre-specified ICU parameters were determined using the Pearson correlation model and assessed through linear regression and ARIMA modeling to predict subsequent acute changes in the patients' ICU statuses. (3) Results: A statistically significant relationship (p value < 0.001) was found between CVP and BP (95% CI = 0.2113; 0.353 r = 0.2841249) and between PEEP and FiO2 (95% CI = 0.6992; 0.770 r = 0.7367744). Although the relationships between pH and PO2 were minor (95% CI = 0.161; 0.308 r = 0.2362575), they were statistically significant. The parameters considered statistically significant (p < 0.001) were chosen for forecasting. In this work, the linear regression model and the ARIMA model used the parameters BP, FiO2, and PO2 for prediction. We forecasted the patients' statuses for the next hour. It was found that the ARIMA model had a lower error rate than the linear regression model. (4) Conclusions: This study helps identify the important parameters for predicting and monitoring patients' statuses in the ICU, with the ultimate goal of providing physicians with an early warning system to anticipate deterioration in clinical and biochemical parameters. The ability to accurately forecast future patients' conditions can enable proactive, targeted interventions, potentially improving outcomes and reducing the risk of adverse events.

CHARACTERISTICS AND OUTCOME OF LEFT MAIN STEM PCI AMONG WOMEN

Left main stem disease is a severe condition affecting a major coronary artery, traditionally treated with coronary artery bypass grafting. Recent advancements in percutaneous coronary intervention have made it a viable option, particularly for women who face unique risks and outcomes compared to men. Objective: This study aims to evaluate the characteristics and outcomes of percutaneous coronary intervention for left main stem disease in female patients, focusing on procedural outcomes and changes in laboratory parameters before and after the intervention. Methods: A prospective observational study was conducted from January to July 2024 with 68 female patients, aged 18 and above, from Fauji Foundation Hospital Rawalpindi. Various percutaneous coronary intervention techniques were used, and data on ejection fractions, access methods, and procedural specifics were collected. Pre- and post-procedural laboratory outcomes including haemoglobin, creatinine, platelet counts, and alanine aminotransferase levels were analyzed. Results: The mean age of participants was 63.6 years. Diabetes, hypertension, and dyslipidemia were common comorbidities. Laboratory results showed stable haemoglobin levels, slight increases in creatinine, and consistent platelet counts and ALT levels post-procedure. Statistical analysis revealed no significant changes in these parameters, indicating minimal impact on anaemia, renal function, and platelet or liver function. Conclusion: percutaneous coronary intervention for the left main stem in females generally results in stable laboratory outcomes with minimal impact on anaemia, renal function, and platelet or liver function. The procedure is safe with a low mortality rate. Continuous monitoring is recommended to manage any potential complications effectively.

The Optimal Prediction Model for Successful External Cephalic Version.

The majority of breech fetuses are delivered by cesarean birth as few physicians are trained in vaginal breech birth. An external cephalic version (ECV) can prevent cesarean delivery and the associated morbidity in these patients. Current guidelines recommend that all patients with breech presentation be offered an ECV attempt. Not all attempts are successful, and an attempt does carry some risks, so shared decision-making is necessary. To aid in patient counseling, over a dozen prediction models to predict ECV success have been proposed in the last few years. However, very few models have been externally validated, and thus, none have been adopted into clinical practice. This study aims to use data from a U.S. hospital to provide further data on ECV prediction models. This study retrospectively gathered data from Carle Foundation Hospital and used it to test six models previously proposed to predict ECV success. These models were Dahl 2021, Bilgory 2023, López Pérez 2020, Kok 2011, Burgos 2010, and Tasnim 2012 (GNK-PIMS score). A total of 125 patients undergoing 132 ECV attempts were included. A total of 69 attempts were successful (52.2%). Dahl 2021 had the greatest predictive value (area under the curve [AUC]: 0.779), whereas Tasnim 2012 performed the worst (AUC: 0.626). The remaining models had similar predictive values as each other (AUC: 0.68-0.71). Bootstrapping confirmed that all models except Tasnim 2012 had confidence intervals not including 0.5. The bootstrapped 95% AUC confidence interval for Dahl 2021 was 0.71 to 0.84. In terms of calibration, Dahl 2021 was well calibrated with predicted probabilities matching observed probabilities. Bilgory 2023 and López Pérez were poorly calibrated. Multiple prediction tools have now been externally validated for ECV success. Dahl 2021 is the most promising prediction tool. · Prediction models can be powerful tools for patient counseling.. · The odds of ECV success can estimated based on patient factors and clinical findings.. · Of the six tested models, only Dahl 2021 appears to have good predictive value and calibration..

Safety of Hepatitis B Virus Screening in Blood Donors from the Hospital Foundation of Hematology and Hemotherapy of the State of Amazonas (HEMOAM) in the Brazilian Amazon

Background: Hepatitis B is an infectious disease of worldwide importance and of great interest to transfusion medicine. The Amazon region has areas of high endemicity, outlining a worrying scenario for transfusion and epidemiological safety. Objective: To analyze the profiles of serological and molecular markers for HBV of blood donors from HEMOAM. Methods: Blood donors with different patterns of reactivity in serological and molecular screening for HBV were tested for viral load by the qPCR method at the reference center for liver diseases in the state of Amazonas. Results: A total of 230,591 donors were tested, with 3104 (1.34%) found reactive for HBV and 2790 (89.9%) found reactive for isolated anti-HBc. Viral load was not detected in 100% of donors reactive only to HBsAg, while 100% of donors with positive anti-HBc and positive HBsAg or HBV NAT demonstrated a detectable viral load. We also detected one case of occult hepatitis B (0.03%) only with reactive HBV NAT and five donors (0.2%) with positive anti-HBc and HBV NAT. Conclusions: With this result, the great importance of the anti-HBc test for the unsuitability of blood donors was verified, as well as the fundamental introduction of the HBV NAT test in screening for hepatitis B in Brazilian blood banks, as this was the only way to detect the viral infection burden in asymptomatic donors who previously would not be treated, which contributed to the maintenance of the endemicity of hepatitis B in the Brazilian Amazon.

Psychological distress, General health and Life satisfaction among children with Thalassemia and children undergoing Haemodialysis.

To compare and find out the relationship between psychological distress, general health and life satisfaction among children with thalassemia and children undergoing dialysis. The current study utilized cross sectional research design. A representative group of children with Thalassemia (n=60) and children undergoing dialysis (n=60) with ages ranging from 6-14 years were included in the sample. The sample was drawn from Children's Hospital and Sundas Foundation from February 2023 to August 2023 through a purposive sampling technique. Psychological distress significantly correlates negatively with general health (-.34**) and life satisfaction (-.44**) in Children with Thalassemia. A significant negative relationship is also observed between psychological distress and general health (-.43**) and life satisfaction (-.54**) in Children undergoing Hemodialysis. Children undergoing hemodialysis experience more psychological distress whereas children with thalassemia have better general health. However, no significant difference was found in life satisfaction. The findings of the present study will be helpful for healthcare professionals and clinical psychologists to develop strategies and training programs which can increase resilience among patients. Training the patients and caregivers regarding how to fight chronic illnesses will lead to an improvement in their quality of life. Psychological distress is higher in children undergoing hemodialysis and general health is also not good but the level of satisfaction is almost equal between the two groups. This is justified that chronic illnesses do not preclude children from leading happy and satisfying lives.

Perlindungan Hukum Bagi Pekerja Di Kota Ambon

Introduction: Sumber Hidup Hospital Ambon, the system of paying wages to its workers is not going well. The Sumber Hidup Hospital Workers' Union filed a lawsuit against Sumber Hidup Hospital at the Ambon District Court.Purposes of the Research: To find out and analyze the wage system based on Government Regulation Number 36 of 2021 Concerning Wages. To find out that companies are required to apply wages based on Government Regulation Number 36 of 2021.Methods of the Research: This research uses normative juridical research methods. The research approach used by the author is a statutory approach (Statute Approach) and a conceptual approach (Conceptual Approach). The procedure for collecting legal materials is carried out by means of library research. The legal materials used by the author in this study are primary legal materials, secondary legal materials, and tertiary legal materials.Results of the Research: Government Regulation no. 36 of 2021 concerning Wages specifically for Sumber Hidup Hospital workers has not been implemented in practice. particularly in relation to the policy of wages and payment of rights and obligations because there are still many irregularities that occur in the implementation of these Government Regulations. This is evident from the complaints and unrest of the Sumber Hidup Hospital workers where the Sumber Hidup Hospital Foundation as the employer has not paid the workers' wages, so the workers' rights and the employer's obligations have not been fulfilled.