Hospital Protocol Research Articles

P0406 Complications after ileal pouch-anal anastomosis in patients with Ulcerative Colitis and primary sclerosing cholangitis

Abstract Background Proctocolectomy with ileal pouch-anal anastomosis (IPAA) is a common treatment approach for patients with primary sclerosing cholangitis (PSC) and medically refractory ulcerative colitis (UC) or colorectal dysplasia. Patients with PSC-UC are more likely to experience pouchitis, chronic pouchitis and pouch failure than patients with UC alone (1, 2). The aim of retrospective study is to compare rates of pouch complications and need for biologics in UC IPAA patients with and without PSC. Methods We performed a retrospective cohort study of patients who underwent IPAA surgery between March 2015 and February 2024 at our tertiary referral centre. According to the internal hospital protocol, pouchoscopies and clinical examination were performed 1, 3, 6, and 12 months after restoration of the faecal stream. Demographics, comorbidities, pouchitis frequency (as by clinician assessment), laboratory tests and medication use were collected from the electronic medical records and compared between groups for the first year following IPAA surgery, and at last follow-up. Descriptive and univariate analyses was performed. Fisher’s exact test was used to compare frequency of pouch complications (pouchitis, need for biologics and pouch failure) between PSC-UC and UC group. Results In our cohort there were 186 patients with UC that underwent IPAA surgery, among them 14 (7.5%) with concomitant PSC. After a similar follow-up between both groups (p=0.99), patients with PSC-UC compared with UC only were more likely to develop pouchitis at any given timepoint, month 1 (n=173: 14.3% vs 10.7 %, p=0.65), month 3 (n=149: 36.4% vs 16.7 %, p=0.11), month 6 (n=154: 25% vs 22.5%, p=1.0), month 12 (n=144: 41.7% vs 18.9%, p=0.13). By month 12, 92.9% of PSC-UC patients had developed pouchitis compared to 61.0% in the UC only group (n= 178, RR 1.52, 95% confidence interval (CI) 0.19-11.92, p=0.02) Fig 1. After a median follow-up of 24 months, the need for biologics in PSC-UC group tended to be higher (n=163: 30.8% vs 12.7%, RR 2.43, 95% confidence interval (CI) 0.68-8.66, p=0.09). Pouch failure tended to occur more frequent in the PSC-UC group (n= 163: 7.7% vs 4.0%, RR 1.92, 95% confidence interval (CI) 0.21-17.31, p=0.45). Conclusion Percentage of patients with at least one episode of pouchitis in the first year after IPAA surgery was significantly higher in UC-PSC group. Additionally, patients with PSC-UC after IPAA surgery appear to be at higher risk for pouch complications, such as pouchitis, the need for biologics and pouch failure, however statistical significance was not achieved due to a low sample size in UC-PSC group. References (1)Barnes EL, Holubar SD, Herfarth HH. Systematic review and meta-analysis of outcomes after ileal pouch-anal anastomosis in primary sclerosing cholangitis and ulcerative colitis. J Crohns Colitis. 2021;15(8):1272-1278. doi:10.1093/ecco-jcc/jjab025 (2)Quinn KP, Urquhart SA, Janssens LP, Lennon RJ, Chedid VG, Raffals LE. Primary sclerosing cholangitis-associated pouchitis: A distinct clinical phenotype. Clin Gastroenterol Hepatol. 2022;20(5): e964-e973. doi: 10.1016/j.cgh.2021.02.006

P0433 Pouchitis described by the SES-CD score is more associated with the need for biologics initiation after IPAA than endoscopic subscore of PDAI

Abstract Background The ileal pouch-anal anastomosis (IPAA) is a well-established approach following proctocolectomy for ulcerative colitis (UC) or colorectal dysplasia. Although the functional results are good, many patients develop pouchitis. The pouchitis disease activity index (PDAI) is the most used tool to assess the inflammation of the pouch. However, the PDAI with endoscopic subscore of PDAI (ePDAI) is often not reliable or responsive (1, 2). The simplified endoscopic score for Crohn’s disease (SES-CD) has recently been proposed for this setting (3). In this retrospective study, we aim to describe the correlation between SES-CD score and several important clinical outcomes. Methods We performed a retrospective cohort study of patients who underwent IPAA surgery between March 2015 and February 2024 at out tertiary referral centre. According to internal hospital protocol, endoscopic and clinical examinations were performed at 1, 3, 6, and 12 months after IPAA for each patient. The ePDAI scores, demographics, comorbidities, laboratory tests and medication use were collected from the electronic medical records. Data was collected for the first year following IPAA surgery, and last known follow up. All pouchoscopies (n=497, 86.4% of total) with video- (83.5%) or photodocumentation (16.5 %) were reviewed by the same reviewer (JS) and additionally scored with SES-CD endoscopic score in the pouch body and afferent ileum. Descriptive and univariate analyses was performed. Kaplan-Meier curves were used to assess the impact of the ePDAI and SES CD scores for initiation of biologics. Pouchoscopies were classified as low-grade (ePDAI ≤ 1; SES CD ≤ 3) or high-grade inflammation (ePDAI > 1; SES CD > 3). Results The total cohort included 206 patients (46.1% female), of which 90.3% underwent IPAA surgery due to ulcerative colitis with a median follow up of 25 months after IPAA construction. Of those, 12.6% were receiving biologic therapy at the last follow up. There was linear corelation between ePDAI and SES-CD score (rho 0.69, p<0.001). For both scores, the patients with high-grade inflammation pouchoscopy at months 1 (p 0.0132 for ePDAI, p 0.0008 for SES-CD) and 6 (p 0.0001 for ePDAI, p 0.0007 for SES-CD) had a higher need for biologic therapy than patients with low-grade pouchoscopy. At month 3 and 12, only SES-CD was associated with higher need for biologic therapy (month 3: p 0.467 for ePDAI, p 0.042 for SES-CD; month 12: p 0.0571 for ePDAI and p 0.0387 for SES CD). Conclusion The SES-CD score may be an alternative to ePDAI for scoring of pouch inflammation. The pouch inflammation described by the SES-CD score is more associated with the need for biologics initiation in patients after IPAA than ePDAI. References (1)Jairath V, Feagan BG, Silverberg MS, et al. Mucosal healing with vedolizumab in patients with chronic pouchitis: EARNEST, a randomized, double-blind, placebo-controlled trial. Clin Gastroenterol Hepatol. Published online 2024. doi: 10.1016/j.cgh.2024.06.037 (2)Sedano R, Nguyen TM, Almradi A, et al. Disease activity indices for pouchitis: A systematic review. Inflamm Bowel Dis. 2022;28(4):622-638. doi:10.1093/ibd/izab124 (3)Barnes EL, Long MD, Raffals L, et al. Development of the endoscopic pouch score for assessment of inflammatory conditions of the pouch. Clin Gastroenterol Hepatol. 2023;21(6):1663-1666.e3. doi: 10.1016/j.cgh.2022.04.026

Predictive Value of First Amniotic Sac IL-6 and Maternal Blood CRP for Emergency Cerclage Success in Twin Pregnancies.

Objectives: To assess the usefulness of first amniotic sac Interleukin-6 (IL-6) to rule out intra-amniotic inflammation (IAI), as well as maternal blood c-reactive protein (CRP), to select patients with a twin pregnancy who may benefit from an emergency cerclage. Materials and Methods: Retrospective, descriptive study among all patients with a twin pregnancy and mid-trimester bulging membranes admitted to a tertiary Hospital from January 2012 to September 2023. According to the Hospital's Protocol, all patients received a vaginal and abdominal ultrasound, a maternal blood test, and an amniocentesis of the first sac to rule out IAI, defined by IL-6 ≥ 2.6 ng/dL. Results: A total of 28 patients with a twin pregnancy and mid-trimester bulging membranes were included. Among them, 18 patients (64.28%) had IL-6 levels ≥ 2.6 ng/dL. Cerclage was placed in 10 patients with IL-6 < 2.6 ng/dL. Perinatal mortality in pregnancies with IL-6 ≥ 2.6 ng/dL was 77.22%. The gestational age at delivery of patients with IL-6 < 2.6 ng/dL was 34 ± 3 weeks, compared to 23 ± 4 weeks when IL-6 was ≥2.6 ng/dL (p < 0.001). The latency to delivery with IL-6 < 2.6 ng/dL was 88.1 ±31.56 days, compared to 13.11 ± 20.43 days when IL-6 was ≥2.6 ng/dL (p < 0.001). Significant differences were found in maternal blood CRP levels in both study groups (no IAI 4.32 ± 3.67 vs. IAI 13.32 ± 15.07, p < 0.05). The area under the curve with an ROC curve was 0.799 (IC 95% 0.596-0.929), with a cut-off of 3.9 mg/L (S 94.4%, % E 62.5%). The gestational age at delivery with CRP < 3.9 mg/L was 33 ± 5 weeks, while in cases with CRP ≥ 3.9 mg/L, it was 24 ± 5 weeks (p < 0.001). The latency days to delivery were 86.5 ± 44.88 and 21.95 ± 30.97 days (p < 0.01), respectively. A positive correlation between the IL-6 values of both amniotic sacs was obtained, along with the Spearman coefficient correlation rank (rho = 0.835, p < 0.001). Conclusions: Compared to those with IAI, patients with a twin pregnancy and mid-trimester bulging membranes without IAI who underwent emergency cerclage had a significantly higher interval from diagnosis to delivery, as well as a significantly lower incidence of preterm birth < 34 weeks and perinatal death. Further studies are needed to assess whether the IL-6 of the first amniotic sac and maternal blood CRP might constitute a useful parameter to select patients who may benefit from an emergency cerclage.

Everolimus Through Plasmatic Concentrations in Cancer Patients: Prospective Longitudinal Observational Multicentric Study (DIANA-1 Project).

Background: Everolimus, an oral inhibitor of the mammalian target of rapamycin (mTOR), is actually used to prevent organ transplant rejection and treat metastatic breast, renal, and neuroendocrine cancers. Despite significant pharmacokinetic variability among patients, routine therapeutic drug monitoring (TDM) is not commonly used in oncology. Methods: The aim of this multicenter, prospective observational cohort study is to assess the prevalence of everolimus minimum concentration at a steady state (Cminss) falling outside the therapeutic range (10-26.3 ng/mL) during a routine TDM programme. Sixty patients with metastatic breast, neuroendocrine, or renal cancers, either starting or continuing everolimus treatment according to hospital protocols, are to be included between 1st of January 2024 and 31st of December 2025 (patients undergoing clinical trials are excluded). We hypothesize that 30-50% of our patients and their blood samples will not achieve the target optimal plasma concentrations. Blood samples are collected every 4-6 weeks to monitor drug levels. The secondary goal is to explore correlation between out-of-range everolimus levels and factors such as demographic and anthropometric data, treatment specifics, lab results, genetic polymorphisms, and the presence of toxicity. Conclusions: This study could offer valuable insights into optimizing dosing strategies and may contribute to future research on personalizing everolimus and other anticancer treatments. This personalized approach seeks to tailor therapy not only to the tumour's molecular profile but also to the individual characteristics of each patient, improving both drug selection and dosing precision.

Implementation of Surgical Site Infection Prevention Bundle in Gynaecological Surgeries: A Quality Control Initiative

Background: Surgical site infection (SSI) is the most common post operative morbidity after gynaecological surgeries. There can be multiple risk associated that may or may not be modifiable. Therefore, perioperative bundled approach are designed to reduce surgical site infections. Aim/Objective: To determine whether surgical site infection (SSI) prevention bundle reduces the risk of SSI by 30 days postoperatively compared with the standard hospital protocol. Methods: A randomized control trial was conducted on women who underwent elective gynaecologic surgery from January 2019 to May 2020. The subjects were divided into intervention and control group. The primary outcome was the rate of SSI by 30 days postoperatively. Results: Total 192 women were randomized. the intervention group included 94 and 98 were assigned to the control group. The SSI rate at 30 days after surgery was 8 /85 (9.5%) in intervention group and 22/85 (25.8%) in control group (p value=0.005; RR=0.36;95% confidence interval [CI], 0.17-0.77). The relative risk reduction of SSI was 64% (p value=0.005) after the bundle was implemented. In subgroup analysis, the primary outcomes were affected by the subgroups like age, co morbidities and operative characteristics. Conclusion: SSI prevention bundle intervention led to significant decrease in overall SSI rate in electively planned gynecological surgeries.

Study of the efficacy of implementing a protocol of perioperative antibiotic prophylaxis using digital technologies

Introduction. Following the modern method of perioperative antibiotic prophylaxis (PAP) is one of the ways to reduce the likelihood of developing antibiotic resistance and decrease the cost of pharmacological prevention of surgical infection. However, even now the real clinical practice of PAP often differs from the scientifically based one; there is often an excessive prescription of antibacterial agents or the choice of suboptimal drugs. Implementation of the PAP procedure using an intelligent program, chatbot, can increase the commitment of doctors to follow modern PAP. Purpose of the study. To develop and implement a mobile application, a chatbot for choosing a decision on the method of perioperative antibiotic prophylaxis based on the local PAP protocol of a multidisciplinary emergency hospital. Materials and research methods. A clinical and economic method: studying medical records of patients in emergency hospitals of surgical departments (trauma, surgery, neurosurgery, gynecology, urology, otorhinolaryngology). Python programming method, web application development. An administrative and documentary method: preparation and publication of orders and instructions for the medical institution on the procedure for implementing the protocol, monitoring compliance with the protocol. Results and discussion. Based on the existing local PAP protocol, standard solutions for choosing the PAP method have been compiled. Applications (Telegram chatbots) have been developed to facilitate this choice for a doctor making a decision on the PAP regimen. It has been established that commitment to the implementation of the PAP protocol continues to grow. This may be due to the lack of increased incidence of infection of the surgical wound despite a multiple reduction in the use of antimicrobial agents. The clarity and ease of use of algorithms for selecting PAP modes using digital technology were also revealed. The implementation of the PAP protocol was carried out with consistent information and administrative support. Conclusions. The implementation and maintenance of local protocol is effectively carried out using digital technologies. Following an evidence-based PAP protocol can achieve significant cost savings while maintaining the effectiveness of antimicrobial prophylaxis.

An Ontology-Based Approach for Understanding Appendicectomy Processes and Associated Resources.

Traditional methods for analysing surgical processes often fall short in capturing the intricate interconnectedness between clinical procedures, their execution sequences, and associated resources such as hospital infrastructure, staff, and protocols. This study addresses this gap by developing an ontology for appendicectomy, a computational model that comprehensively represents appendicectomy processes and their resource dependencies to support informed decision making and optimise appendicectomy healthcare delivery. The ontology was developed using the NeON methodology, drawing knowledge from existing ontologies, scholarly literature, and de-identified patient data from local hospitals. The resulting ontology comprises 108 classes, including 11 top-level classes and 96 subclasses organised across five hierarchical levels. The 11 top-level classes include "clinical procedure", "appendicectomy-related organisational protocols", "disease", "start time", "end time", "duration", "appendicectomy outcomes", "hospital infrastructure", "hospital staff", "patient", and "patient demographics". Additionally, the ontology includes 77 object and data properties to define relationships and attributes. The ontology offers a semantic, computable framework for encoding appendicectomy-specific clinical procedures and their associated resources. By systematically representing this knowledge, this study establishes a foundation for enhancing clinical decision making, improving data integration, and ultimately advancing patient care. Future research can leverage this ontology to optimise healthcare workflows and outcomes in appendicectomy management.

Jet versus vibrating mesh nebulizer for tobramycin aerosol in spontaneously breathing children with tracheostomies: A simulation study.

Tracheostomy tubes act as foreign bodies, predisposing the surrounding airway to respiratory infections. Initial treatment for infections is topical - nebulized tobramycin - although guidelines for standardized treatment are lacking. To quantify tobramycin delivery to simulated, tracheostomized children to inform future administration guidelines. A breathing simulator was programmed for volume-controlled ventilation at 6 mL.kg-1, for a 3 kg and a 16 kg child representing under or over 6-yrs, respectively. Nebulized tobramycin doses based on current guidelines for non-tracheostomized children (80 mg, or 300 mg, under and over 6-yrs, respectively) were delivered using standard hospital protocol, collected on filters, and assayed with chromatography to quantify average tobramycin delivered dose from six replicate measurements. The jet nebulizer delivered more tobramycin than the vibrating mesh nebulizer from an 80 mg (ages <6-yrs) dose for both a 3 kg child: 2.1 vs. 0.7 mg (3 mm, p = 0.047) and a 16 kg child: 8.7 vs. 3.5 mg (5 mm size, p = 0.022), 11.4 vs. 8.3 mg (4 mm size, p = 0.2). The jet nebulizer delivered more tobramycin than the vibrating mesh nebulizer from a 300 mg dose for both a 3 kg child: 8.4 vs. 3.7 mg (3 mm, p = 0.00076) and a 16 kg child: 33.2 vs. 25 mg (5 mm, p = 0.2) but not for a 16 kg child: 39.4 vs. 46.5 mg (4 mm, p = 0.18) The low amount and poor distribution of drug delivered warrants consideration and review of dosing regimens for treatment. Future research should investigate improving the efficiency of drug delivery to tracheostomized children and the safety and efficacy of higher-dosage regimens.

Impact of prostate volume on the active surveillance in prostate cancer

Objective: To determine the influence of the prostate volume (PVo) in the management of patients in active surveillance (AS) for prostate cancer. Materials and methods: A retrospective analysis of clinical, biological, histological and radiological data collected between 2010 and 2021 was performed for patients included in an AS protocol in a university hospital. The impact of initial PVo on the subsequent risk of exiting AS was evaluated. Results: In total, 109 patients were included in this analysis with a mean follow-up period of 52.74 ± 31 months, 50% were out of AS by the end of the follow-up period. The risk of exiting the AS protocol was significantly associated to the PVo: patients with smaller PVo had an increased risk of exiting AS ( p = 0.025). The maximal percentage of core invasion was the only initial predictive parameter for exiting the AS protocol on multivariate analysis of the global cohort ( p = 0.010) and in the sub-group of patients having PVo ⩽ 45 mL ( p = 0.013). In the group having a PVo &gt; 45 mL, no single initial parameter was significantly associated to a risk of exiting AS. Conclusion: Patients having small-sized prostate seemed to be at higher risk of exiting AS during follow-up. Level of evidence: 4

Assessment of the value and findings of CT in diagnosing acute appendicitis

Appendicitis is one of the most common abdominal emergencies. Patients are usually presented with lower right abdominal pain, nausea, vomiting and fever. Acute appendicitis is a challenging clinical diagnosis, and patients with suspected appendicitis can be diagnosed by Ultrasound (US) or computed tomography (CT) according to the hospital protocol and patient clinical condition. The aim of this study is to investigate the value of CT in diagnosing suspected cases of acute appendicitis. Retrospective research to evaluate the role of CT scan in the diagnosis of acute appendicitis, based on data received from King Abdulaziz university hospital in Jeddah, from January 2017 to January 2022. A total of 204 patients (121 Males and 83 Females) ranging in age from 2 to 91 years presented with acute appendicitis were included. The collected data included age, gender, patients' complaints, medical history, laboratory tests, radiology reports, operations, and pathological results. The most prevalent age group was 10-30 years old. Most patients (77%) presented with typical appendicular pain, while (56%) presented with vomiting. CT was requested for 142 patients while 35 patients were referred to Ultrasound. Both modalities were done to 27 patients. The Commonest finding in CT scan was dilated appendix with sensitivity of 84% with 100% overall diagnostic sensitivity. CT is a sensitive tool used to diagnose acute appendicitis and its complications. It is recommended to be used as the primary imaging modality in cases of acute appendicitis.

VIVÊNCIA DAS ESTUDANTES DE ODONTOLOGIA DA FACULDADE DO AMAZONAS – IAES NO PROJETO DE EXTENSÃO REFERENTE ÀS PRÁTICAS MULTIDISCIPLINARES EM ODONTOLOGIA HOSPITALAR – UM RELATO DE EXPERIÊNCIA

Introduction: The role of the university is to train critical, reflective and ethical professionals. In this context, as an educational strategy, aligning theoretical teaching with practice, this experience took place at the Hospital and Emergency Room 28 de Agosto. The study was carried out by undergraduate students of the Dentistry course, in their sixth semester, with the practice taking place on two days a week, monthly, with a total duration of eight hours. The activities included lectures to patients, such as oral hygiene care and intraoral examinations, under the supervision of Prof. MSc. Guilherme Ferreira. Hospital Dentistry is a consolidated specialty in the care of hospitalized patients, encompassing a multidisciplinary approach and dental interventions. The care structure at the hospital was organized, ensuring safety and comfort for patients. In the Intensive Care Unit, there was one intubated patient, receiving continuous monitoring, and the other patients demonstrated good health. This experience report aims to share the experience acquired in the practice of Hospital Dentistry, highlighting the multidisciplinary work, the application of the relevant legislation and the challenges faced. Methodology: Descriptive in nature, providing an insight into the dental practices applied in the hospital environment – ​​description of the care provided, the clinical conditions of the patients, the multidisciplinary approaches and the difficulties faced by the professionals. Results and Discussion: Dental care provided to patients with various clinical conditions was observed, allowing an immersion in hospital dentistry. There was an opportunity to learn about hospital protocols and how they align with the hospital's standards and procedures, in relation to infection control and patient safety. The experience highlighted the complexity of dental care and highlighted the importance of multidisciplinary collaboration. Conclusion: The experience was an essential act for future professional practice, providing theoretical and practical learning, the opportunity to observe in a real clinical environment, to verify the complexity of hospital dental care and to adapt to the challenges of the environment.

Serum Albumin Assessment in Neonatal Jaundice: Impact on Phototherapy Decision-Making.

The objective of this study was to investigate the impact of serum albumin assessment on early neonatal jaundice treatment decisions. A retrospective review of medical records was conducted for infants of 35 weeks' gestation or more, evaluated for early neonatal jaundice in 3 hospitals in Thailand from January 1 to December 31, 2023. Per hospital protocol, serum albumin levels were routinely measured during the jaundice evaluation. Infant demographics; serum albumin; total serum bilirubin (TSB); laboratory work-up for jaundice; hyperbilirubinemia neurotoxicity risk factors; hour-specific, risk-based phototherapy threshold; and rates of phototherapy treatment were evaluated. Out of 935 infants evaluated for hyperbilirubinemia, 250 infants (26.7%) had serum albumin levels less than 3.0g/dL. Among 121 infants who received phototherapy at TSB levels meeting the guideline threshold, 49 infants had serum albumin less than 3.0g/dL as one of the neurotoxicity risk factors. However, the decision for phototherapy would not have changed when other neurotoxicity risk factors were present, when TSB at the time of initiation of phototherapy was higher than the threshold without neurotoxicity risk factors, or when TSB at the time of cessation of phototherapy was lower than the threshold with neurotoxicity risk factors. As a result, the identification of serum albumin less than 3.0g/dL affected phototherapy treatment decision in 16 infants (affected initiation in 13, cessation in 1, and both the initiation and cessation in 2) or 1.7% of all infants evaluated for jaundice. Serum albumin levels less than 3.0g/dL are common, affecting 1 in 4 infants assessed for jaundice. However, this has minimal impact on phototherapy decisions.

‘We tried our best... it wasn’t great’: a qualitative study of clinician experiences on child psychiatry wards at the height of COVID-19

Changing public health and hospital protocols during the height of the COVID-19 pandemic shaped the provision of inpatient mental health care. While a growing body of research explores the challenges of restrictions on adult psychiatric wards, the impact on clinical teams and epidemiological trends in youth mental health, no research has explored inpatient psychiatric hospital services for child and adolescent psychiatry during the pandemic. This study seeks to understand how clinicians in Canada working in child and adolescent mental health wards experienced caring for their patients while navigating pandemic hospital restrictions. Following a qualitative descriptive methodology and also drawing on institutional ethnography we generated data using two methods: 1) an online survey of clinicians across the country asking about experiences providing care and COVID restrictions and 2) in-depth, semi-structured interviews with clinicians. Data from 54 surveys and 14 interviews were analyzed using thematic analysis yielding two major themes. First, clinicians felt that clinical care was compromised with likely impact on patient outcomes. Second, respondents reported that the context of the pandemic provoked tensions and resistance within the clinical teams and the institution. Our findings have important implications not only for future public health crises, but also for rethinking how psychiatric care is provided and prioritized. This study points to the need for 1) mechanisms which support collaborative decision making at the institutional level, to ensure regulations are more flexible and can adapt to the needs of child mental health patients; and 2) that child psychiatry prioritize generating spaces of ethical reflection for clinical teams and institutional decision-makers so that paternalism does not trump principles of primum non-nocere (first, do no harm), autonomy and reciprocity.

The 30-Days readmission among hepatic encephalopathy patients and the associated factors: An experience of a tertiary care hospital in Karachi Pakistan.

Objective: To determine the 30-days readmission rate among hepatic encephalopathy patients and its associated factors among patients admitted in a tertiary care hospital. Study Design: Prospective Cohort study. Setting: Department of Gastroenterology, Liaquat National Hospital, Karachi, Pakistan. Period: July 2023 to June 2024. Methods: Patients of cirrhosis with hepatic encephalopathy discharged from hospital were followed up in out-patient and inpatient department as per the hospital protocol. Data were entered into SPSS version 26 to perform statistical analysis. Results: Total 215 patients were included into the study. Mean age of patients was 55.40 ± 11.05 years and most of the patients were males (59.3%). Incidence of 30 day readmission was 15.3%. Causes of readmission were constipation (51.5%), infection (30.3%), electrolyte imbalance (12.1%) and renal failure (6.1%). Presence of hypertension and diabetes was associated with increased risk of readmission. Increasing potassium levels at the time of discharge were also found to be associated with increased readmission rate. Conclusion: The present study analyzed that main cause of 30 days readmissions were incidence of constipation and infection after discharge. Moreover, the study also showed that patients with comorbidity of hypertension and diabetes were likely to readmit.

Rambam Hospital Protocol for Treatment of Early Stages of Legg-Calve-Perthes Disease

Introduction: The treatment of Leg-Calve-Perthes Disease (LCPD) is an orthopedic enigma without consensus in the literature. Despite all efforts, coxa breva with overgrowth of the greater trochanter (GT) is commonly present in many patients. In 2013, we introduced a protocol that included transepiphyseal drilling of the femoral head, closure of the GT, adductor tenotomy, and 4 months of non–weight-bearing on the affected leg. The purpose of this study was to evaluate midterm results in patients treated by our protocol. Methods: Over 11 years, we treated 31 patients with LCPD. Average age was 7.1 (range 5 to 10) years. We divided all patients into 2 groups: group A included 18 patients in early fragmentation stage, group B contained 12 patients in late fragmentation and one in reossification stage. All patients underwent the same treatment protocol as described. Results: Mean follow-up was 52 months. All patients had a limp before surgery. At the latest follow-up, 22 had no limp, and 23 had substantial improvement in hip range of motion. In group A, 12 patients had Stulberg type 1, 5 Stulberg 2, and 1 Stulberg type 3. In group B, 1 patient had Stulberg type 2, 9 patients had Stulberg type 4, and 3 patients had Stulberg type 5. Conclusions: On the basis of our experience, the proposed protocol can be effective in the treatment of the early fragmentation stage of LCPD.

Perinatal death, collective action and legislation against obstetric violence in Argentina

This article explores the interconnections between perinatal death, collective action, and legislation against obstetric violence in Argentina. It employs a comprehensive methodological approach, including in-depth interviews, document reviews, a survey, and intensive ethnographic fieldwork to provide a multidimensional understanding of how collective actions influence legislative outcomes. Johanna Piferrer’s case, a poignant example detailed in this study, illustrates how personal tragedy catalyzed public and legislative acknowledgement of obstetric violence. This article argues that her advocacy, coupled with the broader feminist movement’s support, was crucial in transforming personal grief into a public issue that led to significant legislative changes. These changes include the creation of “Johanna’s Law,” which mandates improved hospital protocols and health professional training to handle perinatal deaths more sensitively and effectively. The study concludes that collective action is a powerful catalyst for creating transformative legislation that addresses the systemic issues of obstetric violence in Argentina.

Sensitive LC-MS/MS Assay for Total Testosterone Quantification on Unit Resolution and High-Resolution Instruments.

Background: Testosterone is an androgenic hormone that plays important roles in both males and females. The circulating levels of total testosterone vary from 1 to 1480 ng/dL. High-throughput immunoassays often lack accuracy in lower concentration ranges (below 100 ng/dL), particularly when used for females or children. To address this limitation, we developed a total testosterone LC-MS/MS assay on three instruments. Methods: Sample preparation began with the dilution and conditioning of 200 µL of serum. A supported liquid extraction cartridge was used to extract the analyte from biological matrices. Chromatographic separation was achieved using a C18 column with a runtime of 5 min per sample. This assay was validated on a Triple Quad 6500 and an API 4500 instrument. Results: Method validation was carried out according to the CLSI C62-ED2 guideline and our hospital protocol. The within-day coefficient of variation (CV) was less than 10% and the between-day CV was less than 15%. The assay had a limit of quantitation of 0.5 ng/dL with an analyte measure range of 2-1200 ng/dL. A comparison using Deming regression and Bland-Altman plots showed that this assay correlated well with a reference method. The results from the API 4500 and an Orbitrap were consistent with those from the TQ 6500. Both serum-separator tubes (BD) and serum-activator tubes were found to be suitable. Conclusions: We successfully developed and validated a robust total testosterone LC-MS/MS assay for routine clinical testing. This assay was harmonized across two triple quadrupole instruments and one high-resolution mass spectrometer.

Point-of-care lung ultrasound in the diagnosis of childhood pneumonia.

Lung ultrasound is emerging as a rapid, simple and safe alternative for diagnosing pneumonia since it has a higher sensitivity than X-rays and lower radiation exposure than computerized tomography. This is a prospective observational study done at a tertiary care centre in Chennai to study the diagnostic utility of lung ultrasound in pneumonia. Children aged 1 month to 12 years who were admitted to the hospital with complaints of cough, fever and/or breathing difficulty and on examination had tachypnea and/or chest indrawing were included in the study. All children underwent chest X-rays which was a standard hospital protocol. At admission, an independent investigator who was blinded to the clinical and radiological features of the child performed lung ultrasound. In all children, the final diagnosis of pneumonia was made by another independent expert paediatrician on the basis of the clinical features and chest X-ray. The test characteristics of ultrasound and chest X-ray were compared against this gold standard of physician-diagnosed pneumonia. Out of the 252 children studied, 225 (89.3%) had pneumonia while the rest 27 (10.7%) had other diagnoses. Among the 225 children with pneumonia, 223 (99.1%) were detected by ultrasound while 157 (69.8%) were detected by chest X-ray. All the test characteristics such as sensitivity, specificity, positive and negative predictive values of ultrasound were higher than those of chest X-ray. The sensitivity and specificity of ultrasound to diagnose pneumonia were 99.11% and 81.48%, respectively, while the sensitivity and specificity of X-ray for the same were 69.77% and 74.07%, respectively. Overall diagnostic accuracy for chest ultrasonography was 97.22% (94.36% to 98.88%), whereas for chest radiography, it was found to be 70.24% (64.18% to 75.81%).While both modalities were able to diagnose pneumonia significantly, ultrasound had better strength of association (Cramer's V value = 0.849) than X-ray to the final diagnosis. Lung ultrasound can be employed as a point-of-care investigation to diagnose pneumonia in suspected cases and can even replace chest X-ray in such circumstances.

Antimicrobial surface coating in the emergency department as protective technology for infection control (ASEPTIC): a pilot randomized controlled trial

Study objectiveWe examined the effectiveness of an antimicrobial surface coating for continual disinfection of high touch-frequency surfaces in the emergency department (ED).MethodsFollowing a preliminary observation identifying stretcher rails as the surface with highest touch-frequency in the ED, we conducted a pilot randomized controlled trial involving 96 stretcher rails. The stretchers were randomized to receive an antimicrobial surface coating or placebo coating. Routine cleaning of stretchers subsequently continued as per hospital protocol in both arms. Sampling for total aerobic, gram-positive halophilic, gram-negative and methicillin-resistant Staphylococcus aureus bacteria was performed pre- and post-treatment at 24 h, 7 days and 180 days. Individuals who applied the coating and outcome assessors were blinded to the allocated arms. The primary outcome is contamination of antimicrobial versus placebo rails measured as colony forming units per cm2(CFU/cm2).ResultsBaseline total aerobic bacteria was comparable between placebo and intervention arms (0.84 versus 1.32 CFU/cm2, P = 0.235). Total aerobic bacteria contamination was significantly lower on antimicrobial versus placebo rails at 24 h (0.61 versus 1.01 CFU/cm2, median difference 0.40 CFU/cm2, 95% confidence interval [CI] 0.01 to 1.01 CFU/cm2). There was a non-statistically significant tendency for contamination to be lower on antimicrobial versus placebo rails at 7 days (1.15 versus 1.50 CFU/cm2, median difference 0.35 CFU/cm2, 95% CI -0.64 to 1.28 CFU/cm2), but higher at 180 days (2.06 versus 1.84 CFU/cm2, median difference − 0.22 CFU/cm2, 95% CI -1.19 to 0.78 CFU/cm2).ConclusionThis is the first double-blinded, placebo-controlled, randomized trial to evaluate an antimicrobial surface coating on high touch-frequency surfaces in the emergency department. Total aerobic bacteria found on antimicrobial-coated patient transport stretcher rails was significantly lower than placebo rails at 24 h.

Community Healthcare-Associated Infections: Enhancing Control with Software and Tailored Protocols

Abstract Issue/Problem Healthcare-associated infections are major global public health challenges. In Portugal, the prevalence of resistant Enterobacteriaceae is particularly alarming. Studies typically focus on hospitals and long-term care facilities, neglecting community settings where patients, particularly the elderly with multiple comorbidities, often transition between hospital and home. Description of the problem Effective control measures are vital across all healthcare environments. In home care, sporadic implementation of Contact Precautions, due to the lack of specific guidelines and challenges in accessing colonization information, has been a major gap. This project aimed to close this gap by integrating a software, previously used only in hospitals, to enhance infection control in domiciliary care. The intervention adapted contact transmission-based precautions for home settings and used data from the previous year’s infections and colonization to tailor recommendations for each patient, preventing transmission between homes and enhancing caregiver education. Results Preliminary data from a two-month monitoring period involved 40 patients under the care of three domiciliary teams. Eleven had records of infections involving 19 microorganisms, including 7 Enterobacteriaceae, five of which were carbapenemase producers. This led to five customized recommendations for improved precautions. The intervention also heightened nurses’ awareness of patients’ microbiological histories, evidenced by increased inquiries to the infection control team. Lessons Adapting measures to the unique dynamics of home care, distinct from hospital settings, is critical. Involvement of care teams in decision-making ensures practical adherence and enhances measure effectiveness. Regular monitoring is crucial for compliance, making this approach a model for other settings. Key messages • Adapting hospital protocols to community settings and offering close support to caregiving teams increases compliance. • Implementing software that facilitates communication about infection and colonization enhances infection control effectiveness in community settings.