Inappropriate Interventions Research Articles

"You sure she's not making this up?": A qualitative investigation of stigma toward adults with borderline personality disorder in physical healthcare settings.

Borderline personality disorder (BPD) is associated with pervasive stigma that contributes to several consequences, such as inaccessible and inadequate healthcare. Existing literature concerning the experiences of BPD stigma within healthcare settings predominantly centers on mental healthcare contexts. However, individuals with BPD also present with elevated physical disabilities and health concerns, demonstrating a need for regular contact with medical professionals to manage and coordinate physical healthcare. The current qualitative study analyzes the dynamics of stigma and consequences in medical settings for physical healthcare among individuals diagnosed with BPD. Community adults (N = 16, Mage = 29.50, 44% cisgender women) provided qualitative responses describing their experiences with stigma in medical settings other than for mental health purposes. The inductive thematic analysis generated six key themes: (1) Dismissal and Misattribution of Physical Symptoms, (2) Delayed or Inappropriate Medical Diagnosis and Intervention, (3) Communication and Advocacy Challenges, (4) Invalidation of Emotional Well-Being and Distress, (5) Self-Harm Stigma, and (6) Presumed Drug-Seeking Behavior. This article demonstrates the persistent and complex role of stigma across physical healthcare settings for individuals with BPD, affecting their physical and mental healthcare outcomes. It also identifies areas for future research and improvement and offers insights to ameliorate these issues.

Does virtual reality affect breast cancer patients' pain?: A literature review

Purpose: To comprehensively analyze scientific evidence regarding the effect of virtual reality on pain in breast cancer patients. Method: This is literature study using PubMed, ScienceDirect and Cochrane Library databases. The inclusion criteria in this literature review are articles published in the last 5 years (2020-2024), articles using Indonesian and English in journals of national or international reputation and research articles. The selected articles are articles that the author can download or open access. Result: Of the total 493 articles, there were 9 articles that were duplicates or the same article. After that, it was found that the titles of 457 articles did not match the topic. There were 14 articles that did not meet the inclusion criteria and 7 articles had inappropriate interventions and methodology. Finally, 5 articles were obtained that were suitable for analysis. Conclusion: The use of VR can effectively reduce levels of pain, anxiety, fatigue and depression in breast cancer patients, as well as improve their quality of life. These findings suggest that VR has the potential to be a valuable adjunct in the pain management of breast cancer patients.

Long-Term Outcomes in ICD: All-Causes Mortality and First Appropriate Intervention in Ischemic and Nonischemic Etiologies

Real-life data comparing the long-term outcome in patients with different heart diseases carrying an implantable cardioverter defibrillator (ICD) are scarce. This study aimed to compare the long-term risk of the first appropriate ICD intervention and overall survival in patients with ICD and heart disease of different etiologies. Patients with an ICD implanted between January 1, 2010, and December 31, 2022, followed in our center were included. Study outcomes were all-cause mortality and first appropriate ICD intervention. A comparison between ischemic heart disease (IHD) and non-IHD (NIHD) was performed. In NIHD different etiologies of dilated cardiomyopathy (DCM) were analyzed. Overall, 1184 patients (592 IDH; 592 NIHD) were included. During a median follow-up of 53 months all-cause death occurred in 399 patients (34%) whereas first appropriate ICD intervention occurred in 320 (27%). All-cause mortality was significantly higher in IHD vs NIHD patients (60% vs 43%; p <0.0001) but no differences in appropriate ICD intervention rate at 10 years (34% vs 40%; p = 0.125) were observed. In patients with NIHD, a higher 10-year mortality rate was found in valvular heart disease, post-radio/chemotherapy DCM (rctDCM), and hypertensive DCM. Hypertrophic cardiomyopathy, alcoholic DCM, and rctDCM were the least arrhythmic phenotypes in NIHD. Of note, inappropriate interventions in alcoholic DCM and rctDCM were higher than appropriate ones. In conclusion, the rate of ICD-appropriate interventions and mortality is different according to the etiology of heart disease and cardiovascular risk profile; this should be taken into consideration in the prognostic stratification of these patients at the time of implantation.

Hybrid lane change strategy of autonomous vehicles based on SOAR cognitive architecture and deep reinforcement learning

Research on lane change strategies for autonomous vehicles holds paramount importance in optimizing traffic flow efficiency, enhancing driving safety, and adapting to complex traffic environments. While numerous rule-based or machine-learning approaches have been explored to tackle the challenge of lane change on highways, they frequently exhibit limited performance owing to the complexity of driving environments. This study proposes a novel lane change strategy for autonomous vehicles, which utilizes a hybrid framework integrating the SOAR cognitive architecture and deep reinforcement learning (DRL) to address the lane change challenge on highways. First, we introduce a rule extraction algorithm, the RuleCOSI+, which is based on tree ensemble algorithms, designed to extract concise lane change rules from large-scale human driving data. These straightforward rules, together with traffic regulations and safety rules, constitute the long-term memory of the SOAR cognitive architecture, enabling transparent decision-making processes. Next, by analyzing the clipping mechanism of the proximal policy optimization (PPO) algorithm, we propose an Adaptive Clipping PPO (ACPPO) algorithm which is based on the importance of samples. This algorithm adopts different clipping strategies for SOAR samples and ACPPO samples during the training process, enabling the algorithm to more effectively utilize samples with different levels of importance. Then, we propose a hybrid decision-making algorithm: SOAR-ACPPO, which combines the SOAR cognitive architecture with the ACPPO algorithm. This algorithm leverages SOAR’s prior knowledge to effectively and safely guide agent learning. Finally, by selecting appropriate intervention probability and weaning strategy, the system avoids inappropriate knowledge intervention and ensures adequate environment exploration. Simulation experiments conducted using the CARLA simulator illustrate that the proposed strategy not only improves model learning efficiency but also enhances driving efficiency and safety. Additionally, it demonstrates a certain degree of human-like characteristics and interpretability.

Predicting somatic mutation origins in cell-free DNA by semi-supervised GAN models

MotivationDistinguishing between pathogenic cancer-associated mutations and other somatic variants present in cell-free DNA (cfDNA) is one of the challenges in the field of liquid biopsy. This distinction is critical, since the misclassification of mutations stemming from clonal hematopoiesis (CH) as tumor-derived and vice versa could result in inaccurate diagnoses and inappropriate therapeutic interventions for patients. ResultsWe addressed this by developing a specialized machine learning technique to differentiate tumor- or CH-related mutations in cfDNA. We established a comprehensive in-house reference catalog, comprising approximately 25,000 single nucleotide variants (SNVs), each linked to either tumor or CH origin. This reference serves as a foundation for training a deep learning model, which is structured on the semi-supervised generative adversarial network (SSGAN) architecture. By analyzing genomic coordinates and nucleotide composition of cfDNA variants, our model attains 95 % area under the curve (AUC) in classifying uncharacterized variants as CH or tumor-derived. In conclusion, our research emphasizes the potential of genomic feature prediction, using cfDNA data, to stand as a robust alternative to conventional multi-analyte sequencing methods. This approach not only enhances the accuracy of distinguishing CH from tumor mutations in liquid biopsy data, but also highlights the potential of advanced data analysis techniques and machine learning in genomics and personalized medicine. Availability: https://github.com/FPalizban/SSGAN.

Racism, not race: Quantitative analysis of the use of race and racism in the addiction literature

RationalePrior research has demonstrated that medical journals rarely mention racism, potentially contributing to an incorrect understanding of and inappropriate interventions for health inequities affecting Black and Brown communities in the US. While this infrequency of mentions of racism has been documented in the general medical literature, it is unknown if this pattern extends to the addiction literature, where some have argued that structural racism has played a specific role in shaping policy and treatment. ObjectiveTo assess how frequently the addiction literature for the last 30 years has mentioned race and racism and if these rates vary with social movements. MethodsWe created an algorithm to download and process over 30,000 published articles published from 1990 to 2022 in five major addiction journals: Addiction, Addictive Behaviors, Drug and Alcohol Dependence, Journal of Substance Abuse and Treatment, and International Journal of Drug Policy. Using this data, we reported temporal patterns of mentioning both race and racism across journals and article types. Further, we utilized interrupted time series analysis to identify if the social movements against police violence and the murder of George Floyd in 2020 were associated with significant changes in rates of mentioning racism. ResultsWhile over 30% of the articles in addiction medicine journals included the word race, only 1.5% of articles mentioned racism. Based on an interrupted time series model, after the racial reckoning following the murder of George Floyd in 2020, mentions of racism increased in the addiction literature (OR = 3.21, 95% CI: [2.39, 4.32], P<.001). ConclusionsA large chasm remains between how often authors mention race versus racism in addiction medicine, a field with a unique history intertwined with structural racism. Addressing inequities in addiction outcomes, including burgeoning inequities in overdose deaths, will require acknowledging racism in the scientific literature.

Pain management experience among emergency working nurses

Pain is one of the main reasons why a patient is required to appear at the emergency department. According to the literature, one of the main factors leading to inadequate nursing care of pain has been inadequate assessment of the pain threshold, delay in interventions, and poor knowledge of the nursing staff. This study aimed to explore and describe emergency nurses’ experiences during pain management and identify the barriers they encounter when providing this care. A qualitative study, with a focus group composed of 10 nurses, through open questions, was conducted in April 2023 at the emergency nurses of the Regional Hospital "Xhaferr Kongoli" Elbasan. The questions were designed based on the literature and included the evaluation of the method of pain management in the emergency room, the interventions of nurses, the obstacles that nursing staff face during patient care, and the way to address these obstacles. The duration of the interviews ranged from 25 to 35 minutes. Demographic data were analyzed using descriptive statistics, and interview data were analyzed by qualitative thematic analysis. Ten nurses were interviewed, with a mean age of 40.1 years and 7.3 years of work experience in the emergency department. The thematic analysis of the data identified three main themes and subthemes, including Management of situations, Planning, and Challenges. Our study identified nurses' experiences in planning interventions for patients with pain. Early protocol-based pain management can improve patient outcomes and reduce inappropriate interventions. More research is needed to identify these interventions and examine how they interact with ineffective pain management. More studies are needed to highlight the role of nurses in pain assessment and pain management in emergency departments.

Mach band effect: A source of diagnostic error in intensive care unit

Abstract This is a case of pseudopneumothorax caused by skin fold artifact in chest X-ray. This is important to diagnose as it can lead to inappropriate intervention or radiation exposure as in this case. Human eye’s ability to perceive margin by contrast difference is Mach band effect.

Predictors of occult metastases in potentially Resectable pancreatic ductal adenocarcinoma

BackgroundPatients with resectable (R) or borderline resectable (BR) pancreatic ductal adenocarcinoma (PDAC) sometimes show unexpected liver, peritoneal, and para-aortic lymph node metastases intraoperatively. Despite radical pancreatectomy, a nonnegligible number of patients relapse within 6 months after surgery. The aim of this study was to identify the preoperative predictors of occult metastases (OM), defined as intraoperative distant metastases or within 6 months after pancreatectomy. Materials and methodsThis study included patients with R and BR PDAC who underwent curative-intent pancreatectomy or staging laparoscopy between 2006 and 2021. Multivariate logistic regression and Cox hazard analyses were performed to identify the preoperative predictors of OM and to assess the impact of these factors on prognosis after pancreatectomy. ResultsOf the 279 patients, OM was observed intraoperatively in 47 and postoperatively in 34. In the OM group, there were no differences in prognosis between patients who had intraoperative metastases and recurrence within 6 months (median survival time [MST], 18.1 vs. 12.9 months), and between patients who underwent pancreatectomy and those who did not (MST, 13.9 vs. 18.1 months). Preoperative tumor size ≥22 mm (odds ratio [OR], 2.03; 95 % confidence interval [CI], 1.16–3.53; p = 0.013) and preoperative CA19–9 level ≥ 118.8 U/mL (OR, 2.64; 95 % CI, 1.22–5.73; p = 0.014) were significant predictors of OM. Additionally, positive OM predictors were strong independent prognostic factors for overall survival after pancreatectomy (hazard ratio, 2.47; 95 % CI, 1.54–3.98; p < 0.001). ConclusionMultidisciplinary treatment strategies should be considered for patients with predictors of OM to avoid inappropriate surgical interventions.

Placebo immune-related adverse events (irAEs): A neglected phenomenon in cancer immunotherapy trials

PurposeThis study aims to investigate the underexplored prevalence of placebo-reported immune-related adverse events (irAEs) in immune checkpoint inhibitor (ICI) trials. MethodsWe searched public databases for randomized clinical trials (RCTs) involving ICI versus placebo treatments in patients with malignancies. Study characteristics and irAEs occurrences were extracted for meta-analyses using a random-effects model. Main OutcomesProportions of patients reported to experience any grade and grade 3 to 5 placebo irAEs; the risk ratio (RR) of reporting 'false' irAEs in the experiment arm (defined as 'false-irAE ratio', calculated by dividing the proportion of patients documented with irAEs in the placebo arm by that in the experimental arm). Results47 RCTs with 30,119 patients were analyzed. The pooled proportion of patients reported to experience any grade and grade 3 to 5 irAEs among placebo participants was 22.85 % (17.33 %−29.50 %) and 3.40 % (2.35 %−4.63 %), respectively. The pooled proportion of placebo-treated patients who experienced serious irAEs was 0.67 % (0.03 %−1.91 %). Treatment discontinuation and death due to placebo irAEs occurred in 0.69 % (<0.01 %−1.30 %) and 0.12 % (<0.01 %−0.40 %) of patients, respectively. The false-irAE ratio for any grade and grade 3 to 5 irAEs were 0.49 and 0.28. The false-irAE ratio was significantly higher in RCTs with control arms of placebo plus non-immunotherapy than in those with placebo alone (any grade: 0.57 vs. 0.32, P < 0.001; grade 3 to 5: 0.36 vs. 0.12, P = 0.009). ConclusionOur analyses of placebo-treated participants in ICI RCTs document the common occurrence of placebo irAEs. These findings are important for interpreting irAE profiles, avoiding inappropriate therapeutic interventions.

Schwannoma masquerading as a thyroid nodule: A diagnostic delimma.

We present a case of a 70 years old female presenting with a long-standing neck swelling with a recent increase in size and new onset pain. It was initially diagnosed and operated on as a cold nodule of thyroid as her thyroid scan showed left cold nodule and FNAC was inconclusive. However, a final diagnosis of schwannoma with Antoni A structures was made on histopathological attributes. Schwannomas are benign peripheral nerve tumors which grow slowly on parent nerves. The mainstay of treatment is surgical excision. To avoid unnecessary or inappropriate interventions, thorough pre-operative assessment is required in case of thyroid or non-thyroidal lesions as most are hypoechogenic on ultrasonography and fine needle aspiration has low diagnostic yield. The key pre-operative investigations are ultrasound and ultrasound guided cytology and immunohistochemical staining (for example S-100, calcitonin, CEA, thyroglobulin, TTF-1, melan-A, HMB45 and Ki-67). MRI is also a good diagnostic tool in neck swellings where diagnosis is uncertain.

Identifying, Understanding, and Minimizing Unconscious Cognitive Biases in Perioperative Crisis Management: A Narrative Review.

Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.

Cytopathology and clinicopathological correlation of renal neuroendocrine neoplasms

There is a lack of documentation regarding cytopathology of renal neuroendocrine neoplasms (NENs) due to their rarity. Five cytology cases were gathered from 3 institutes. Cohort consisted of 4 females and 1 male. Fine needle aspiration biopsy and touch preparation slides of core needle biopsy revealed cellular samples, composed of round, plasmacytoid, or columnar cells. Tumor cells were present in nested, acinar, 3D cluster, and individual cell patterns. Tumor cells in 3 cases exhibited uniformly round to oval small nuclei with inconspicuous nucleoli, finely granular chromatin, and smooth nuclear membranes, whereas 2 other cases showed pleomorphic nuclei with conspicuous nucleoli, nuclear molding, and irregular nuclear membranes. Tumor cells displayed pale or granular cytoplasm, with 1 case showing small vacuoles. Examination of cores and cell blocks demonstrated tumor cells in sheets, nests, or acini. All tumor cells were positive for neuroendocrine immunomarkers. Based on mitotic count, Ki-67 index and morphology, 3 tumors were graded as well-differentiated neuroendocrine tumor (WDNET) (1 grade [G] 3, 1 G2, 1 G1) and 2 as large cell neuroendocrine carcinoma. Deletion of 7q, 10q, and 19q was detected in WDNETs. Two patients with large cell neuroendocrine carcinoma and 1 with WDNET G3 underwent chemotherapy due to aggressiveness, whereas nephrectomy was performed for patients with WDNET G1 and 2 without metastasis. Cytopathological characteristics of renal NENs closely resemble those affecting other organs. Despite its rarity, renal NENs should be kept in mind when confronted with morphological resemblances to NENs, to prevent misdiagnosis and inappropriate therapeutic interventions.

Unmasking the Imitators: Challenges in Identifying Intracranial Atherosclerosis‐Related Large Vessel Occlusion Mimics During Mechanical Thrombectomy

This manuscript provides a comprehensive review of intracranial atherosclerosis (ICAS)‐related large‐vessel occlusion (ICAS‐LVO) and its mimics, focusing on the challenges in diagnosis and the need for precise diagnostic methodologies, particularly in the context of endovascular therapy. ICAS‐LVO is a significant contributor to acute ischemic stroke, with varying prevalence rates across regions. ICAS‐LVO is characterized by the presence of residual focal fixed stenosis or reocclusion following endovascular treatment or evidence of distal hypoperfusion or watershed infarction on follow‐up imaging. Despite digital subtraction angiography being the gold standard, diagnosing ICAS‐LVO is complicated by similarities with other occlusive conditions, leading to misdiagnosis and inappropriate interventions. The review explores angiographic mimics of ICAS‐LVO, such as intracranial vasospasm, intracranial dissection, partially occlusive thrombus, and rare vasculopathies like Moyamoya disease, reversible cerebral vasoconstriction syndrome, and vasculitis. Each mimic is meticulously examined, providing insights into their distinctive features, diagnostic considerations, and potential interventions. The manuscript emphasizes the importance of early identification of these mimics to guide appropriate interventions and prevent complications. Future perspectives include the incorporation of advanced imaging tools such as integration of artificial intelligence for automated image analysis, and deployment of advanced imaging techniques such as intravascular ultrasound and optical coherence tomography for a more comprehensive radiographical characterization of ICAS‐LVO. Improved diagnostic criteria and ongoing research will play a pivotal role in addressing the challenges of distinguishing ICAS‐LVO from its mimics.

Managing End of Life Care for the Critically Ill: A Novel Program to Deliver Bedside Critical Care Without Transfer to the Intensive Care Unit.

Background: Navigating medical care at the end of life can be a challenging experience for patients. There are also significant resource burdens, including intensive care unit (ICU) admissions, accompanying terminal illness. For actively dying patients, developing a care plan based on patient goals and delivering care at the bedside can enhance patient well-being, avoid inappropriate transfers or interventions, and improve resource management. Methods: The Rapid Response Team (RRT) is an around the clock intensivist service that responds to all acutely decompensating patients in our hospital. Through the Appropriate Care Escalation (ACE) program, the RRT intensivist identifies amongst decompensating patients, terminally ill individuals for whom prognosis is extremely poor irrespective of available interventions. These patients receive discussions about goals of care, code status, and management options. They receive care on a dedicated stepdown unit without escalation to the ICU. If aligned with patient goals, care plans incorporate critical care interventions including ventilator and vasopressor therapy. Results: Over 5years, RRT identified 413 terminally ill patients under the ACE program to continue end of life care on the stepdown unit. Following discussions of goals, 60.8% of patients requested DNR/DNI, 30.9% were full code, and 8.5% requested DNR/OK-TO-INTUBATE status. At discharge, 82.1% of ACE patients expired compared to 23% of all RRT consultations. Patients received 233 critical care procedures at bedside including intubations, central access catheters and bronchoscopy. Conclusion: The ACE program helped identify, in real time, actively dying, terminally ill patients, establish patient goals, and expand critical care services outside the ICU.

Lime thermal plasters and energy efficiency in traditional buildings : Ancient materials combined to optimise building performance

Traditional buildings have a central role to play in Europe’s plans to be the first climate-neutral continent by 2050, with the building sector being the single largest energy consumer in the EU with 40 per cent of total energy use. Seventy-five per cent of the existing housing stock is energy inefficient with minute numbers renovated each year. Existing buildings offer huge potential for energy use reduction. Research has shown that a historic retrofit can emit less carbon compared to demolishment and rebuilding. Reductions in carbon emissions of up to 62 per cent were observed across a body of case studies by Historic England, including a 95 per cent reduction in the mews case study described in this paper. Moreover, carefully managed thermal retrofits, taking a ‘whole house approach’, have many benefits, including improved indoor comfort and air quality as well as reduced operational costs. These are factors which are fundamental in ensuring the continued use of historic constructions while improving their standards of preservation and durability. Thermally upgrading traditional building is still a much-debated topic. Inappropriate thermal interventions with unsuitable materials and finishes can have unforeseen consequences, resulting in building damage and a reduction in internal comfort, health and well-being. This paper aims to contribute to this discussion by providing an overview of key considerations when thermally upgrading the walls of traditional buildings while preserving unique characteristics and functionality. Advantages of adopting thermal mortars such as cork lime are put forward, and their potential efficacy is discussed, concluding with a case study focusing on the deep retrofit of a London mews within a conservation area.

Brugada syndrome in Iran: Insights from a 12-year longitudinal study.

Brugada syndrome (BrS) is characterized by ST-segment elevation in the right precordial leads, which is not explained by ischemia, electrolyte disturbances, or obvious structural heart disease. In present study, we aim to evaluate presentation, long-term outcome, genetic findings, and therapeutic interventions in patients with BrS. Between September 2001 and June 2022, all consecutive patients with diagnosis of BrS were enrolled in the present study. All patients gave written informed consent for the procedure, and the local ethical committee approved the study. Of the 76 cases, 79% were proband and 21% were detected during screening after diagnosis of BrS in a family member. Thirty-three (43%) patients had a typical spontaneous electrocardiogram (ECG) pattern. Thirty percent of the patients were symptomatic; symptomatic patients were more likely to have spontaneous type 1 Brugada ECG pattern in their ECGs (p = .01), longer PR interval (p = .03), and SCN5A mutation (p = .01) than asymptomatic patients. The mean PR interval was considerably longer in men than women (p = .034). SCN5A mutation was found in 9 out of 50 (18%) studied patients. Fifteen percent received appropriate implantable cardioverter-defibrillator (ICD) therapy and inappropriate ICD interventions were observed in 17%. Presentation with aborted SCD or arrhythmic syncope was the only predictor of adverse outcome in follow-up (odds ratio: 3.1, 95% confidence interval: 0.7-19.6, p = .001). Symptomatic patients with BrS are more likely to present with spontaneous type 1 Brugada ECG pattern, longer PR interval, and pathogenic mutation in SCN5A gene. Appropriate ICD interventions are more likely in symptomatic patients and those with SCN5A mutation.

Standard practices in cardiac monitoring: training needs of intensive care unit nurses

BackgroundEnforcing practice standards for cardiac monitoring in intensive care units (ICUs) has been shown to reduce misdiagnoses and inappropriate interventions. Continuous professional development (CPD) programs are committed to aligning clinical practices with recommended standards. The crucial initial phase in CPD development involves assessing the training needs of the targeted population.ObjectiveTo assess the training needs of ICU nurses in cardiac monitoring. The overarching goal was to formulate a focused Continuous Professional Development (CPD) program geared towards implementing standard practices in cardiac monitoring.MethodsThis study employed a generic qualitative approach with a descriptive design, utilizing interviews and focus groups from July to September 2018. Involving 16 ICU nurses. Content analysis was employed, encompassing transcription, fluctuant and iterative reading, unitization, categorization, coding, description, and interpretation.ResultsAll nurses recognized cardiac monitoring’s importance in the ICU but reported barriers to its effective implementation which were related to factors that could addressed by a CPD as insufficient knowledge and skills. Training needs were identified in both clinical and technical aspects, with recommendations for practical and theoretical activities and e-learning strategies. Barriers related to organizational aspects (equipment and communication within the healthcare team) were also mentioned.ConclusionICU nurses presented clear and specific training needs related to cardiac monitoring as knowledge, skills, and competencies. Other organizational aspects were also reported as barriers. Addressing these learning needs through targeted CPD aligned with organizational initiatives can contribute to enhancing the quality of cardiac monitoring practices in ICUs.

1882 Treatment Escalation Plans (TEP): benefits in adult in-patient facilities

Abstract Introduction Treatment escalation plans (TEP) guide level of life sustaining therapeutic interventions that should occur for each patient admitted to hospital and can prevent inappropriate and undignified interventions. However, implementation of TEP in routine clinical practise has been ad hoc partly due to the paucity of literature on their benefits. Our aim was to systematically review the literature to ascertain the use and benefits of TEP in adults. Methods A systematic search for studies reporting TEP use were performed in the databases OVID Medline, Embase, Scopus and Web of Science. Search terms were ‘Treatment Escalation Plan’ Treatment Limitation, ‘Therapy Escalation’, ‘Escalation of Care’, ‘Palliative’, End of Life’, ‘Advanced Care Plan’. Exclusion criteria included studies prior to 2007, systematic reviews, case reports and letters. Results 468 records were retrieved, 117 duplicates removed, 351 records were screened. 302 were excluded by date or relevance. Of 49 eligible records, 39 were excluded by criteria or unavailability of full text articles. 10 Studies using case control and quality improvement methodology conducted between 2010-2022 involving 1614 patients were subject to a narrative review. 8 different TEP proformas were used. All studies reported an increase in TEP use across all clinical settings and after each PDSA intervention ranging from 78%-100%. TEP reduced the frequency of non-beneficial interventions and was associated with an average saving of £220 per patient. Conclusions TEP lead to more frequent and proactive discussions with patients on ceilings of care and provide clear guidance to clinical staff out of hours, facilitate patient handover over successive shifts and enable proactive discussions with critical care. We identified the need for TEP to be successfully implemented in a unified manner across all healthcare facilities in order to improve patient care, reduce the burden of non-beneficial interventions and align with the NHS Long Term Plan.

Spontaneous Rupture of the Gravid Uterus in a Multigravida Women with a Previous History of Caesarean Section: A Case Report

Spontaneous uterine rupture is a rare obstetric complication that has catastrophic effects on both the mother and foetus, resulting in significant morbidity and 80 to 90% foetal mortality. Rupture of the uterus through a previous lower uterine segment scar is the most common cause in developing nations. However, factors such as lack of antenatal care, inappropriate obstetric interventions, obstructed labour, grand multiparity, unbooked status, limited access to emergency obstetric care, and low socioeconomic status play a crucial role in uterine rupture in developing countries like India. Hereby, the authors present a case report of a 31-year-old pregnant patient at 19 weeks of gestation with sudden severe lower abdominal pain. An ultrasound revealed the absence of foetal cardiac activity, placenta located outside the uterus, an empty endometrial cavity, and minimal free fluid in the pelvis. Further, an Magnetic Resonance Imaging (MRI) of the pelvis showed a rupture of the anterior and right lateral uterine wall, through which the foetus and most of the placental tissue had passed into the peritoneal cavity. After confirming the diagnosis, the patient underwent emergency laparotomy, during which the uterine wall defect was closed with appropriate haemostasis. The patient recovered without any untoward complications.