Patient Bedside Research Articles

A taxonomy for brainstem cavernous malformations: subtypes of midbrain lesions.

Anatomical taxonomy is a practical tool that has successfully guided clinical decision-making for patients with brain arteriovenous malformations. Brainstem cavernous malformations (BSCMs) are similarly complex lesions that are difficult to access and highly variable in size, shape, and position. The authors propose a novel taxonomy for midbrain cavernous malformations based on clinical presentation (syndromes) and anatomical location (identified with MRI). The taxonomy system was developed and applied to an extensive 2-surgeon experience over a 30-year period (1990-2019). Of 551 patients with appropriate data who underwent microsurgical resection of BSCMs, 151 (27.4%) had midbrain lesions. These lesions were further subtyped on the basis of predominant surface presentation identified on preoperative MRI. Five distinct subtypes of midbrain BSCMs were defined: interpeduncular (7 lesions [4.6%]), peduncular (37 [24.5%]), tegmental (73 [48.3%]), quadrigeminal (27 [17.9%]), and periaqueductal (7 [4.6%]). Neurological outcomes were assessed using modified Rankin Scale (mRS) scores. A postoperative score ≤ 2 was defined as a favorable outcome; a score > 2 was defined as a poor outcome. Clinical and surgical characteristics and neurological outcomes were compared among subtypes. Each midbrain BSCM subtype was associated with a recognizable constellation of neurological symptoms. Patients with interpeduncular lesions commonly presented with ipsilateral oculomotor nerve palsy and contralateral cerebellar ataxia or dyscoordination. Peduncular lesions were associated with contralateral hemiparesis and ipsilateral oculomotor nerve palsy. Patients with tegmental lesions were the most likely to present with contralateral sensory deficits, whereas those with quadrigeminal lesions commonly presented with the features of Parinaud syndrome. Periaqueductal lesions were the most likely to cause obstructive hydrocephalus. A single surgical approach was preferred (> 90% of cases) for each midbrain subtype: interpeduncular (transsylvian-interpeduncular approach [7/7 lesions]), peduncular (transsylvian-transpeduncular [24/37]), tegmental (lateral supracerebellar-infratentorial [73/73]), quadrigeminal (midline or paramedian supracerebellar-infratentorial [27/27]), and periaqueductal (transcallosal-transchoroidal fissure [6/7]). Favorable outcomes (mRS score ≤ 2) were observed in most patients (110/136 [80.9%]) with follow-up data. No significant differences in outcomes were observed between subtypes (p = 0.92). The study confirmed the authors' hypothesis that taxonomy for midbrain BSCMs can meaningfully guide the selection of surgical approach and resection strategy. The proposed taxonomy can increase diagnostic acumen at the patient bedside, help identify optimal surgical approaches, enhance the consistency of clinical communications and publications, and improve patient outcomes.

Prognostic factors in a contemporary cohort of cardiogenic shocks managed in ICU

Prognostic factors of cardiogenic shock remain imperfectly known. Studies where mostly interested in cardiogenic shock complicating myocardial infarction at the acute phase, thus forgetting other etiologies frequently met in the ICU. Furthermore, there is very little data on hemodynamic factors, even if they are easily accessible on daily practice at the patient bedside thanks to the current echocardiographic and biological measures. The aim of our study was to investigate the prognostic power of hemodynamic factors assessed in our daily practice at the ICU, whether they are biological (measurement of SvO 2 , lactates, pH and bicarbonates) or echocardiographic (cardiac index). We retrospectively included patients admitted to the ICU at the Louis-Pradel Hospital (Lyon – France) for cardiogenic shock in a single-center cohort (USICHOC). Inclusions took place from 2019 to 2021. Demographic, ultrasound and biological data (including arterial and venous blood gas) were collected for all patients at admission time. A total of 63 patients were included. Most of them were male (66.7%), the average age was 57 years, 44.4% were already known to have heart disease, most often ischemic. The precipitating factor for cardiogenic shock was also primarily ischemic. A SvO 2 ≤ 45% on admission was significantly associated with increased 30-day mortality (70% at 30 day). Arterial lactate ≥ 5 mmol/L on admission was also significantly associated with increased mortality (60% at 30 days). Neither acidosis (pH < 7.45), nor decreased bicarbonates (< 20 mmol/L), nor decreased cardiac index (< 1.8 L/min/m 2 ) were associated with a worse prognosis at 1 month. The overall death rate at 30 days was 28.6%. Furthermore, SvO 2 was significantly correlated with cardiac index. After 24 hours of treatment according to international guidelines, SvO 2 , pH, bicarbonate and cardiac index increased, while lactate decreased significantly. The median LVEF of the population at inclusion was 21% [31-15]. No association was found between LVEF and cardiac index. This is the first study to show that a SvO 2 ≤ 45% was significantly and associated with one-month mortality in patients admitted to the in the ICU for cardiogenic shock. Lactate elevation ≥ 5 mmol/L at admission time was also associated with an increased risk of one-month death. Neither cardiac index estimated by cardiac ultrasound at patient beside nor admission pH or bicarbonates were associated with a poorer prognosis.

Assess of Chemical and Biosensor Chips

A biosensor is an analytical instrument that combines a biological component with a physicochemical detector to detect a chemical molecule. A biosensor is a biological detection device that combines a biological component with a transducer to perform biochemical amount measurement. Biosensors are often designed to convert physical, chemical, or biological events into measurable signals, providing qualitative and/or quantitative data on the target analytes. While the topic of biosensors has attracted a lot of attention from scientists, combining it with micro fluidics could result in even more substantial gains in terms of sensitivity and specificity, resolution, automation, throughput, repeatability, dependability, and accuracy. Biosensors-on-chip (BoC) might thus serve as a bridge between diagnostics in central laboratories and diagnostics at the patient's bedside, allowing for significant breakthroughs in point-of-care (PoC) diagnostic applications. The purpose of this publication is to present an up-to-date review of BoC system development and their most current application in cancer, infectious diseases, and neurological disorders diagnosis. Leland C. Clark invented enzyme electrodes in 1962, which marked the beginning of biosensor development. A biosensor typically consists of an enzyme, antibody, or cell receptor, as well as a detecting device or transducer. Covalent bonding, matrix entrapment, physical adsorption, and membrane entrapment are some of the ways used to combine these two elements. A biosensor is a type of analytical equipment that detects chemical substances. They normally consist of three segments: sensor, transducer, and related electrons, and combine a biological component with a physicochemical conductor. Keywords: Biosensor chips, Silicon square chips, integrated photonic biosensors, revolutionize biology, bioreceptor, Biosensor technology

The Sword of Damocles: Family Presence and Extracorporeal Life Support During The COVID-19 Pandemic and Beyond.

During Ontario’s busiest surge of COVID-19 (coronavirus disease) to date, our Pediatric ICU at the Hospital for Sick Children (normally an entirely pediatric referral centre) admitted adult patients under our care. Our extracorporeal life support (ECLS) program quickly adapted to this new reality—we admitted adults previously cannulated to ECLS and cannulated a number of adult patients, while maintaining our usual pediatric ECLS cases. The following reflections stem from the family presence restrictions in place due to COVID-19, in particular the clarity these constraints have lent to our role in supporting families as they navigate the unique tension between life and death that is ECLS. Dionysius II, an ancient ruler of Syracuse, responded to a courtier’s flattery by having him rule in his stead for one day. That courtier, Damocles, eagerly embraced the opulence and power of his role but, looking up from his throne, noticed that Dionysius had placed a sword directly above his head—its handle was suspended from the ceiling by a single hair, to teach Damocles the danger inherent in the life of a ruler. Terrified, Damocles abandoned his newfound privileges and returned the crown to Dionysius. More than two millennia have passed, and we find ourselves struggling against the despotic rule of COVID-19, its viral structure even boasting its own corona, crown. Amidst the armamentarium of modern medicine, ECLS has affirmed its role as a last resort—veno-venous (V-V) ECLS, judiciously applied, has become a bridge to recovery1 (and in rare cases, lung transplantation2) with 90 day survival in the Extracorporeal Life Support Organization COVID-19 registry dashboard approaching 50%.3 When you place a patient on V-V ECLS after several hours of trying to coax gas exchange out of lungs which have become like stones, the team breathes a sigh of relief and, like Damocles surveying the gilt palace, basks in the glow of a better blood gas while the ECLS console hums with newfound hope in recovery. But like Damocles we all look up, sooner or later, and remember the sword that plagues our hopes and safety. Device failure, an intracranial bleed, an intrathoracic bleed, a gastrointestinal bleed, an opportunistic infection… these are kept at bay by a very thin thread. None of this is new to anyone who cares for patients supported on ECLS, yet we all forget at times to look up and ponder that sword. And more importantly, we struggle to help families maintain that awareness, to understand that when we say their loved one is stable on ECLS the latter two words represent a radical caveat to the first. The COVID-19 pandemic has served as an urgent reminder of the importance of ensuring families understand the inherently tenuous nature of their loved one’s path to recovery with ECLS. For those who cannot visit in person due to public health and infection control measures, it becomes imperative to use whatever tools are possible (including video platforms and language translation when necessary) to highlight the absolute dependence—of their spouse or partner, their parent, or their child or sibling—upon a machine that, at great risk, pumps blood in and out of their body through an oxygenator membrane. The myriad risks must be clear and ever present. For those who can visit, during and beyond COVID-19, we must advocate for frequent visits, daily if possible, consistent with the accompaniment that we would wish for any patient whose life hangs in the balance. COVID-19 has brought a tragic loss of life throughout the world, with the concomitant tragedy and trauma of countless patients who have borne suffering and died unaccompanied. Where public health authorities and infection control policies give us an inch we must take a mile and bring families to the bedside of patients supported on ECLS. When each day might see the sword of Damocles descend, it behooves us to make that sword visible and, more importantly, to make patients and families visible to one another as best we can. The challenge of supporting families through a patient’s prolonged dependence upon a terrifyingly high-risk therapy is a relatively novel challenge that will become more common in the years ahead, given the ever-expanding role of ECLS and increasingly versatile heart and organ-assist devices. How can we ensure that all parties glance with some regularity at the thin thread of survival, while also providing reassurance and encouraging some adaptation to a new normal that will never be normal? COVID-19 has served to highlight the fragile nature of communication in healthcare, and while the pandemic’s reign may end before long, we are now better equipped than ever before to engage patients and families in the day-to-day journey that is ECLS. Acknowledgment We wish to acknowledge the dedication of our extracorporeal life support (ECLS) team during our unprecedented role in treating adult patients with COVID-19 in our Pediatric ICU.

Visual Rounds Based on Multiorgan Point-of-Care Ultrasound in the ICU.

Point-of-care ultrasonography (POCUS) is performed by a treating clinician at the patient's bedside, provides a acquisition, interpretation, and immediate clinical integration based on ultrasonographic imaging. The use of POCUS is not limited to one specialty, protocol, or organ system. POCUS provides the treating clinician with real-time diagnostic and monitoring information. Visual rounds based on multiorgan POCUS act as an initiative to improve clinical practice in the Intensive Care Unit and are urgently needed as part of routine clinical practice.

'Excited Delirium', acute behavioural disturbance, death and diagnosis.

In the 1980s the traditional Hippocratic term excited delirium was transplanted from the bedsides of febrile, agitated and disoriented patients to the streets of Miami. Deaths in custody of young men who were intoxicated with cocaine and who were restrained by the police because of their erratic or violent behaviour were attributed to excited delirium. The blood concentrations of cocaine in these subjects were approximately ten times lower than the lethal level and other factors which might have contributed to the fatal outcome, such as the police use of neck-holds, choke-holds or 'hog-tying', were relegated to a minor role compared with the reframed 'diagnosis' of excited delirium. Over the course of the next few decades 'excited delirium' might be applied to virtually any highly agitated person behaving violently in a public place and who subsequently died in custody while being restrained or shortly afterwards. Expert witnesses, mainly forensic pathologists, testified that the deceased's death was probably inevitable given the perilous nature of excited delirium, even though this diagnostic entity lacked any consistent neuropathological basis and depended entirely on observed behaviour. This history of the rise and fall of this disputed diagnosis is a partial response to the sociologist Phil Brown's 1995 paper asking who benefits, or at least avoids trouble, by the identification and use of a diagnosis.

PRACTICAL ORIENTATION OF STUDENTS 'EDUCATION FROM THE POSITION OF INTEGRATION INTO THE SINGLE EDUCATIONAL EUROPEAN SPACE

Today, our country is actively integrating into the single European educational space, which consists in reforming and modernizing higher education through modern technologies of reorganization of the educational process, which results in improving the quality of education. Integration processes are ambiguous, have many different problems, the most important of which is the problem of unification of national cultures and national education systems, loss of national identity and loss of educational, cultural, national and ethnic diversity of the world. Training future doctors at the level of international standards is one of the most important strategic tasks of higher education in Ukraine.The teaching methodology involves a model of educational and professional activities designed by the teacher, which is implemented as a set of specific techniques, actions and operations. The method of teaching from the standpoint of teaching pediatric disciplines is a way of joint activities of a doctor-teacher and a student, aimed at achieving the goals and values that determine the formation of the future doctor's personality and mastering the basics of professional activity. Accordingly, there is a need to help improve the quality of practical knowledge and skills of future professionals. No matter how useful remote technologies are, the methods of the classical domestic medical school were and remain the main ones at the clinical department. Studying at the patient's bedside allows the student to better feel the atmosphere of the future profession. Analysis and evaluation of achievements is carried out with the help of pedagogical control and self-control, which allows to accurately identify the level and quality of knowledge, skills and abilities acquired by students, the degree of formation of educational activities and "internal" increments learning and under its influence understanding of oneself, one's changes. It is extremely important that students understand the functions of pedagogical control, so that they can cooperate with teachers and contribute to the improvement of the educational process. The quality of medical student training is the main indicator of the effectiveness of the department, faculty and the university in general. This directly affects the rating of a medical university, as well as the system of medical education in Ukraine.

Ward Round Management Skills of Pediatric Surgery Residents During Pediatric Burn Intensive Care Unit Rounds

Aim: Ward rounds are a central activity that all healthcare professionals are expected to perform daily in the hospital. In this study, it was aimed to evaluate the ward round management skills of pediatric surgery residents during their Pediatric Burn Intensive Care Unit ward rounds.Methods: In this cross-sectional study, the observation method was used. The study group of the research consisted of 8 pediatric surgery residents working in the pediatric surgery department of the center where the research was conducted. Two bedside clinical observations were made for each pediatric surgery resident participating in the study. In order to assess the ward round management skills of pediatric surgery residents, observations of 114 bedside patient rounds were made in 43 rounds. Number, percentage, mean and Mann Whitney U test were used to evaluate the data.Results: In both observations, it was determined that the averages of non-technical ward round management skills of the residents were lower than the averages of technical ward round skills. At the end of the first observation, there was no difference in terms of the experience period of the physicians and pediatric surgeons of the residents, but at the end of the second observation, there was a difference (p=0.044) in the mean score of the non-technical ward round management skills of the residents.Conclusions: It was observed that the technical ward round management skills of pediatric surgery residents were higher than the non-technical ward round management skills. According to the results of the second observation, non-technical ward round management were found to differ according to the experience and level of pediatric surgery residents.

Discordance between Emergency Department Electronic Health Record and Patient Self-Reported Data

Electronic Health Records (EHRs) have many clinical, financial, and logistical benefits, yet the extent of their accuracy is unknown. We compared patient self-reported data at emergency department (ED) presentations with the corresponding EHR, focusing on key demographics, physical characteristics, and social history. Emphasis was placed on understanding whether major life stressors were noted on patients’ charts and how that could impact quality of care. Life stressors are defined as life-altering and emotionally demanding or traumatic events. We enrolled a convenience sample of 357 ambulatory, English speaking, adult patients at the Vanderbilt University Medical Center Emergency Department, an urban, academic, tertiary care ED (annual census 70,000). We compared the EHR with self-reported data from bedside patient interviews, including information on demographics (age, sex, race, ethnicity), physical characteristics (height, weight), and life history (smoking, life stressors). Data was described using median and percent frequency, and it was analyzed using Cohen kappa statistics and Bland-Altman plots. Between EHR and patient-reports, sex and age matched in 99%, and race/ethnicity matched in 90%. Race was more discordant when the patient self-identified as multiple races, as it was only reflected in 24% of those patients’ EHRs. Weight, height, and smoking were similar between patient interviews and EHR. Of 281 self-reported life stressors, only 75 were recorded in the EHR. Although most demographic and clinical data were concordant, life stressors were frequently absent from the EHR which suggests a discrepancy in data collection and maintenance.

A multimodal nanoparticles-based theranostic method and system.

We propose a nanoparticles‐based system for the early detection of tumors, treatment under real‐time feedback, and monitoring. The building blocks of the system comprise a few modalities that are integrated into one powerful system which can operate at the patient's bedside in an outpatient clinic setting. The method relies on the unique characteristics of superparamagnetic nanoparticles. It takes advantage of their ability to produce acoustical signals under alternating magnetic fields (AMFs) and to produce heat under these same AMFs with different parameters. It utilizes the nanoparticles' coating for specific binding. The manuscript describes the various parts of this method for localization, source separation, confined heat elevation, triggering of cell death, and monitoring the response to treatment through fluorescence signaling. The entire system continues to evolve into a minimally invasive trans‐endoscopic set‐up.This article is categorized under:Diagnostic Tools > In Vivo Nanodiagnostics and ImagingTherapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease

Administration of High-Risk Medication: A Hospital Based Prospective Study

Background: High-risk medicines are outlined as those medicines that have a high risk of inflicting pain or death once employed to patients in error. Hence, this work was done to identify key parameters of mishandling observed by the administration on high-risk medication.&#x0D; Methods: The audit team conjointly assessed compliance with policies and tips associated with the administration of medication. Moreover, key documents including several of the nursing ability checklists were reviewed. The major attributes are taken as ICU, ER, Wards, Pre-Post-Operative &amp; CCU. The measurable elements include documented policies, and procedures for medication administration; close monitoring on records for adverse drug incidents. Analysis revealed that a significant improvement in high-risk medicine accessibility along with the provision of a list of drugs, high-risk medicines were still found at patient bedside in few scenarios. Nurses were found to be highly knowledgeable regarding high-risk medications policies but fall short in executing them at workstations.&#x0D; Results: Findings suggest that there is a need for revision in policies concerning high-risk medicines placement and storage; and also, they must be separated from the usually used medicines; timely training programs should be conducted for staff and individual attention. Documentation related to high-risk medicines starting from prescription, double authentication, verification, pre-, and post-administration should be improvised. Special attention needs to be paid to reporting medication errors like prescription errors; adverse drug reactions related to high-risk medicine administration.

Under-5-Minute Immunoblot Assays by Vortex Fluidic Device Acceleration.

Unlocking the potential of personalized medicine in point-of-care settings requires a new generation of biomarker and proteomic assays. Ideally, assays could inexpensively perform hundreds of quantitative protein measurements in parallel at the bedsides of patients. This goal greatly exceeds current capabilities. Furthermore, biomarker assays are often challenging to translate from benchtop to clinic due to difficulties achieving and assessing the necessary selectivity, sensitivity, and reproducibility. To address these challenges, we developed an efficient (<5 min), robust (comparatively lower CVs), and inexpensive (decreasing reagent use and cost by >70 %) immunoassay method. Specifically, the immunoblot membrane is dotted with the sample and then developed in a vortex fluidic device (VFD) reactor. All assay steps-blocking, binding, and washing-leverage the unique thin-film microfluidics of the VFD. The approach can accelerate direct, indirect, and sandwich immunoblot assays. The applications demonstrated include assays relevant to both the laboratory and the clinic.

Under‐5‐Minute Immunoblot Assays by Vortex Fluidic Device Acceleration

AbstractUnlocking the potential of personalized medicine in point‐of‐care settings requires a new generation of biomarker and proteomic assays. Ideally, assays could inexpensively perform hundreds of quantitative protein measurements in parallel at the bedsides of patients. This goal greatly exceeds current capabilities. Furthermore, biomarker assays are often challenging to translate from benchtop to clinic due to difficulties achieving and assessing the necessary selectivity, sensitivity, and reproducibility. To address these challenges, we developed an efficient (&lt;5 min), robust (comparatively lower CVs), and inexpensive (decreasing reagent use and cost by &gt;70 %) immunoassay method. Specifically, the immunoblot membrane is dotted with the sample and then developed in a vortex fluidic device (VFD) reactor. All assay steps—blocking, binding, and washing—leverage the unique thin‐film microfluidics of the VFD. The approach can accelerate direct, indirect, and sandwich immunoblot assays. The applications demonstrated include assays relevant to both the laboratory and the clinic.

The development of the MENTOR_D nursing intervention: Supporting family involvement in delirium management.

Although families are increasingly seen as allies to improve delirium management and reduce its consequences, their involvement in the postcardiac surgery setting is challenging considering patients' critical state and short hospital stay. To our knowledge, no theory-based nursing intervention exists that optimally supports the involvement of families in delirium management in the context of postcardiac surgery. We aimed to develop MENTOR_D, a nursing intervention to support the involvement of families in delirium management. MENTOR_D was developed based on Sidani and Braden's (2011) intervention development framework. Narrative literature reviews paired with the clinical experience of an expert committee were used to inform these three steps: (1) develop an understanding of the problem under study; (2) define the objectives of the intervention and identify a theoretical framework for highlighting strategies to be used in the intervention; and (3) operationalize the intervention and identify its anticipated outcomes. As a result of the three steps, the MENTOR_D nursing intervention relies on a caring-mentoring relationship between a nurse and the family. The aim of MENTOR_D is to increase the presence of the family at their relative's bedside and their involvement in delirium management. MENTOR_D's content is delivered over three phases that are organised around the visits of the family at the patient's bedside. During these phases, families used their knowledge of the patient to tailor the delirium management actions. These actions include orientation and reminiscence and were aimed at diminishing anxiety and increasing sense of self-efficacy in families and diminishing delirium severity and improving recovery in patients. A deep understanding of the underlying mechanisms of an intervention is key in its success to reach the targeted goals of effectiveness in practice. This understanding can be achieved through the careful development of a theory of the intervention before the operationalisation of its components and its testing. The proposed paper presents the theory of the MENTOR_D intervention, that is, its conceptualization and proposed mechanisms of action. As delirium continues to be a major complication, this intervention is a promising solution to increase families' involvement in delirium management and highlights the support that nurses can offer to facilitate this involvement. With its use in future studies and practice, it can be further refined.

Advanced Biomaterials for Cell-Specific Modulation and Restore of Cancer Immunotherapy.

The past decade has witnessed the explosive development of cancer immunotherapies. Nevertheless, low immunogenicity, limited specificity, poor delivery efficiency, and off‐target side effects remain to be the major limitations for broad implementation of cancer immunotherapies to patient bedside. Encouragingly, advanced biomaterials offering cell‐specific modulation of immunological cues bring new solutions for improving the therapeutic efficacy while relieving side effect risks. In this review, focus is given on how functional biomaterials can enable cell‐specific modulation of cancer immunotherapy within the cancer‐immune cycle, with particular emphasis on antigen‐presenting cells (APCs), T cells, and tumor microenvironment (TME)‐resident cells. By reviewing the current progress in biomaterial‐based cancer immunotherapy, here the aim is to provide a better understanding of biomaterials’ role in targeting modulation of antitumor immunity step‐by‐step and guidelines for rationally developing targeting biomaterials for more personalized cancer immunotherapy. Moreover, the current challenge and future perspective regarding the potential application and clinical translation will also be discussed.

Intraoral and transcutaneous point-of-care-ultrasound: an adjunct bedside tool for oral and maxillofacial clinicians.

Point-of-care-ultrasound (PoCUS) is performed by the clinician at the patient's bedside and is an essential diagnostic tool in many medical subspecialties, in hospital-based care, emergencies, trauma, and in general practice. A simple, novel approach for implementation of PoCUS of the oral cavity and maxillofacial complex is introduced. Relevant indications include differentiating abscess from cellulitis, detecting jaw and facial fractures, assessment of surgical complications, removing foreign bodies, and evaluating soft tissue masses. Intraoral and transcutaneous approaches may be used alone or in combination. This pilot series shows the capability of PoCUS to improve diagnostic accuracy, speed diagnosis, guide procedures, and improve management. Prospective studies are underway to determine the strengths and weaknesses of the method and its impact on patient outcomes.

691 ‘ARE YOU CONCERNED ABOUT ME TODAY’ - AN MDT APPROACH TO IMPROVING DELIRIUM RECOGNITION

IntroductionDelirium is a common neuropsychiatric syndrome that increases the likelihood of adverse outcomes for patients admitted to hospital. Delirium is preventable and treatable. Recognition of the syndrome is challenging. Our aim was to increase this recognition through robust inpatient screening, utilising a multi-disciplinary team (MDT) approach.MethodStakeholder analysis for a quality improvement project revealed that junior doctors were members of the team most likely to perform a 4AT. Plan, do, study, act (PDSA) cycles were carried out: 1. Junior doctor engagement 2. Verbal prompts in huddle 3. Healthcare assistant (HCA) questionnaires.ResultsBaseline data showed that on average 0.6% patients had new 4AT over one week on elderly care wards. Intervention 1 involved 4AT handouts given to junior doctors. Number of 4ATs was 3% of patients per week. Intervention 2 used prompts in the morning MDT huddle, asking about concerns for patients. This increased the number of patients having 4AT per week to 6.5%. HCAs did not attend huddles and were targeted in the third intervention. A questionnaire with delirium information and the subsequent question ‘are you concerned about this patient’ was placed in patient bedside folders. This gave opportunity for HCAs to escalate patients to huddle so 4ATs could be carried out. The questionnaire was completed for 62% of patients, but only 1.4% patients were flagged up and subsequently had 4AT. This time was complicated however by the wards becoming Covid-19 wards.ConclusionDelirium is common however there is missed opportunity for earlier identification. Utilising HCAs with bedside questionnaires was time efficient and ensured robust escalation to prompt further investigation. When incorporated into huddle this could lead to more delirium diagnoses if carried out over a longer period, outside of the Covid-19 pandemic and on a ward solely populated with elderly care patients.

Philosophical principles of ancient medicine

Summary. The article describes the philosophical principles of ancient medicine from the end of VII century B.C. to the beginning of VI century A.D. At the beginning the ancient medicine was closely linked to philosophical knowledge. Many personalities not only solved philosophical problems, but also were engaged in medical practice. Doctors and philosophers were: Galen, Heraphilus, Heraclitus, Erasistratus, Pythagoras, Philolaus, Empedocles, Alcmaeon, Diogenes. Aristotle also had a medical education. The aim of the study – to expand and deepen the knowledge of the basics of ancient medicine, as well as to inspire and motivate modern physicians to an individual-oriented approach to every patient. Materials and Methods. Based on the Internet searching data bases, a review and analysis of materials about ancient medicine and the role of philosophy in its development has been made. Results. The contribution of ancient philosophers and physicians – Greeks and Romans – in the spiritual treasury of humankind cannot be overestimated. Hippocrates believed that "observation at the patient's bedside" was extremely necessary, because experience alone was "deceptive." He emphasized the need, although, complexity, at the same time of reasoning, the participation of the mind, thinking in the process of putting diagnosis of the disease. Hippocrates wrote: "Life is short, the path of art is long, a convenient case is fleeting, the experience is deceptive, and reasoning is difficult." Only by studying the interpenetration of soul and body, you can count on the effectiveness of treatment. Horace suggested defining mental health as a state in which a person is satisfied with himself, treats others correctly and is able to withstand life's troubles. Aristotle followed the principle that the soul cannot be separated from the body, so if a person has a healthy body, he has a healthy soul. The philosopher combined the concepts of physical and mental health. To paraphrase Newton, if we see further than they do, it is because we are standing on their shoulders. Conclusions. The process of history formation and development of philosophy and medicine is inextricably linked with the general history of humankind and science. The progress of medicine certainly directly affects the life of each of us in particular and society in general, and has such a social significance that it is simply impossible not to consider it when analyzing the development of society and its prospects

Explicating Integrative and Declarative Shared Treatment Decision Making in Rehabilitation Encounters When Patients are Without a Voice: A Grounded Theory Analysis

<h3>Research Objectives</h3> To describe the extent of collaboration in everyday treatment decisions between practitioners (e.g., rehabilitation therapists, physiatrists) and family caregivers of a patient with disorders of consciousness (DoC). <h3>Design</h3> Ethnographic approach used rehabilitation observations triangulated with narrative interviews. <h3>Setting</h3> Observations of rehabilitation encounters occurred in a level I trauma hospital. Interviews occurred either virtually or in-person at a mutually agreed upon location. <h3>Participants</h3> 14 encounters among rehabilitation practitioners (n=8), family caregivers (n=2), and adult patients with disorders of consciousness (n=2). Interviews with family caregivers (n=17) and rehabilitation practitioners (n=7). <h3>Interventions</h3> Not applicable. <h3>Main Outcome Measures</h3> Not applicable. <h3>Results</h3> Data were analyzed using open coding and constant comparison techniques based in a grounded theory approach. 88 interactions were identified across 14 rehabilitation encounters. For analysis, we defined micro-decisions as small-scale treatment decisions that often occur multiple times within a rehabilitation encounter. Each rehabilitation encounter had multiple treatment activities and micro-decisions at the patient's bedside. Two types of shared treatment decisions were identified—integrative and declarative. Integrative decision-making occurred when family were included in the treatment session and their unsolicited contributions provided new information for in-the-moment decision-making. Declarative decision making occurred when the practitioner elicited the patient's values, preferences, and/or priorities from the family and then the practitioner executed these preferences within the session. Identifying and describing two ways in which sharing treatment decisions occurs makes the tacit explicit. <h3>Conclusions</h3> Because individuals in DoC cannot advocate for themselves, partnership between the rehabilitation practitioners and family caregivers is the hallmark of rehabilitation treatments with these individuals. Explicating two types of shared treatment decision-making informs the rehabilitation field so that we can communicate the process of engaging families as partners in rehabilitation treatment decisions. <h3>Author(s) Disclosures</h3> No known conflicts.

A Prospective Study on Cephalosporin Utilization by Pattern in Pediatric Patients

Pediatric is the medicine specialization concerned with the health of infants, children, and adolescents. Worldwide, many infectious diseases were controlled in the 20th century by improving living standards, public health, and various antimicrobial agents. Antibiotics, in particular, cephalosporin, are amongst the most widely dispensed medications in Pediatric departments worldwide, especially in countries where there are no strict guidelines to regulate their use. A prospective cross-sectional study was conducted at 150 Bedded Pediatric ward of Peoples University of Medical and Health Sciences for Women (PUMHSW), Nawabshah, Shaheed Benazirabad to assess the utilization pattern of cephalosporin among all admitted in-patients. Patients' demographic details were recorded from the Patient's Bedside File (PBF). Data were analyzed by using Microsoft Excel and Microsoft SPSS 20. Among all admitted patients, 1285 patients met the inclusion criteria, and their PBF were evaluated for cephalosporin. A total of 2863 antibiotics were prescribed among 1932 patients. The most commonly prescribed class of antibiotics among the study population was Cephalosporin 1971 (68.83%), followed by Cefotaxime (20.39%). 76.20% of pediatric patients were prescribed antibiotics through the parenteral route and 23.8% through the oral route. The most common diagnosis was Pneumonia (23.4%), diarrhea (11.6%), and Bronchitis (11.2%), following other indications. Antibiotics were being prescribed without national antibiotic guidelines or institutionally approved protocols, which are currently unavailable. The study findings shall help the hospital administration and government design and implement official policies to promote rational utilization of antibiotics.