Patients In High-risk Category Research Articles

Assessing adherence to treatment guidelines and complications among atrial fibrillation patients in the United Arab Emirates.

Atrial fibrillation (AF), a potential trigger for stroke development, is considered a modifiable condition that can halt complications, decrease mortality, and prevent morbidity. The CHA₂DS₂-VASc and HAS-BLED scores are categorized as risk assessment tools used to estimate the risk of thrombosis development and assess major bleeding among atrial fibrillation patients. Our study aims to assess the adherence to post-discharge treatment recommendations according to CHA₂DS₂-VASc score risk group and evaluate the impact of CHA₂DS₂-VASc score and HAS-BLED score risk categories on death, length of hospital stay, complications, and hospital readmission among United Arab Emirates (UAE) patients. This was a multicenter retrospective study conducted from November 2022 to April 2023 in the United Arab Emirates. Medical charts for AF patients were assessed for possible enrolment in the study. A total number of 400 patients were included with a mean age of 55 (±14.5) years. The majority were females (67.8%), and most had high CHA₂DS₂-VASc and HAS-BLED scores (60% and 57.3%, respectively). Our study showed that adherence to treatment recommendations upon discharge was 71.8%. The bivariate analysis showed that patients with a high CHA₂DS₂-VASc score had a significantly higher risk of death (p-value of 0.001), hospital readmission (p-value of 0.007), and complications (p-value of 0.044) vs. the low and moderate risk group with a p-value of <0.05. Furthermore, our findings showed that the risk of death (0.001), complications (0.057), and mean hospital stay (0.003) were significantly higher in the high HAS-BLED risk score compared to both the low- and moderate-risk categories. Hospital stay was significantly higher in CHA₂DS₂-VASc and HAS-BLED high-risk score categories compared to the low-risk score category with a p-value of <0.001. Our study concluded that the adherence to treatment guidelines in atrial fibrillation patients was high and showed that patients received the most effective and patient-centered treatment. In addition, our study concluded that the risk of complications and mortality was higher in high-risk category patients.

Cognitive reserve and well-being in migraine patients: a multidimensional approach to migraine assessment in an Italian tertiary headache center

Background: Migraine is a painful neurological condition affecting emotional, cognitive, and daily life functioning. Cognitive reserve (CR) is a protective factor against neurological damage and deterioration, but its proxies have been under-investigated in migraine. The present crosssectional study aims to investigate the relationship between CR and several self-reported health measures in migraine; and how these health measures differ between CR grades. Methods: Data were collected from an Italian tertiary center between 2022 and 2023. One hundred and eighty eligible outpatients aged from 18 to 75 years were administered a protocol consisting of: the Migraine Disability Assessment; Brief Pain Inventory (BPI); Numeric Rating Scale; Short Form-36; Self-Rating Anxiety Scale; Self-rating Depression Scale (SDS). In addition, years of illness, frequency and intensity of migraine attacks, and Cognitive Reserve Index as a gradable measure of CR, were also collected. Spearman correlation and ANOVAs were performed, setting p significance at &lt;0.05. Results: A negative correlation between perceived pain intensity, attacks, and socio-behavioral proxies of CR emerged. Higher CR was also associated with fewer headache attacks (rs=-0.176; p=0.019). Lower intensity was found to be specifically related to leisure time (rs=-0.084; p=0.049). ANOVAs highlighted differences across graded CR levels in headache-related indices, including psychological and functional status (BPI-interference: F=4.302; p=0.026; SDS: F=3.887; p=0.033; enjoyment of life: F=3.672; p=0.043), also post-hoc confirmed. Conclusions: Overall, our results suggest a link between CR levels and headache-related measures, emphasizing the importance of life-long coping strategies and healthy habits to decrease pain perception. In particular, individuals with low CR reporting higher levels of pain may benefit from integrated assessment and tailored treatment options to experience. Further studies may delve into the CR threshold hypothesis in the context of headache to identify high-risk categories of patients and foster their symptom management.

High ADMA Is Associated with Worse Health Profile in Heart Failure Patients Hospitalized for Episodes of Acute Decompensation

Background and Objectives: episodes of acute decompensation in chronic heart failure (ADHF), a common health problem for the growing elderly population, pose a significant socio-economic burden on the public health systems. Limited knowledge is available on both the endothelial function in and the cardio-metabolic health profile of old adults hospitalized due to ADHF. This study aimed to investigate the connection between asymmetric dimethylarginine (ADMA)—a potent inhibitor of nitric oxide—and key health biomarkers in this category of high-risk patients. Materials and Methods: this pilot study included 83 individuals with a known ADHF history who were admitted to the ICU due to acute cardiac decompensation. Selected cardiovascular, metabolic, haemogram, renal, and liver parameters were measured at admission to the ICU. Key renal function indicators (serum creatinine, sodium, and potassium) were determined again at discharge. These parameters were compared between patients stratified by median ADMA (114 ng/mL). Results: high ADMA patients showed a significantly higher incidence of ischemic cardiomyopathy and longer length of hospital stay compared to those with low ADMA subjects. These individuals exhibited significantly higher urea at admission and creatinine at discharge, indicating poorer renal function. Moreover, their lipid profile was less favorable, with significantly elevated levels of total cholesterol and HDL. However, no significant inter-group differences were observed for the other parameters measured. Conclusions: the present findings disclose multidimensional, adverse ADMA-related changes in the health risk profile of patients with chronic heart failure hospitalized due to recurrent decompensation episodes.

Prevention, Diagnosis, and Management of Intraoperative Spinal Cord Injury in the Setting of Spine Surgery: A Proposed Care Pathway.

This study is a mixed methods approach. Intraoperative spinal cord injury (ISCI) is a challenging complication in spine surgery. Intra-operative neuromonitoring (IONM) has been developed to detect changes in neural function. We report on the first multidisciplinary, international effort through AO Spine and the Praxis Spinal Cord Institute to develop a comprehensive guideline and care pathway for the prevention, diagnosis, and management of ISCI. Three literature reviews were registered on PROSPERO (CRD 42022298841) and performed according to PRISMA guidelines: (1) Definitions, frequency, and risk factors for ISCI, (2) Meta-analysis of the accuracy of IONM for diagnosis of ISCI, (3) Reported management approaches for ISCI and related events. The results were presented in a consensus session to decide the definition of IONM and recommendation of its use in high-risk cases. Based on a literature review of management strategies for ISCI, an intra-operative checklist and overall care pathway was developed by the study team. An operational definition and high-risk patient categories for ISCI were established. The reported incidence of deficits was documented to be higher in intramedullary tumour spine surgery. Multimodality IONM has a high sensitivity and specificity. A guideline recommendation of IONM to be employed for high-risk spine cases was made. The different sections of the intraoperative checklist include surgery, anaesthetic and neurophysiology. The care pathway includes steps (1) initial clinical assessment, (2) pre-operative planning, (3) surgical/anaesthetic planning, (4) intra-operative management, and (5) post-operative management. This is the first evidence based comprehensive guideline and care pathway for ISCI using the GRADE methodology. This will facilitate a reduction in the incidence of ISCI and improved outcomes from this complication. We welcome the wide implementation and validation of these guidelines and care pathways in prospective, multicentre studies.

Clinical impact and public health challenges of a PVL-MRSA bacteraemia outbreak amongst people who inject drugs in South Yorkshire, UK.

Panton-Valentine leukocidin (PVL) Staphylococcus aureus (SA) is an emergent public health concern. PVL toxin has been mostly associated with methicillin-sensitive S. aureus (MSSA)-related skin and soft tissue infections occurring in high-risk groups such as people who inject drugs (PWID). The emergence of PVL methicillin-resistant S. aureus (MRSA) infection is causing severe and life-threatening disease in PWID. We present an outbreak of eight PVL-MRSA bacteraemia cases at a UK teaching hospital between 2018 and 2022. An additional four patients developed bacteraemia with PVL-negative MRSA of the same multilocus sequence type (MLST). All patients were PWID and aged 33-51 years old. Four patients developed MRSA bacterial endocarditis. Three patients died. These cases represent the initial cases detected at Doncaster and Bassetlaw Teaching Hospitals of what is an ongoing and developing outbreak. An outbreak investigation has been undertaken in association with the UK Health Security Agency. Epidemiological factors have been explored, including via direct contact at a local sheltered accommodation and the possibility of a contaminated drug supply. Whole-genome sequencing confirmed that all isolates were closely related and of the same MLST (sequence type 5). A community substance misuse group disseminated health education on the prevention of PVL-MRSA. Preventing infection in PWID presents a major challenge due to the impact of addiction on engagement with services and the significant barriers faced by our patients in observing infection prevention measures. PVL-MRSA is of major public health concern and outbreak investigation and mapping out local epidemiological patterns plays a vital role in preventing further spread throughout the community. Additionally, this work enables targeted and early treatment in patients in high-risk categories for disease. These cases of PVL-MRSA infection in PWID highlights the transmissibility, pathogenic potential and severe clinical disease spectrum within this population. Further work is required to tackle transmission and infection from this pathogenic strain.

Direct-to-patient telemedicine: Expanding access to regional pediatric specialty care.

Telemedicine is seen as a useful tool in reducing gaps in health care but this technology-enabled care can also exacerbate health inequity if not implemented with a focus on inclusivity. Though many studies have reported improvements as well as exacerbation of disparities in access to care in their telehealth programs, there does not exist a common evaluation tool to assess these programs. To mitigate the impact of COVID-19 on health care workers and protect medically vulnerable children, in March 2020 we expanded our pre-established specialty and subspecialty direct-to-patient pediatric telemedicine program in a high volume urban pediatric health system. Our program aimed to prevent disparities in pediatric health care. In this study, using a "Pillars of Access" approach as a model to evaluate impact and access to care of our direct-to-patient telemedicine program, we analyzed the patients that were seen pre-COVID versus post-COVID. Our study demonstrated an increase in telemedicine visits for patients from diverse socioeconomic and racial backgrounds, and geographically underserved communities. We also observed an increase in telemedicine visits for mental health complaints and for certain categories of high-risk patients. This study was not designed to identify language and cultural barriers to telemedicine. Future identification of these specific barriers is needed. The tool to evaluate telehealth impact/access to care through a "Pillars of Access" approach presented here could serve as a model for implementation of telehealth programs. Our study highlights telemedicine programs as a mechanism to address healthcare inequity and overcome barriers to care.

Serum Copeptin Level as a Predictor of One-Year Mortality after Acute Decompensated Heart Failure Hospitalization

Background: Acutely decompensated heart failure patients have variable clinical outcomes. Some predictors of mortality in acute heart failure as resting heart rate, blood pressure, Pro-BNP level, and others have been identified. This study addresses the question whether copeptin may add value in the one-year prognosis in this category of high-risk patients. Results: To assess the relationship of serum copeptin level with one year mortality, we evaluated serum copeptin at admission and after 72 hours in 106 consecutive patients hospitalized for acute decompensated heart failure between May 2021 and November 2021 in a tertiary care hospital. Twenty-four patients (23.3%) died during the one-year follow-up period. The mortality was significantly higher in patients with advancing age, male sex, smokers, NYHA class IV heart failure, lower ejection fractions, higher heart rate, higher burden of arrhythmic events, lower creatinine clearance, and higher levels of copeptin at baseline and at day 3. Copeptin level at day 1 with cutoff value of ˃25.4 pmol/l predicted mortality with sensitivity 87.5% and specificity 70.73% [hazard ratio (95% confidence interval): (0.725 - 0.898), P&lt;0.001], while copeptin level at day 3 with cutoff value ˃ 26.1 pmol/l predicted mortality with sensitivity 100% and specificity 73.17% [hazard ratio (95% confidence interval): (0.876 - 0.981), P&lt;0.001]. Finally, increase in copeptin level from bassline was independently associated with increased mortality. (p˂0.001). Conclusions: Elevated copeptin level at baseline and 72 hours post-admission is suggested to be a strong predictor of one year mortality in patients with acute decompensated heart failure.

Застосування антифібринолітичної терапії у періопераційному періоді у дітей та дорослих

перебіг оперативних втручань у дітей можуть ускладнюватися розвиткомперіопераційної кровотечі. Застосування препаратів із антифібринолітичною дією зменшуєта превентує розвиток інтраопераційної крововтрати у дорослих та пацієнтів дитячого віку.Антифібринолітичні препарати такі, як транексамова кислота (ТКК) проявила свою ефективністьу якості зменшення обсягу періопераційної крововтрати, трансфузії у дорослих пацієнтів тадітей при травмі, кардіохірургічних та великих ортопедичних втручань. Проте використанняданого препарату у категорії пацієнтів високого ризику та у навантажувальних дозах &gt; 100 мг/кг може асоціюватися із розвитком тромбоемболічних та судомних ускладнень. Однією із перевагзастосування амінокапронової кислоти (АКК) є її широка доступність, вартість і водночасефективність. Порівнюючи ефективність лізинових похідних у пацієнтів із краніостенозомА. Borst, C. Bonfield зазначають, що при використанні АКК в порівнянні із ТКК підвищуєтьсярівень інтраопераційної крововтрати (21 ± 13 vs. 17 ± 10), проте статистично вона не є значима.Апротинін, у якості препарату для зменшення крововтрати у кардіохірургічних пацієнтів впорівнянні із лізиновими похідними, являється більш ефективним для зниження періопераційної&#x0D; крововтрати. Проте після дослідження The Blood Conservation Using Antifibrinolytics in a Random-ized Trial (BART) (Fergusson D. et al. 2008) є обмежено доступний у багатьох країнах через високу&#x0D; кількість тромбоемболічних ускладнень та підвищену смертність. На даний момент активнодосліджуються протизапальні властивості не лише апротиніну, а й ТКК та АКК.

Comparison and evaluation of the 2009 and 2021 chronic kidney disease-epidemiological collaboration equations among Jordanian patients with type 2 diabetes mellitus.

This study compared the 2009 versus 2021 chronic kidney disease (CKD) Epidemiological Collaboration (CKD-EPI) equations to calculate estimated glomerular filtration rate (eGFR) among Jordanian patients with T2DM to assess their agreement and impact on CKD staging. This cross-sectional study included 2382 adult Jordanian patients with T2DM. The 2009 and 2021 CKD-EPI equations were used to calculate eGFR. Patients were reclassified according to kidney disease-Improving Global Outcomes (KDIGO) categories. Agreement between the equations was assessed using Bland-Altman plots and Lin's concordance correlation. The 2021 equation significantly increased eGFR by a median of 2.1mL/min/1.73 m2 (interquartile range: 0.6-3.6mL/min/1.73 m2). However, there was significant agreement between equations (Kappa: 0.99; 95% confidence interval: 0.95-1.00), independent of age, sex, and the presence of hypertension. In total, 202 patients (8.5%) were reclassified to higher KDIGO categories using the 2021 equation, with category G3 being most affected. The overall prevalence of patients in the high to highest risk categories decreased (28.0% vs. 26.5%). Although there was significant agreement with the 2009 equation, the 2021 equation increased eGFR and resulted in the reclassification of a subset of subjects according to KDIGO criteria. The uncertain impact of reducing high-risk category patients raises concerns about potential delays in referral and intervention, while holding the potential to enhance high-risk patient categorization, thus alleviating healthcare burden.

Nutritional rehabilitation of malnourished children detected by Screening Tool for Assessment of Malnutrition in Pediatric: Urban versus rural settings

Malnutrition presents a major global health burden. In Egypt, it remains an important issue in children under 5 years especially in rural communities. The aim of the study was to screen 2-5 years old children enrolled from Egyptian hospitals in rural and urban areas for the risk of malnutrition using Screening Tool for Assessment of Malnutrition in Pediatric (STAMP) and to evaluate the effectiveness of nutritional intervention programs. This cross-sectional study was conducted on 90 patients recruited from two hospitals in urban and rural Cairo, Dietary history and anthropometric measurements were assessed. Patients at intermediate and severe risk of malnutrition according to STAMP were given tailored nutritional programs. In the rural hospital, 4.4% of the screened children were underweight, 22.2% were marginally underweight, and 73.3% had normal weight. Regarding the urban hospital, 15.6% were marginally underweight, 84.4% had normal weight and no underweight patients. Among the rural group 35.6% were at high risk according to STAMP score results compared to 20% in the urban group. Nevertheless, the only significant differences were the more stunting and higher BMI in rural hospital patients. After nutritional intervention, high-risk category patients decreased in both groups coupled by significant improvement in the anthropometric parameters and nutrition data with no significant differences between them. Nutritional education and prompt implementation of nutritional rehabilitation program for malnourished children detected by screening tools result in improvement in their nutritional status disregards their location whether urban or rural.

Cardiac arrest and cardiopulmonary resuscitation in pediatric patients with cardiac disease: a narrative review.

Children with cardiac disease are at a higher risk of cardiac arrest as compared to healthy children. Delivering adequate cardiopulmonary resuscitation (CPR) can be challenging due to anatomic characteristics, risk profiles, and physiologies. We aimed to review the physiological aspects of resuscitation in different cardiac physiologies, summarize the current recommendations, provide un update of current literature, and highlight knowledge gaps to guide research efforts. We specifically reviewed current knowledge on resuscitation strategies for high-risk categories of patients including patients with single-ventricle physiology, right-sided lesions, right ventricle restrictive physiology, left-sided lesions, myocarditis, cardiomyopathy, pulmonary arterial hypertension, and arrhythmias. Cardiac arrest occurs in about 1% of hospitalized children with cardiac disease, and in 5% of those admitted to an intensive care unit. Mortality after cardiac arrest in this population remains high, ranging from 30 to 65%. The neurologic outcome varies widely among studies, with a favorable neurologic outcome at discharge observed in 64%-95% of the survivors. Risk factors for cardiac arrest and associated mortality include younger age, lower weight, prematurity, genetic syndrome, single-ventricle physiology, arrhythmias, pulmonary arterial hypertension, comorbidities, mechanical ventilation preceding cardiac arrest, surgical complexity, higher vasoactive-inotropic score, and factors related to resources and institutional characteristics. Recent data suggest that Extracorporeal membrane oxygenation CPR (ECPR) may be a valid strategy in centers with expertise. Overall, knowledge on resuscitation strategies based on physiology remains limited, with a crucial need for further research in this field. Collaborative and interprofessional studies are highly needed to improve care and outcomes for this high-risk population. What is Known: • Children with cardiac disease are at high risk of cardiac arrest, and cardiopulmonary resuscitation may be challenging due to unique characteristics and different physiologies. • Mortality after cardiac arrest remains high and neurologic outcomes suboptimal. What is New: • We reviewed the unique resuscitation challenges, current knowledge, and recommendations for different cardiac physiologies. • We highlighted knowledge gaps to guide research efforts aimed to improve care and outcomes in this high-risk population.

BLOOD PRESSURE LOWERING TREATMENT AND BASELINE CARDIOVASCULAR RISK IN PRIMARY PREVENTION: SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED TRIALS

Objective: Blood pressure (BP) lowering is accompanied by reduced cardiovascular (CV) outcomes and death in hypertensive patients. No data are available for the effect of BP lowering in trials stratified according to baseline CV risk according to the SCORE-2 system. Design and method: A systematic review was conducted to identify randomized trials in electronic databases (Pubmed and CENTRAL, years: 1966 to 11/2022) for the effect of BP-lowering treatment against placebo, no treatment or less intense BP reduction on fatal or non-fatal CV outcomes. Selected studies reported outcomes in patients without a history of previous CV disease. In each study, we calculated baseline cardiovascular risk using SCORE-2. Risk ratios (RR) were calculated together with their 95% confidence interval (CI) under the random-effects model. Results: We studied 12 trials with low-to-moderate CV risk, n = 21,192 patients; 13 trials with high risk, n = 66,886; and 29 trials with very high risk, n = 79,061. For a standard SBP/DBP reduction of 10/5 mmHg, the relative risk of the combined outcome of major CV events (i.e., myocardial infarction, stroke, and heart failure) was decreased by 27% (95% CI, 22-35%) in the category of very high-risk patients, and by 10% in the category of high-risk patients (p value for interaction = 0.020). Also, the relative risk reduction of the combined outcome was progressively greater the higher the baseline CV risk (p trend = 0.006). The risk reduction of CV death showed a significant trend from lower to higher baseline CV risk (p trend = 0.036). CV death showed a significant reduction in the high-risk group compared to the low-moderate risk group (p = 0.005), and in the very high-risk group compared to the low-moderate risk group (p = 0.001). Conclusions: The greatest outcome benefit from BP lowering treatment in primary is observed in patients at higher baseline cardiovascular risk, as calculated by the SCORE-2.

Improving VTE prophylaxis in ward and ICU surgical urology patients: a Six-Sigma DMAIC methodology improvement project

PurposeThis study intends to improve the quality of venous thromboembolism (VTE) prophylaxis practices including proper VTE risk assessment and the appropriate prophylaxis measures for surgical urology patients.Design/methodology/approachThe authors applied the Six-Sigma define, measure, analyze, improve and control (DMAIC) improvement methodology in a pre–post interventional study that involved all adult patients above 18 years old indicated and scheduled for urology surgical interventions including endoscopic urological surgeries in a urology specialized 60-bed hospital. The pre-intervention sample included all patients meeting the inclusion criteria over a period of six months. Post-intervention sample included all patients meeting the inclusion criteria over a period of six months. The improvement areas included both the VTE risk assessment as well as the VTE prophylaxis prescription.FindingsDMAIC methodology has achieved a substantial sustained improvement in surgical urology VTE prophylaxis practices with an average of 70% on both levels; VTE risk assessment practices and VTE prophylaxis prescribing practices were statistically significant. The post-intervention results also showed a statistically controlled process with no special cause variations. Based on the study results, the Six-Sigma DMAIC methodology can be considered of high value when applied in healthcare clinical practice improvement projects.Research limitations/implicationsThe project study includes some pitfalls that can be addressed as follows: 1. The lack of VTE rate incidence tracking. This limitation can be partly refuted when the authors conduct a literature review and explore that the VTE prophylaxis effectiveness had been proven with sufficient evidence to an extent that pushed several scientific societies to develop their own guidelines to support VTE prophylaxis. (Algattas et al., 2018). 2. Another limitation of this study can be that it handled only surgical patients and more specifically surgical urology patients. Of course, VTE prophylaxis is a crucial life-threatening problem not only for the surgical admitted patients but also for all the medical admitted patients either in hospital wards or ICUs. However, the prediction that surgical patients especially surgical urology patients are more prone to VTE development risk as they have -in several cases-two or three main additive risk factors which are age, procedure duration and malignancy in elderly men. (Tikkinen et al., 2014). So, the authors consider the study project to be a prototype that hopefully can be utilized for future study projects that will manage both other surgical specialty patients and medical patients on the national level and can track accurately and effectively report the VTE incidence rates.Practical implicationsSeveral recommendations can be extracted from the research project that is summarized in the following points: Paying focused attention to continuous healthcare quality improvement initiatives and projects as a main approach for healthcare improvement especially for the public health-related problems. This might be achieved through periodic region-specific or specialty-specific focus groups from which public health problems could be addressed and prioritized to be considered as a part of country healthcare campaigns regarding cost-utility and feasibility studies. The adoption of a system thinking approach in dealing with the improvement strategies; all efforts and resources are to be employed to achieve a common objective. This includes the generation of a national-wide electronic health information system that can aid in healthcare resource allocation and direct the healthcare efforts towards the most important, high-priority public health problems. Electronic national-wide health record is really an effort, and resources consuming activity, but actually, it's worth exerting efforts, and its valuable outcomes may be seen several years later. 3. Development of unified national specialized VTE prophylaxis pathways to standardize the patient-specific VTE prophylaxis plans. Standardization of healthcare pathways enables healthcare professionals to follow an evidence-based practice which will be reflected on the improvement of healthcare quality level, cost-effectiveness enhancement, and timely patient care on all levels especially in high critical areas like ER and ICU. 4. Incorporation of VTE prophylaxis costs in the universal health insurance diagnosis-related group (DRG) insurance packages and service pricing. Universal health insurance is a nationwide strategy that is aiming to cover all Egypt residents by the year 2030. Universal health insurance is being following the DRG reimbursement policy that is thought to control all the healthcare-associated costs so, the VTE prophylaxis costs shall be added as the main cost item to encourage all healthcare facilities to follow an evidence-based VTE prophylaxis pathway taking into consideration the high-risk patient categories who will definitely represent a high-cost burden on the long run if they suffer a VTE event.Originality/valueDMAIC improvement methodology applications in healthcare are still relatively limited, especially on the clinical level. The study can be considered one of a kind in Egypt dealing with a comprehensive DMAIC methodology application on the clinical level.

Implementation and outcomes of a uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum

Placenta accreta spectrum disorders are a continuum of placental pathologies with significant maternal morbidity and mortality. Morbidity is related to the overall degree of placental adherence, and thus patients with placenta increta or percreta represent a high-risk category of patients. Hemorrhage and transfusion of blood products represent 90% of placenta accreta spectrum morbidity. Both tranexamic acid and uterine artery embolization independently decrease obstetrical hemorrhage. This study aimed to provide an evidence-based intraoperative protocol for placenta accreta spectrum management. This study was a pre- and postimplementation analysis of concomitant uterine artery embolization and tranexamic acid in cases of patients with antenatally suspected placenta increta and percreta over a 5-year period (2018-2022). For comparison, a 5-year (2013-2017) preimplementation group was used to assess the impact of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum. Patient demographics and clinically relevant outcomes were obtained from electronic medical records. A total of 126 cases were managed by the placenta accreta spectrum team, of which 66 had suspected placenta increta/percreta over the 10-year time period. Two patients were excluded from the postimplementation cohort because they did not undergo both interventions. Thus, 30 (30/64; 47%) were treated after implementation of the uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum, and 34 (34/64; 53%) preimplementation patients did not undergo uterine artery embolization or tranexamic acid infusion. With the uterine artery embolization and tranexamic acid protocol, operative times were longer (416 vs 187 minutes; P<.01), and patients were more likely to receive general anesthesia (80% vs 47%; P<.01). However, blood loss was reduced by 33% (2000 vs 3000 cc; P=.03), overall blood transfusion rates decreased by 51% (odds ratio, 0.05 [95% confidence interval, 0.001-0.20]; P<.01), and massive blood transfusion (>10 units transfused) was reduced 5-fold (odds ratio, 0.17 [95% confidence interval, 0.02-0.17]; P=.02). Postoperative complication rates remained unchanged (4 vs 10 events; P=.14). Neonatal outcomes were equivalent. The uterine artery embolization and tranexamic acid protocol for placenta accreta spectrum is an effective approach to the standardization of complex placenta accreta spectrum cases that results in optimal perioperative outcomes and reduced maternal morbidity.

Gestational Trophoblastic Neoplasia—A Retrospective Analysis of Patients Treated at a Tertiary Care Oncology Center in North India

Objectives The aim of this study was to do a retrospective analysis of patients of gestational trophoblastic neoplasia (GTN) treated at our center concerning their clinical features and treatment outcomes. Materials and Methods Patients diagnosed and treated from May 2018 to December 2021 were included. All relevant information pertaining to eligible patients was retrieved from the electronic medical records. Patients were risk-stratified based on the World Health Organization (WHO) risk scoring system with a score of seven and above being classified into the high-risk category. Patients were monitored for response by measuring β-human chorionic gonadotrophin (β-HCG) levels before each consecutive cycle. Statistical Analysis Appropriate statistical analysis was performed using SPSS version 26. Results Records of 39 eligible patients were analyzed for clinical features out of which 38 were eligible for response assessment. The median age of presentation was 28 years with the majority of patients (79.4%) diagnosed based on β-HCG levels and clinical history alone. The most common symptom was bleeding per vagina (64%), while the majority of antecedent pregnancies were abortions (59%).Of the 14 low-risk category patients, 12 received single-agent methotrexate/actinomycin D, while 2 received etoposide, methotrexate actinomycin D (EMACO) regimen. Overall response rates were 85.7% with the others responding to the second-line EMACO regimen. Five patients in this group had a WHO score of 5 or 6 and all of them responded to single-agent treatment. Among the 25 high-risk category patients, all received the EMACO regimen with high-dose methotrexate added to those with brain metastasis. The response rate was 87.5% with all the nonresponders having features of ultra-high risk of liver/brain metastasis and/or a WHO score of more than 12. While one nonresponder had expired despite treatment, the other two responded to the etoposide methotrexate and actinomycin D/ etoposide and cisplatin regimen. Conclusion Our results are in consonance with other reported studies. The subcategories of low-risk GTN with a WHO score of 5 and 6 and high-risk GTN with ultra-high-risk features deserve further research in the form of multicenter prospective studies.

Effectiveness of Foot reflexology on level of fatigue among peripheral neuropathy, patient with Tuberculosis

Background: In India, Tuberculosis has been mentioned in the Vedas and the old Ayurvedic scriptures. Historically speaking, fight against Tuberculosis in India can be broadly classified into three periods: early period, before the discoveries of x-ray and chemotherapy; post-independence period, during which nationwide Tuberculosis control programs were initiated and implemented; and the current period, during which the ongoing WHO-assisted Tuberculosis control program is in place. Tuberculosis incidence is seasonal, with peaks occurring every spring and summer. The reasons for this are unclear, but may be related to vitamin D deficiency during the winter. There are also studies linking tuberculosis to different weather conditions like low temperature, low humidity and low rainfall. It has been suggested that tuberculosis incidence rates may be connected to climate change Tuberculosis is closely linked to both overcrowding and malnutrition, making it one of the principal diseases of poverty. Those at high risk thus include: people who inject illicit drugs, inhabitants and employees of locales where vulnerable people gather (e.g., prisons and homeless shelters), medically underprivileged and resource-poor communities, high-risk ethnic minorities, children in close contact with high-risk category patients, and health-care providers serving these patients. Factors contributing to this include higher prevalence of predisposing health conditions and behaviours, and overcrowding and poverty. In some Canadian aboriginal groups, genetic susceptibility may play a role. Methods: Quasi-experimental design (one group pre-test post-test design) was recruited by non-probability purposive sampling technique used for the present study. Necessary administrative permission was obtained from the concerned authority. The Structured interview schedule was used to elicit the baseline data. Result: The study revealed that among 180 Tuberculosis patients, the Chalder Fatigue scale pre-median was 27.0, Post-test I median was 14.0, and whereas post-test II median was 7.0. In Michigan Neuropathy scale pre-median was 15.0, the post-test I median was 14.0, and post-test II median was 7.0. Conclusion:-The study concluded that the foot reflexology of anti-tuberculosis drug-induced peripheral neuropathy among Tuberculosis patients from selected community area, Ramanagara Taluk &amp; District, Karnataka carried out the study was found to be effective in decreasing the fatigue levels among peripheral neuropathy in person with Tuberculosis patients as evidenced by the significant change between pre-test and post-test scores.

The Impact of Caprini Guideline Indicated Venous Thromboembolism Prophylaxis in Colorectal Surgery Patients: Experience of a Single Health System.

Venous thromboembolism (VTE) is the most common cause of preventable mortality following colorectal surgery (CRS), occurring in about 2% of patients. As a result, prophylaxis including discharge chemoprophylaxis is recommended. While VTE risk assessment tools are available, the consistent adoption and utilization of these tools remains elusive. Our study objectives were to determine the utilization and impact of risk adjusted VTE prophylaxis in CRS patients. CRS cases performed between 1/1/2016 and 5/31/2021 were retrospectively analyzed. Caprini score and implemented VTE prophylaxis measures were determined. The primary outcome measure was receiving Caprini guideline indicated VTE prophylaxis. Secondary outcomes included VTE and bleeding. Categorical variables were compared by chi-square and Fisher's exact tests, and continuous variables by Kruskal-Wallis test. Logistic regression models were used to determine predictors of receiving appropriate VTE prophylaxis or experiencing postoperative VTE and bleeding. 10,422 CRS cases were analyzed and 90.6% were high risk for VTE. In-hospital appropriate prophylaxis rates in low, moderate, high, and very high-risk category patients were 91.2%, 56.1%, 61.0%, and 63.1%, respectively. Inpatient VTE was reduced by 75% in those receiving appropriate VTE prophylaxis. At discharge, 5.8% of patients received appropriate prophylaxis, in whom there were no VTE events at 30- and 90 days from discharge. Increasing Caprini score positively correlated with VTE risk in both the inpatient and discharge cohorts, but inversely correlated with the likelihood of receiving appropriate prophylaxis at discharge (OR .31, P <.0001). Caprini guideline indicated VTE prophylaxis in CRS patients reduced VTE events without increasing bleeding complications.

Efficacy of blunt abdominal trauma scoring system in management of blunt abdominal trauma

Background: Although there are many scores to evaluate a patient having trauma, BATSS is a newer score specifically designed for blunt abdominal trauma which is not adequately studied. The objective was to study the efficacy of BATSS by comparing it with conventional experience-based management of Blunt abdominal trauma.Methods: 100 patients presenting with blunt abdominal trauma between March 2019 to May 2020 were randomly selected. Patients were treated by conventional experience-based management and it was compared with management guided by BATSS by prospective observation. Analysis was done by assessing need for CT scan of abdomen and laparotomy to check efficacy of BATSS.Results:100 patients were included in study. CT Abdomen is rarely required in low-risk category (BATSS&lt;8, p &lt;0.0001). In Moderate and High-risk category (BATSS&gt;8), CT Abdomen is required to accurately identify Intra-abdominal injury (p=0.0006 and 0.0965 respectively). Laparotomy may be necessary in any risk category patient for hollow viscous perforation. BATSS does not have a variable like X-ray-Chest standing to diagnose hollow viscous perforation. So, some patients in Low-risk category may also need Laparotomy (p 0.06892) which is not indicated by BATSS. Not all patients in high-risk category needs laparotomy (p=0.00009).Conclusions: Variables used to score the severity of trauma are inadequate and some patients would be improperly categorised in blunt abdominal trauma scoring system. So, we conclude that BATSS is not useful in our setup and requires modifications.

Outcomes in Live Renal Allograft Transplants with Different Modalities of Induction

Introduction: The immunosuppressant regimen after kidney transplantation typically includes initial induction therapy followed by a maintenance regimen. The induction therapy was introduced with the aim of reducing acute rejections. A retrospective study was conducted to compare the outcomes in patients with different modalities of induction. Materials and Methods: This is a hospital-based retrospective study where 148 patients who have undergone live renal allograft transplantation at SCB Medical College and Hospital from March 2012 to February 2019 were included in the study. All cases included were crossmatch negative, ABO-compatible live renal allograft transplantations. All patients received tacrolimus, mycophenolate sodium, and steroids. Induction therapy varied depending on immunological risk and changes in protocol over time. Basiliximab, anti-T-lymphocyte globulin (ATLG), and anti-thymocyte globulin (ATG) were given in 56, 21, and 21 patients, respectively, and no induction therapy in 50 patients. All patients with an acute rise in serum creatinine and without an obvious cause of graft dysfunction were subjected to renal biopsy. The incidence of acute rejection, patient survival, and graft survival was calculated from the follow-up records and compared among patients receiving different induction therapies. Results: In the high-risk category patients, 31%, 20%, and 18.2% of patients (P = 0.6) and in the low risk category, 37%, 27.3%, and 20% of patients (P = 0.6) had acute rejections in basiliximab, ATLG, and ATG group, respectively. The patient survival at 1 year was 79.3%, 70%, and 81.8% in high-risk group patients (P = 0.84) and 88.9%, 81.8%, and 80% in low-risk group patients (P = 0.88) in the basiliximab, ATLG, and ATG groups, respectively. The graft survival at 2 years was 96.6%, 90%, and 90.9% in high-risk group patients (P = 0.32) and 88.9%, 90.9%, and 90% in low-risk group patients (P = 0.65) in the basiliximab, ATLG, and ATG groups, respectively. Conclusion: In the low-risk group, the use of different modalities of induction does not have any advantage over no induction therapy in reducing the incidence of acute rejection, or improving patient and graft survival. In the high-risk group, all the induction therapies used lead to similar outcomes and none show any advantage over the other in terms of statistical significance. However, patients who received ATLG or ATG have an increased incidence of septicemia as compared to basiliximab and no induction group.

Inflammatory Bowel Disease: An Indication to Screen for Thrombophilia?

Inflammatory bowel diseases (IBD) are systemic conditions characterized by multiple intestinal and extra-intestinal manifestations related to the associated chronic inflammatory state. Among their diverse extra-intestinal complications, venous thromboembolism (VTE) remains one of the most under recognized causes of morbidity and mortality in these patients, highlighting the need for a better understanding of the underlying mechanism of hypercoagulability, in addition to the role of acquired and inherited risk factors that further increase the risk of thrombosis with its impact on patients’ outcomes. We hereby present a review of the data regarding thrombosis in the setting of IBD, elucidating the possible role for screening in this high-risk category of patients and specifically in areas where inherited thrombophilia is expected to be highly prevalent, reporting two patients with IBD, one who developed a cerebrovascular event and another one who had recurrent VTE events; nevertheless, both of them had inherited thrombophilic mutations. The identification of specific genetic abnormalities in those patients reintroduces the controversy related to the need to screen a specific category of patients with IBD for hereditary thrombophilia, especially in regions characterized by a higher prevalence of such thrombophilic alterations.