Peripheral Centers Research Articles

Single-center Experience of Slow Thrombolysis in Stuck Mechanical Mitral Valve in India

ABSTRACT Introduction: India is the rheumatic heart disease (RHD) capital of the world. It is home to 40% of all people of RHD. Many of these patients undergo valve replacement surgeries in our country. These patients present with prosthetic heart valve thrombosis (PHVT) as the international normalized ratio (INR) is not monitored due to several restraints. Many precious lives are lost due to the scarcity of cardiac surgery centers and the high mortality associated with redo procedures. Various international studies have proved the efficacy and low complication rate of slow thrombolysis with tissue plasminogen activator (tPA) compared to surgery in PHVT. Most Indian studies have used streptokinase for PHVT and data on tPA are lacking. Materials and Methods: Twenty-one patients with prosthetic mechanical mitral valve presenting with dyspnea, a high gradient across the prosthetic valve, and decreased leaflet motion were included in the study. As it is not always possible to differentiate pannus from a thrombus and association of some degree of thrombosis even in pannus, we offered thrombolysis as the first line of treatment to all patients. Slow thrombolysis with 25 mg of tPA over 6 h followed by unfractionated heparin for 18 h was given, and thereafter, patients were reassessed for thrombolytic success or complications if any. A total four sessions of thrombolysis were given, and thereafter, patients with failed thrombolysis were referred for valve replacement surgery. Results: Out of 21 patients, 67% were females. The mean age of patients was 54.33 ± 10.6 years. Fifty-seven percent of patients were in the New York Heart Association (NYHA) III/IV. Atrial fibrillation was present in 62% of patients. The mean time of interval from the time of valve surgery to the time of thrombosis was 80 ± 57 months and the mean INR was 1.43 ± 0.4. The total success rate was 71% in this study, 9% had complications, and 19% had failed thrombolysis and underwent redo mitral valve replacement. The mean dose of tPA was 56.58 mg in this study and a mortality rate of 4%. Age had no effect on the success of thrombolysis. The presence of sinus rhythm, NYHA class I/II status, EF more than 40%, and mean gradient <20 mmHg was associated with a higher likelihood of success. Conclusion: In this study of PHVT in Indian patients, slow (6 h) infusion of low-dose (25 mg) tPA proves to be associated with a low complication rate, low mortality, and a promising success rate. This regimen can be offered to PHVT patients in our peripheral centers where cardiac surgical facilities are not readily available.

Updating the WHO target product profile for next-generation Mycobacterium tuberculosis drug susceptibility testing at peripheral centres.

There were approximately 10 million tuberculosis (TB) cases in 2020, of which 500,000 were drug-resistant. Only one third of drug-resistant TB cases were diagnosed and enrolled on appropriate treatment, an issue partly driven by a lack of rapid, accurate drug-susceptibility testing (DST) tools deployable in peripheral settings. In 2014, World Health Organization (WHO) published target product profiles (TPPs) which detailed minimal and optimal criteria to address high-priority TB diagnostic needs, including DST. Since then, the TB community's needs have evolved; new treatment regimens, changes in TB definitions, further emergence of drug resistance, technological advances, and changing end-users requirements have necessitated an update. The DST TPP's revision was therefore undertaken by WHO with the Stop TB Partnership New Diagnostics Working Group. We describe the process of updating the TPP for next-generation TB DST for use at peripheral centres, highlight key updates, and discuss guidance regarding technical and operational specifications.

Health system adaptions to improve care for people living with non-communicable diseases during COVID-19 in low-middle income countries: A scoping review.

During the COVID-19 pandemic, access to health care for people living with non-communicable diseases (NCDs) has been significantly disrupted. Calls have been made to adapt health systems and innovate service delivery models to improve access to care. We identified and summarized the health systems adaptions and interventions implemented to improve NCD care and their potential impact on low- and middle-income countries (LMICs). We comprehensively searched Medline/PubMed, Embase, CINAHL, Global Health, PsycINFO, Global Literature on coronavirus disease, and Web of Science for relevant literature published between January 2020 and December 2021. While we targeted articles written in English, we also included papers published in French with abstracts written in English. After screening 1313 records, we included 14 papers from six countries. We identified four unique health systems adaptations/interventions for restoring, maintaining, and ensuring continuity of care for people living with NCDs: telemedicine or teleconsultation strategies, NCD medicine drop-off points, decentralization of hypertension follow-up services and provision of free medication to peripheral health centers, and diabetic retinopathy screening with a handheld smartphone-based retinal camera. We found that the adaptations/interventions enhanced continuity of NCD care during the pandemic and helped bring health care closer to patients using technology and easing access to medicines and routine visits. Telephonic aftercare services appear to have saved a significant amount of patients' time and funds. Hypertensive patients recorded better blood pressure controls over the follow-up period. Although the identified measures and interventions for adapting health systems resulted in potential improvements in access to NCD care and better clinical outcomes, further exploration is needed to establish the feasibility of these adaptations/interventions in different settings given the importance of context in their successful implementation. Insights from such implementation studies are critical for ongoing health systems strengthening efforts to mitigate the impact of COVID-19 and future global health security threats for people living with NCDs.

Global Perspectives in Acute Kidney Injury: Spain.

Global Perspectives in Acute Kidney Injury: Spain.

EVALUATING THE MATERNAL OUTCOME IN OBSTETRIC ICU A STUDY FROM A TERITIARY CARE HOSPITAL IN SOUTH INDIA

Background : Critically ill obstetric patients pose challenges to the intensive care unit team due to their altered physiology as well as due the presence of the foetus and safety of both the mother and the foetus is of most important. A better knowledge of the spectrum, characteristics and outcomes of the diseases involving this group of patients is the first step towards achieving prevention and the current study is done to supplement the present knowledge on obstetric emergencies requiring ICU care. Aims and Objectives :The objective is to study the profile of cases admitted to obstetric ICU and to evaluate maternal outcome and prognosis. Materials and Methods :This is observational study was conducted at Andhra Medical College ,visakhapatnam a teritiary care hospital from January 2022 to June 2022 . 1. All antenatal women irrespective of the period of gestation and postnatal women within 42 days of delivery requiring ICU admission for obstetric, non-obstetric reasons,irrespective of age, parity, mode of delivery, and co-morbid conditions were included . 2. Results were subjected to statistical analysis and conclusions drawn. Results : During the study period of 6 months, a total number of 82 obstetric patients were admitted to ICU. Specific interventions that had been undertaken at the ICU (such as the use of intubation, mechanical ventilation, and intensive monitoring )were recorded. The complications that were encountered at the ICU, such as disseminated intravascular coagulation (DIC) and multiorgan failure, were recorded. Majority were of obstetric reasons (n=58, 70.7%).Non-obstetric reasons (n=24, 29.3%) 28 maternal deaths occurred during the study period.Most common cause of death in our study was MODS followed by complications of hypertensive disorders of pregnancy. Discussion : Present centre being a tertiary care hospital majority of the women had severe complications and many were referred after a significant amount of delay .This stresses the idea that, in cases involving obstetric patients, there could not be much time for transfer to an intensive care unit and that things could swiftly deteriorate. Lack of antenatal care, poor socio economic background, delay in referral from the peripheral health centres predicted poor outcomes. Conclusion : The findings of the present study reinforce the statement by WHO that There is a story behind every maternal death or life-threatening complication. Understanding the lessons to be learned can help to avoid such outcomes. A multidisciplinary team approach is required in ICU. All residents of obstetrics and gynaecology should have short mandatory training phase in critical care.

Management of a penetrating vertebral artery injury in a peripheral hospital

Vertebral artery (VA) injuries in penetrating trauma are rare but can be life threatening. Management is often reliant on interventional radiology (IR), although such services may be lacking in peripheral centres. We report a case of a 22-year-old man who sustained a right VA injury from a stab wound to the posterolateral neck that was managed in a rural hospital. On presentation, the patient was initially haemodynamically stable but began exsanguinating heavily whilst undergoing imaging and was subsequently transferred to the operating theatre. Intraoperatively, bleeding was noted from the C5/C6 interforaminal space. Due to difficulty with exposure and lack of specialist surgical services, bimanual pressure was continuously applied to the wound whilst awaiting the arrival of a vascular surgeon and neuro-interventionalist who were transported by air from a tertiary hospital. At the time of angiography, bleeding had ceased and no further intervention was required. This case highlights the importance for surgeons in peripheral centres to be aware of some of the operative manouvres used in managing VA injuries including the utility of continued direct pressure. Moreover, it serves as a reminder that there remains a role for operative intervention in the unstable patient despite increasing reliance on radiological techniques to treat such injuries.

Minimally Invasive Technique for Spontaneous Intraparenchymal Hemorrhage

Abstract Objective The aim of this study was to introduce a cost-effective and less invasive method for the evacuation of intraparenchymal hemorrhage (IPH). Background IPH in the presence or absence of intraventricular hemorrhage has severe morbidity and has almost 50% mortality whether the patient is managed surgically or medically. Development of minimally invasive surgical techniques offers better outcomes but requires the use of special instruments and a unique skill set that is costly and requires special training. Method We inserted infant feeding tube within the hematoma via the left Kocher's burr hole. We instilled 40,000 IU of urokinase serially at an 8 hours interval for 3 days to evacuate the left gangliocapsular hematoma. Result We have treated a 50 years old hypertensive male patient with left gangliocapsular IPH and right hemiparesis (power: ⅖ on admission). After a month, on follow-up, the patient was conscious and oriented with improved right hemiparesis (power: ⅘). Conclusion This technique of evacuating hematoma is instrumental in peripheral centers in developing as well as under-developed countries where there are limited resources and a better outcome is expected with minimal morbidity.

Cancer screening behaviors and preferences among women in southern India

IntroductionIn 2020, India’s cancer cases were estimated at 1.32 million (International Agency for Research on Cancer et al., 2020) and were predicted to double by 2040 (Smith and Mallath, 2019). MethodsStarting in March 2019, we recruited 211 adult women in the Trivandrum area of India who had an outpatient office visit within the past 6 months to participate in a structured survey. We identified the study population from the Gokulam Medical College and four peripheral centers. Two trained interviewers collected survey information from the participants, including information on breast, oral, and cervical cancer screening eligibility, history, recommendations, and screening initiation. For analysis, we stratified the sample into two groups by age: a priority screening group, aged 30–65 (n = 132), and an overall group, containing the entire sample, aged 19–85 (n = 211). Results14.22% of respondents in the overall group and 14.39% in the priority screening group reported receiving a prior cancer screening. Among women who had not received cancer screening, the most common reasons were "no provider recommendation” (42.18%) and not knowing they needed to be screened (40.76%). Most women estimated their risk of developing cancer to be “very low” (64.93%), although the vast majority also believed early detection could improve cancer outcomes (84.83%). Among those who had not been screened for cancer, 61.61% overall and 65.15% in the priority screening group responded that they would undergo all eligible cancer screenings if recommended by their provider. The figure jumps to 79.62% in the overall group and 77.27% in the priority screening group if additional respondent-identified barriers to screening were addressed. ConclusionProvider recommendations can be used to mitigate the suboptimal screening uptake and late-stage diagnosis that exacerbate the mortality and economic burden due to cancer in India. Policy summaryThis study finds that provider recommendations can shape the trajectory of outcomes by increasing cancer screening among women.

Haglund's Syndrome

Background: Haglund's syndrome an important cause of posterior heel pain presents with a prominent bony contour, a retrocalcaneal bursitis or achillis tendinitis these can also occur in isolation hence for the diagnosis of etiology of Haglund's disease certain radiological parameters and soft tissue parameters have been created to evaluate the anatomical variations which will assist in its exact diagnosis. Study aims to distinguish between the bony and soft tissue causes of Haglund's disease radiologically. Methodology: After Institutional ethical committee clearance an observational cross-sectional study was conducted with subjects coming to radiology OPD for X-ray foot with complains of posterior heel pain fulfilling inclusion and exclusion criteria were examined for X-ray lateral view of foot. Parameters like calcaneal inclination angle (CIA), Fowler Philip angle (FPA), parallel pitch line (PPL), Steffenson & Evenson angle (SEA) measured, posterior/calcaneal spur and posterior calcaneal step were noted. The data obtained was analyzed for mean, Standard deviation, sensitivity % and false negative %. Result: Sensitivity of the parameters were analyzed to find CIA, SEA &PPL to be 63.3%, 55% and 55% sensitive respectively. CIA could be assigned most sensitive but regarding soft tissue parameters none were sensitive. Conclusion: CIA, SEA & PPL were found to be sensitive among bony parameters. But none of the soft tissue parameters were sensitive radiologically highlighting a need for its correlation with clinical symptom in peripheral health centers where MRI is not available. Sensitivity of bony and soft tissue parameters were analyzed to find CIA, SEA & PPL to be sensitive. CIA could be assigned most sensitive among bony parameter but with regards to soft tissue parameters none were sensitive.

Adverse Neonatal Outcomes and Associated Antenatal Risk Factors - A Matched Case-Control Study from a Tertiary Care Hospital, South India.

The incidence of neonatal mortality has declined over the past few decades, but it remains a major concern. Identifying risk factors associated with adverse outcomes may help prevent and manage neonatal morbidity and mortality. The study aimed to explore the associated antenatal risk factors among pregnant women delivering in a tertiary care hospital in South India with adverse neonatal outcomes. This was a hospital-based, matched case-control study among pregnant women belonging to Puducherry and admitted for delivery. Cases were pregnant women who gave birth to adverse neonatal outcomes, while controls were pregnant women who gave birth to alive and healthy babies. Data was collected from various sources, primarily from medical records, and triangulated. Adverse neonatal outcomes were ten times more if pregnant women had placental complications and seven times more for intrauterine growth restriction noted during pregnancy. Pregnant women referred from peripheral care centers had 1.6 times more risk of adverse neonatal outcomes. Prior hospital admission during the present pregnancy had a protective effect in the final adjusted analysis. Risk factors should be routinely monitored in all health centers. Women with high-risk pregnancies should be identified earlier, and appropriate care should be provided.

A pilot study to evaluate the cholesterol lowering effect in camellia sinensis 3x

One of the best natural sources of antioxidants is Camellia Sinensis (green tea), and it has one positive effect on cholesterol levels. Moreover, Homoeopathy increases the medicinal value of the particular medicine. Thus, this study is to evaluate whether Homoeopathically prepared Camellia sinensis in its 3x potency can bring changes to the Cholesterol levels. A sample of minimum 40 cases were selected from Out Patient Department and other Peripheral centres of Father Muller Homoeopathic Medical College and Hospital, according to inclusion and exclusion criteria. After selecting the cases, informed consent was taken from each patient. A blood Investigation to know the level of Plasma triglycerides, Total Cholesterol, Low density Lipoprotein, High Density lipoprotein and Very Low Density Lipoprotein was done and filed. The selected patients were given Homoeopathically prepared Camellia sinensis 3X, three pills thrice a day (3-3-3) for a time period of 3 months. After 3 months of administration of the remedy, the levels of Plasma triglycerides, Total Cholesterol, High Density Lipoprotein, Low density Lipoprotein and VLDL were investigated and filed. The data available were then statistically analysed with the help of paired t test.Out of the 40 patients, it was seen that the 60% of the subjects were females. The age group mostly affected were that of 20 years – 25 years having 22.5%. 45% of the subjects belonged to Christian community, 42.5% were from Islamic community and 12.5% were Hindu community. Out of the 40 cases, most of the cases showed significant reduction in the levels of Total Cholesterol, Plasma Triglyceride and Low Density Lipoprotein, it also saw a reduction of the levels of High Density Lipoprotein and increase in the levels of Very Low Density Lipoprotein. The statistical analysis clearly stated the non-significant action of Camellia sinensis 3x on the High Density Lipoprotein (p>.001) and Very Low Density Lipoprotein (p>.001). It also stated the significant action of Camellia sinensis 3x on Total Cholesterol (p

TIF Standards for Haemoglobinopathy Reference Centres

Haemoglobin disorders are hereditary, lifelong and characterised by the need for multifaceted management. The question of quality in meeting standards of care that are likely to bring the best possible outcomes for patients is a necessary consideration. The concept of reference centres supporting peripheral treatment centres in a formal networking relationship is a response to the real needs of patients and a practical solution in public health terms. In this report, a team of advisors of Thalassaemia International Federation (TIF) attempts to suggest a set of standards for haemoglobinopathy reference centres, also based on the founding principles of TIF, aiming to act as a guideline for its member associations and professional collaborators. The standards described herein can form the basis of an accreditation process and also serve as a guide for those who would advocate for quality improvement for thalassaemia services.

Knowledge, attitudes and practice of breast control in primary care centers: impact on breast cancer epidemiology in San Rafael, Mendoza

Introduction: Breast cancer is the most frequent cancer in women globally and the leading cause of cancer death among women in developing countries. Objectives: The main objectives of this study were: to evaluate the clinico-pathological characteristics of patients with breast cancer at the San Rafael Regional Public Hospital, Mendoza; and, additionally, to determine the knowledge of an independent cohort of women regarding breast controls in the peripheral Health Centers of this city. Material and method: For the epidemiologic analysis of breast cancer in San Rafael, the Mendoza Provincial Tumor Registry was consulted. To study the clinico-pathological variables, a decryptive, cross-sectional type study was conducted on 51 consecutive patients with breast cancer diagnosis, during the period January 2014 to July 2016, in the Gynecology Service of the Hospital “ . Teodoro Schestakow” of the City of San Rafael, Mendoza. To determine the level of knowledge regarding breast-river control, surveys were conducted in peripheral health centers in the neighborhoods of Pueblo Diamante, Constitution, El Molino, Villa Laredo and El Sosneado, San Rafael, with prior authorization from the Directorate of the Municipal Health Area. Results: Breast cancer in women corresponded to 33.9% of all cancers in the period 2008-2012, according to the Provincial Tumor Registry. The mean age at the time of diagnosis was 53 years (range: 24-81 years). Advanced stages (III and IV) were diagnosed in 41.2% of patients. The 96.1% of patients presented breast symptomatology at the time of diagnosis, being breast tumor (on self-examination) the most frequent. Only 22% of women surveyed perform annual breast control; and only 7% of patients refer to having a breast examination performed at the medical consultation. Conclusion: Breast cancer diagnosis in San Rafael is performed mainly in symptomatic patients, which reflects deficiencies in early diagnosis, breast controls and information on the female population. This represents an opportunity to conduct population-targeted prevention campaigns, as well as education of health effectors from peripheral centres.

From Peripheral Stereogenic Center to Axial Chirality: Synthesis of 3‐Arylthiophene Atropisomers

AbstractA practical synthesis of axially chiral biaryls via chirality transfer from peripheral stereogenic carbon centers is reported. In contrast to the traditional aromatization process of a non‐aromatic structure withipsostereogenic centers, this method is based on a Pd‐catalyzed carbon‐carbon bond cleavage/ring‐opening reaction of optically active 8H‐indenothiophen‐8‐ols with an achiral ligand, enabling synthesis of highly functionalized 3‐arylthiophene atropisomers in high enantioselectivity.magnified image

Giant Occipital Meningoencephaloceles: Challenges in Management and Our Experience

Introduction: Giant encephalocele are encephalocele more than the size of head from which it arises. They pose a management challenge in view of risk of associated anomaly, challenges in anaesthesia and surgical management. There is no literature available from peripheral tertiary care centres from India apart from few case reports. Methods: This case series comprises of seven cases operated at our institute from 2014 to 2021. After routine clinical examination, patients subjected to recommended radiological investigations. Patients were anaesthetised with standard protocol with intubation in lateral or supine position with head hanging at edge of table and supported at table. Surgery carried out in lateral position with complete excision of sac with CSF diversion if pre existing hydrocephalus was present. Results: Out of seven cases, 3 were males and four female with age range from 12 days to 14 Mo. All patients were anaesthetised with standard protocol and had excision of sac with CSF diversion if required with satisfactory outcome in post operative phase and follow up. No death was recorded. Conclusion: With careful assessment and all recommended investigation with standard practice of anaesthesia and surgery, acceptable outcomes can be expected. Emphasis should be laid for good antenatal folate supplementation and possible antenatal diagnosis of meningoencephaloceles.

A community based prospective study on thyroid dysfunction among pregnant females and its effect on maternal and neonatal outcome

Background: Thyroid disorders are often overlooked in pregnancy because of their non-specific symptoms and the hypermetabolic state of pregnancy. The laboratory measurements of thyroid function play an important role in the assessment of maternal thyroid health. Thyroid disorders can have grievous effect on mother and new-borne which can be prevented. The study was aimed to find the prevalence of thyroid dysfunction among pregnant females and its effect on maternal and neonatal outcome.Methods: A prospective study was conducted from August 2019 to October 2020 among 360 pregnant females in the rural fields practice area of a medical college. Thyroid function test was done in all pregnant females and the maternal and neonatal outcome was noted.Results: 20.31% of the pregnant females were found to be suffering from thyroid dysfunction which is approximately 1/5th of the total sample. Out the total females with thyroid dysfunction maximum females suffered from subclinical hypothyroidism that is 10.94% while 1.56% had overt hypothyroidism. 1.88% and 5.94% had subclinical and overt hyperthyroidism respectively. Postpartum haemorrhage, pre term delivery, abortion and neonatal deaths were more common in females with thyroid dysfunction as compared to euthyroid females although not statistically significant.Conclusions: Though pregnancy outcome was not found to be significantly adverse among females with thyroid dysfunction, very high prevalence of thyroid dysfunction among pregnant warrants its detection during antenatal care to be uniformly included in peripheral health care centres.

Infected dentigerous cyst in maxillary antrum mimicking maxillary sinusitis

Cyst is defined as a pathological cavity which may or may not be lined by an epithelium and is usually filled with solid, semisolid or gaseous material. Dentigerous cyst is of odontogenic origin and is usually associated with an impacted tooth. Dentigerous cyst in maxillary antrum is often misdiagnosed in peripheral health care centers due to initial complaints mimicking maxillary sinusitis with patients reporting to general physicians/otolaryngologist for treatment. This article intends to report a case of infected dentigerous cyst initially managed as recurrent maxillary sinusitis in a peripheral rural health care center in high altitude region with limited health care facilities.

Assembling Hexagonal‐Bipyramidal {Mn8Zn2} and {Mn8Zn4} Clusters

AbstractReaction between Mn(NO3)2 ⋅ 6H2O, Zn(NO3)2 ⋅ 6H2O, 1,3,5‐tri(2‐hydroxyethyl)‐1,3,5‐triazacyclohexane (H3L) and pyrazole in MeOH under basic conditions leads to the formation of the decanuclear complex [MnIII6MnII2ZnII2(L)2(pyr)4O4(OH)4(NO3)2 (MeOH)2(H2O)4](NO3)2 ⋅ Η2Ο (1 ⋅ Η2Ο). The metallic core of the cationic cluster consists of a central hexagonal‐bipyramidal {MnIII4MnII2ZnII2} unit connected to two peripheral trivalent Mn centers arranged in a “trans” fashion, with one MnIII center lying above and one MnIII center below the hexagonal plane. Replacing Mn(NO3)2 ⋅ 6H2O with MnBr2 ⋅ 4H2O and repeating the same reaction leads to the formation of the related, neutral decanuclear complex [MnIII6MnII2ZnII2(L)2(pyr)4O4(OH)4Br4(H2O)2] (2), displaying the same metallic core as 1. Addition of THF to the reaction mixture that produces (2) affords the neutral dodecanuclear complex [MnIII6MnII2ZnII4(L)2(pyr)6O4(OH)4Br6(H2O)4] ⋅ 8THF (3 ⋅ 8THF), whose metallic skeleton retains the central hexagonal‐bipyramidal {MnIII4MnII2ZnII2} unit found in 1 and 2 but is now connected to two peripheral {MnIIIZnII} units. Magnetic susceptibility and magnetization measurements carried out in the T=2–300 K temperature range and in fields up to B=7.0 T for all three complexes reveal dominant antiferromagnetic exchange interactions.

Transcranial Surgery for Pituitary Tumors: A "Community Neurosurgery Experience".

Despite the evolution of endoscopic techniques, large pituitary adenomas with unfavorable characteristics and irregular anatomical configurations continue to pose a challenge for the dexterity, skills, and patience of endoscopic surgeons. Transcranial surgery retains a significant role in these situations where the tumor access, hemostasis, and dissection around adjoining neurovascular tissues can be controlled efficaciously. In this report, we describe our experience with transcranial surgery for pituitary adenomas highlighting its safety and versatility in peripheral centers. We accessed the case files and imaging records of pituitary tumors operated between 2001 and 2019 at a private hospital in a major Indian city. The records were analyzed with emphasis on postoperative clinical course, visual, and endocrinological outcomes. The data was analyzed with respect to differences between transcranial and transsphenoidal procedures. Categorical variables were compared with Chi-square test/Fischer's exact test and difference in means evaluated with Welch's t-test. A total of 178 procedures were performed in 173 patients with pituitary adenoma, who were the subjects of this study. Ninety-eight (56.7%) patients were treated by transsphenoidal excision whereas 80 (46.2%) underwent transcranial procedures (75 primary and five secondary). In the patients operated transcranially, we observed three deaths and nine patients suffered from significant morbidity. Visual outcomes were similar to the group operated transsphenoidally. However, incidence of panhypopituitarism was significantly higher in transcranial procedures; the extent of resection was poorer than transsphenoidal surgeries owing to more extensive nature of tumors. In low-volume centers, the endoscopic skills required for transsphenoidal resection of large and complex pituitary adenomas may be scarce. Transcranial surgery, dependent on familiar microsurgical techniques and equipment, may still be viable, safe, and an effective option.

Implementation of the South African Triage Scale (SATS) in a New Ambulance System in Beira, Mozambique: A Retrospective Observational Study.

In 2019, an urban ambulance system was deployed in the city of Beira, Mozambique to refer patients from peripheral health centres (HCs) to the only hospital of the city (Beira Central Hospital—HCB). Initially, the system worked following a first-in–first-out approach, thus leading to referrals not based on severity condition. With the aim of improving the process, the South African Triage Scale (SATS) has been subsequently introduced in three HCs. In this study, we assessed the impact of SATS implementation on the selection process and the accuracy of triage performed by nurses. We assessed 552 and 1608 referral charts from before and after SATS implementation, respectively, and we retrospectively calculated codes. We compared the expected referred patients’ codes from the two phases, and nurse-assigned codes to the expected ones. The proportion of referred orange and red codes significantly increased (+12.2% and +12.9%) while the proportion of green and yellow codes decreased (−18.7% and −5.8%). The overall rates of accuracy, and under- and overtriage were 34.2%, 36.3%, and 29.5%, respectively. The implementation of SATS modified the pattern of referred patients and increased the number of severe cases receiving advanced medical care at HCB. While nurses’ accuracy improved with the routine use of the protocol, the observed rates of incorrect triage suggest that further research is needed to identify factors affecting SATS application in this setting.