Peripheral Hospital Research Articles

CASE SERIES: CHALLENGES AND OUTCOMES OF TLIF PROCEDURES IN A PERIPHERAL HOSPITAL IN BHARATPUR, RAJASTHAN

Objective: Chronic back pain, particularly from degenerative spinal conditions, significantly impacts patient quality of life, especially in regions with limited healthcare resources, such as rural Rajasthan. Transforaminal Lumbar Interbody Fusion (TLIF) has been recognized for its efficacy in treating severe spinal degeneration and instability. This case series examines the application of TLIF in a peripheral hospital setting, assessing its challenges and outcomes in such environments. Methods: This study included three patients aged 34 to 75, who underwent TLIF at a peripheral hospital in Bharatpur, Rajasthan, from February to July 2024. Detailed preoperative and postoperative evaluations were conducted, focusing on pain levels and functional mobility. Follow-ups were performed at the first, second, and fourth weeks post-surgery to monitor recovery and assess surgical success. Results: All patients reported significant improvements in pain and mobility by the first-month follow-up. The 34 y old female experienced complete pain relief and returned to full activities by four weeks. The 75 y old female and 65 y old male also showed considerable improvements in pain and function, with no severe complications noted during or after surgery. Conclusion: TLIF can be effectively implemented in peripheral hospital settings with outcomes comparable to those in higher-resource environments. This case series demonstrates the feasibility and significant benefits of advanced spinal surgeries in resource-limited settings, highlighting the potential for expanding such sophisticated interventions to improve healthcare accessibility and patient outcomes in rural areas.

Impact of COVID-19 on cardiology and neurology services in a peripheral hospital in Northern Israel

Abstract Background The indirect impact of COVID-19 pandemic on clinical services remains incompletely described in secondary care hospitals outside major urban centers. We compared clinical outcomes before and during the pandemic in a disrupted service (Neurology) and a non-disrupted one (Cardiology) in a peripheral hospital in Israel, using Cerebral Vascular Accident (CVA) and ST-elevation myocardial infarction (STEMI) as clinical indicators, respectively. Methods We compared demographics, treatment and outcomes from CVA and STEMI patients who attended Ziv Medical Center, Israel, during the pandemic (15/3/2020-15/4/2022) and before (1/1/2018-14/3/2020), Using chi-square, t-test and Wilcoxon-Mann-Whitney tests. Results 1029 CVA and 497 STEMI patients were included. Those who arrived during the pandemic were demographically comparable to those arriving before. Compared to pre-pandemic, intra-pandemic median time for CVA patients from arrival to imaging was longer (23 vs. 19 minutes, p = 0.001). However, timing from arrival to tissue Plasminogen Activator administration was similar (49 vs. 45 min, p = 0.61). The likelihood of transfer to another hospital was higher (20.3% vs. 14.4% p = 0.01) and median length of stay (LOS) was shorter (3 vs. 4 days, p < 0.05). Among STEMI patients, median time from arrival to percutaneous coronary intervention during the pandemic was shorter than before (45 vs. 50 minutes p = 0.02) and median ejection fraction at discharge was higher (50% vs. 45% p = 0.02). Mean LOS was shorter (3.86 vs. 4.48 p = 0.01), and unplanned re-admission to the ED was less frequent (7.8% vs. 14.6% p = 0.01). No significant changes in mortality were observed. Conclusions Our data shows no major negative impact of the COVID-19 pandemic on CVA and STEMI outcomes, and possibly improved care in the less disrupted department. Follow-up qualitative studies with neurology and cardiology staff already in action to comprehend how quality of care was maintained during the crises. Key messages • In peripheral setting, COVID-19 hadn’t negatively impact Neurology or Cardiology acute clinical outcomes. • The consequences of maintaining clinical performance when working under adverse conditions requires further research.

A mcgyvering way to left bundle branch area pacing : using the treadmill test machine ECG system and modified V1 / V6 leads connected to the pacing system analyser for left bundle branch area pacing

Abstract Background Left bundle branch area pacing (LBBaP) is a novel pacing modality which provides physiological synchronisation of both the ventricles. However, its use and adoption requires the presence of a standardised electrophysiological (EP) system with 12 lead ECG to show left bundle branch area capture. Purpose The aim of the study was to assess the feasibility and outcomes of using the conventional treadmill test (TMT) machine 12 lead ECG system and modified V1 and V6 leads connected to the pacing system analyser (PSA) to demonstrate conduction system capture during left bundle branch area pacing (LBBaP). Methods LBBaP was attempted by a single operator in a mixed cohort of patients at peripheral hospitals lacking the standardised EP system. The presence of LBB area capture was tested with the aid of the 12 lead ECG system connected to the standard TMT machine (1). Conduction system capture was also assessed using modified V1 and V6 leads connected to the PSA for measurement of V6 left ventricular activation time (LVAT)(2) . The baseline clinical, procedural, pacing, electrocardiographic parameters, echocardiographic response (> 10% improvement in ejection fraction {EF}) and clinical response to LBBaP were assessed. Results LBBaP was attempted in 19 patients and was successful in 18 patients (94.7%). Patient characteristics include age 66.7 +/- 11.47 years, female 47.37%, male 52.63%, ischaemic cardiomyopathy 10.52% and non-ischaemic cardiomyopathy 5.26% .The mean baseline EF and QRS duration was 45%+/-14% and 130.18 +/-10.45 milliseconds(ms) respectively. LBBaP threshold was 0.59 +/-0.168 volts and R wave amplitude was 12+/-3.5 millimetres , which remained stable during the mean follow up of 15.9 +/-13.67 months. The mean fluoroscopic duration was 11.57 +/-2.58 minutes and procedural time was 108.78+/-29.20 minutes. LBBaP resulted in impressive narrowing of the QRS duration to 102.39 +/-10.55 ms (p<0.001) with LVAT of 68.94 +/-9.94 ms. LVEF improved in the patients with cardiomyopathy from 33.4 +/- 5.77 % to 48.2+/-12.37 % (p=0.028) .Clinical and echocardiographic response was noted in 87.5% of patients with cardiomyopathy. Conclusion The 12 lead ECG system with the standardised TMT machine in conjunction with the modified V1 and V6 leads connected to the PSA is a feasible alternative to the EP system to perform successful left bundle branch area pacing.ECG leads connected during LBBapClinical profile of patients

Cast-OFF 2: one week versus three to five weeks of plaster cast immobilization for non-or minimally displaced distal radius fractures, a stepped wedge cluster randomized controlled trial.

Implementation of one week of cast immobilization followed by gradually increasing wrist mobilization for non- or minimally displaced DRF and comparison of the functional outcomes and pain scores with the usual care (three to five weeks of cast immobilization). Design: A randomized stepped wedge cluster design, prospective cohort. Academic and peripheral hospitals in level 1, 2, and 3 trauma centers. All patients between 18 and 85 years old with an isolated non- or minimally and nonreduced DRF were eligible for inclusion. Participating hospitals were randomized to transition from usual care (three to five weeks of cast immobilization) to one week of cast immobilization, following the stepped wedge design. Patient characteristics, secondary dislocation, surgical treatment, visual analog scale (VAS), Patient Rated Wrist Evaluation (PRWE), Patient Reported Outcomes Measurement Information System Pain Interference (PROMIS-PI), Pain Catastrophizing Scale 4 (PCS-4), and patient satisfaction were compared between control, and intervention group at week 1, 3-5, 6, month 3, 6, and 12. A difference around 11 points on the PRWE scale was considered clinically significant. 402 patients were included (control n=197 vs intervention n=205, 267/135, female/male). There were no differences in age (53.7 ± 18.6 vs 53.3 ± 19.5, P = 0.27), sex (66% vs 67% female, P 0.44), dominant hand fractured (44% vs 53%, P 0.39), and type of fracture (39% vs 41% extra-articular, P = 0.44) After six weeks, the PRWE score showed no clinically significant differences (-4.5 [CI -12.9, 4.02], P = 0.30). No significant differences were observed for function, pain scores, and patient satisfaction between groups (all P > 0.05). Furthermore, there was no significant difference in secondary dislocation rate (control 1.5% vs intervention 1.0%, p=0.32, P = 0.32) and operation rate (control 1.5% versus 1.5% intervention P = 0.92). This study compared one week of cast immobilization followed by gradually increasing wrist mobilizationto the usual care of three to five weeks for nonreduced DRF. No clinically significant differences in function, pain scores, patient satisfaction, secondary dislocation, and operations were observed. Therefore, one week of plaster immobilization can be safely recommended for the non- or minimally displaced and nonreduced DRF treatment. Level II. See Instructions for Authors for a complete description of levels of evidence.

Timing of Fracture Fixation in Ankle Fracture-Dislocations.

Ankle fracture-dislocations may require delayed internal fixation. Our aim was to compare acute open reduction and internal fixation (ORIF) with delayed ORIF, using external fixation or cast splint in ankle fracture-dislocations. Factors that affect the rates of re-operation and Surgical site infection (SSI) were identified. In this retrospective cohort study, patients were included with open and closed ankle fracture-dislocations treated with ORIF from two large peripheral hospitals and one academic center in the Netherlands. This study included 447 patients with an ankle fracture-dislocation. In the multivariate analysis, the difference between surgery <48 hours compared to bridging with cast or external fixation had no significant influence on unscheduled re-operation or SSI. Higher body mass index (BMI) and open fractures had a significant positive correlation with re-operation while diabetes mellitus (DM) and open fractures correlated with SSI. In patients with open fractures, there was also no significant difference in outcome between acute or delayed internal fixation. We suggest that it is safe to perform primary ORIF on all dislocated ankle fractures if the soft tissue injury allows surgery within 48 hours. When significant swelling is present, patients with well-reduced fractures and with no soft tissue injury could be treated safely with a cast until delayed ORIF is possible.Level of Evidence: Therapeutic level 2B (retrospective cohort study).

Outcomes of pediatric in-hospital cardiac arrest in the emergency department of a tertiary referral hospital in Tanzania: a retrospective cohort study

BackgroundCardiopulmonary resuscitation (CPR) is an emergency procedure performed to restore heart function to minimize anoxic injury to the brain following cardiac arrest.Despite the establishment of emergency department and training on Pediatric Advanced Life Support (PALS) at Muhimbili National Hospital (MNH) the outcomes of pediatric in-hospital cardiac arrest have not been documented. We ought to determine the outcomes and factors associated with 24-h survival after pediatric in-hospital cardiac arrests at MNH in Tanzania.MethodsWe conducted a retrospective study of all patients aged 1 month to 18 years who had in-hospital cardiac arrests (IHCA) prompting CPR in the Emergency Medicine Department (EMD) at MNH, Tanzania from January 2016 to December 2019. Data was collected from electronic medical record (Wellsoft) system using a standardized and pretested data collection form that recorded clinical baseline, pre-arrest, arrest, and post-arrest parameters. Bivariate and multivariable logistic regression analyses were performed to assess the influence of each factor on 24-h survival.ResultsA total of 11,951 critically ill patients were screened, and 257 (2.1%) had cardiac arrest at EMD. Among 136 patients enrolled, the median age was 1.5 years (interquartile range: 0.5–3 years) years, and the majority 108 (79.4%) aged ≤ 5 years, and 101 (74.3%) had been referred from peripheral hospitals. Overall stained return of spontaneous circulation was achieved in 70 (51.5%) patients, 24-h survival was attained in 43 (31.3%) of patients, and only 7 patients (5.2%) survived to hospital discharge. Factors independently associated with 24-h survival were CPR event during the day/evening (p = 0.033), duration of CPR ≤ 20 min (p = 0.000), reversible causes of cardiac arrest being identified (p = 0.001), and having assisted/mechanical ventilation after CPR (p = 0.002).ConclusionIn our cohort of children with cardiac arrest, survival to hospital discharge was only 5%. Factors associated with 24-h survival were CPR events during the daytime, short duration of CPR, recognition of reversible causes of cardiac arrest, and receiving mechanical ventilation. Future studies should explore the detection of decompensation, the quality of CPR, and post-cardiac arrest care on the outcomes of IHCA.

Intra-orbital Foreign Body

Abstract Background: This case report describes a young man with an intra-orbital foreign body (FB) in both eyes. Case Report: Intra-orbital FBs are rare, with few cases reported in the literature. This is because the orbit protects the globe from external forces, and the orbit is a closed cavity with one opening. This report details the case of a 28-year-old man who presented to the emergency unit with an 11-hour history of an intra-orbital FB. The patient was lying on a bench when a stationary motorcycle fell on him. He noticed that he was unable to open both eyes and was rushed to a peripheral hospital, then subsequently referred to this tertiary center. On examination, he was ill-looking and anxious but not febrile or pale. Systemic examination did not reveal any abnormality. Unaided visual acuity in the right eye (OD) was nil perception of light, while left eye visual acuity (OS) was counting fingers. The right eyelid was ptotic due to edema. He underwent basic laboratory investigations that were all normal. A plain X-ray revealed a radio-opaque FB penetrating the left orbit, fracturing the medial walls into the right orbit, with the round end positioned behind the right globe. The FB was identified as a broken part of a brake/clutch lever from the motorcycle. A computerized tomography scan showed a metallic object in both orbits, accompanied by pneumocephalus, and suggested transection of the right optic nerve. The patient was prepared for FB removal and repair of the lid penetration under general anesthesia, following review by the ENT surgeon and neurosurgeon. The brake lever was successfully removed, and the patient was administered antibiotics. Post-operatively, visual acuity in the right eye remained at nil perception of light, while that in the left eye improved to 6/9 upon discharge. Conclusion: There is no established protocol for managing intra-orbital FBs, as removal depends on factors such as the size, composition, and potential compression damage to structures around the globe, which could further compromise vision or function. Small inert objects may be left in place if removal would cause damage. However, in this case, removal was deemed necessary for several reasons.

Management of cloacal exstrophy: Experience from tertiary hospital, Tanzania. Case series

Introduction and importanceCloacal exstrophy (CE) is defined as a complex anomaly that affects the urogenital and intestinal tracts. It is the most serious form of anomaly that is described within the so-called exstrophy-epispadias complex. These malformations usually present a challenge in the management of particular conditions, as most of these forms require multiple surgeries, resulting in the use of multidisciplinary approaches, including reconstructive urologists, pediatric surgeons, orthopedic surgeons, endocrinologists, pediatricians, psychologists and nutritionists. Additionally, these patients present with ambiguous genitalia, which is another aspect that needs to be taken into consideration during the management of this condition. Case presentationThe first patient, a baby who was 8 days of life and referred from a peripheral hospital, presented with classic features of cloaca exstrophy. He underwent first-stage cloacal exstrophy repair. The intraoperative findings included a bi-halved bladder and phallus, and the ureters were not appreciated, but there was continuous urine leakage from the bi-halved bladder and no uterus or ovaries. Poorly formed cecum, cecal-cutaneous fistula with an everted part of the terminal ileum protruding outside (mucosa-out), no transverse, no descending colon, collapsing small bowel, left undescended testis in the inguinal region, and right abdominal undescended testis. He first underwent surgery, which involved ileostomy, omphalocele closure and proper bladder exstrophy construction.The second patient, a 6-day-old female, had a similar presentation and physical findings as the first patient did, except that she had elephantoid trunk deformity with a cecal fistula, bifid clitoris, two cervical orifices, and two uteri completely separated with ovaries. Mobilization of the hindgut, closure of the cecal fistula, and proper bladder exstrophy after repair of the posterior wall were performed.The third patient was a 10-day-old female, similar to the second patient, but this patient presented with a left leg deformity with wide diastasis. In this case, the urinary bladder was not bivalved, and the cecal fistula had perforated just below the posterior wall of the urinary bladder. A mild omphalocele, bifid clitoris and vagina, one cervical orifice, and two uteri completely separated, with ovaries observed. Mobilization of the hindgut, closure of the cecal fistula, and proper bladder exstrophy after repair of the posterior wall were performed. The postoperative period was uneventful. Clinical discussionSurgical management of cloacal exstrophy is typically undertaken in the newborn period (48–72 h) as a combined effort between pediatric surgery and urology. In the setting of associated spinal dysraphism, neurosurgical consultation and closure should be undertaken as soon as the infant becomes medically stable. Early operation minimizes bacterial colonization of exposed viscera and may decrease the need for pelvic osteotomy. The goals of treatment include securing the abdominal wall and bladder closure, preserving renal function, preventing short bowel syndrome, creating functional and cosmetically acceptable genitalia, and attaining acceptable urinary and fecal continence. ConclusionCloacal exstrophy remains a rare and complex congenital anomaly characterized by an array of anatomical defects affecting multiple organ systems. With respect to the approach of this congenital malformation, it is therefore important that these individuals and their families remain under the care of a multidisciplinary team of providers who can offer medical care, counseling and life-long follow-up.

Management of Bile Duct Injury Complicating Cholecystectomy: Experience of the General Surgery Department of Avicenne Military Hospital in Marrakesh

Bile duct injuries are the most feared complication of a commonly performed cholecystectomy, which is generally considered as a safe and benign intervention. Eighteen cases of bile duct injuries were collected through a retrospective study conducted between January 2019 and December 2023 in the general surgery department of the Military Hospital Avicenne in Marrakesh. The average age was 53 years old, sex ratio M/F was 0.38. Acute cholecystitis, acute pancreatitis, obesity and anatomical variations were the main risk factors found in our patients. For 13 patients, the iatrogenic injury had occurred in our department. For the remaining 5 patients, they were referred from peripheral hospitals. Intraoperative diagnosis was made in five cases. In the postoperative period, 6 patients had bile leakage from the drain, 5 patients had abdominal pain, one patient presented incisional bile leakage and one patient had a jaundice. The repair consisted mostly on Roux-en-Y hepaticojejunostomy which was performed in 9 cases. Cystic duct ligation was performed in five cases. Two patients underwent primary repair on common bile duct with T-tube insertion. Two cases were treated by endoscopically. The six months’ follow up was favorable for 66,7% of the cases. The prevention and the respect of surgical rules and recommendations (critical view of safety) during cholecystectomy are the best means to avoid these lesions.

A Cross-Sectional Study of Acute Poisoning Cases Admitted in a Tertiary Care Hospital in Mangaluru, Karnataka, India

Abstract Introduction: A poison is a substance that causes serious illness and endangers the life of a person when ingested in a relatively small quantity. Poisoning is one of the most common problems encountered in day-to-day clinical practice. Poisoning causes morbidity and mortality which can be prevented and managed if clinicians are sensitized with adequate knowledge of common poisons. Therefore, this study was conducted to know the profile of acute poisoning cases admitted in a tertiary care hospital in Mangaluru. Materials and Methods: 100 patients admitted in the intensive care units and wards of the General Medicine department, Kasturba Medical College, Mangaluru, and Government Wenlock District Hospital, Mangaluru with various poisoning were evaluated for various factors like the distribution of poisoning cases according to age, gender, intention of poisoning, nature of poisons consumed and the nature of treatment received at another hospital before getting admitted. Results: Most of the cases of poisoning occurred in the age group between 21-30 years of age (38%). The majority of the patients in the study were males (60%) and females formed 40% of the study population. The majority of patients in this study (99%) consumed poison with suicidal intention. 77% of patients received first-aid treatment in a peripheral hospital before getting admitted to our hospital. Conclusion: This study shows that the peak incidence of acute poisoning cases was seen in the age group of 21 to 30 years with male predominance. The pattern of poisoning was suicidal in the majority of the patients.

Dried plasma spot as an innovative approach to therapeutic drug monitoring of apixaban: Development and validation of a novel liquid chromatography-tandem mass spectrometry method.

Apixaban, a direct oral anticoagulant drug (DOAC), typically does not require routine therapeutic drug monitoring (TDM), yet recent guidelines propose its use in specific clinical scenarios. While various antifactor Xa (anti-FXa) chromogenic assays serve as useful proxies for measuring plasma exposure to apixaban in emergencies, they lack specificity compared with chromatographic methods. This research project is intended to the development and validation of a standardized protocol of liquid chromatography-tandem mass spectrometry (LC-MS/MS) in conformity with the ICH guidelines M10 for the measurement of apixaban in both plasma and dried plasma spots (DPSs). Samples preparation included protein precipitation after the addition of a deuterated internal standard (IS), and the chromatographic separation was carried out on a Thermo Scientific™ Accucore™ Polar Premium column (50 mm × 2.1mm, i.d. 2.6 m). The newly developed LC-MS/MS method for apixaban mesurement from both plasma and DPS resulted linear over a wideconcentration range (31.25-500 ng/mL), accurate, and reproducible without matrix effects, allowing for specific and rapid quantification. Stability was assessed on quality controls and a real sample, allowing the setting up of a robust TDM protocol that was applied to five anonymized plasma samples obtained from adult patients undergoing apixaban treatment at steady-state. In conclusion our novel LC-MS/MS method is adequate for accurate apixaban quantitation from both plasma and DPS matrixes, andmay thus facilitate the guidelines suggested implementation of apixaban TDM, even in peripheral hospitals through shipment of DPS at reference laboratories.

Tuscany Normothermic Regional Perfusion Mobile Teams for Controlled Donation After Circulatory Death.

To facilitate the implementation of controlled donation after circulatory death (cDCD) programs even in hospitals not equipped with a local extracorporeal membrane oxygenation (ECMO) team, some countries have launched a local cDCD network with an ECMO mobile team for normothermic regional perfusion (NRP). In the Tuscany region, in 2021, the Regional Transplant Authority launched a cDCD program to make the cDCD pathway feasible even in peripheral hospitals with NRP mobile teams, which were "converted" existing ECMO mobile teams, composed of highly skilled and experienced personnel. We describe the Tuscany cDCD program, (2021-2023), for cDCD from peripheral hospitals with NRP mobile teams. Twenty-six cDCDs (26/40, 65%) came from peripheral hospitals. Following the launch of the cDCD program, cDCDs from peripheral hospitals increased, from 33% (2021) to 75% (2022 and 2023) of the overall cDCDs. The mean age was 63 years, with older donors (>75 years) in half the cases. The median warm ischemia time was 45 min (20 min are required by the Italian law for death certification), ranging from 35 to 59 min. Among the 20 livers retrieved and 18 kidneys retrieved, 16 livers, and 11 kidneys (single kidney transplantation) were transplanted, after ex vivo reperfusion, respectively. The use of NRP mobile teams proved to be feasible and safe in the management of cDCD in peripheral hospitals. No complications were reported with NRP despite the advanced age of most cDCDs.

Nursing managers' perceptions of teamwork and collaboration in mining primary healthcare clinics in Gauteng.

Teamwork and collaboration among nursing managers, nurses, doctors and peripheral hospitals treating mining patients is pivotal. A case study of specific mining primary healthcare clinics revealed a lack of teamwork among the doctors and nursing managers, even on decisions that show productivity. The aim of this study was to explore and describe nursing managers' perceptions of teamwork and collaboration in mining primary healthcare clinics in Gauteng. A qualitative, exploratory, descriptive and contextual research design was adopted to conduct this study. Data were collected by conducting semi-structured individual interviews with 10 participants and thematically analysed. Data saturation was reached by the seventh participant and confirmed with three more interviews. Trustworthiness measures and ethical considerations were preserved as protocols because of the nature of the study. Three themes emanated from the study: (1) team coordination and support improve teamwork and collaboration in primary healthcare clinics, (2) there is a lack of involvement from the nursing team, negatively influencing teamwork and collaboration and (3) collaboration can improve the quality of healthcare services rendered in mining primary healthcare clinics. All mining primary healthcare clinic team members should be involved in operational activities to foster teamwork and collaboration.Contribution:This study revealed that teamwork and collaboration should be facilitated to improve the quality of healthcare service in mining primary healthcare clinics.

A Cognitive Load Theory Perspective of the Undergraduate Anesthesia Curricula in South Africa.

Safe anesthesia is indispensable to achieve global safe surgery and equitable health care access. The disease burden and lack of specialists in South Africa (SA) require junior, nonspecialist doctors to be fit-for-purpose from day 1 when they provide anesthetic services in peripheral hospitals with limited supervision. Graduating students report low self-perceived preparedness for administering anesthesia, but it is not known how their curricular experiences influence their learning. Cognitive load theory defines intrinsic, extraneous, and germane cognitive loads (subtypes). Intrinsic load relates to learning tasks, extraneous load to distractions, and germane load to students' learning processes. This study used a cognitive load theory lens to explore SA students' experiences of their undergraduate anesthesia training. In a constructivist cross-sectional descriptive study, we explored the qualitative factors that influenced students' curricular experience of undergraduate anesthesia training in SA. Two investigators analyzed the data independently in an initial coding round. An emerging theme of lack of time to achieve the expected outcomes, prompted the use of cognitive load theory as a conceptual framework for further analysis by the 3 authors. The subsequent analysis informed the development and refinement of a final cognitive load theory framework for anesthesia training, the COLOAD (COgnitive LOad in Anesthesia eDucation) framework. Data were collected between November 2017 and February 2019. The 1336 respondents (79% participation) reported a variety of determinants of learning pertaining to all 3 cognitive load subtypes. Participants were novices in an inherently complex environment and experienced a high cognitive load during anesthesia training. The number-, complexity-, and interactivity of tasks influenced intrinsic load, while extraneous load was affected by ineffective instructional methods, external- and internal distractors. Program design, metacognition, and learner motivation impacted germane load. Cognitive load theory provided a useful theoretical basis for understanding students' curricular experiences. The COLOAD framework suggests a microlevel interrelatedness of the constituting elements of the 3 cognitive load subtypes. This has implications for curriculum design, pedagogy, and student support. Learning outcomes development and curriculum mapping are important to ensure a lean curriculum, but measures to enhance germane cognitive load might be equally important to achieve competence. Attention to the hidden curriculum and active promotion of reflective practice might reduce cognitive load in complex learning environments such as anesthesia training.

Optimizing diuretic management in acute decompensated heart failure: the impact of diuretic algorithm in real-world setting

Abstract Background/Introduction Achieving euvolaemia is an important prognostic factor in acutely decompensated heart failure (ADHF). The European Society of Cardiology (ESC) guidelines suggest that a stepwise diuretic treatment algorithm based on regular reassessment of urinary output and natriuresis may be superior compared to current standard of care. We studied the implementation and effectiveness of such a pre-specified algorithm in a real-word cohort for realizing euvolaemia. Methods In 2020 we implemented the stepped diuretic strategy from the Heart Failure Association position statement, now stated in the 2021 ESC guidelines, in a peripheral hospital. Afterwards we conducted a retrospective cohort study, including patients with ADHF (with hospitalization duration &amp;gt; 3 days for decongestive treatment). Patients admitted between 10-Jan-2021 and 04-Dec-2021, who were treated according to the diuretic algorithm (protocol cohort), were compared to patients who were treated between 04-Jan-2018 and 19-jan-2019 (before implementation of this algorithm). Our primary outcomes were length of hospital stay (days), complications during hospitalization, such as electrolyte disturbance, kidney function, arrhythmias, infections and mortality during hospitalization. Results The study comprised 221 patients, with 107 in the pre-protocol cohort and 114 in the protocol cohort. Baseline characteristics were similar between the cohorts, expect for the kidney function and NT-proBNP levels at admission. Mean eGFR was slightly better in the protocol cohort (53 [36-71] vs 43 [29-63] ml/min/1.73m2, p .016), were as NT-proBNP was higher in the pre-protocol cohort (990 vs 480 pmol/l) (Table 1). The mean length of stay was shorter in the protocol cohort (7.0 [5.1-10.3] vs 7.5 [5.9-10.9] days). The incidence of complications, such as electrolyte disturbances and arrhythmias, were comparable. Notably, the mean eGFR on third day of hospitalization was higher in the protocol cohort (50 ± 21 vs. 42 ± 19 ml/min/1.73m2). There was a difference in the median weight lost during the admission between the two cohorts (Figure 1). Conclusion Our data suggest that a pre-specified stepwise diuretic treatment algorithm, based on urinary output is feasible and effective in achieving euvolaemia in a real-world cohort. Furthermore, it reduces length of hospital stay without increasing the risk of complications.

HOSPITAL ADMINISTRATION IN A PERIPHERAL REMOTE LOCATION HOSPITAL: A EVIDENCE BASED STUDY

Objective: The organisation of the human society has undergone a unique transition throughout the last decades. With the rise of ever growing technologization and disruptive innovations, populations also demand more social and environmental initiatives from firms and governments. In 2015, the United Nations (UN) member states agreed upon a 2030 Agenda for Sustainable Development. Developing a sustainable UHC is decisive to ensure better economic prospects and social equality across socioeconomic classes. This can be achieved by lowering the barriers to access health services to the most vulnerable groups and improve mortality and disability rates in the potential workforce. Methods: The present study was conducted in a remote location defence hospital catering to the health care needs of serving personnel of Indian armed forces and civilians residing in this peripheral area. The basic specialties including Obstetrics, paediatrics, medicine and general surgery are provided at this centre 24*7 by the dedicated medical officers of Indian Armed forces. Results: Sustainability of care continuously evolves towards becoming a major factor for public healthcare organisations, and more accountability will likely be demanded of managers to deliver on each aspect of its triple bottom line. This study shows that prevention and patient empowerment both carry great potential to attain this objective. Conclusion: It is necessary to set priorities and act according to available resources and organisational vision. The central threats to sustainability of public health care welfare systems in peripheral hospitals identified, namely the ageing population and rise in chronic diseases. UHC at a meso and micro level, could provide a much better rationale for scholars to evaluate the need for change, and contribute to draft more inclusive sustainable strategies.

508 The Introduction of Daycase HoLEP in a Peripheral Hospital

508 The Introduction of Daycase HoLEP in a Peripheral Hospital

Case Series Analysis of Wild Elephant Attack-Related Trauma Victims at a Peripheral Base Hospital in Sri Lanka

Case Series Analysis of Wild Elephant Attack-Related Trauma Victims at a Peripheral Base Hospital in Sri Lanka

Our initial experiences with laparoscopic urologic surgery in a peripheral hospital in Central Java, Indonesia

Introduction: Nowadays, laparoscopic surgery in urology is widely adopted as a surgical technique for almost all cases, rendering the traditional open surgery approach obsolete. The increased use of laparoscopic surgical procedures has significantly contributed to progress in many urology areas. This study evaluates the initial experience with laparoscopic urology surgery in Banyumas General Hospital, a peripheral hospital in Indonesia. Method: Between May 2023 and October 2023, laparoscopic urologic surgery was performed on 36 patients. The patient’s demographic characteristics, pre-operative diagnosis, type of laparoscopic approach, and intraoperative and post-treatment results were gathered and analyzed retrospectively. Result: The mean patient age is 58.69±13.52 years, with 12 (33.33%) female patients and 24 (66.67%) male patients. While 20 had ureterolithotomy, 3 had pyelolithotomy, 5 had radical cystectomy, 2 patients received unroofing renal cyst, 1 had pyeloplasty, 1 had ureteral Anastomosis, and 1 had radical nephroureterectomy, 1 had a simple nephrectomy, 1 had diverticulectomy, and 1 had orchidopexy. 2 (5,56%) of the 36 patients must be converted to open surgery. The mean duration of surgery for procedures we did was as follows: ureterolithotomy 86.25 ± 7.23 minutes, pyelolithotomy 96.67 ± 7.64, radical cystectomy 418± 64.09 min, unroofing renal cyst 57.5 ± 10.61 minutes, pyeloplasty 130 minutes, ureteral anastomosis 220 minutes, radical nephroureterectomy 210 minutes, simple nephrectomy 140 minutes, diverticulectomy 215 minutes, and orchidopexy 125 minutes. The mean hospital stay was 4.39 ± 2.28 (2-11) days. There are major complications, but no mortality was encountered. Conclusion: Laparoscopic surgery is an effective technique with excellent outcomes, a safe and feasible alternative to open surgery in urology.

Diagnosis and management approach of acute cholangitis with sepsis complications in a peripheral hospital: a case report

Acute cholangitis is a systemic, life-threatening condition that develops as a result of obstruction and infection of the bile ducts. The two main processes leading to acute cholangitis include obstruction of the biliary tract and the growth of bacteria in the bile. A case of acute cholangitis has been reported at Rote Ndao public hospital, Rote Ndao district, East Nusa Tenggara, in a 57-year-old woman, with the main complaint of right upper abdominal pain, jaundice, and fever. The diagnostic approach is based on anamnesis, physical examination, and supporting examinations. Based on the Tokyo guideline 2018 (TG18) the patient met a suspected diagnosis, with A criteria that was evidence of systemic inflammation in the form of fever (body temperature 38.7o C), evidence of an inflammatory response with increasing leukocyte count (26,200/cm3), and for the B criteria that was evidence of cholestasis in the form of jaundice, increasing of total bilirubin (19.8 mg/dL), abnormal liver function tests (SGOT 135 IU/L, SGPT 74 IU/L), while C criteria cannot be performed due to limited hospital imaging facilities. Limitations of investigations should not limit the diagnosis and initial management so it can give the good prognosis. Even though there were complications of sepsis, the patient did not experience signs of shock which could lead to mortality.