Pre-intervention Data Research Articles

Effectiveness of individualized counseling in reducing leave against medical advice among neurosurgical patients in the emergency department

Objective: Leave against medical advice (LAMA) in the emergency department (ED) is a significant challenge in low- and middle-income countries, often leading to higher rates of readmission, increased mortality, and disrupted continuity of care. This study aimed to evaluate the effectiveness of individualized counseling in reducing LAMA incidents among neurosurgical patients in the ED. Materials and Methods: This quality improvement study employed a prospective case-control design to compare LAMA rates between patients who received individualized counseling and those who did not. A “nursing-coordinator program” was introduced, focusing on patient communication and engagement. Trained staff followed a standardized checklist to address the concerns of patients and their caregivers, providing “individualized counseling.” Data collected after the intervention were compared with retrospective pre-intervention data, and the results were analyzed. Results: A total of 554 patients, ranging from 1 to 94 years of age, were included in the study, with 60.5% being male. Among the 353 patients who received the “individualized counseling” intervention, 60 opted for LAMA (study group), compared to 49 LAMA cases out of 201 patients who did not receive counseling (control group). The LAMA rate significantly decreased from 24.4% to 16.9% post-intervention (P = 0.035). The “individualized counseling” intervention effectively reduced LAMA due to factors such as misinformation about disease severity (P = 0.009), economic constraints (P < 0.001), and poor prognosis (P < 0.001). However, it was less effective for reasons like proximity to home (P = 0.007), inadvisable transfers for personal reasons (P = 0.023), and family problems (P = 0.293). Conclusions: This study demonstrates that individualized counseling is an effective intervention for reducing LAMA among neurosurgical patients in the ED. By addressing non-medical factors often overlooked due to inadequate counseling, this quality improvement strategy can help prevent vulnerable patients from prematurely terminating their treatment.

Impact of three weeks of integrative neuromuscular training on the athletic performance of elite female boxers.

To investigate the effects of integrative neuromuscular training (INT) on the athletic performance of elite female boxers. A before-and-after controlled experiment was conducted on 37 elite Chinese female boxers (Age: 26.00±3.11 years). All included athletes have competed at the international level. The INT intervention was administered 11 times per week for 3 weeks. This training includes strength training, explosive training, core stability, agility exercises, high intensity intervals and sprint intervals. Basic physical fitness tests, including the deep squat and bench press one-repetition maximum (1RM), vertical long jump, 30 m sprint run, 400 m run, 3,000 m run, 1-minute hexagonal jump, and 3-minute double shake; as well as specialized striking ability tests, including single-punch striking and 10-second, 30-second, and 3-minute continuous punching, were conducted before and after the intervention. Compared with pre-intervention baseline data, significant differences were found in the athletes' post-intervention baseline physical fitness, including squat and beach press (1RM), vertical jump, 30 m sprint run, 400 m run, 3,000 m run, 1-minute hexagonal jump, and 3-minute double shake (p<0.05). Additionally, 10-second, 30-second, and 3-minute continuous punching were significantly different compared with pre-intervention (p<0.05). However, no significant differences were found in single punch power (p>0.05). The 3-week INT can significantly improve the maximum strength, vertical explosive power, linear acceleration, agility, and continuous punching abilities of Chinese elite female boxers. The use of INT in physical training may enhance their athletic performance.

Advancing care in type 2 diabetes and atherosclerosis: assessing pharmacist-led strategies in England's primary care - a retrospective observational study

Abstract Background Type 2 diabetes (T2D) mellitus is a complex multi-system disorder with a tendency to develop complications. ‘Persistence to therapy’ plans affect almost 50% of all people with T2D, leading to suboptimal glycaemic and cardiovascular (CVD) risk factor control. The interplay between T2D and established atherosclerotic cardiovascular disease (ASCVD) underscores the need for a comprehensive, multidisciplinary approach to care that addresses both glycaemic control and CVD risk factors. Purpose This study retrospectively analysed pharmacist-led interventions in patients living with T2D and established ASCVD in general practices in a large UK city. Methods A retrospective pre-post observational study was conducted using electronic health record data from men and women diagnosed with T2D and ASCVD. Participants attended an independent prescribing pharmacist-led clinic within 21 general practices. The practices operated linked and comprehensive electronic health records systems, facilitating access to high-quality longitudinal data that align with study objectives. Results A total of 380 patients received pharmacist-led interventions. Comparisons of pre-intervention and post-intervention data revealed a significant decrease in HbA1c levels (73.7 ± 10.7 mmol/mol vs 67.2 ± 8.5 mmol/mol, p &amp;lt; 0.01), systolic blood pressure (132 ± 10.2 mmHg vs 125.9 ± 9.9 mmHg, p &amp;lt; 0.01), and diastolic blood pressure (76.8 ± 5.9 mmHg vs 72.4 ± 5.0 mmHg, p &amp;lt; 0.001). Additionally, total cholesterol levels significantly reduced from 4.4 ± 0.7 mmol/L to 3.9 ± 0.7 mmol/L (p &amp;lt; 0.001). The proportion of patients achieving the triple target of HbA1c (≤58 mmol/mol), BP (≤140/80 mmHg), and total cholesterol (≤5 mmol/L) increased significantly from 2.4% before the intervention to 23.4% afterward (p &amp;lt; 0.001). The initiation of the sodium-glucose co-transporter 2 inhibitors (SGLT2i) therapies was the most common prescribing intervention (67%). Conclusions Pharmacist-led interventions in a general practice setting significantly improved several critical diabetes and CVD risk related outcomes. These findings underscore the potential benefits of integrating pharmacist-led care models into the management of T2D, particularly for patients with concurrent ASCVD and adopting an individualised, evidence-based approach to prescribing interventions.

9397 Shatter Proofing Bones: Revamping Osteoporosis Screening

Abstract Disclosure: R. Subramani: None. T. Gupta: None. M. Anwar: None. J. Pamula: None. Background: Osteoporosis is a common disease characterized by low bone mass, structural deterioration of bone tissue, and increased risk of fractures. The World Health Organization (WHO) has defined osteoporosis based on bone density measurements. According to their definition, osteoporosis is diagnosed when the bone density at the hip or spine is at least 2.5 standard deviations (SDs) below the mean bone density of a reference population of young, healthy women (T score ≤ -2.5). According to NHANES data from 2017-2018, the overall prevalence of osteoporosis among adults over 50 was found to be 12.6%. It was observed that the prevalence of osteoporosis was higher among women (19.6%) compared to men (4.4%). According to US Preventative Services Task Force (USPSTF), the guidelines for screening are as follows: BMD Testing (DEXA) for all women aged 65 and older, postmenopausal women younger than 65 with clinical risk factors for fracture including advancing age, previous fracture, glucocorticoid therapy, parental history of hip fracture, low body weight, current cigarette smoking, excessive alcohol consumption, rheumatoid arthritis, secondary osteoporosis. BMD Testing for Men is not recommended. The most used bone measurement test to screen for osteoporosis is central DXA which measures BMD at the hip and lumbar spine. Goal: To improve the osteoporosis screening using DXA scan in the outpatient internal medicine resident patient panel by 5% Study Design:Subjects were identified by an EPIC report and will include retrospective chart review of records from July 2022 and prospective screening until April 2024 for the outpatient IM clinic list of patients including both resident panel. Methods: Pre-intervention data analysis of current rates; Educating residents about appropriate screening; Utilization of osteoporosis screening as care-gap in EPIC ;Calling patients who are due for screening from IM residents patient panels; Post-interventional data analysis Results: The total number of patients on the residents panel was 196. Before interventions, screening rate for osteoporosis were 71.2% among residents' patients. After intervention, screening rates increased to 75.5%. There was a 4.3 % improvement in screening rate. Conclusion: Resident education, addressing Osteoporosis care gaps in EPIC and patient outreach are effective interventions to improve screening rates. Discussion: Osteoporosis screening remains an area of needed improvement in IM clinic. EPIC system should not only take age for prompting osteoporosis screening but also other factors such as family history, pre-mature fractures, steroid use, etc. Adding osteoporosis screening into the metric system are few steps to be considered for future directions. Presentation: 6/3/2024

Positive effects of lower extremity constraint-induced movement therapy on balance, leg strength and dual-task ability in stroke patients: a longitudinal cohort study.

To investigate whether high-intensity lower extremity constraint-induced movement therapy can improve balance, leg strength, and dual-task ability. A longitudinal cohort study in a real-world outpatient clinic. 147 community-dwelling participants in the subacute and chronic poststroke phases. Participants received lower extremity constraint-induced movement therapy for 6 hours/day during 2 consecutive weeks, including balance, strength, and functional training. The Berg Balance Scale (BBS), Single-Leg-Stance (SLS) bilaterally, one Repetition Maximum (1RM) in a leg press, symmetry of leg strength (Diff-1RM), Timed Up and Go (TUG), and the TUG Manual test were assessed before, after, and 3 months after lower extremity constraint-induced movement therapy. Compared with preintervention data, statistically significant improvements after lower extremity constraint-induced movement therapy (p < 0.001) were demonstrated for balance with an absolute value in BBS at 1.9 points (effect size 0.38) and SLS at 2.4 s (effect size 0.24), and for leg strength at 10.2 kg (effect size 0.54) for the affected leg. Diff 1RM decreased significantly at 5.8 kg (effect size 0.39) and improvements on dual-task ability at 2.7 s were significant (effect size 0.14). The effects persisted at the 3-month follow-up. High-intensity lower extremity constraint-induced movement therapy may be a feasible treatment option for middle-aged stroke patients to affect balance, leg strength, and dual-task ability positively in an out-patient clinical setting.

Improving the quality and guideline concordance of multidisciplinary gastric cancer care in a safety net hospital.

314 Background: Gastric cancer is a leading cause of cancer death worldwide and disproportionally affects people of East Asian and Latin American ethnicities. This study aimed to implement and evaluate an intervention to improve the quality and guideline concordance of multidisciplinary gastric cancer care at a public safety net hospital, Zuckerberg San Francisco General Hospital (ZSFG). Methods: A quality improvement (QI) intervention was developed and evaluated by pre-post comparison of clinical data. (1) An in-depth chart review of all patients with gastric adenocarcinoma in 2017-2019 (n=17) evaluated concordance with evidence-based guidelines and quality metrics. (2) Multidisciplinary meetings identified barriers to high quality care and established targets for improvement. (3) A clinical algorithm tailored for ZSFG was disseminated to standardize gastric cancer management. (4) A post-intervention chart review was conducted of all patients from 2021-2022 (n=22). (5) Descriptive statistics and pre-post comparison of QI metrics with Chi square and Kruskal Wallis tests were performed. Results: Pre-intervention clinical data and multidisciplinary input identified gaps in care: variation in provider knowledge and practices, rapidly evolving guidelines, limited access to advanced diagnostic modalities, and non-standardized surgical documentation. After implementation of a standardized approach to address these gaps, pre-post improvement was seen in rates of tumor board presentation (36.3% vs. 85.7%, P= 0.033), use of endoscopic ultrasound (9.09% vs. 64.2%, P= 0.017), pre-treatment nodal staging (27.2% vs. 78.5%, P= 0.030), receipt of neoadjuvant chemotherapy (20% vs. 80%, P=0.007 ), documentation of lymphadenectomy type (25% vs. 100%, P= 0.015), and a trend toward reduced time to PET/CT scan (median, 8.5 weeks pre vs 7.1 weeks post, P= 0.268). Conclusions: A QI intervention was successfully implemented to standardize gastric cancer care at ZSFG. Significant improvements were seen in all targeted metrics except time to outside PET scan. Potential confounders affecting pre-post care quality included personnel changes in a small workforce and the COVID-19 pandemic. Nevertheless, our intervention led to sustained improvements in practice patterns. We aim to replicate this success with other malignancies. Category Pre-Intervention Target Post-Intervention P value* Tumor Board% cM0 cases presented 36% (n=11) &gt;90% 86% (n=14) 0.033 Endoscopic ultrasound (EUS)% cM0 cases referred for clinical staging 9% (n=11) &gt;90% 64% (n=14) 0.017 Nodal staging (with EUS or PET) 27% (n=11) N/A 79% (n=14) 0.030 Receipt of neoadjuvant chemotherapy% eligible patients 20% (n=10) &gt;80% 80% (n=10) 0.007 Surgery documentationLymphadenectomy type (i.e., D1 or D2) 25% (n=8) 100% 100% (n=7) 0.015 Time from diagnosis to PET/CT (median) 8.5 wks &lt;5 wks 7.1 wks 0.268 *Chi square test, Kruskal-Wallis test.

Clinician engagement strategies to increase palliative care access in a multi-site community oncology practice.

196 Background: Despite nearly 20 years since PC was recognized as a medical subspecialty, and ACS, ASCO and NCCN’s recommendations for early involvement, many oncologists continue to categorize PC synonymously with hospice and therefore refer to palliative medicine specialists very late in the disease trajectory, if at all. Each year, more oncology and PC researchers study and report the life changing impact of early PC for patients living with stage III and IV “advanced cancer” (AC). While mandating PC would have its challenges, creating workflows to encourage providers to change their behavior and attitude regarding PC, while empowering other clinical team members to directly refer, should result in patients and families receiving earlier PC services. Methods: The study included a pre-intervention period (9/1/2023 - 12/31/2023), and an intervention period (1/1/2024 - 4/30/2024). Pre-intervention referral data was collected from OncoEMR, OneAnalytics and Social Work reports. PC referrals were requested for both oncology and hematology patients, regardless of diagnosis date or stage. During the intervention period, 6 strategies were designed to increase PC referrals and were deployed equally in all 8 oncology/hematology offices. Strategies included 1) weekly MD/APP huddles with one of the goals to discuss the palliative care needs of all patients, 2) self-directed referrals from nursing, 3) self-directed referrals from social work, 4) APP referrals for advance care planning, 5) proactive chart reviews by PC APNs and direct PC referral suggestions to MD/APPs for AC patients, and 6) hardwiring timely scheduling of PC referrals. The primary end point is the percent of unique cancer (UC) patients who had a PC referral; the secondary end point is the percent of referred AC patients with early PC referral as defined by referral within 8 weeks of diagnosis. Results: During the pre-intervention period, of the 8,551 UC patients, 154 (1.8%) received PC referrals as compared to 227 (2.8%) of the 8,055 UC patients during the intervention period, yielding a 56% increase in the intervention period. In the pre-intervention period, 24 (14%) of the 177 newly diagnosed AC patients received early PC referrals compared to 32 (21%) of the 153 newly diagnosed AC patients in the intervention period, giving rise to a 50% increase. Conclusions: Strategies to increase PC referrals in a community oncology practice increased overall referrals as well as earlier referrals in newly diagnosed AC patients. As the interventions mature, the total number of PC referrals and a shift toward earlier referrals will likely be seen. Future goals will include assessing patient and family comfort with their treatment plan with PC versus without PC, as well as assessing providers' perceived value of PC over time. With attitude and behavior change, practice culture change is anticipated amid PC becoming the standard of care for all AC patients.

Improving the detection and documentation of patients’ symptoms in an integrated gastrointestinal oncology and palliative care clinic.

336 Background: Patients with gastrointestinal (GI) malignancies experience a high burden of disease-related symptoms and treatment side effects. We established an integrated GI oncology and palliative care (PC) clinic in which a PC physician is co-located with the oncology team and can provide timely response to patient distress and facilitate communication with the interdisciplinary palliative care team. Yet, even in the integrated clinic, patient symptoms were unreliably assessed, leading to missed opportunities to address patient suffering. Between October 2023 and January 2024 for patients seen in-person in the integrated clinic for oncology or PC visits, the median rate of symptom documentation was 45%. Emotional, financial, and spiritual distress documentation rates were lowest. We hypothesized that by implementing a systematic, comprehensive patient-reported symptom assessment tool, we could increase the detection and documentation of symptoms, and in turn, improve communication around patient distress and timely response to symptoms. Methods: We measured the rate of symptom documentation (primary outcome) and the use of a patient-reported symptom assessment tool for adults with GI cancers seen in-person in the integrated clinic in Spring 2024. Based on the Edmonton Symptom Assessment Scale (ESAS) and expert consensus, we determined which symptoms were most important to identify. Documentation rates were assessed via manual chart review of visit notes and flowsheet data. Prospective post-intervention data (March to May 2024) were compared to retrospective pre-intervention baseline data (October 2023 to January 2024). Interventions included modification of the ESAS to include GI oncology-specific symptoms, implementation of the tool in paper format to encourage patient-clinician communication, frequent staff education and feedback sessions, creation and dissemination of a resource guide for clinicians to respond to identified distress, and patient satisfaction surveys. Results: 126 patients were included in the study (31 pre-intervention and 95 post-intervention). During the post-intervention period, the median rate of symptom documentation increased from 45% to 83% and the median rate of ESAS survey completion increased from 9% to 68%. Documentation of financial and spiritual distress increased from 13% to 71%, for both, and documentation of emotional distress increased from 35% to 72%. On satisfaction surveys (N=20), most patients reported the tool was helpful in sharing their symptoms (70%), was easy to read and understand (100%), and that their clinician was engaged in addressing their symptoms (67%). Conclusions: The implementation of a patient-reported symptom assessment tool in an integrated GI oncology/PC clinic increased documentation of important symptoms, potentially increasing clinician awareness of patient distress.

Curriculum Innovation: A Standardized Experiential Simulation Curriculum Equips Residents to Face the Challenges of Chief Year.

A chief resident's role incorporates administrative, academic, and interpersonal responsibilities essential to managing a successful residency program. However, rising chief residents receive little formal exposure to leadership training. To (1) define leadership styles; (2) understand the effect of cultural competence on leadership styles; (3) learn effective methods to advocate as the chief resident; (4) provide effective peer feedback; (5) provide effective supervisor feedback; (6) learn effective conflict management; (7) ensure psychological safety. We developed a 1-day curriculum combining didactics and simulation activities for our program's rising chief residents. Implementation of our curricular design included a morning session focusing on small groups and didactic-based lectures on specific topics pertinent to leadership, along with a debriefing of a psychometric evaluation tool administered before the curriculum day. The simulation activity consisted of 3 group objective structured clinical examination (G-OSCE) scenarios: (1) providing a struggling junior trainee with feedback; (2) debriefing an adverse clinical outcome as the team leader; (3) navigating a challenging situation with a supervising physician. Standardized participants were surveyed for specific objectives. Learners completed precurricular and postcurricular surveys on their familiarity and preparedness for their chief year. Comparison of preintervention (n = 16) and postintervention (n = 10) data shows improvements in familiarity with leadership models (p = 0.006), cultural competence in leadership (p = 0.027), and team organizational structure (p = 0.010) with notable improvement in report of advocating for the team to 100% of participants in the postcurricular survey. In addition, although not statistically significant, familiarity with specific strategies for feedback delivery improved (p = 0.053), as did learner comfort levels with feedback delivery (comparing 51% of learners were either very or somewhat comfortable precurriculum to 90% postcurriculum). This is further supported by standardized participant data after the G-OSCEs. Although familiarity with wellness resources did improve across learners (p = 0.421), learner-reported use of wellness resources was noted to be reduced after the curricular intervention and remains a result of further interest for exploration. A 1-day leadership development curriculum combining didactics and simulation is an effective means of preparing rising chief residents to succeed in their transition to this leadership role.

Developing intercultural sensitivity in prospective teachers: the potential role of Roma culture immersion field experience

ABSTRACT Teacher preparation programmes through cultural immersion field experiences in Schools as Learning Communities have the potential to increase the intercultural sensitivity of future teachers to provide an effective response to the needs of Roma children. This research evaluated the impact of an intercultural training programme for prospective teachers that included instruction on the situation of the Roma community in the educational system and the transformative potential of the Schools as Learning Communities project, as well as a cultural immersion field experience in a school as a learning community in a vulnerable context. An experimental research design was used that involved collecting pre and post intervention data on a total sample of 321 undergraduate students who were assigned to either a control or experimental group. Results showed that the community-based immersion experience increased the intercultural sensitivity of prospective teachers. Specifically, the intervention, which took place in Spain, had an effect on the dimensions of Respect for Cultural Differences and Interaction Confidence between the control and experimental groups, with greater initial intercultural sensitivity shown by women in the dimensions Respect for Cultural Differences, Interaction Enjoyment and Interaction Engagement. The role of schools as learning communities in contextualised training through direct interaction with culturally diverse individuals is discussed.

Indian Buffet process factor model for counterfactual analysis

This article proposes a factor model-based counterfactual analysis. We explicitly estimate the underlying factor structure of the outcome variables and estimate the counterfactual values of the unit subject to an intervention. With the help of the non-parametric Bayesian Indian Buffet Process prior, our approach is capable of exploring heterogeneous factor exposures, and the number of latent factors is endogenously determined in the estimation process. The flexible Markov Chain Monte Carlo algorithm utilizes the maximal intervention-free information provided by the data, whereas the original synthetic control only uses pre-intervention data. The counterfactual values are estimated by simulating from the posterior predictive distribution so that we can integrate out any parameter estimation uncertainty. We also calculate the posterior predictive upper- and lower-quantile bounds for inference. The two applications, namely California’s Tobacco Control Program and the West German Reunification, demonstrate the usefulness of our approach compared to the synthetic control method and the elastic net model. The Monte Carlo simulation study also shows the robustness of our approach with respect to nonlinear dynamics in the underlying factor process.

FP5.14 - Enhancing Patient Communication in Surgical Care: an Audit of Practice at a DGH

Abstract Aims This audit aimed to evaluate current communication standards at a DGH (based on inpatient feedback) and assess the alignment with NICE Guidelines for improving the experience of care in adult NHS-services. The standards assessed included: providing clear information on diagnosis, oral and written communication, and communication in the presence of family or next of kin. Methods Inpatient feedback on surgical wards was collected to assess guideline adherence, with a pre-intervention survey designed to assess opinions before implementing an intervention. Two assessment cycles were conducted, with 12 responses in Cycle 1 (1-15 Nov 2023) and 13 responses in Cycle 2 (16-30 Nov 2023). The intervention included providing clear written information on imaging results and ongoing plans, and encouraging patients to use an information sheet throughout their admission, which could also be relayed to family members. Results Pre-intervention data revealed a diverse age distribution, predominantly in the 55-64 age group. Understanding of diagnosis varied pre-intervention but showed improvements post-intervention. Post-intervention, the majority (n=9) felt the information was appropriately pitched. Thirteen respondents received accessible information, finding the universally distributed information sheet helpful. A written response highlighted its utility in explaining clinical information to families. Healthcare professionals received improved 'clarity' and 'helpfulness' ratings post intervention, indicating positive outcomes. Conclusions Effective communication is integral to exceptional patient care. This audit underscores the potential to enhance patient understanding, alleviate concerns, and improve communication in surgical settings. The intervention, a simple information sheet, proved effective and emphasised the need for accessible, clear and standardised patient communication.

Impact of hemispherotomy on quality of life and burden of caregivers in children and adolescents: a retrospective observational study.

To evaluate QOL and caregiver burden of children and teenagers submitted to hemispherotomy for pharmacoresistant epilepsy, by comparing pre and post-surgical intervention data. Retrospective analysis of pediatric patients submitted to surgical hemispherotomy before intervention (preOP) and their follow-up at 6months (6M PO) and 2years (2Y PO) after surgery. QOL was evaluated through the Quality of Life in Childhood Epilepsy (QVCE-50) questionnaire and caregiver burden, through the Zarit Burden Interview (ZBI) tool. Twenty-two patients were included in the study. Sixteen patients (72%) were classified as Engel I at 2Y PO follow-up. QVCE-50 scale showed improvement of total QOL at 2Y PO. In relation to QVCE-50-specific domains, there was an improvement in the physical domain and in the cognitive-education a decrease in psychological and a stabilization in social/familiar domain scores. The majority of caregivers classified their burden as mild to moderate, with no PO improvement. Hemispherotomy represents an effective seizure control treatment, as well as it contributes to improvement of QOL, particularly in the physical domain and in spite of children's physical and cognitive limitations. However, no improvement in caregiver burden was observed, probably due to the chronic condition of these patients, which might be worsened by social issues.

Impact of Remedial Exercise Training on Work-Related Musculoskeletal Morbidity Among Handloom Weavers in Kanchipuram District: A Quasi-experimental Study.

The handloom weaving industry is integral to developing countries, especially in South Asia, where traditional techniques are still widely practiced. In India, the handloom sector is a significant part of the informal economy, employing millions and preserving rich cultural heritage. Despite its economic and cultural importance, the sector faces severe challenges, including poor working conditions that lead to a high prevalence of work-related musculoskeletal disorders (WMSDs). This study focuses on assessing the prevalence of musculoskeletal morbidity and the effectiveness of physiotherapy interventions in reducing WMSDs among handloom weavers in Kanchipuram, Tamil Nadu. This quasi-experimental study utilized a pre- and post-test design conducted over 12 months. A total of 121 handloom weavers from four major cooperative societies in Kanchipuram were selected using multistage sampling. Inclusion criteria were adults over 18 years, full-time weavers with more than a year of experience, and those who consented to participate. The study involved initial data collection through interviews using a pre-tested semi-structured questionnaire and the Standardized Nordic Musculoskeletal Questionnaire to assess pain prevalence. The intervention phase included physiotherapy exercise training thrice a week for three months, followed by post-intervention data collection and analysis. Pre-intervention data indicated high prevalence rates of musculoskeletal pain, with 62% of participants reporting knee pain and 54.5% reporting ankle/foot pain over the past year. Post-intervention assessments showed significant reductions in pain across all body parts, with the most substantial decreases in knee and shoulder pain. For instance, knee pain scores decreased from 3.10 ± 2.61 to 1.81 ± 1.69. The overall mean pain rating significantly dropped from 1.72 ± 0.88 pre-intervention to 1.00 ± 0.50 post-intervention, demonstrating the effectiveness of the physiotherapy exercises. The study confirms the high prevalence of musculoskeletal disorders (MSDs) among handloom weavers and demonstrates the significant impact of physiotherapy interventions in alleviating pain. Implementing regular physiotherapy exercises can substantially improve the well-being and productivity of handloom weavers, ensuring the sustainability of this vital cultural and economic industry. The results advocate for policy changes and increased support for ergonomic and health interventions in the handloom sector.

A Month of Vestibular Migraine: Symptom Characterization Using Ecological Momentary Assessment.

This study investigated the frequency and intensity of vestibular migraine (VM) symptoms using Ecological Momentary Assessment (EMA). This approach was intended to provide insights into the day-to-day experiences of individuals with VM, contributing to a more comprehensive understanding of this condition. Participants reported symptoms to an automated text system, rating their dizziness over the prior 24 h as none, mild, moderate, or severe. Definitive Dizzy Days (DDDs) were defined as days with moderate or severe dizziness. A student's independent group t-test was used to compare the number of DDDs between VM and probable VM subjects. Sixty-six subjects were included, with an average of 29 days of pre-intervention data (SD = 1.4). The average number of days with no dizziness was 3.5 (SD = 6.5), mild dizziness was 9.1 (SD = 6.7), moderate dizziness was 11 (SD = 6.1), and severe dizziness was 5.4 (SD = 6.3). Out of the 66 patients, 52 were classified as VM and 14 as pVM. The average number of DDDs was not significantly different between VM (17.0, SD = 8.3) and pVM (15.3, SD = 10.0) patients, with a two-tailed p-value of 0.44. With EMA, we found that the average subject with VM had some degree of dizziness almost every day, and more than 15 DDDs per month. III Laryngoscope, 2024.

Educational Intervention Can Improve the Pilot Balloon Palpation Method of Tracheal Tube Cuff Pressure Monitoring: An Experimental Study

Abstract Background: Considerable morbidity is attributable to inappropriate tracheal cuff pressure. An earlier study undertaken in our hospital revealed that a normal cuff pressure of 20–30 cm H2O was achieved in only 6% of intubated patients using subjective estimation methods. Objective: To determine whether a training intervention could improve the accuracy of the subjective estimation method in our tracheal cuff monitoring. Materials and Methods: A 1-day training session was conducted in April 2022 for our anaesthesia providers. The cuffs of different sizes of endotracheal tubes were inflated to 25 cm H2O, and each staff was requested to feel the turgor of the pilot balloon. Subsequently, anaesthesia providers used pilot balloon palpation for the regulation of the tracheal cuff pressure in consecutive patients undergoing general anaesthesia with endotracheal intubation. During each intubation, a manometer was used to crosscheck the inflated cuff pressure objectively. The incidence of post-operative sore throat was also evaluated. The obtained outcomes were compared with pre-intervention data obtained from an earlier study conducted in the health facility from October 2020 to September 2021. Significant differences were considered when P &lt; 0.05. Results: The mean tracheal cuff pressure was improved post-intervention (49.2 ± 24.1 cm H2O versus 77.1 ± 31.1 cm H2O; P &lt; 0.001). A significantly higher proportion of tracheal cuffs (20%; 31/156) were inflated within the normal range compared to 6% (9/141) prior to the intervention (P = 0.003). Fewer patients developed post-operative sore throat following the educational intervention (32.8%; 41/125) versus pre-intervention (47.7%; 53/111; P = 0.019). Conclusion: The educational intervention improved the safety of tracheal cuff management, which could positively impact airway management, especially in poor resource settings without cuff manometers.

FORECASTING NUMBER OF INTERNATIONAL TOURIST ARRIVALS USING MULTI INPUT INTERVENTION ARIMA MODEL

In 2020, the Covid-19 pandemic caused a very significant impact resulting in the drastic decline in the number of international tourist visits. As the Covid-19 pandemic ends, the government reopen international flight to Indonesia in early 2022 to remark the revival of the tourism industry. To determine how big the impact of the Covid-19 pandemic as well as the recovery process on international tourist visits through Soekarno-Hatta, Ngurah-Rai, and Kualanamu airports in the coming period, forecasting is needed. The forecasting method utilized in this study is multi-input intervention analysis. The first input is caused by the outbreak of Covid-19 pandemic, while the second input is due to the international flight reopening. The type of intervention variable chosen is a step function because both inputs give permanent effect to the international tourist arrivals. The data used in this study are monthly international tourist arrivals based on the entrances to Soekarno-Hatta, Ngurah-Rai, and Kualanamu International Airports from January 2008 to September 2023, taken from the Central Bureau of Statistics website. Based on the results, it was found that the number of international tourist arrivals entering Soekarno-Hatta airport can be modelled using SARIMA (0,1,1)(0,1,0)12 with (b=2, s=1, r=0) and (b=2, s=[3], r=0) for first and second input of intervention variable, respectively. Furthermore, the number of international tourist visits through Ngurah-Rai airport was more appropriate to be modelled using SARIMA (1,1,1)(0,1,1)12 with intervention inputs (b=1, s=[2], r=0) and (b=4, s=0, r=1). In Kualanamu airport, the first intervention order is equal to that in Ngurah-Rai airport, with (b=3, s=[3], r=0) for second intervention input and SARIMA (0,1,1)(1,1,1)12 for pre-intervention data. The forecast results show that the number of international tourist arrivals entering Soekarno-Hatta, Ngurah-Rai, and Kualanamu international airports are already recovered to pre-pandemic conditions at a quick pace

Combined measures in lake restoration – A powerful approach as exemplified from Lake Groote Melanen (the Netherlands)

Controlling lake eutrophication is a challenge. A case-specific diagnostics driven approach is recommended that will guide to a suite of measures most promising in restoration of eutrophic lakes as exemplified by the case of the shallow lake Groote Melanen, The Netherlands. A lake system analysis identified external and internal nutrient load as main reasons for poor water quality and reoccurring cyanobacterial blooms in the lake. Based on this analysis, a package of restoration measures was implemented between January 2015 and May 2016. These measures included fish removal, dredging, capping of peat rich sediment with sand and an active barrier (lanthanum-modified bentonite), diversion of two inlet streams, reconstruction of banks, and planting macrophytes. Dredging and sand capping caused temporarily elevated turbidity and suspended solids concentrations, while addition of the lanthanum-modified clay caused a temporary exceedance of the Dutch La standard for freshwaters. Diversion of inflow streams caused 35 % less water inflow and larger water level fluctuations, but the lake remained water transporting with strongly improved water quality as was revealed by comparing five years pre-intervention water quality data with five years’ post-intervention data. Total phosphorus concentration in the water column was reduced by 93 % from 0.47 mg P l-1 before the intervention to 0.03 mg P l-1 after the intervention, total nitrogen by 66 % from 1.27 to 0.21 mg N l-1, total chlorophyll-a by 75 % from 68 to 16 µg l-1, cyanobacteria chlorophyll-a by 88 % from 32 to 4 µg l-1. Turbidity had declined by 58 % from 23.5 FTU to on average 9.9 FTU. No cyanobacteria blooms were recorded over the entire post-intervention monitoring period (2016–2021). Submerged macrophytes increased from complete absence before intervention to around 10 %–15 % coverage after intervention. Repeated fish removal lowered the fish stock to below 100 kg ha-1 with 12 % of bream and carp remaining. Hence, the package of cohesive measures that was based on a thorough diagnosis resulted in rapidly, strongly and enduringly improved water quality. This case provides evidence for the power of combining measures in restoring eutrophic lakes.

Impact of a Bundle of Interventions on Quality-of-Care Indicators for Staphylococcus aureus Bacteraemia: A Single-Centre, Quasi-Experimental, Before-After Study.

Staphylococcus aureus bacteraemia (SAB) is a life-threatening bloodstream infection. Improved adherence to quality-of-care indicators (QCIs) can significantly enhance patient outcomes. This quasi-experimental study evaluated the impact of a bundle of interventions on QCI adherence in adult patients with SAB. Additionally, a molecular rapid diagnostic test (mRDT) for S. aureus and methicillin resistance was introduced during weekdays. We compared pre-intervention (January-December 2022) and post-intervention (May 2023-April 2024) data on QCI adherence and time to appropriate treatment. A total of 56 and 40 SAB episodes were included in the pre- and post-intervention periods, respectively. Full QCI adherence significantly increased from 28.6% to 67.5% in the post-intervention period (p < 0.001). The mRDT diagnosed SAB in eight cases (26.6%), but the time to achieve appropriate target therapy did not improve in the post-intervention period (54 h (IQR 30-74) vs. 72 h (IQR 51-83), p = 0.131). The thirty-day mortality rate was comparable between the two periods (17.9% vs. 12.5%, p = 0.476). This study demonstrates that a bundle of interventions can substantially improve adherence to SAB management QCIs.

Overutilization of Proton Pump Inhibitors (PPIs) in a Community-Based Hospital: A QI Initiative

Introduction: Proton pump inhibitors (PPIs) are indicated for GERD, erosive esophagitis, and prophylactic use in patients at high risk for stress ulcerations. Long-term PPI therapy is associated with increased incidence of C. diff infections and community- and hospital-acquired pneumonia. Discontinuation of stress ulcer prophylaxis upon discharge and reevaluation of continued therapy will help reduce chronic, inappropriate treatment, which predisposes patients to adverse side effects. Aim: We sought to reform the process of inpatient PPI prescriptions based on clinical indications of therapy in order to reduce use and associated costs of PPIs by 30% over 6 months. Model for Improvement: We obtained an IRB exemption for a retrospective chart review study and collected pre-intervention data from 200 patients who had received PPI therapy between July-Aug 2022. Of these, 186 met inclusion criteria. We identified PPT overuse among all inpatient admissions, including those admitted under teaching services. Evaluating the timing of PPI initiation after admission, we found that a majority (83.8%) were started upon admission; 28.5% required PPIs throughout; and 25.2% of orders were placed within 1 day of discharge. The average duration of therapy was 3.9  2.59 days. On average, 50.5% of patients had a prior diagnosis of GERD, gastritis, or erosive esophagitis, justifying initiation of PPI therapy. However, almost a third (32.8%) met the criteria for stress ulcer prophylaxis. 17% of the cohort developed an adverse side effect, and almost 53% of patients were discharged with a new prescription for PPI. Measures: Root cause analysis revealed a lack of knowledge regarding adverse PPI effects leading to longer hospital stays. During the first PDSA, we conducted a session on “Use of PPI Inhibitors: Indications for Inpatient Prescriptions and Stress Ulcer Prophylaxis” in April 2023, educating Internal Medicine and Family Medicine resident teaching services about PPI therapy indications, contraindications, and adverse effects. Results: After our educational intervention, we collected and analyzed data from May 2023 to August 2023 and found 301 patients who met inclusion criteria. Their average age was 73.29 years. 169 patients (56%) had pre-existing diagnoses (GERD or erosive esophagitis), justifying initiation of Protonix. Of the remaining 132 without pre-existing conditions, 44 (35%) met criteria for starting stress ulcer prophylaxis. This was a 3% increase in appropriate utilization when compared to our pre-intervention data. 181 patients were discharged with a prescription for pantoprazole, of which 46 were PPI-naïve prior to admission. Conclusion: We found a decrease in inappropriate inpatient PPI administration by 3% after education. Although the post-intervention sample size was larger, the education resulted in a positive response in 1 month. The next PDSA cycle will alter the EMR order to provide only 3 orders for pantoprazole – one oral, one IV, and one for infusion, and orders will also require the selection of indication.