Regional Tertiary Hospital Research Articles

Metabolic acidosis in patients with diabetes 2 undergoing cardiac surgery: The impact of SGLT2 inhibitor use: a retrospective cohort study.

Sodium-glucose cotransporter 2 inhibitors (SGLT2-i) lower blood sugar and reduce cardiovascular events and kidney failure. However, there have been increasing reports of euglycaemic diabetic ketoacidosis (eDKA) linked to SGLT2-i medicines. Investigating the association between SGLT2-i use and the incidence of metabolic acidosis in patients with type 2 diabetes undergoing cardiac surgery. A retrospective observational cohort study comprising 121 patients, with 38 in the SGLT2-i group and 83 in the control group. A 2-year period at Haukeland University Hospital, a tertiary regional hospital in Western Norway. Patients with type 2 diabetes undergoing cardiac surgery. Collection of clinical and laboratory data, including acid/base balance parameters, surgery details and SGLT2-i use. Base excess and anion gap measurements as indicators of ketosis development. A subgroup analysis in patients without renal failure (glomerular filtration rate > 60 ml min-1 m-2). Lower base excess levels and increased anion gaps were observed in the SGLT2-i group compared with controls at various time points postoperatively, with no significant differences in serum lactate levels.Twelve hours postoperatively, 41% of SGLT2-i patients without renal failure had a base excess -3 mmol l-1 or less after correction for serum lactate (indicating ketosis) compared with only 8% in the control group (P < 0.001). The anion gap was elevated in the SGLT2-i group compared to the control group at 12 h postoperatively (P = 0.018).Multivariable regression analysis identified SGLT2-i use as an independent factor associated with a lower base excess after correction for lactate levels (P < 0.001). Cessation of SGLT2-i medication did not correlate with the degree of acidosis. While taking SGLT2 inhibitors, diabetic patients undergoing heart surgery are at an increased risk of ketosis and possibly metabolic acidosis. This emphasises the importance of careful observation and effective treatment strategies within this group.

Plasma pesticide residues-serum 8-OHdG among farmers/non-farmers diagnosed with lymphoma, leukaemia and breast cancers: A case-control study.

A hospital-based cross-sectional case-control study was conducted to investigate the association between exposure through various pesticide residues detected in the plasma and serum 8-OHdG levels among farmers and non-farmers diagnosed with leukaemia, lymphoma and breast cancers and compare the same with healthy controls with no cancer and no exposure. The present study was conducted among the farmers and non-farmers visiting a regional tertiary cancer care hospital in Hyderabad, Telangana State, India. Data were collected by administering a pre-tested questionnaire through an interview followed by the collection of blood samples which were analyzed for pesticide residues using LC-MS/MS while the serum levels of 8-OHdG were measured using ELISA. Data were analyzed using SPSS 24. The pesticide residues detected were chlorpyrifos, dimethoate, malathion, phosalone, and quinalphos which were approved and recommended for their use on the crops that were cultivated by the farmers in their plasma samples along with banned pesticide residues like monocrotophos, diazinon, and dichlorvos among farmers diagnosed with all three types of cancers while the non-farmers and healthy controls were not detected with any such residues. In addition, farmers diagnosed with leukemia had higher levels of all the pesticide residues in their plasma than those diagnosed with lymphoma and breast cancers. Further, a significant difference was also observed between profenofos residues in plasma and serum 8-OHdG levels. In the present study, though the farmers diagnosed with three types of cancers were detected with various types of pesticide residues analysed, only residues of profenofos showed a significant difference with serum levels of 8-OHdG suggesting the need for an in-depth follow up molecular studies in a larger cohort to assess the possible association between 8-OHdG levels with the pesticide residues among the exposed.

Evaluation of preoperative antibiotic prophylaxis in clean-wound general surgery procedures: a propensity score-matched cohort study at a regional hospital.

The administration of antibiotic prophylaxis for clean-wound surgeries is controversial among surgeons, despite guidelines suggesting its use. This study aimed to evaluate its effectiveness in preventing surgical site infections (SSIs) in clean-wound surgeries within a regional setting with varied practices regarding prophylaxis. This retrospective cohort study included four types of common general surgeries performed from March 2021 to February 2023 at a tertiary regional hospital in Thailand. The surgeries included skin/subcutaneous excision, thyroidectomy, inguinal hernia repair, and breast surgeries, all of which required regional or general anesthesia. Antibiotic prophylaxis was administered at the discretion of the attending surgeons. SSI diagnosis followed standard diagnostic criteria, involving reviewing medical records and the records of the infection control unit. Infection risk factors were examined. The primary outcome comparison used inverse probability treatment weighting of propensity scores, with covariate balance evaluated. Of the 501 surgeries identified, 84 were excluded, leaving 417 eligible for analysis. Among these patients, 233 received prophylactic antibiotics, for an SSI rate of 1.3%, while 184 did not receive antibiotics, for an SSI rate of 2.2%. A comparative analysis using propensity score weighting revealed no statistically significant difference in the incidence of SSI between the groups (risk ratio [95% confidence interval]: 0.54 (0.11, 2.50), p = 0.427). In this practical setting, with the given study size, antibiotic prophylaxis in common general surgeries involving clean wounds did not significantly prevent SSIs. Routine use recommendations should be re-evaluated. Not applicable as this study is a retrospective cohort study and not a clinical trial.

Development of a team-specific research strategy using a modified Delphi method in a regional public hospital dietetics department.

Evaluate research capacity and culture among regional hospital dietitians, develop a team specific research strategy, and build research skills of novice researchers. The Research Capacity in Context Tool was used to assess current research capacity and culture at organisational, team and individual levels. Results were analysed using descriptive statistics and content analysis of free text responses. A modified Delphi method gained consensus regarding research capacity building. Mixed method study. Dietetics department of a regional tertiary hospital (Modified Monash Category 2). All clinical dietitians currently employed within the hospital (n = 20) regardless of employment duration. Self-rated response to research capacity and culture to produce a dietetics-specific research strategy. Fifteen dietitians (75%) completed the Research Capacity in Context Tool. The overall mean score was highest at an organisational level at 7.9 (IQR 2), and lowest at team and individual levels at 4.3 (IQR 2.7) and 4.9 (IQR 3.3) respectively. Common barriers to research included time, lack of skills, knowledge and support. Using the modified Delphi method 39 statements relating to research capacity building met consensus and informed the creation of a research strategy. The results of the Research Capacity in Context Tool from this regional study reflect those reported in the literature at metropolitan sites. A dietetic-specific research strategy was developed to assist with increasing research capacity at a team and individual level in a regional setting. Evaluation of long-term outcomes post implementation will be the subject of further research.

Early coronary angiography in NSTEMI: a regional Victorian perspective.

Current guidelines highlight a paucity of evidence guiding optimal timing for non-ST-elevation myocardial infarction (NSTEMI) in high-risk and non-high-risk cases. We assessed long-term major adverse cardiovascular events (MACEs) in NSTEMI patients undergoing early (<24 h) versus delayed (>24 h) coronary angiography at 6 years. Secondary end-points included all-cause mortality and cumulative MACE outcomes. Baseline characteristics and clinical outcomes were assessed among 355 patients presenting to a tertiary regional hospital between 2017 and 2018. Cox proportional hazard models were generated for MACE and all-cause mortality outcomes, adjusting for the Global Registry of Acute Coronary Events (GRACE) score, patient demographics, biomarkers and comorbidities. Two hundred and seventy patients were included; 147 (54.4%) and 123 (45.6%) underwent early and delayed coronary angiography respectively. Median time to coronary angiography was 13.3 and 45.4 h respectively. At 6 years, 103 patients (38.1%) experienced MACE; 41 in the early group and 62 in the delayed group (hazard ratio (HR) = 2.23; 95% confidence interval (CI) = 1.50-3.31). After multivariable adjustment, the delayed group had higher rates of MACE (HR = 1.79; 95% CI = 1.19-2.70), all-cause mortality (HR = 2.76; 95% CI = 1.36-5.63) and cumulative MACE (incidence rate ratio = 1.54; 95% CI = 1.12-2.11). Subgroup analysis of MACE outcomes in rural and weekend NSTEMI presentations was not significant between early and delayed coronary angiography (HR = 1.49; 95% CI = 0.83-2.62). Higher MACE rates in the delayed intervention group suggest further investigation is needed. Randomised control trials would be well suited to assess the role of early invasive intervention across all NSTEMI risk groups.

Renal artery occlusion in a young woman - a tale of mysterious thrombosis.

Renal artery thrombosis is rare and limited reports exist in the young population. The most common aetiology is thromboembolic disease or abdominal trauma in this population and isolated occurrences are extremely rare. We present the case of an 18-year-old woman with spontaneous unilateral renal artery thrombosis and infarction for whom reperfusion was achieved through endovascular intervention. The aetiology of her thrombosis remains unclear and is under investigation with differential diagnoses being fibromuscular dysplasia, large and medium vessel vasculitis, and thromboembolic causes. To demonstrate the value in attempting salvage of an ischaemic kidney in a young patient with an unexplained spontaneous renal thrombosis. JM is an 18-year-old woman who presented to a large regional tertiary hospital with 3days of right flank pain. She had no infective symptoms and no urinary or bowel changes before admission. She was not pregnant, and her only medication was the oral contraceptive pill commenced 3months prior. A CT angiogram demonstrated right renal artery thrombosis with renal infarction. The kidney was deemed potentially salvageable, and ultrasound defined adequate vessel calibre to access for thrombectomy in the context of a negative coagulopathy screen. The patient underwent thrombolysis, thrombectomy and balloon angioplasty. Intraoperatively, a thin segment of distal stenosis was identified, and angiogram reperfusion was achieved with subsequent improvement in renal function. Renal artery thrombosis in young people is extremely rare and presents a diagnostic and management challenge requiring input from multiple teams including nephrology, rheumatology, paediatrics and vascular surgery. Systemic coagulopathy and vasculitis are differentials against anatomical aetiologies such as fibromuscular dysplasia. Our case adds to the limited literature regarding this in the young population. Renal artery thrombosis with occlusion in young people is very rare and is most often associated with a systemic coagulopathic disorder, such as antiphospholipid syndrome or structural pathology of the renal vasculature such as fibromuscular dysplasia. The work-up of a young female presenting with renal artery thrombosis without any previous medical history screens for a wide range of pathological processes.

A Multifaceted Approach to Interpreting Reaction Time Deficits After Adolescent Concussion.

Reaction time (RT) is a critical element of return to participation (RTP), and impairments have been linked to subsequent injury after a concussion. Current RT assessments have limitations in clinical feasibility and in the identification of subtle deficits after concussion symptom resolution. To examine the utility of RT measurements (clinical drop stick, simple stimulus-response, single-task Stroop, and dual-task Stroop) to differentiate between adolescents with concussion and uninjured control individuals at initial assessment and RTP. Prospective cohort study. A pediatric sports medicine center associated with a regional tertiary care hospital. Twenty-seven adolescents with a concussion (mean age = 14.8 ± 2.1 years; 52% female; tested 7.0 ± 3.3 days postconcussion) and 21 uninjured control individuals (mean age = 15.5 ± 1.6 years; 48% female). Participants completed the Post-Concussion Symptoms Inventory (PCSI) and a battery of RT tests: clinical drop stick, simple stimulus-response, single-task Stroop, and dual-task Stroop. The concussion group demonstrated slower clinical drop stick (β = 58.8; 95% CI = 29.2, 88.3; P < .001) and dual-task Stroop (β = 464.2; 95% CI = 318.4, 610.0; P < .001) RT measures at the initial assessment than the uninjured control group. At 1-month follow up, the concussion group displayed slower clinical drop stick (238.9 ± 25.9 versus 188.1 ± 21.7 milliseconds; P < .001; d = 2.10), single-task Stroop (1527.8 ± 204.5 versus 1319.8 ± 133.5 milliseconds; P = .001; d = 1.20), and dual-task Stroop (1549.9 ± 264.7 versus 1341.5 ± 114.7 milliseconds; P = .002; d = 1.04) RT than the control group, respectively, while symptom severity was similar between groups (7.4 ± 11.2 versus 5.3 ± 6.5; P = .44; d = 0.24). Classification accuracy and area under the curve (AUC) values were highest for the clinical drop stick (85.1% accuracy, AUC = 0.86, P < .001) and dual-task Stroop (87.2% accuracy, AUC = 0.92, P < .002) RT variables at initial evaluation. Adolescents recovering from concussion may have initial RT deficits that persist despite symptom recovery. The clinical drop stick and dual-task Stroop RT measures demonstrated high clinical utility given high classification accuracy, sensitivity, and specificity to detect postconcussion RT deficits and may be considered for initial and RTP assessment.

Etiological differences in demographics, clinical course and consequences of acute pancreatitis: a retrospective study.

Aim: The study is intended to consider acute pancreatitis from the point of view of its etiological structure, as well as demographic description, features of the clinical course, distribution of morphological forms, severity and consequences of the disease in different etiological variants. Materials and Methods: The work was based on a retrospective analysis of the medical records of 677 patients with acute pancreatitis who underwent inpatient treatment from 2017 to 2022 in an emergency hospital and a tertiary regional hospital in Vinnytsia, Ukraine. Results: The etiological structure of the general sample was as follows: the alimentary factors - 37,5% of cases, biliary - 18,6%, alcohol - 14,0% and postoperative - 7,8%, respectively. The oldest patients were observed in the group with biliary AP (age [median, interquartile range] 61 [46-72] years), the youngest - in the group with alcoholic AP (age [median, interquartile range] 40 [35-47] years). Men significantly predominated in the groups with alimentary and alcoholic AP. A significant predominance of women was observed in the group with biliary AP (62,7% vs. 37,3%, p=0,0003). The highest mortality was in the alcoholic AP group (22,1%), also here was a significantly lower rate of inpatient bed days (6,0). Edematous AP was dominant in all etiological variants. While infected necrotic pancreatitis was significantly more often found in patients with alcoholic genesis (7,4%). Conclusions: The etiologic variations of acute pancreatitis differ by demographic and clinical indicators and require more detailed study to understand its prognosis, management, and development of effective prevention and treatment strategies.

Health care utilisation of asylum seekers and refugees in the South-West of Germany.

Limited evidence on utilisation of health care by recently arrived asylum seekers and refugees in high-income countries is available. This study aims to describe the implementation of an integrated care facility (ICF) in an initial reception centre and measure the utilisation of care and the influence of operational parameters. In a retrospective cohort study design, using medical records, we followed inhabitants of a reception centre in Germany between 11.10.2015 and 30.05.2018. We assessed frequency of visits and revisits to a newly established integrated care facility (ICF), and the effects of the ICF on visits to the local emergency department (LED) in the regional tertiary hospital using survival analysis and time series regression. We also explore the influence of operational parameters on the different implementation phases; phase 1: provisional clinic with 1-2 hours of physician presence daily, phase 2: implementation of ICF with 2-4 hours of care by a team of doctors and nurses daily, phase 3: routine running of ICF with daily operational hours of 10am-2pm with care provided by an interdisciplinary team of doctors and nurses. 14,419 total medical visits were recorded from 1,883 persons seeking health care in the ICF. The absolute number of visits per day remained similar over the study period (19·9/day), yet the relative number of visits changed from 2·2 to 15 per 100 inhabitants from phase 2 to 3, respectively. Most visits were due to respiratory infections (612/3080, 20%), and trauma and musculoskeletal conditions (441/3080, 14%). The rate of revisits to ICF was 2·9 per person per month (95%CI 2·9-3), more for those older, female, from North Africa and those with a translator present. The ratio of visits to the LED changed from 0·3/100 inhabitants per day to 0·14/100 inhabitants after implementation of the ICF and back to 0·3/100 inhabitants during the routine running. Though seasonal variation and referral practices must be considered, a high rate of revisits to the ICF were recorded. While visits to the LED decreased after the implementation of the ICF, visits returned to the pre-ICF levels during the routine running of the ICF. The results show that AS&R require reliable access to health care, yet the needs of specific groups of migrants may be different, especially those with language barriers, minority groups or those from certain regions. As such, care should be migrant sensitive and adapt to the changing needs of the population. Though more research is required to better understand the differing needs of migrants, this study may help to inform guidelines surrounding migrant sensitive standards of care in Germany.

Association of remoteness and ethnicity with major amputation following minor amputation to treat diabetes-related foot disease.

Minor amputation is commonly needed to treat diabetes-related foot disease (DFD). Remoteness of residence is known to limit access to healthcare and has previously been associated with poor outcomes. The primary aim of this study was to examine the associations between ethnicity and remoteness of residency with the risk of major amputation and death following initial treatment of DFD by minor amputation. A secondary aim was to identify risk factors for major amputation and death following minor amputation to treat DFD. This was a retrospective analysis of data from patients who required a minor amputation to treat DFD between 2000 and 2019 at a regional tertiary hospital in Queensland, Australia. Baseline characteristics were collected together with remoteness of residence and ethnicity. Remoteness was classified according to the 2019 Modified Monash Model (MMM) system. Ethnicity was based on self-identification as an Aboriginal and Torres Strait Islander or non-Indigenous person. The outcomes of major amputation, repeat minor amputation and death were examined using Cox-proportional hazard analyses. A total of 534 participants were included, with 306 (57.3%) residing in metropolitan or regional centres, 228 (42.7%) in rural and remote communities and 144 (27.0%) were Aboriginal or Torres Strait Islander people. During a median (inter quartile range) follow-up of 4.0 (2.1-7.6) years, 103 participants (19.3%) had major amputation, 230 (43.1%) had repeat minor amputation and 250 (46.8%) died. The risks (hazard ratio [95% CI]) of major amputation and death were not significantly higher in participants residing in rural and remote areas (0.97, 0.67-1.47; and 0.98, 0.76-1.26) or in Aboriginal or Torres Strait Islander people (HR 1.44, 95% CI 0.96, 2.16 and HR 0.89, 95% CI 0.67, 1.18). Ischemic heart disease (IHD), peripheral artery disease (PAD), osteomyelitis and foot ulceration (p<0.001 in all instances) were independent risk factors for major amputation. Major amputation and death are common following minor amputation to treat DFD and people with IHD, PAD and osteomyelitis have an increased risk of major amputation. Aboriginal and Torres Strait Islander People and residents of remote areas were not at excess risk of major amputation.

Factors Affecting the Discrepancy Between Coagulation Times on Extracorporeal Circulation Using Unfractionated Heparin in Children and Young Adults.

In unfractionated heparin (UFH) monitoring during extracorporeal circulation, the traditional measures of activated clotting time (ACT) or activated partial thromboplastin time (APTT) may diverge, confounding anticoagulant adjustments. We aimed to explore the factors explaining this discrepancy in children and young adults. This retrospective observational study, conducted at an urban regional tertiary hospital, included consecutive pediatric patients who received UFH during extracorporeal circulation (continuous kidney replacement therapy or extracorporeal membrane oxygenation) between April 2017 and March 2021. After patients whose ACT and APTT were not measured simultaneously or who were also taking other anticoagulants were excluded, we analyzed 94 samples from 23 patients. To explain the discrepancy between ACT and APTT, regression equations were created using a generalized linear model (family = gamma, link = logarithmic) with ACT as the response variable. Other explanatory variables included age, platelet count, and antithrombin. Compared to APTT alone as an explanatory variable, the Akaike information criterion and pseudo-coefficient of determination improved from 855 to 625 and from 0.01 to 0.42, respectively, when these explanatory variables were used. In conclusion, we identified several factors that may explain some of the discrepancy between ACT and APTT in the routinely measured tests. Evaluation of these factors may aid in appropriate adjustments in anticoagulation therapy.

A COVID-19 Silver Lining-Decline in Antibiotic Resistance in Ischemic Leg Ulcers during the Pandemic: A 6-Year Retrospective Study from a Regional Tertiary Hospital (2017-2022).

Antibiotic resistance (AR) associated with chronic limb-threatening ischemia (CLTI) poses additional challenges for the management of ischemic leg ulcers, increasing the likelihood of severe outcomes. This study assessed AR prevalence in bacteria isolated from CLTI-associated leg ulcers before (1 January 2017-10 March 2020; n = 69) and during (11 March 2020-31 December 2022; n = 59) the COVID-19 pandemic from patients admitted with positive wound cultures to a regional hospital in Chiang Mai (Thailand). There was a marked reduction in AR rates from 78% pre-pandemic to 42% during the pandemic (p < 0.0001), with rates of polymicrobial infections 22 percentage points lower (from 61% to 39%, respectively; p = 0.014). There were reduced AR rates to amoxicillin/clavulanate (from 42% to 4%; p < 0.0001) and ampicillin (from 16% to 2%; p = 0.017), as well as multidrug resistance (19% to 8%; p = 0.026). Factors associated with increased AR odds were polymicrobial infections (adjusted odds ratio (aOR) 5.6 (95% CI 2.1, 15.0); p = 0.001), gram-negative bacteria (aOR 7.0 (95% CI 2.4, 20.5); p < 0.001), and prior use of antibiotics (aOR 11.9 (95% CI 1.1, 128.2); p = 0.041). Improvements in infection control measures and hygiene practices in the community during the pandemic were likely key factors contributing to lower AR rates. Thus, strategic public health interventions, including community education on hygiene and the informed use of antibiotics, may be crucial in mitigating the challenges posed by AR in CLTI. Further, advocating for more judicious use of empirical antibiotics in clinical settings can balance effective treatment against AR development, thereby improving patient outcomes.

Financial Toxicity and Out-of-Pocket Costs for Patients with Head and Neck Cancer: An Australian Perspective

Financial toxicity is under-investigated for patients with head and neck cancer (HNC). The aim of this study was to quantify and describe the financial toxicity and out-of-pocket costs for patients with HNC in regional Australia and to consider its relationship with quality of life. A cross-sectional survey was administered to patients with mucosal HNC who were disease free and 1-3 years after completion of radiotherapy at a regional tertiary hospital in Australia. The survey included questions on socio-demographics, out-of-pocket expenses, and health-related quality of life (HRQoL) measured with the FACT-H&N. Financial toxicity was evaluated using the Financial Index of Toxicity (FIT) survey, which scores financial toxicity on a scale of 0-100 (higher score indicating higher financial toxicity). The relationship between high financial toxicity scores (top quartile) and HRQoL was explored. Of 57 total patients, 41 (72%) reported out-of-pocket expenses at a median of AU$1,796 (interquartile range AU$2,700) and a maximum of AU$25,050. The overall median FIT score was 13.9 (interquartile range 19.5) and patients with high financial toxicity (n = 14) reported poorer HRQoL (76.5 vs 114.5, p < 0.001). Patients who were not married had a higher financial toxicity score (23.1 vs 11.1, p = 0.01). Similarly, those participants with lower levels of education had higher financial toxicity (19.3 vs 11.1, p = 0.06). Participants with private health insurance were found to have lower rates of financial toxicity (8.3 vs 17.6, p = 0.01). Medications (41%, median AU$400), dietary supplements (41%, median AU$600), travel (36%, median AU$525) and dental (29%, AU$388) were the most common out-of-pocket expenses. Only nineteen patients (33%) reported that a member of their treating team had asked if they have any financial concerns. Participants living in rural locations (> 100km from the hospital) had higher out-of-pocket expenses (AU$2655 vs AU$730, p = 0.01). Financial toxicity is a significant issue for a significant proportion of patients with head and neck cancer which was associated with a reduced HRQoL. All clinicians should consider asking patients with HNC about financial concerns and be aware of what financial support is available in their region. Interventions are required to reduce the burden of financial toxicity for patients with HNC.

Caregiver burden and its associated factors among primary caregivers of stroke survivors at Amhara regional state tertiary hospitals: a multicenter study

BackgroundCaregivers of stroke survivors play a crucial role in post-stroke functional recovery and the prevention of complications. Although the situation is incredibly stressful and intimidating and the caregiver burden is high, there is little evidence in the local Ethiopian context of the extent of the burden among caregivers of stroke survivors. Therefore, the aim of this study was to assess the level of caregiver burden and its associated factors among primary caregivers of stroke survivors in Ethiopia.MethodsA cross-sectional study was conducted in Amhara regional state tertiary hospitals from April to June 2022. A standardized questionnaire was used to record factors associated with caregiver burden, including sociodemographic, clinical, and care situation factors. The Zarit caregiver burden interview (short form) was used to assess the level of caregiver burden. A systematic random sampling method was employed to select the study participants. Multinomial logistic regression was employed to identify the potential factors associated with the level of caregiver burden.ResultsThe overall prevalence burden among primary caregivers of stroke survivors was 67%. 61.1% had a mild to moderate burden, while 5.9% had a severe burden. In multivariable multinomial logistic regression analysis, sex, household income, duration of care, and duration of caregiving hours per day were factors significantly associated with the level of burden among caregivers of stroke survivors.ConclusionsBeing female, having a low household income, caring for more than 3 months, and caring for more than 6 h per day were factors significantly associated with the burdens of the primary caregivers of stroke survivors. It is better: health care providers must recognize and screen for burdens and provide special attention.

Six Sigma can significantly reduce costs of poor quality of the surgical instruments sterilization process and improve surgeon and operating room personnel satisfaction

Operating room (OR) management is a complex multidimensional activity combining clinical and managerial aspects. This longitudinal observational study aimed to assess the impact of Six-Sigma methodology to optimize surgical instrument sterilization processes. The project was conducted at the operating theatre of our tertiary regional hospital during the period from July 2021 to December 2022. The project was based on the surgical instrument supply chain analysis. We applied the Six Sigma lean methodology by conducting workshops and practical exercises and by improving the surgical instrument process chain, as well as checking stakeholders’ satisfaction. The primary outcome was the analysis of Sigma improvement. Through this supply chain passed 314,552 instruments in 2022 and 22 OR processes were regularly assessed. The initial Sigma value was 4.79 ± 1.02σ, and the final one was 5.04 ± 0.85σ (SMD 0.60, 95%CI 0.16–1.04, p = 0.010). The observed improvement was estimated in approximately $19,729 of cost savings. Regarding personnel satisfaction, 150 questionnaires were answered, and the overall score improved from 6.6 ± 2.2 pts to 7.0 ± 1.9 pts (p = 0.013). In our experience the application of the Lean Six Sigma methodology to the process of handling the surgical instruments from/to the OR was cost-effective, significantly decreased the costs of poor quality and increased internal stakeholder satisfaction.

Effect of cumulative radiation exposure from Coronary catheterization on lung cancer mortality

BackgroundCoronary catheterization (CC) procedure inevitably exposes patients with cardiovascular disease (CVD) to radiation, while cumulative radiation exposure may lead to higher risk of cancer.MethodsThis multi-center, retrospective study was based on the CC procedure in Cardiorenal ImprovemeNt II cohort (CIN-II, NCT05050877) among five regional central tertiary teaching hospitals in China between 2007 and 2020. Patients without known cancer were stratified according to the times they received CC procedure. Baseline information from their last CC procedure was analyzed. Cox regression and Fine-Gray competing risk models were used to assess the relationship between cumulative radiation exposure from CC procedures and cancer-specific, all-cause and cardiovascular mortality.ResultsOf 136,495 hospitalized survivors without cancer at baseline (mean age: 62.3 ± 11.1 years, 30.9% female), 116,992 patients (85.7%) underwent CC procedure once, 15,184 patients (11.1%) on twice, and 4,319 patients (3.2%) underwent CC procedure more than three times. During the median follow-up of 4.7 years (IQR: 2.5 to 7.4), totally 18,656 patients (13.7%) died after discharge, of which 617 (0.5%) died of lung cancer. Compared with the patients who underwent CC procedure once, the risk of lung cancer mortality increased significantly with the increase of the number of CC procedure (CC 2 times vs. 1 time: HR 1.42, 95% CI 1.13 to 1.78, P < 0.001; CC ≥ 3 times vs. 1 time: HR 1.64, 95%CI 1.13 to 2.39, P < 0.05). Similar results were observed in all-cause mortality and cardiovascular mortality, but not in other cancer-specific mortality.ConclusionsOur data suggest that substantial proportion of CVD patients are exposed to multiple high levels of low-dose ionizing radiation from CC procedure, which is associated with an increased risk of cancer mortality in this population.Trial registrationClinicalTrials.gov: NCT05050877; URL:http://www.clinicaltrials.gov; 21/09/2021.

Depressive Symptoms and Its Associated Factors Among Primary Caregivers of Stroke Survivors at Amhara Regional State Tertiary Hospitals: Multicenter Study.

Stroke is one of the leading causes of severe disability and functional limitation, which are reasons for being dependent on their family for daily activities and participation in social affairs. After discharge from the hospital, most stroke survivors require physical, psychosocial, and financial support from caregivers at home, which is one of the most stressful events for families. The stroke survivors and their caregivers may influence each other during the caregiving process and social life. The stroke survivor's disability and depressive symptoms affect the quality of life of the survivor and their caregivers. Therefore, the purpose of this study was to assess the prevalence and associated factors of depression among caregivers of stroke survivors. An institution-based, cross-sectional study was conducted in Amhara regional state tertiary hospitals. A systematic random sampling technique was employed to select 424 participants. The data were collected using an interviewer-administered and chart-reviewed structured questionnaire. The Patient Health Questionnaire-9 (PHQ-9) was used to assess depression. Univariable and multivariable logistic regression analyses were performed to identify factors associated with depression. Adjusting the odds ratio with the corresponding 95% confidence interval and variables with a P-value < 0.05 was considered significantly associated with depression. The overall prevalence of depressive symptoms was 65.6% (95% CI: 60.8-69.8). Being female, older than 40, having no formal education, having a low family monthly income, being the son or daughter, and spending more than six hours per day were associated with depression. We found that depression was prevalent among primary caregivers of stroke survivors. To reduce the risk of developing depression, policymakers should fully recognize the role of caregivers in caring for stroke patients. More attention should be given to caregivers who are female, elderly, have a low income, are sons or daughters, and spend a long time caring per day.

A new dyslipidemia-based scoring model to predict transplant-free survival in patients with hepatitis E-triggered acute-on-chronic liver failure

Background/AimsHepatitis E virus (HEV)-triggered acute-on-chronic liver failure (ACLF) has unacceptably high short-term mortality. However, it is unclear whether the existing predictive scoring models are applicable to evaluate the prognosis of HEV-triggered ACLF.MethodsWe screened datasets of patients with HEV-triggered ACLF from a regional tertiary hospital for infectious diseases in Shanghai, China, between January 2011 and January 2021. Clinical and laboratory parameters were recorded and compared to determine a variety of short-term mortality risk factors, which were used to develop and validate a new prognostic scoring model.ResultsOut of 4952 HEV-infected patients, 817 patients with underlying chronic liver disease were enrolled in this study. Among these, 371 patients with HEV-triggered ACLF were identified and allocated to the training set (n = 254) and test set (n = 117). The analysis revealed that hepatic encephalopathy (HE), ascites, triacylglycerol and apolipoprotein A (apoA) were associated with 90-day mortality (P < 0.05). Based on these significant indicators, we designed and calculated a new prognostic score = 0.632 × (ascites: no, 1 point; mild to moderate, 2 points; severe, 3 points) + 0.865 × (HE: no, 1 point; grade 1–2, 2 points; grade 3–4, 3 points) − 0.413 × triacylglycerol (mmol/L) − 2.171 × apoA (g/L). Compared to four well-known prognostic models (MELD score, CTP score, CLIF-C OFs and CLIF-C ACLFs), the new scoring model is more accurate, with the highest auROCs of 0.878 and 0.896, respectively, to predict 28- and 90-day transplantation-free survival from HEV-triggered ACLF. When our model was compared to COSSH ACLF IIs, there was no significant difference. The test data also demonstrated good concordance.ConclusionsThis study is one of the first to address the correlation between hepatitis E and serum lipids and provides a new simple and efficient prognostic scoring model for HEV-triggered ACLF.

Epidemiology, antifungal susceptibility, risk factors, and mortality of persistent candidemia in adult patients in China: a 6-year multicenter retrospective study

BackgroundData on persistent candidemia (PC), a recognized complication of candidemia, are lacking in China. This study aimed to investigate the clinical characteristics and risk factors for the mortality of PC among adults in China.MethodsThis 6-year retrospective study analyzed the prevalence, species distribution, antifungal susceptibility, risk factors, and patient mortality of PC among adults in three regional tertiary teaching hospitals in China from 2016 to 2021. We collected electronic laboratory records data of PC and non-PC patients and used the Student test or Mann–Whitney U test for a retrospective study. Logistic regression was used to identify risk factors associated with persistent candidemia.ResultsThe definition of PC was fulfilled by 36 patients (13.7%, 36/263). The mean age of the patients was 59.9 years (60 years for patients with PC; 59.8 years for those with non-PC; P > 0.05) and 131 (60.1%) were men [16 with PC (44.4%), 115 with non-PC (63.2%), P < 0.05]. The mean annual incidence was 0.15/1000 admissions (including PC 0.03/1000 admissions vs. non-PC 0.12/1000 admissions, P < 0.05). Candida parapsilosis (14/36, 38.9%) and Candida albicans (81/182, 44.5%) were the predominant pathogens in patients with PC and non-PC, respectively. Most isolates were susceptible to flucytosine (99.0%) and amphotericin B (99.5%), and the activity of antifungal agents against Candida species was not statistically significantly different between patients with PC and non-PC (P > 0.05). The 30-day mortality rate was 20.2% (16.7% with PC vs. 20.9% with non-PC, P > 0.05). Multivariable regression analysis showed that use of broad-spectrum antibiotics (odds ratio (OR), 5.925; 95% confidence interval (CI), 1.886–18.616, P = 0.002), fluconazole (OR, 3.389; 95% CI, 1.302–8.820, P = 0.012) and C. parapsilosis infection (OR, 6.143; 95% CI, 2.093–18.031, P = 0.001) were independent predictors of PC, sex (male) (OR, 0.199; 95% CI, 0.077–0.518, P = 0.001) was the protective factor for PC. Respiratory dysfunction (OR, 5.763; 95% CI, 1.592–20.864, P = 0.008) and length of hospital stay(OR, 0.925; 95% CI, 0.880–0.973, P = 0.002) were independent predictors of 30-day mortality in patients with non-PC. C. tropicalis bloodstream infection (OR, 12.642; 95% CI, 1.059–150.951; P = 0.045) was an independent predictor of 30-day mortality in patients with PC.ConclusionsThe epidemiological data of patients with PC and non-PC were different in the distribution of Candida species, the mean annual incidence and independent predictors of 30-day mortality. Flucytosine and amphotericin B could be used as first-choice drugs in the presence of PC infections.

Prevalence and factors associated with polypharmacy among patients with rheumatoid arthritis: a single-centre, cross-sectional study.

This study aimed to identify factors associated with polypharmacy, including social aspects, among patients with rheumatoid arthritis. We conducted this single-centre, cross-sectional study at a 715-bed regional tertiary care teaching hospital in Japan from 1 September to 30 November 2020. Polypharmacy was defined as having five or more medications administered orally regularly, and excessive polypharmacy was defined as having 10 or more medications administered orally regularly. The prevalence of polypharmacy and excessive polypharmacy, distribution of medication types, and factors associated with polypharmacy and excessive polypharmacy were investigated among patients with rheumatoid arthritis. The proportions of polypharmacy and excessive polypharmacy were 61% and 15%, respectively, in 991 patients. Polypharmacy and excessive polypharmacy were associated with older age (odds ratio, 1.03 and 1.03, respectively), high Health Assessment Questionnaire Disability Index (odds ratio, 1.45 and 2.03, respectively), medication with glucocorticoids (odds ratio, 5.57 and 2.42, respectively), high Charlson comorbidity index (odds ratio, 1.28 and 1.36, respectively), and a history of hospitalisation in internal medicine (odds ratio, 1.92 and 1.87, respectively) and visits to other internal medicine clinics (odds ratio, 2.93 and 2.03, respectively). Moreover, excessive polypharmacy was associated with the presence of public assistance (odds ratio, 3.80). Considering that polypharmacy and excessive polypharmacy are associated with a history of hospitalisation and glucocorticoid medication in patients with rheumatoid arthritis, medications during hospitalisation should be monitored, and glucocorticoids should be discontinued. Key points • The proportion of polypharmacy (five or more medications administered orally regularly) was 61%. • The proportion of excessive polypharmacy (10 or more medications administered orally regularly) was 15%. • Medications during hospitalisation should be reviewed and examined, and glucocorticoids should be discontinued.