Regular Ward Research Articles

Intrathecal opioids for the management of post-operative pain.

Intrathecal opioids are highly effective in the management of post-operative pain. The technique is simple with a very low risk of technical failure or complications, and it does not require additional training or expensive equipment such as ultrasound machines and, therefore, is widely practised around the world. The high-quality pain relief is not associated with sensory, motor or autonomic deficits. This study focuses on intrathecal morphine (ITM) which is the only US Food and Drug Administration-approved opioid for intrathecal administration and remains the most commonly used as well as extensively studied. The use of ITM is associated with prolonged analgesia lasting 20-48h after a variety of surgical procedures. ITM has a well-established role in thoracic, abdominal, spinal, urological and orthopaedic surgeries. It is considered the 'gold standard' analgesia technique for caesarean delivery which is generally performed under spinal anaesthesia. As the role of epidural technique in post-operative pain management continues to decrease, ITM has emerged as the neuraxial technique of choice for pain management after a major surgery as a component of multimodal analgesia in Enhanced Recovery After Surgery (ERAS) protocols. ITM is recommended by many scientific groups and societies such as ERAS, PROSPECT, the National Institute for Health and Care Excellence and the Society of Obstetric Anesthesiology and Perinatology. The doses of ITM have decreased successively; today they are a fraction of those used in the early 1980s. With these dose reductions, the risks have decreased; current evidence shows that the risk of the much-feared respiratory depression with low-dose ITM (up to 150 mcg) is no greater than that with systemic opioids used in routine clinical practice. Patients receiving low-dose ITM can be nursed in regular surgical wards. The monitoring recommendations from societies such as the European Society of Regional Anaesthesia and Pain Therapy (ESRA), the American Society of Regional Anesthesia and Pain Medicine and the American Society of Anesthesiologists need to be updated so that the requirements for extended or continuous monitoring at postoperative care units (PACUs), step-down units, high-dependency units, and intensive care units can be eliminated, thereby reducing additional costs and inconvenience and making this simple, versatile and highly effective analgesia technique available to a wider patient population in resource-limited settings.

Intensive care unit admission is not necessary after venous sinus stenting

BackgroundVenous sinus stenting (VSS) has emerged as a safe and effective treatment option for idiopathic intracranial hypertension. Many physicians routinely admit patients to the intensive care unit (ICU) for close...

Multidisciplinary Pulmonary Embolism Response Team (PERT) a propensity score matched single centre experience from Germany

Abstract Funding Acknowledgements Type of funding sources: None. Background Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE). Purpose To investigate the composition and added clinical value of PERT in our city. Methods Over a 5-year period (01/2017-09/2022), patients with confirmed PE were enrolled in a prospective single-centre cohort study (PERT). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE prior and after the formation of PERT at our institution. The primary outcome was in-hospital PE-related mortality before and after the formation of PERT. Results During the period from 2017 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a mean age of 68 years; among these 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 84.9% of the patients. In total, 42.0% were classified as intermediate-risk PE and 11.6% as high-risk PE. First PERT contact originated mostly by emergency departments (33.3 %) and intensive care unit (30.0%), followed by chest pain unit (21.3%) and regular ward (12.0%) (Figure 1a). The participation rate of specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT activations followed by radiologist (95.9%) or anesthesiologist (87.8%). Further disciplines were present in few cases as summarized in Figure 1b. When comparing patients characteristics of the pre-PERT era with the PERT era, more patients were classified as sPESI ≥1 and as high-risk according to ESC 2019 guidelines in the pre-PERT era (78.4% and 18.2%) opposed to the PERT era (71.6 and 11.4%) (Figure 2). A considerable higher all-cause mortality (31.8% vs. 14.8%) and PE-related mortality rate (22.7% vs. 13.6%) was observed in patients in the pre-PERT era compared to the PERT era. After propensity matching (1:1) by including parameters as age, sex, sPESI and ESC risk classes, an univariate regression analyses demonstrated, that the PE management based on a PERT-decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p=0.009) and PE-related mortality (OR, 0.54 [95%CI 0.24-1.18]; p=0.121) compared to patients without a PERT-decision. Conclusion PERT implementation tended to reduce the mortality rate in patients with acute PE. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.

Added value of chest CT in a machine learning-based prediction model to rule out COVID-19 before inpatient admission: A retrospective university network study

PurposeDuring the coronavirus disease 2019 (COVID-19) pandemic, hospitals still face the challenge of timely identification of infected individuals before inpatient admission. An artificial intelligence approach based on an established clinical network may improve prospective pandemic preparedness. MethodSupervised machine learning was used to construct diagnostic models to predict COVID-19. A pooled database was retrospectively generated from 4437 participant data that were collected between January 2017 and October 2020 at 12 German centers that belong to the radiological cooperative network of the COVID-19 (RACOON) consortium. A total of 692 (15.6 %) participants were COVID-19 positive according to the reference of the reverse transcription-polymerase chain reaction test. The diagnostic models included chest CT features (model R), clinical examination and laboratory test features (model CL), or all three feature categories (model RCL). Performance outcomes included accuracy, sensitivity, specificity, negative and positive predictive value, and area under the receiver operating curve (AUC). ResultsPerformance of predictive models improved significantly by adding chest CT features to clinical evaluation and laboratory test features. Without (model CL) and with inclusion of chest CT (model RCL), sensitivity was 0.82 and 0.89 (p < 0.0001), specificity was 0.84 and 0.89 (p < 0.0001), negative predictive value was 0.96 and 0.97 (p < 0.0001), AUC was 0.92 and 0.95 (p < 0.0001), and proportion of false negative classifications was 2.6 % and 1.7 % (p < 0.0001), respectively. ConclusionsAddition of chest CT features to machine learning-based predictive models improves the effectiveness in ruling out COVID-19 before inpatient admission to regular wards.

Retrospective Study of Decubitus Ulcer in Hospitalized Patients

Background: Decubitus ulcer is an area of necrotic tissue due to compression of protrusion because of prolonged immobilization. Decubitus ulcer is complication that often occur due to prolonged bed rest. Decubitus ulcer can interfere with patient’s recovery process and prolonged hospital stay. Purpose: To investigate profile of decubitus ulcer in hospitalized patients in Dr. Moewardi General Hospital Surakarta during 2017- 2020. Methods: This descriptive retrospective study was conducted by using medical record of decubitus ulcers (ICD 10 L89.0, L89.1, L89.2, L89.3) in Dr. Moewardi General Hospital Surakarta during 1st January 2017-31st December 2020. Result: There were 375 decubitus ulcer patients, mostly aged 70 years or more (29.1%) and dominated by women (56%). Patients with decubitus ulcers often hospitalized in the regular ward (75.2%) with the longest length of stay being around 0-10 days (49.6%) and the most common comorbidities was malignancy (20.5%). Systemic antibiotic ceftriaxone was most often given to decubitus ulcer patients (21.6%). Most of the patients with decubitus ulcers had stage 2 decubitus ulcers (53.6%) with a predisposition to the affected area being the sacrum area (33%). The most frequently used therapy for decubitus ulcers was hydrogel dressing (33.9%). Conclusion: Decubitus ulcers are often found in patients over 70 years of age with comorbid malignancies. The most common diagnosis was stage 2 decubitus ulcers, predisposing to the sacral region and the most frequently used therapy was hydrogel dressing with ceftriaxone as a systemic antibiotic.

Nutritional Gap When Transferring From The Icu To Regular Wards – A Retrospective, Cross-Sectional Study

Nutritional Gap When Transferring From The Icu To Regular Wards – A Retrospective, Cross-Sectional Study

Telemedical support of feto-neonatal care in one region - Part II: Structural requirements and areas of application in neonatology

Telemedical infrastructure for patient assessment, care and follow-up as well as interdisciplinary exchange can contribute to ensuring patient care that is close to home and meets the highest quality standards, even outside specialised centres. In neonatology, synchronous audio-visual communication across institutions has been used for many years, especially in the Anglo-American countries. Areas of application include extended neonatal primary care and resuscitation, specific diagnostic applications, e.g. ROP screening and echocardiography, as well as parental care, regular telemedical ward rounds and further training of medical staff, especially using simulation training. For the implementation of such telemedical infrastructures, certain organisational, medical-legal and technical requirements for hardware, software and structural and process organisation must be met. The concrete realisation of a telemedical infrastructure currently being implemented for the region of Eastern Saxony is demonstrated here using the example of the Saxony Center for feto/neonatal Health (SCFNH). Within the framework of feto-neonatal competence networks such as the SCFNH, the quality of medical care, patient safety and satisfaction in a region can be increased by means of a comprehensive, well-structured and established telemedical infrastructure.

Clinical and Personal Predictors of Helmet-CPAP Use and Failure in Patients Firstly Admitted to Regular Medical Wards with COVID-19-Related Acute Respiratory Distress Syndrome (hCPAP-f Study).

Acute Respiratory Distress Syndrome (ARDS) caused by COVID-19 is substantially different from ARDS caused by other diseases and its treatment is dissimilar and challenging. As many studies showed conflicting results regarding the use of Non-invasive ventilation in COVID-19-associated ARDS, no unquestionable indications by operational guidelines were reported. The aim of this study was to estimate the use and success rate of Helmet (h) Continuous Positive Airway Pressure (CPAP) in COVID-19-associated ARDS in medical regular wards patients and describe the predictive risk factors for its use and failure. In our monocentric retrospective observational study, we included patients admitted for COVID-19 in medical regular wards. hCPAP was delivered when supplemental conventional or high-flow nasal oxygen failed to achieve respiratory targets. The primary outcomes were hCPAP use and failure rate (including the need to use Bilevel (BL) PAP or oro-tracheal intubation (OTI) and death during ventilation). The secondary outcome was the rate of in-hospital death and OTI. We computed a score derived from the factors independently associated with hCPAP failure. Out of 701 patients admitted with COVID-19 symptoms, 295 were diagnosed with ARDS caused by COVID-19 and treated with hCPAP. Factors associated with the need for hCPAP use were the PaO2/FiO2 ratio &lt; 270, IL-6 serum levels over 46 pg/mL, AST &gt; 33 U/L, and LDH &gt; 570 U/L; age &gt; 78 years and neuropsychiatric conditions were associated with lower use of hCPAP. Failure of hCPAP occurred in 125 patients and was associated with male sex, polypharmacotherapy (at least three medications), platelet count &lt; 180 × 109/L, and PaO2/FiO2 ratio &lt; 240. The computed hCPAP-f Score, ranging from 0 to 11.5 points, had an AUC of 0.74 in predicting hCPAP failure (significantly superior to Call Score), and 0.73 for the secondary outcome (non-inferior to IL-6 serum levels). In conclusion, hCPAP was widely used in patients with COVID-19 symptoms admitted to medical regular wards and developing ARDS, with a low OTI rate. A score computed combining male sex, multi-pharmacotherapy, low platelet count, and low PaO2/FiO2 was able to predict hCPAP failure in hospitalized patients with ARDS caused by COVID-19.

Sensibility and Specificity of the VitaPCR™ SARS-CoV-2 Assay for the Rapid Diagnosis of COVID-19 in Older Adults in the Emergency Department.

(1) Background: During the COVID-19 pandemic, rapid and reliable diagnostic tools are needed for detecting SARS-CoV-2 infection in urgent cases at admission to the hospital. We aimed to assess the performances of the rapid molecular VitaPCR™ test (Menarini Diagnostics) in a sample of older adults admitted to the Emergency Department of two Italian hospitals (2) Methods: The comparison between the rapid VitaPCR™ and the RT-PCR was performed in 1695 samples. Two naso-pharyngeal swab samplings from each individual were obtained and processed using the VitaPCR™ and the RT-PCR for the detection of SARS-CoV-2 (3) Results: VitaPCR™ exhibited good precision (<3% CV) and an almost perfect overall agreement (Cohen’s K = 0.90) with the RT-PCR. The limit of detection of the VitaPCR™ was 4.1 copies/µL. Compared to the RT-PCR, the sensitivity, the specificity, and the positive and negative predictive values of VitaPCR™ were 83.4%, 99.9%, 99.2% and 98.3%, respectively (4) Conclusions: The VitaPCR™ showed similar sensitivity and specificity to other molecular-based rapid tests. This study suggests that the VitaPCR™ can allow the rapid management of patients within the Emergency Department. Nevertheless, it is advisable to obtain a negative result by a RT-PCR assay before admitting a patient to a regular ward.

Associations of subjective and objective cognitive functioning after COVID-19: A six-month follow-up of ICU, ward, and home-isolated patients

BackgroundSubjective and objective cognitive dysfunction are reported after COVID-19 but with limited data on their congruence and associations with the severity of the acute disease. The aim of this cohort study is to describe the prevalence of subjective and objective cognitive dysfunction at three and six months after COVID-19 and the associations of subjective cognitive symptoms and psychological and disease-related factors. MethodsWe assessed a cohort of 184 patients at three and six months after COVID-19: 82 patients admitted to the Intensive Care Unit (ICU), 53 admitted to regular hospital wards, and 49 isolated at home. A non-COVID control group of 53 individuals was included. Demographic and clinical data were collected. Subjective cognitive symptoms, objective cognitive impairment, and depressive and post-traumatic stress disorder (PTSD) symptoms were assessed. ResultsAt six months, subjective cognitive impairment was reported by 32.3% of ICU-treated, 37.3% of ward-treated, and 33.3% of home-isolated patients and objective cognitive impairment was observed in 36.1% of ICU-treated, 34.7% of ward-treated, and 8.9% of home-isolated patients. Subjective cognitive symptoms were associated with depressive and PTSD symptoms and female sex, but not with objective cognitive assessment or hospital metrics. ConclusionsOne-third of COVID-19 patients, regardless of the acute disease severity, reported high levels of subjective cognitive dysfunction which was not associated with results from objective cognitive screening but with psychological and demographic factors. Our study stresses the importance of thorough assessment of patients reporting long-term subjective symptoms, screening for underlying mental health related factors such as PTSD or depression.

A novel technique for the detection of Covid-19 patients with the applications of three-way decisions using variance-based criterion

Everyone is making constant efforts to establish an effective diagnostic approach, therapy and control of the spread of the pandemic. Due to a flexible formulation, the parameters prior to the normal distributions and explicitly formulate assumptions on the transition probabilities between these categories over time. The spread of the COVID-19 pandemic represents a serious threat for scientists and academics, health professionals and even governments today. The Hospital wards are classified into Intensive Care Unit (ICU), Regular Wards (RW) with Recovered (R) and Deceased (D).. The formulation may be truncated to include particular hypotheses with an epidemiological interpretation. The principles of Three-Way Decision Theory could be used to anticipate and diagnose COVID-19 patients were classified into one of three zones based on their symptoms: Positive, Negative, or Boundary, and treatment are recommended if necessary. The thresholds that distinguish the three zones are determined using a variance-based criterion. Examine the impact of nonpharmaceutical interventions and the findings from data gathered during the second wave of the pandemic in Trivandrum, India.The Three-Way Decision Theory model has a good fit and gives good predictive performance, especially for RW and ICU patients, according to suitable discrepancy metrics that were created to assess and compare models. 95 percent accuracy increased and calculated values for 10 days to demonstrate the temporal aspects of the expected daily reproduction number R

A case report of late onset systemic lupus erythematous presenting with large pericardial effusion

Background: Systemic lupus erythematosus (SLE) is a multi-systemic autoimmune disease that affects multiple organ systems. Age at onset has become recognized as having a mediating effect on the clinical manifestation of SLE, late-onset presentations in individuals 50 years of age and older may represent a unique subtype of SLE. Case Presentation: A 75-year-old Saudi female patient known case of diabetes mellitus, hypertension, osteoarthritis, and morbid obesity. She was presented to the emergency department with a history of shortness of breath and dysuria for 1 week. The patient was admitted to the regular ward and in the following day the patient was developed tachycardia and hypotension and increased serum creatinine 2.59 mg/dl. Then she was shifted to intensive care unit (ICU). In ICU, she was seen by cardiology and electrocardiogram showed atrial fibrillation and T-wave inversion in Lead ll, lll, AVF, and the transthoracic echocardiogram done showed ejection fraction 68% with large effusion around lateral and posterior wall 22 mm and mild effusion around right ventricle. Becks triad was excluded. There was no obvious cause for pericardial effusion at that time, autoimmune disease was suspected, and we consulted the rheumatology department. She was seen by rheumatologist and blood test of autoimmune antibody showed antinuclear antibody positive, anti-dsDNA positive, at that time confirmed diagnosis of SLE. Clinical Discussion: Serositis is defined as pleural and pericardial effusions, up to 50% of SLE patients pericardial effusion may be seen, it is often minor and asymptomatic and it is more uncommon as an initial symptom. Conclusion: We report a rare case of late onset of SLE presenting with large pericardiac effusion, which should be considered one of the rare first signs of SLE in older patient.

1206. Epidemiological interaction of MRSA, ESBL E.coli and C. difficile between ICU/Step-down Unit of University-affiliated Community Hospital and LTACs in Japan: Utility of Molecular Epidemiology Analysis by PCR-based ORF Typing (POT method)

Abstract Background Epidemiological interaction of drug resistant organisms between ICU and surrounding health facilities including LTACs have been of interest in the era of antimicrobial resistance (AMR) and aging society. In addition, conventional molecular epidemiology methods such as pulsed-field gel electrophoresis, and multilocus sequence typing are time-consuming and difficult to perform in a standard microbiology laboratory. Methods Patients admitted to a university-affiliated community hospital in Japan was recruited if their cultures collected clinically during admission grew the following target pathogens: Methicillin-resistant Staphylococcus aureus (MRSA), Vancomycin Resistant Enterococci (VRE), ESBL Gram negative rods (GNR), carbapenem-resistant Enterobacteriaceae (CRE), multi-drug resistant Pseudomonas (MDRP) and Clostridioides difficile (C. diff). Their clinical information including admission to ICU/step-down unit vs regular wards and disposition was analyzed with chi-square test for binary outcomes. For the isolates of MRSA, ESBL E. coli, and C. diff, further molecular epidemiology analysis was made, using PCR-based open-reading frame (ORF) Typing (POT method), a more resource-friendly and time-efficient technology originally developed in Japan. Results Among total 9639 hospital admissions in 2018-2019, the above-mentioned target pathogens grew from 233 patients (2.4%). There were 96 MRSA isolates (41.2%, out of 233), followed by 93 ESBL GNR (39.9%), 21 C. diff (9.0%), 13 CRE (5.6%), 10 MDRP (4.3%), and no VRE, respectively. Patients admitted to ICU/step-down unit were more likely to grow the target pathogens (117/1605 vs 116/7801, RR 4.90, 95% CI 3.81-6.30, p&amp;lt; 0.001), and to be discharged to LTACs than patients admitted to regular wards (70/113 vs 32/116, RR 2.17, 95% CI 1.56-3.02). Molecular epidemiology analysis with POT method identified 5, 3 and 3 common strains across 20, 11, and 7 patients with MRSA, ESBL E.coli, C. diff, respectively. Conclusion The study suggests the pathogens of higher priority were more prevalent in ICU/step-down unit and that the discharge from ICU/step-down unit to LTACs could impact on further transmission in the surrounding region. POT method can be utilized for more efficient molecular epidemiology analysis in the era of AMR. Disclosures All Authors: No reported disclosures.

The delivery of obstetric anaesthetic care in UK maternity units: a survey of practice in 2021

BackgroundAnaesthetists are crucial members of the maternity unit team, providing peri-operative analgesia and anaesthesia, and supporting the delivery of medical care to high-risk women. The effective contribution from obstetric anaesthetists to safety in maternity units depends on how anaesthesia services are organised and resourced. There is a lack of information on how obstetric anaesthetic care is resourced in the UK. MethodsThe Obstetric Anaesthetists’ Association surveyed UK clinical leads for their hospital’s obstetric anaesthetic service and examined compliance with national recommendations. ResultsThere were 153 responses by lead obstetric anaesthetists from 184 maternity units in the UK (83%). The number of consultants per 1000 deliveries was 2.2 [1.6–2.7] (median [IQR]). In 20% of units, there was a dedicated on-call rota (on-call only for obstetric anaesthesia), whilst the remainder had a ‘combined’ on-call rota (on-call for other clinical areas in addition to obstetrics). Multidisciplinary ward rounds were held in 83% of units. Twenty-five (16%) units reported having no regular multidisciplinary ward rounds, of which nine (6%) did not have any multidisciplinary ward rounds. Planned operating lists for elective caesarean sections were provided in 77% of units. ConclusionsIn the largest survey of obstetric anaesthesia workload to be reported for any health system, we found significant disparities between obstetric anaesthesia service provision and current national recommendations for areas including consultant staffing, support for elective caesarean section lists, antenatal anaesthetic clinics, and consultant support for service development. Wide national variation in service provision was identified.

Sotrovimab in Hospitalized Patients with SARS-CoV-2 Omicron Variant Infection: a Propensity Score-Matched Retrospective Cohort Study.

In vitro data suggest the monoclonal antibody sotrovimab may have lost inhibitory capability against the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) Omicron variant. We aimed to provide real-life data on clinical outcomes in hospitalized patients. We retrospectively analyzed patients who were treated at the University Medical Center Hamburg-Eppendorf, Germany, between December 2021 and June 2022. Out of all 1,254 patients, 185 were treated with sotrovimab: 147 patients received sotrovimab monotherapy, and 38 received combination treatment with sotrovimab and remdesivir. We compared in-hospital mortality for the different treatment regimens for patients treated on regular wards and the intensive care unit separately and performed propensity score matching by age, sex, comorbidities, immunosuppression, and additional dexamethasone treatment to select patients who did not receive antiviral treatment for comparison. No difference in in-hospital mortality was observed between any of the treatment groups and the respective control groups. These findings underline that sotrovimab adds no clinical benefit for hospitalized patients with SARS-CoV-2 Omicron variant infections. IMPORTANCE This study shows that among hospitalized patients with SARS-CoV-2 Omicron variant infection at risk of disease progression, treatment with sotrovimab alone or in combination with remdesivir did not decrease in-hospital mortality. These real-world clinical findings in combination with previous in vitro data about lacking neutralizing activity of sotrovimab against SARS-CoV-2 Omicron variant do not support sotrovimab as a treatment option in these patients.

Student perceptions of an online surgical teaching programme during the COVID-19 pandemic at the University of KwaZulu-Natal: A short report

&#x0D; &#x0D; &#x0D; &#x0D; Background. The COVID-19 pandemic has led to an unprecedented global health crisis, with impacts on many facets of the health system, including lack of access to regular training wards and the need for social distancing, which posed particular challenges to undergraduate teaching.Objectives. To explore the perceptions of students of the online surgical programme at UKZN.Methods. An online survey was administered to 258 final-year students. Data were collected on student demographics, impact of COVID-19 restrictions on the teaching programme, engagement and learning from live Zoom sessions, overall perceptions about the module and general feedback on students’ experience of the programme.&#x0D; Results. Most students (84%, 77/91) supported the need to change to the virtual programme. The module was perceived as well-structured (89%, 81/91). Most students (87%, 79/91) regarded the online resource materials as beneficial. Analysis of open-ended responses showed that asynchronous delivery allowed students to review and revisit resources in their own time. Student challenges included poor internet connectivity, difficulty in concentrating where live sessions exceeded an hour, and lack of clinical exposure.&#x0D; Conclusion. Online teaching in medical education is a feasible option for remote learning. However, it cannot replace the benefits gained during clinical exposure. Findings from this study will help to set a benchmark for online surgical training at UKZN and develop best practices for blended teaching models. As we adapt to a new normal in the era of COVID-19, the disruptions and results of innovative teaching methods have the potential to change the future of medical education.&#x0D; &#x0D; &#x0D; &#x0D;

To Rx or Not: Mainstreaming Informal Providers

On a hot summer afternoon, there is a huge commotion around the Jawnpore District Hospital. There is passionate sloganeering by the ruling party supporters competing with protests by the opposition party activists against the alleged lack of personnel and infrastructure in the district hospital. Not far away from this hullabaloo, Grameen Arogya, a non-governmental organization, stages a satyagraha to silently protest against the official silence on dysentery deaths in the region. A motorcade of government cars enters the hospital grounds. The local leaders of the ruling party and the District Hospital Superintendent are waiting to welcome and garland Shri Jagatprakash Goel, Union Health Minister, visiting the hospital. Goel ji joins the doctors in their regular ward rounds and inspects the hospital. Then he addresses the public and the medical community including a few office bearers of the medical association (the association of registered doctors). The moment Goel ji concludes the address, Mr Das from Grameen Arogya, rushes to the podium and hands a memorandum to Goel ji. He grabs the microphone and makes an emotional account of the deplorable healthcare situation in Jawnpore. He discusses the difficulties arising due to a lack of registered doctors and rampant absenteeism in the public hospital, particularly when there is no private provider of healthcare. He proposes that the only practical way to alleviate these difficulties in providing rural healthcare is to ‘mainstream the quacks’ and cites a 2006 multi-national survey-based research study ( Chaudhury et al., 2006 ). He appeals to Shri Jagatprakash Goel, the minister, to make provision for special training of informal providers (Ips), to fill the need for medical practitioners in rural areas. Supporters of the ruling party and members of the medical community run to the dais to stop Mr Das from speaking further. But the minister asks the crowd to calm down and handles the situation. He assures Grameen Arogya that he will investigate the issue.

D-Dimer Sebagai Salah Satu Parameter Perbaikan Klinis pada Kasus Covid-19 Gejala Berat

Background. Coronavirus Disease 2019 (COVID-19) has been a global pandemic since March 2020. The number of patients is massive and clinical symptoms vary from mild to severe symptoms. Several laboratory results showed abnormal values in Covid-19 patients, including an increase in the value of D-dimer. Elevated levels of D-dimer in COVID-19 patients are strongly associated with severity and increased mortality. We report a case of a severe symptomatic COVID-19 patient with high D dimer levels at the start of treatment and showing clinical improvement according to a decrease in D dimer levels. Methods. We treat and follow the clinical and laboratory developments of COVID-19 patients with severe symptoms from the time they enter the Intensive Care Unit (ICU) until they move to a regular ward. Results. A 53-year-old male patient diagnosed with viral pneumonia et causa covid-19 was admitted to the ICU with severe symptoms and high initial d-dimer levels (1,413 ug/ml). The patient received ventilator assistance and standard therapy according to the Covid 19 management protocol of the Ministry of Health of the Republic of Indonesia. Anticoagulation using heparin intravenously with a dose adjusted to the level of d dimer, aPTT, and clinical condition of the patient who is monitored regularly. The trend of d dimers decreased parallel to the decrease in C reactive protein (CRP) levels, increased lung gas exchange function was evaluated from the PaO2/Fio2 ratio (PF ratio) and the clinical improvement of the patients. Conclusion. D-dimer is closely related to the severity of covid 19 patients. D dimer can be used as one of the parameters of patient clinical improvement.

Improvements in AML Treatment Outcomes By Twinning at the Instituto De Prevision Social Hospital in Paraguay

Background: The Central Hospital of the Instituto de Prevision Social (IPS) is the primary care point for 30% of the Paraguayan population. Patients with AML were treated on a general ward and had to change citizenship to receive allogeneic stem cell transplant (HSCT) abroad. Following the poor overall survival (OS) of the patients, a twinning program was started in 2015 with the help of the Worldwide network for Blood and Marrow Transplantation (WBMT). Physicians were trained at a JACIE/FACT accredited center for 6 months and the Hospital, staff, and nurses with an experience of 115 mostly autologous HSCT were inspected. The program started in 2016 by daily supervisory telemedicine visits including monitoring of vital signs, blood counts, chemistry and radiological analysis. In 2019, the need to improve treatment of AML prompted the Hospital to include newly diagnosed patients in the twining program. Now after 6 years, the outcome of AML patients was evaluated and compared to the results before the cooperation in 2012-2015. Changes: One of the biggest challenges was the availability of essential drugs. Busulfan and several other preparative regimens and immunosuppressive drugs for HSCT were either not available or accessible only as oral formulation. Supportive therapy was a challenge considering lack of modern antifungal and antiviral therapy. To start the program, essential medications according to the WBMT recommendations were either donated from outside the country, included in the Insurance medications or ordered through the Ministry of Health. The allogeneic HSCT program was started using standard operating procedures (SOP) for central venous line care, neutropenia care, febrile neutropenia, transfusion threshold, visitors, patients per room, multidrug resistant bacteria active search and isolation of colonized patients, bacterial, viral, and fungal prophylaxis, and treatment. It was soon realized that only very few patients with AML survived induction therapy and reached CR. Therefore, the HSCT program started to include patients with AML from diagnosis in 2019. Newly diagnosed AML patients were therefore treated either on the conventional ward with 2-6 beds per room and common bathrooms or in the HSCT unit according to the availability of beds. SOP from HSCT patients were used for induction and consolidation treatments wherever possible. As quality control, OS was evaluated in the AML patients diagnosed in 2019-2021 according to treatment location and compared to the historical controls of 2012-2015 and to the HSCT patients. Results: Between 2019 and 2021, 23 patients received intensive chemotherapy induction, 8 patients in the HSCT Unit (Group A1) and 15 in the Regular Ward (Group A2). The controls included 31 historical patients with AML treated between 2012 - 2015 (Group B) and 50 patients after autologous or allogeneic HSCT between 2016-2021 (Group C). Patient`s characteristics are shown in Table 1. In comparison to the historical controls, diagnostics improved, and the treatment was given according to international protocols. Causes of death due to infection were reduced substantially to 12.5% in group A1 in comparison to 40% and 51% in group A2 and B, respectively. No bleeding fatalities were observed in Group A1 possibly because of strict transfusions according to SOP. In the HSCT control Group C only 4% died of infection and none of bleeding. Figure 1 shows overall survival for all four groups. There were significant differences in median OS of the Group A1 (18 months), Group A2 (0,8 months), Group B (3,2 months) and Group C (not reached; p<0.0001). OS at 12 months amounted to 81% for Group A1, 15% for Group A2, 11% for Group B and 79% for Group C. Conclusions: Improved survival following standardized treatment according to SOP can be achieved with strict adherence to protocols. Lower infection rate following isolation and standardized infection prevention and handling. Infection rate similar to the highest intensity of conditioning (autologous HSCT) and immunodeficiency (allogeneic HSCT). Even with the addition of new antifungal drugs and antivirals available at the regular ward between 2019-2021patients had low overall survival mostly due to bacterial infections following missing isolation, active surveillance, and prophylaxis. With this measures mortality following induction can be reduced effectively and is comparable to regular HSCT patients from developed countries. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Combined interprofessional and intraprofessional clinical collaboration reduces length of stay and consultations: a retrospective cohort study on an intensive collaboration ward (ICW)

ABSTRACT Patients with multiple health problems are a growing population at high risk of receiving fragmented care, resulting in a poorer quality of care, preventable hospitalisations, and higher costs. Health agencies such as the World Health Organization (WHO) advocate the implementation of interprofessional care, which should lead to better patient care. This retrospective cohort study investigated the effect of combined interprofessional and intraprofessional collaboration on the management of mainly elderly patients with multiple health problems on an Intensive Collaboration Ward (ICW). Patient health outcomes, patient experience, and the cost and value of care were assessed. In total, 200 patients admitted to the ICW were compared with 51 control patients with an indication for the ICW who were admitted to a regular ward because of a shortage of ICW beds. Patients admitted to the ICW had a shorter length of hospital stay than control patients (median 5 vs 7 days, p = .004) and had fewer in-hospital consultations (p = .003). Patient satisfaction did not differ between the ICW and control patients (mean rating (1–10) 8.22 vs 8.75, p = .060). This study indicates that interprofessional and intraprofessional clinical collaboration reduces the length of hospital stay and the number of in-hospital consultations, without affecting patient satisfaction.