Rural Medical Center Research Articles

Long-term follow-up of patients with multiple sclerosis treated with a cost-effective protocol from a rural medical center in India: a retrospective case series

Background and objectives: Multiple sclerosis affects young adults resulting in dependency after 15 years of disease. Treatments are time-consuming, expensive and do not provide full protection. The purpose of this study is to assess the therapeutic effects of rational therapy on multiple sclerosis in patients from a tertiary centre, India. Subjects and methods: This retrospective case series study included 23 patients treated with a very cost-effective protocol that was practiced for three decades in a government medical college setting in a population of 250 patients. All rational options were explained to the patients who were diagnosed with multiple sclerosis according to modified Mc Donald criteria. The patients who were willing to undergo the scheduled regime were followed up. Multiple sclerosis relapse, lesion load, and Expanded Disability Status scale (EDSS) scores were evaluated at 1 and 3 years and thereafter in a need based way. This study was approved by the Institutional Review Board, National Institute of Mental Health And Neurosciences (NIMHANS), India. Results: The mean duration of illness of 23 patients with multiple sclerosis was 6.8 ± 5.23 years and the mean remission period was 4.09 ± 3.5 years. The mean EDSS score was 3.83 ± 0.78 at onset and it was 1.15 ± 0.5 after treatment. Thirteen (22%) patients had replaces during the above period of illness but were managed well with a pulse of 5 g methyl prednisolone. Conclusion: The treatment protocol for multiple sclerosis designed for patients from an Indian rural medical center is cost-effective and has very good effects on the control of relapse and progression.

“Sharing in hopes and worries”—a qualitative analysis of the delivery of compassionate care in palliative care and oncology at end of life

ABSTRACT Purpose: To explore the methods through which physicians deliver compassionate care during end-of-life (EOL). Compassionate care provides benefits to patients and providers and is particularly important for patients with serious illnesses, yet its practice remains limited. We aim to qualitatively characterize methods utilized by physicians that facilitate the delivery of compassionate care at EOL. Methods: We conducted 13 semi-structured interviews with physicians from palliative care and medical oncology subspecialities at a rural academic medical centre in New Hampshire. Interviews were transcribed and analysed using a qualitative research design. Results: Participants described methods of compassionate care ranging from symptom control to less tangible, non-verbal methods. Primary barriers to the delivery of compassionate care were described as within the broader healthcare system and within the inherent emotional difficulty of EOL care. Physicians from both subspecialities emphasized the importance of successful inter-provider relationships. Conclusions: Methods for delivering compassionate care at EOL are wide ranging, but barriers on a systemic and individual level should be addressed to make its practice more widespread. This can be accomplished, in part, by the standardization of EOL conversations, training physicians how to have meaningful EOL conversations, and integration of such conversations into electronic medical records.

Adaptation and Implementation of a Transitional Care Protocol for Patients Undergoing Complex Abdominal Surgery

Transitional care protocols are effective at reducing readmission for medical patients, yet no evidence-based protocols exist for surgical patients. A transitional care protocol was adapted to meet the needs of patients discharged to home after major abdominal surgery. The Coordinated-Transitional Care (C-TraC) protocol, initially designed for medical patients, was used as the initial framework for the development of a surgery-specific protocol (sC-TraC). Adaptation was accomplished using a modification of the Replicating Effective Programs (REP) model, which has four phases: (1) preconditions, (2) preimplementation, (3) implementation, and (4) maintenance and evolution. A random sample of five patients each month was selected to complete a phone survey regarding patient satisfaction. Preimplementation planning allowed for integration with current systems, avoided duplication of processes, and defined goals for the protocol. The adapted protocol specifically addressed surgical issues such as nutrition, fever, ostomy output, dehydration, drain character/output, and wound appearance. After protocol launch, the rapid iterative adaptation process led to changes in phone call timing, inclusion and exclusion criteria, and discharge instructions. Survey responders reported 100% overall satisfaction with the transitional care program. The adaptable nature of sC-TraC may allow for low-resource hospitals, such as rural or inner-city medical centers, to use the methodology provided in this study for implementation of local phone-based transitional care protocols. In addition, as the C-TraC program has begun to disseminate nationally across US Department of Veterans Affairs (VA) hospitals and rural health settings, sC-TraC may be implemented using the existing transitional care infrastructure in place at these hospitals.

Clinical Characteristics of Roux-en-Y Gastric Bypass Patients with Death from Accidental Overdose or Intentional Self-Harm: a Descriptive Study.

The objective of this descriptive study was to identify clinical characteristics of Roux-en-Y gastric bypass (RYGB) patients who died from intentional self-harm or accidental overdose postoperatively. This retrospective, descriptive study included RYGB patients from a large rural medical center that completed surgery between January 2004 and December 2014 and died from intentional self-harm or accidental overdose through December 2015. Specific causes of death were obtained from the National Death Index and clinical data from electronic health records. Clinical characteristics explored were age, sex, time to surgery, weight loss expectations, postoperative weight loss, medication, diagnoses, psychiatric histories (diagnoses, self-harm, suicidal ideation and behaviors, medications, substance use, preoperative Beck Depression Inventory-II scores), pain, social support, and reported life stressors. Overall, 22 patients of 146 total deceased patients died from intention self-harm (n = 6) or accidental overdose (n = 16) over the study period (77.3% female, mean age at time of surgery = 38.4 ± 9.1years). Younger age (< 40years), history of self-harm or depression, preoperative pain, and use of opioids at the time of surgery emerged as common characteristics in weight loss surgery patients who died from intentional self-harm or accidental overdose. No trends regarding social support, life stressors, or actual or expected weight loss were identified. Certain weight loss surgery patients may be at risk for death from self-harm or overdose and may benefit from greater surveillance postoperatively.

Medical emergency response in non-hospitalized patients (Code Whites) in a rural tertiary academic medical center: A 7 year observational study

Medical emergency response in non-hospitalized patients (Code Whites) in a rural tertiary academic medical center: A 7 year observational study

An Assessment of an Outpatient Antimicrobial Therapy Program in a Rural Medical Center : A Retrospective Chart Review.

Current literature supports outpatient parenteral antimicrobial therapy (OPAT). This article presents results from a research study that evaluated an OPAT program that treated community-acquired pneumonia. If patients had the opportunity to receive outpatient intravenous antibiotics for community-acquired pneumonia, would this prevent future hospitalization? Was there a decrease in hospital admissions? An informal cost-benefit analysis comparing OPAT with inpatient hospital admissions for the same disease was also reviewed to provide evidence whether there was a change. What was the overall health care cost savings? The medical charts of 50 patients with confirmed pneumonia who had received OPAT in a 3-month period were reviewed. A retrospective medical record review was performed. All patients were evaluated by the in-house OPAT team. The resulting analysis provided evidence that an estimated savings of approximately $2100 per day would be achieved by decreasing hospital readmissions for patient who had been treated with OPAT. The conclusion of this study provides evidence that the implement of an OPAT program was, and is, essential for patient care and evidence-based best practice adherence.

Escape Room Recruitment Event: Description and Lessons Learned.

The U.S. nursing workforce is facing a severe shortage of professionals due to an anticipated retirement of more than 500,000 RNs in the next 5 years. An Escape to Nursing event was created and delivered in a rural medical center college of nursing in the spring of 2017. This faculty team developed four distinct rooms that were designed with key nursing concepts and patient health conditions. Recruits worked in teams to solve the patient health care puzzle, which then enabled them to proceed to the next room. Feedback was positive from the recruits, including comments about expanding the game to more health care scenarios and reaching out to more recruits. Additional recruitment may lead to better turnout of recruits. Linear, sequential formatting for the escape room game design is recommended for use with recruits into nursing. The use of escape rooms for recruitment is a positive activity. [J Nurs Educ. 2018;57(3):184-187.].

Clinical and laboratory profile of diabetic ketoacidosis in elderly with type 2 diabetes mellitus

INTRODUCTION: Diabetic ketoacidosis (DKA) in elderly is rare and poses a special problem because of high degree of mortality, comorbidity, age-related impairment of functional ability, and increased chances of hypoglycemia. OBJECTIVES: The main objective is to study the precipitating factors, clinical and laboratory profile of DKA in elderly. MATERIALS AND METHODS: A total of 100 type 2 diabetes mellitus (T2DM) patients, ≥60 years, admitted in a rural tertiary medical center were included in this study. RESULTS: Most of them had prolonged diabetes with mean duration of 7.3 ± 4.6 years. 24 patients were newly detected diabetes mellitus. Systemic infections seen in 67 patients (respiratory –32.8%, sepsis – 28.4%, acute gastroenteritis – 22.4%, and urinary tract infections– 16.4%), were the main precipitating factors, followed by noncompliance to drugs (34). Osmotic symptoms were reported by most (62) followed by pain abdomen (56). Dehydration was seen in 72 patients, whereas altered sensorium in 48. Blood glucose at presentation (493.12 ± 72.38 mg/dl) and HbA1c levels (9.63 ± 0.94%) were found to be elevated with lowered arterial pH (7.14 ± 0.07) and bicarbonate (13.7 ± 4.2 mEq/L). 22 had severe acidosis and 10 had mild acidosis. There was no mortality in the present series. CONCLUSION: DKA is more common in T2DM than anticipated. The most common precipitating factor is infection followed by noncompliance even in elderly. Majority had poor glycemic control. All elderly diabetic patients with high serum glucose level must be investigated for ketosis as the symptoms of DKA are minimal and morbidity and mortality are high in these patients.

Simultaneous surgery for primary and nodes in carcinoma penis: a rural tertiary medical centre experience and results

Background: Historically surgery for nodes in carcinoma penis was done as staged procedure due to fear of higher morbidity and longer hospital stay. However, in view of the established safety of the simultaneous procedure, very few centres do simultaneous surgery for nodes and primary in cancer penis.Methods: A retrospective analysis of all the simultaneous surgeries for nodes and primary for carcinoma penis done at our hospital, during the period April 2015 to March 2017 were done and various parameters were calculated and compared with historical standards of various series.Results: The various parameters namely wound morbidity, hospital stay and complications were analysed and compared with historical standards. A total of 15 patients during the above mentioned were found to be suitable for the analysis after having excluded patients who had previous therapy and inoperable tumours. The mean follows up period was 12 months (ranging from 8 to 20 months). The mean hospital stay was 15 days (range from 12 days to 25 days). The skin margin necrosis rate was 6.67%, wound infection rate was 6.67% and there were no perioperative deaths. The same was compared with historical standards.Conclusions: Simultaneous surgery for primary and nodes in carcinoma penis is safe and the standard results are reproducible in a rural tertiary medical centre like ours.

293 Goals of Care Determination Prior to Transfer: A Missed Opportunity

To determine the prevalence of goals of care discussion documentation by sending institutions among adults transferred to our tertiary care medical center who died within the first 48 hours of their transfer. We performed a retrospective chart review of patients 18 years and older transferred from outlying hospital emergency departments and inpatient units to our rural tertiary medical center as either floor level or critical care level patients from October 2011 through April 2016 who died within 48 hours of arriving. Data was abstracted from both the referring hospital’s documentation provided upon transfer and our electronic medical record. Physiologic and laboratory data was abstracted from the referring facilities chart or our electronic medical record reflecting the patient’s condition at the time of transfer; this was used to calculate the Charlson Age-Comorbidity Index. The presence of documented goals of care was specifically determined through review transfer documentation accompanying the patient. Data was analyzed using STATA 10 statistical software. A total of 181 patients met the inclusion criteria. The average age was 69.3 years and 47.5% were female. 76% of the referring hospitals were critical access hospitals. 45 % came from emergency departments, 55% from inpatient units. The mean Charlson Age-Comorbidity Index score was 5.5±2.7. Mode of transfer to our facility was local EMS 52.5% of the time, critical care helicopter 32%, and critical care ground transport 15.5%. The cause of death was septic shock for 24.9%, cerebrovascular accident for 14.4%, and acute myocardial infarction or cardiogenic shock for 12.7%. Documented goals of care discussion was available in 18 of 181 (10%) of transfer records. Our chart review revealed 22 (12%) instances of initial goals of care discussion taking place on admission to the hospital which resulted in the decision to transition to a comfort-based end-of-life care upon arrival. Care was transitioned to a comfort-based care within the first 24 hours for 88 (49%) of the patients. While transfer to a higher level of care is often necessary, the sought after care should be in line with the patient’s goals. In this single center review of critically ill patients, it was striking that only 1 in 10 patients who were critically ill had a discussion about their goals of care addressed and documented prior to transfer. Although the decision to transfer a critically ill patient must often be made with in information, these results suggest an opportunity to improve on the current state. The 12% of patients transitioned to comfort-based care upon arrival to our hospital suggests an opportunity to improve patient care while also decreasing unnecessary transfer. Addressing goals of care along with aggressive medical interventions is important to providing a therapy consistent with our patients’ goals and avoiding costly and invasive treatments that do not align with their goals of care.

Studying of prevalence of the most significant urological diseases in the Aral Sea Area

This article studies isues of prevalence of the most significant urological diseases in the Aral Sea Area in the environment of primary health care . Survey was conducted in four ruralmedical centers of the region. In order to carry out the inspection the representative sampling was formed, where the both gender personalities of the age of 1 year and older w ere included. In total 7597 people were inspected that made 85.4% of the number subject to inspection. As a result of epidemiologic survey the level of true illness level of the population in the Aral Sea Area was established on certain nosological forms o f urologic diseases. The analysis has shown that the most widespread among the population i s the urine tract infection (10.75±0.36), followed by preprelithiasis (5.82±0 .27), BPH (3.37±0.21) and urolithiasis (1.40±0.13) per 100 surveyed. It should be not ed that in no case the comparison of prevalence rate of urological diseases in Khorezm region and in the Republic of Karakalpakstan has revealed significant territorial indicators differences (р>0.05). Big importance in conduction of epidemiologic survey i s given to involving to its fulfillment of initial health care link (general practitioners), as the most approached and having the possibility to carry out the early diagnostics of urological diseases.

Independent risk factors for surgical site infection after cesarean delivery in a rural tertiary care medical center.

We aimed to determine the incidence of surgical site infection (SSI) after cesarean delivery (CD) and identify the risk factors in a rural population. We identified 218 SSI patients by International Classification of Disease codes and matched them with 3131 parturients (control) from the electronic record database in a time-matched retrospective quality assurance analysis. The incidence of SSI after CD was 7.0%. Risk factors included higher body mass index (BMI) [40.30±10.60kg/m2 SSI (95% CI 38.73-41.87) vs 34.05±8.24kg/m2 control (95% CI 33.75-34.35, P<0.001)], years of education [13.28±2.44years SSI (95% CI 12.9-13.66) vs 14.07±2.81years control (95% CI 13.96-14.18, P<0.001)], number of prior births [2 (1-9) SSI vs 1 (1-11) control (P<0.001)], tobacco use (OR 1.49; 95% CI 1.06-2.09, P=0.03), prior diagnosis of hypertension (OR 1.80; 95% CI 1.34-2.42, P<0.001), gestational diabetes (OR 1.59; 95% CI 1.18-2.13, P=0.003), and an emergency/STAT CD (OR 1.6; 95% CI 1.1-2.3, P=0.01). Risk factors for SSI after CD included higher BMI, less years of education, higher prior births, tobacco use, prior diagnosis of hypertension, gestational diabetes, and emergency/STAT CD. The presence of ruptured membranes was protective against SSI.

Conversion Disorder in an Appalachian Community.

Conversion disorder (CD) is believed to be the manifestation of physical and/or neurological symptoms for primary gain without an identifiable organic cause. Although it is believed to be more common in rural areas, the literature examining this claim is sparse. To our knowledge, no study has been published evaluating the prevalence of CD in a rural Appalachian population. The aim of this study was to characterize and determine the prevalence of CD per Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria in a rural Appalachian psychiatric consultation service and to compare this population with control patients from the same service. We performed a retrospective chart review of all patients diagnosed as having CD per Diagnostic and Statistical Manual of Mental Disorders, 5th Edition, criteria on a psychiatric consultation service at a rural Appalachian academic medical center during a 13-month time period. For each case, two consecutive control patients were selected from the same service and time span. There were 21 cases and 42 controls in this study, with a CD prevalence rate of 6.0% (N = 21/351). Sociodemographic, comorbidity, and recent symptomatology data were obtained. Compared with controls, cases were significantly younger and were more likely to have a history of sexual abuse, seizure disorder, antiepileptic use, neurologic referral, electroencephalogram, magnetic resonance imaging of the brain, and history of CD. We found it interesting that fewer cases reported alcohol and drug use. The observed prevalence of 6.0% does not support the historical theory that CD is more prevalent in rural or lower socioeconomic populations. Our data add to the characterization of the Appalachian CD population.

Bariatric Surgery Patients and Their Families: Health, Physical Activity, and Social Support.

This study evaluated the social environment of bariatric surgery patients in the preoperative period. Forty bariatric surgery patients (mean = 46.2 ± 11.2years), 35 adult cohabitating family members (mean = 45.2 ± 12.7years), and 15 cohabitating children (mean = 11.5 ± 3.6years) were recruited from a large rural medical center. Adult participants (patients and family members) completed height, weight, body composition, blood draws, and physical activity assessments (accelerometry), as well as eating behavior and social support inventories before the patient underwent bariatric surgery. Child participants completed demographic, height, and weight assessment only. Over 90% of adult family members were overweight or obese (body mass index (BMI) ≥ 25kg/m2, as were 50% of children (BMI percentile ≥ 85%). More than one third (37.1%) of family members met the criteria for moderate to severe insulin resistance. Physical activity measured by accelerometry was moderately correlated between the patient and adult family members (r = 0.46, p = 0.023). Bariatric surgery patients reported high levels of social support from their family members on multiple social support measures. Many family members of bariatric surgery patients also lived with obesity and related comorbidities, and demonstrate high sedentary behavior. However, patients reported high levels of support from family members, including support in following a healthy diet and engaging in physical activity. Engaging families in behavior change may help bariatric surgery patients and their families to become healthier.

Cycling Injuries in Southwest Colorado: A Comparison of Road vs Trail Riding Injury Patterns

To describe the epidemiology of injuries sustained in cyclists and compare the injury patterns in road vs trail biking accidents. A retrospective chart review was performed of injured road and trail cyclists presenting to a rural mountain resort-based medical center during a 3-year study period. Of 304 patients, 70% were male, with 67% sustaining trail injuries and 33% sustaining road cycling injuries. There was a bimodal age distribution. Prehospital care was activated in 16% of patients. The most common injuries were lacerations and abrasions (64%), upper extremity fractures (26%), head injuries (9%), and thoracic trauma (6%). Head injury was more common in road- vs trail-related trauma (16% vs 6%; P = .005), whereas thoracic injury was more common in trail riders (7% vs 2%; P = .053). Head injury and lower extremit y fracture were the most common reasons for patient transfer. Patients with head injuries who did not use a helmet were more likely to require transfer to a neurosurgical unit (38% vs 17%; P = .296); however, this difference did not meet statistical significance. Lacerations and abrasions are the most common injuries sustained in cycling. Quantifying the role of protective extremity gear in reducing these injury patterns may be of interest for future studies. Protective helmet use may be important in reducing morbidity from cycling-related head trauma; however, more data are needed. Prehospital care providers responding to the injured trail cyclist should be equipped to manage laceration, fracture, head injury, and thoracic trauma in the field.

Patients’ Knowledge, Beliefs, and Distress Associated with Detection and Evaluation of Incidental Pulmonary Nodules for Cancer: Results from a Multicenter Survey

IntroductionPulmonary nodules are detected in more than 1 million Americans each year. Prior qualitative work suggests that the detection of incidental pulmonary nodules can be burdensome for patients, but whether these findings generalize to a broader sample of patients is unknown. We categorized patients’ knowledge, beliefs, and distress associated with detection and evaluation of a pulmonary nodule, as well as their impressions of clinician communication. MethodsWe administered a cross-sectional survey to adults with an incidental pulmonary nodule who were recruited from a rural medical center, an urban safety net hospital, and a Veterans Affairs hospital. ResultsOf the 490 individuals mailed surveys, 244 (50%) responded. Median nodule size was 7 mm, mean patient age was 67 years, 29% of respondents were female, and 86% were white. A quarter of the respondents (26%) reported clinically significant distress related to their nodule, our primary outcome, as measured by the Impact of Event Scale. Patients reported multiple concerns, including uncertainty about the nodule’s cause (78%), the possibility of cancer (73%), and the possible need for surgery (64%). Only 25% of patients accurately estimated their lung cancer risk (within 15% of their actual risk); overall, there was no correlation between perceived and actual risk (r = –0.007, p = 0.93). The 23% of patients who did receive information on cancer risk from their provider were more likely to find this information reassuring (16%) than scary (7%). ConclusionA quarter of patients with incidental pulmonary nodules experienced clinically significant distress. Knowledge about cancer risk and evaluation was poor. Clinician communication may help bridge knowledge gaps and alleviate distress in some patients.

Histopathological patterns of endometrial lesions in patients with abnormal uterine Bleeding in rural area of Western Maharashtra

Background: Abnormal uterine bleeding (AUB) is considered one of the most common and challenging problems presenting to the gynecologist. Histopathological examination of endometrial biopsy is gold standard diagnostic tool in evaluation of AUB. Our study is aimed at determining the spectrum of endometrial pathologies in different age group patients presenting with AUB at our hospital which caters largely to women living in rural area. Methods: This was a retrospective study done on patients presenting with AUB over the period Jan 2013- Dec.2015, in Department of Pathology, Ashwini rural medical college and research centre, Kumbhari, Tq. South Solapur, in Western Maharashtra(India). The histopathological findings of AUB were categorized into functional and organic causes. A detailed histological study was carried out and the findings were noted. A statistical analysis between age of presentation and a specific endometrial cause was done using chi-square test. Results: The most common age group presenting with AUB was 41- 50 yrs (42%). Mean age for women presented with AUB was 44.2 years. The commonest pattern in these patients was normal cyclical endometrium (33.9%): Proliferative and secretory phase. The commonest pathology was endometrial hyperplasia (22.2%). Other causes identified were disordered proliferative endometrium(13.7%), atrophic endometrium(13.2%), benign endometrial polyp(8%), deficient secretory phase(3.3%), chronic endometritis(2.4%), and endometrial carcinoma(2.3%). It has been observed that, there was highly significant association between age group and histopathological diagnosis (p

Working out and inculcation organizing measures of accreditation of Health. Care primary units institutions activity — rural medical centers (RMC)

The developed system of self — estimation of therapeutic-prophylactic institutions can be used for any type level of Healthcare institutions, as it gives the opportunity to motivate the process of medical help administration, to receive objective marks based on the facts and it is directed to increase in formativeness of the institutions of Healthcare on existing problems, demanding the solutions.

Evaluation of patronage nurse at rural medical centre

The system of evaluation quality and effectiveness of medical care must functionate constantly, that allows to get operatively the necessary information for control. By that the main factor of turning from quality evaluation and effectiveness to their increase is education and constantly improvement knowledge and skills of personnel. The disciplinary measuresor punishments are extreme measures and little effective means of improvement quality for medical care.

English

INTRODUCTION: OBJECTIVES: 1) To study maternal and fetal outcome among obstetric patients with deranged liver function tests. 2) To study the relationship between type of liver disease based on etiology and maternal and fetal outcome METHODS: 3 years prospective and retrospective study was carried out from Jan 2011 to Jan 2014 at rural medical Centre. 40 cases of pregnancy with deranged liver function tests were analyzed for incidence, maternal and fetal outcome. RESULTS: 1) Incidence of liver disease during pregnancy was 1.6%.in our study. 2) Majority of causes of jaundice were pregnancy specific. 3) Common causes of deranged liver function tests in the pregnancy were pregnancy induced hypertension with HELLP syndrome (37%), acute fatty liver of pregnancy (37%) and viral hepatitis (20%). 4) Overall maternal and perinatal mortality found in our study were 17.5% and 35% respectively. 5) Majority cases of HELLP & acute fatty liver of pregnancy were young primes (20-30years) at 32-34 weeks of gestation. 5) All cases of HELLP were associated with pregnancy induced hypertension. 6) Disseminated intravascular coagulation was most common morbidity. 8) 14 cases (56%). 7) Maternal mortality was highest 35% in acute fatty liver of pregnancy which reduces to 18% if unbooked cases with uncorrected disseminated intravascular coagulation are excluded. 8) Perinatal mortality was highest with HELLP syndrome (50%). CONCLUSION: 1) Majority of causes of deranged liver function tests during 3rd trimester were pregnancy induced. 2) Maternal and fetal outcome depends on gestational age of presentation, early recognition of the disease and tertiary care support.