Tertiary Care Setting Research Articles

Pattern of Healthcare-Associated Infections in a Tertiary Care Setting

Pattern of Healthcare-Associated Infections in a Tertiary Care Setting

The bacterial profile and antibiotic susceptibility in skin and soft tissue infections at a tertiary care hospital of Quetta, Pakistan.

To determine the bacterial profile and antibiotic susceptibility in skin and soft tissue infections among patients in a tertiary care setting. The cross-sectional cohort study was conducted at the Centre for Advanced Studies in Vaccinology and Biotechnology, University of Balochistan, Quetta, Pakistan, from June 2021 to May 2022, and comprised bacteriainfected skin samples that were collected from the Bolan Medical Complex Hospital, Quetta, and the Sandeman Provincial Hospital, Quetta. The swab samples were immediately cultured, and positive samples were evaluated for biochemical tests, antibiotic susceptibility test and polymerase chain reaction. Data was analysed using SPSS 22. Of the 800 samples, 598(74.7%) tested positive for pathogenic bacteria. Staphylococcus aureus accounted for 316(39.5%) infections, followed by clostridium perfringens 18.96(2.37%), escherichia coli 120(15.12%), pseudomonas aeruginosa 98(12.25%) and klebsiella pneumoniae 44(5.5%). Among all the infected samples, 380(47.5%) belonged to males, 218(27.25%) to patients aged 5-20 years, 448(56%) to the uneducated subjects, and 462(57.87%) to patients having lower socioeconomic status. Pseudomonas aeruginosa showed the highest level of resistance against all antibiotics. Regular surveillance and proper use of antibiotics should be encouraged in hospitals to limit the spread of antibiotic resistance against pathogenic bacteria.

High comorbidity burden and low incidence of adverse events in primary shoulder arthroplasty in tertiary care at a university hospital

BackgroundReducing perioperative risk is in the focus of primary arthroplasty caregivers. Primary shoulder arthroplasty patients are considered among those with the lowest perioperative risk. Nonetheless, in tertiary care centres and university settings patients with significant comorbidities are being treated. It remains unclear whether the overall comorbidity burden is truly higher and if this results in an increased frequency of adverse events (AE). As a result, we conducted a study to assess the comorbidity burden and the frequency of major perioperative adverse events and predictive factors following primary shoulder arthroplasty in the university setting. MethodsA retrospective cohort analysis was conducted on patients undergoing primary shoulder arthroplasty for a non-trauma, non-tumour indication from January 1st, 2014 through December 31st, 2018. Administrative data were recorded to assess comorbidity burden and revision surgery within the first postoperative year. Major adverse events were routinely recorded on a weekly basis by the treating physicians. Descriptive and comparative statistical analyses were performed. The cohort was compared against a large North American sample. ResultsOf 386 patients who underwent 400 primary shoulder arthroplasties 14 (3.5 %) experienced adverse events. While AE were distributed equally among anatomical and reverse shoulder arthroplasties, no adverse event was recorded in the 34 hemiarthroplasty patients. The cohort showed an increased comorbidity burden in international comparison. Peptic ulcer disease was significantly associated with AE, while mild liver disease experienced a trend towards AE. ConclusionWe found an increased comorbidity burden and a low rate of AE for primary shoulder arthroplasty in a tertiary care and university setting. The distinct role of peptic ulcer disease in this cohort and the trend in mild liver disease merit further investigation in larger samples. The findings underscore the importance of perioperative risk assessment and management. Level of evidenceIII, retrospective cohort study.

Prevalence and impact of diabetes and prediabetes on presentation and complications of primary hyperaldosteronism at diagnosis

BACKGROUND Primary hyperaldosteronism (PH) is considered to contribute to increased risk of developing type 2 diabetes mellitus (T2DM) and prediabetes. Both PH and DM are associated with increased risk for hypertension, cardiovascular diseases, and chronic kidney diseases. However, data on prevalence of T2DM and prediabetes in PH, and impact of T2DM and prediabetes on presentation and cardio renal complications in PH at presentation is sparse. AIM To determine the prevalence of T2DM and prediabetes in PH at diagnosis and impact on presentation and complications of PH. METHODS A retrospective cohort study was conducted in tertiary care settings in individuals with confirmed diagnosis of PH at presentation. Demographic variables, clinical presentations, duration and degree of hypertension, complications, laboratory parameters including sodium, potassium levels, plasma aldosterone concentration (PAC), plasma renin activity (PRA), and aldosterone to renin ratio (ARR) and cardio-renal parameters were collected. Comparison was done between three groups: PH with no DM (Group A) or with pre-diabetes (Group B) or with T2DM (Group C). P < 0.05 was statistically significant. RESULTS Among 78 individuals with confirmed PH, 62% had pre-diabetes or diabetes; with 37% having DM. Mean duration of T2DM was 5.97 ± 4.7 years. The mean levels of glycaemic parameters among the group A vs B vs C individuals were fasting plasma glucose (mg/dL): 87.9 ± 6.5, 105.4 ± 9.02, 130.6 ± 21.1; post prandial plasma glucose (mg/dL): 122.7 ± 9.8, 154.9 ± 14, 196.7 ± 38.0; glycated haemoglobin (%) (5.3 ± 0.2, 5.9 ± 0.2, 7.5 ± 0.6, P < 0.05 ), respectively. There was no significant difference in the biochemical parameters (PAC, PRA, ARR, sodium, potassium levels), presentation and complications between the groups. Cardio renal parameters or degree and duration of hypertension were comparable between the groups. CONCLUSION Significant prevalence of T2DM and prediabetes in PH at diagnosis does not impact its presentation or complications. Early screening for undetected PH in T2DM and prediabetes subjects with hypertension may prevent complications.

Association between gallstone disease and carotid intima-media thickness: a prospective observational cross-sectional study in a tertiary care center.

Gallstone disease (GD) is a prevalent health issue globally, particularly in developed nations, and has notable associations with cardiovascular disease (CVD). This prospective observational cross-sectional study aimed to investigate the association between gallstone disease and carotid intima-media thickness (CIMT), a marker of carotid atherosclerosis, in a tertiary care setting. Conducted at a tertiary care center, the study included 96 participants (48 with gallstone disease and 48 age and sex-matched controls). Data collection involved demographic information, BMI calculation, abdominal ultrasonography for gallstone detection, and carotid ultrasonography for CIMT measurement. Statistical analysis was performed using SPSS version 26. The study revealed higher CIMT values in GD patients compared to controls (P<0.001). Additionally, a positive correlation was observed between CIMT and age (r=0.450, P<0.001) and BMI (r=0.550, P<0.001). The Cohen's d-test indicated a clinically significant difference in CIMT between GD patients and controls (d=1.47). This study revealed a significant association between gallstone disease and elevated CIMT, correlating with higher BMI indicating a potential link between gallstone disease and increased risk of carotid atherosclerosis. These findings highlight the importance of assessing cardiovascular risk in patients with gallstone disease, highlighting the potential utility of carotid ultrasonography as a non-invasive screening tool. Early intervention strategies may be warranted to mitigate cardiovascular risks associated with gallstone disease.

Prevalence of Premalignant Conditions and Their Transformation Into Oral Cancers: A Clinical Study.

The purpose of this study is to look at how often premalignant oral diseases are among patients who visit a tertiary care center, as well as how often these problems progress to become mouth malignancies. Between 2017 and 2022, 200 patients at a tertiary care facility who were identified with premalignant oral lesions had their medical records retrospectively examined. Information on lesion features, histological results, and demographics was gathered. Statistical analysis was used to determine the prevalence of premalignant oral lesions and the rate at which these lesions turned into oral malignancies, with a significance threshold of P < 0.05. The research population's mean age was 55 years (SD ± 10), with a 65% male preponderance. The most prevalent premalignant lesions were leukoplakia (45%), erythroplakia (30%), and oral submucous fibrosis (25%). Remarkably, during follow-up, 40% of patients showed development of premalignant lesions into mouth malignancies. Based on statistical analysis, there were significant correlations (P < 0.05) between dysplastic alterations, age, tobacco use, and the development of oral malignancies from premalignant lesions. In conclusion, this study highlights the need of early diagnosis and focused therapies in tertiary care settings by offering important insights into the occurrence and evolution of premalignant oral lesions. The results provide important information that may be used to create screening programs and preventive measures that will lessen the incidence of oral cancer.

Characterization of Clinical Presentation, Etiology, and Antibiotic Sensitivity Patterns in Neonatal Septicemia: A Comprehensive Analysis of Bacterial Isolates.

Neonatal septicemia remains a significant healthcare challenge, particularly in resource-limited settings, with both early-onset neonatal septicemia (EONS) and late-onset neonatal septicemia (LONS) presentations contributing to morbidity and mortality. This study aimed to characterize the clinico-etiological profile and antibiotic susceptibility patterns of neonatal septicemia in a tertiary care setting in north India. An analytical cross-sectional study was conducted from March 2021 to February 2022, encompassing neonates admitted to the Department of Pediatrics with suspected neonatal septicemia, confirmed by positive blood cultures. A total of 96 neonates were included, predominantly male (71.9%). Gram-negative bacteria constituted 61.6% of isolates, and the most common organism isolated was non-lactose fermenter group (38.4%) followed by coagulase-negative staphylococci (CoNS) (33.4%). Non-lactose fermenter group bacteria were prominent in EONS cases (44.6%), while CoNS predominated in LONS cases (51.6%). Birthplace, birth weight, and perinatal score were significantly associated with both EONS and LONS. Linezolid exhibited high efficacy against gram-positive bacteria, while ciprofloxacin and meropenem demonstrated effectiveness against various gram-negative pathogens. Methicillin-resistant Staphylococcus aureus (MRSA) strains exhibited resistance to all the antibiotics used in the study except for linezolid. These findings underscore the importance of tailored empirical therapy guided by local epidemiological data to optimize clinical outcomes and mitigate antimicrobial resistance.

Arthro-distension with early and intensive mobilization for shoulder adhesive capsulitis: A randomized controlled trial

BackgroundThere are several therapeutic options for the management of shoulder adhesive capsulitis (AC). The superiority of arthro-distension over intra-articular steroid injection (ISI) for AC remains controversial. ObjectivesTo evaluate the efficacy of a single arthro-distension procedure combined with early and intensive mobilization (ADM) and physiotherapy, versus ISI and physiotherapy, in people with AC lasting ≥3 months. MethodsThis was a prospective, 2 parallel-group, 2-center, observer-blind randomized controlled trial conducted in tertiary care settings. Adults with AC were randomly assigned to the treatment or control group. Efficacy was assessed using the self-administered Shoulder Pain and Disability Index (SPADI). Total, pain and disability SPADI scores 15 days, 6 weeks, and 3, 6 and 12 months after the procedure (total SPADI at 15 days: primary outcome; other outcomes were secondary) were compared between groups using analysis of covariance (ANCOVA). A post hoc analysis stratified on the initial range of passive glenohumeral abduction, which had not been pre-specified, was conducted. ResultsThere were 33 participants in each group. Both groups improved over time. Mean (SD) total SPADI score at 15 days was 33.8 (19.6) in the treatment group and 32.8 (17.5) in the control group, p = 0.393. There were no significant differences for any variables in the overall sample. The post hoc analysis found ADM to be associated with a significant decrease in total SPADI score at 15 days compared with ISI (p = 0.049) in individuals with initial passive glenohumeral abduction >45°. ConclusionsThe effects of ADM on pain and function were not statistically different from those of ISI. However, ADM may be useful in individuals with initial passive glenohumeral abduction >45°. Database registrationNCT00724113.

An Analogy between Gold Standard SARS-CoV-2 RT-qPCR with the SARS-CoV-2 Rapid Antigen Test in a Tertiary Care Setting in Central State of India

Reverse transcription-quantitative PCR (RT-qPCR)-based assays are extensively being utilized to detect coronavirus disease 2019 (COVID-19). However, due to a lack of RT-qPCR testing capability, these tests cannot be carried out in community clinics. The intention of our study was to evaluate the specificity and sensitivity of Rapid Antigen Detection (RAT) tests versus those of RT-qPCR using nasopharyngeal and oropharyngeal specimens. Respiratory swab specimens were collected from the COVID-19 patients admitted at Dr. Bhimrao Ambedkar Memorial Hospital, Raipur, CG, India, during March to April 2022. RAT and RT-qPCR were performed using standard methods as per guidebook instructions, and subjects were chosen using a convenience sample technique. 100 swabs from patients, who had earlier verified positive and 100 from who had earlier verified negative for SARS-CoV-2 via RT-qPCR, were taken for study. Study was approved by the institutional ethical committee before data collection and initiation of the study. We evaluated for the sensitivity and specificity of the STANDARD Q COVID-19 Ag test kit (SD Biosensor). On testing, an over-all sensitivity and specificity of the kit was recorded as 74% and 100%, respectively in comparison to the RT-qPCR kit. Further, the assay’s sensitivity was shown to be 100%, 94.87%, 77.27%, and 55.56%, respectively, for samples with cycle thresholds (Ct) of 15-25, 25-30, 30-35, and &gt;35. We draw the conclusion that the RT-qPCR assay has superior sensitivity and specificity to the antigen assay. However, in all situations where RT-qPCR testing is difficult, the antigen assay could serve as a rapid and simple option for separating SARS-CoV-2 contagious from non-contagious patients.

Assessment of Adequate Blood Culture Incubation Time to Accentuate Clinically Relevant Results from Blood Culture Instrument and Media System in a Tertiary Care Hospital Lahore

Background: Bloodstream infections necessitate rapid identification and management. Automated blood culture systems have revolutionized diagnostic microbiology by expediting pathogen detection and enabling effective clinical interventions. This study assesses the optimal incubation period for blood cultures in a tertiary healthcare setting, aiming to enhance diagnostic accuracy and support antibiotic stewardship. Objective: To evaluate the adequacy of incubation times in blood cultures for producing clinically significant results using an automated system in a tertiary care setting. Methods: This cross-sectional descriptive study was conducted at the Microbiology Section of Combined Military Hospital, Lahore, from October 2022 to March 2023. All patient blood samples processed through the Bactec/Alert system were studied. Positive samples were cultured on Blood and MacConkey agar and incubated at 35 ± 2°C for 24 hours. Positivity rates, contamination, and patient demographics were analyzed using the Laboratory Information Management System. Results: Of the 8,216 blood culture bottles processed, 490 (5.96%) were flagged as positive. Early detection within the first 24 hours was noted in 41.63% (n=204) of cases, with subsequent detections on the second day at 58.65% (n=258), the third day at 5.30% (n=26), and the fourth day at 0.20% (n=1). The isolated pathogens included gram-positive organisms (16.32%, n=80), gram-negative organisms (80.20%, n=393), and Candida spp. (3.46%, n=17). Conclusion: Timely and effective blood culturing is crucial for the diagnostic confirmation of bacteremia, enabling appropriate pathogen identification and antimicrobial therapy. Shortening detection times can significantly impact clinical outcomes, reduce healthcare costs, and promote antimicrobial stewardship.

Barriers to medical consultation and strategies for enhancing the prevention and reporting of child abuse: A cross-sectional survey of caregivers of paediatric patients at a tertiary care center in Karachi, Pakistan.

To assess the knowledge of caregivers in a tertiary care setting about child abuse, their perception of potential barriers in the way of seeking medical advice for the victims, and to identify proposed solutions to ensure prevention and reporting of child abuse. The cross-sectional study was conducted from June to December 2022 at the paediatric ward of the Aga Khan University Hospital, Karachi, and comprised caregivers who were attendants of inpatients. Data was collected using a predesigned anonymous questionnaire consisting of demographic information and 27 items that were scored on a 6-point Likert scale. Data was analysed using SPSS 20. Of the 144 caregivers, 96(66.6%) were females and 48(33.3%) were males. Overall, 86(59.7%) were aged <35 years, 132(91.7%) were married, and 120(83.3%) were the admitted child's parent. The majority of caregivers 110(76.4%) perceived themselves to possess a high level of knowledge about child abuse. Barriers identified included a lack of trust in police and medicolegal departments 136(94.4%), fear of repercussion from the suspect 120(83.3%) and lack of confidentiality of the victims' identity 116(80.6%). The proposed solutions included spreading awareness among teachers 136(94.4%) and caregivers 131(91.0%) about timely reporting and consultation, and developing proper mechanisms to follow-up on victims 133(92.4%). There were significant associations between some demographic characteristics of the respondents and their self-perceived knowledge and perceptions (p<0.05). There was found a need to enhance public trust, ensure confidentiality, and fostering awareness through targeted strategies for a safer and more facilitative environment for children.

Diagnostic characteristics and management outcome in patients with acromegaly: a 15-year experience at a tertiary care hospital in Pakistan

Objectives: To assess the diagnostic features of acromegaly, and analyse its management outcomes over a 15-year period in a tertiary care setting. Method: The descriptive, cohort, retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of adult patients of either gender diagnosed with acromegaly based on biochemical and radiological evidence between January 2005 and December 2019. Data was retrieved from the medical records. Data was analysed using SPSS 19. Results: Of the 84 subjects, 54(64.3%) were males and 30(35.7%) were female. The overall mean age was 38.69±13.52 years. The patients presented 5.43±4.3 years after the onset of symptoms, with somatic growth features, such as enlarged hands and feet which was the most common complaint 81(96.4%). Of all the patients, 73(86.9%) underwent trans-sphenoidal surgery for the removal of the pituitary adenoma, while 11(13.1%) opted out of the surgical option. Further, 9(12.3%) patients showed biochemical and radiological remission 6 months post-surgery. Out of the remaining 64(87.7%) patients, 38(59.4%) received radiosurgery or radiotherapy, 15(23.4%) underwent repeat trans-sphenoidal surgery, and 11(17.2%) chose medical treatment. Conclusion: Majority of patients failed to achieve remission after trans-sphenoidal surgery, which is the first line of treatment. Radiotherapy/repeat surgery was generally the options taken by those with persistent disease. Key Words: Acromegaly, Characteristics, Diagnosis, Management, Outcome, Pituitary tumour, Growth hormone.

Outcomes of dorsal nasal augmentation using costochondral graft.

To assess functional and aesthetic outcomes in patients having undergone dorsal nasal augmentation with costochondral graft in a tertiary care setting. The single-centre, retrospective, observational study was conducted at Shifa International Hospital, Islamabad, Pakistan, and comprised data of patients who underwent dorsal nasal augmentation using costochondral graft between January 1, 2018, and December 31, 2022. Aesthetic outcomes in terms of patient satisfaction were assessed using Facial Appearance, Health-related Quality of Life and Adverse Effects scores. Data was analysed using SPSS 26. Of the 46 patients, 28(61%) were males and 18(39%) were females. The overall mean age was 28.39±9.13 years. Dorsal nasal deficiency occurred secondary to congenital causes in 12(26.1%) patients, trauma 19(41.3%) and prior surgery 15(32.6%). Postoperative complication rate was 7(15%); 3(6.5%) had recipient site infection and 2(4.3%) had rib graft resorption. Besides, 1(2.2%) patient reported pain 2 months postoperatively and 1(2.2%) had hypertrophic scarring. Patient satisfaction with the outcome was noted in all the 10 parameters analysed. Most commonly reported problem was that the nose was 'looking thick/swollen' by 12(26.1%) patients, but the issue resolved during 1-year follow-up. Costochondral graft was found to be an ideal material for dorsal nasal augmentation, with high patient satisfaction rate.

Outcomes of dorsal nasal augmentation using costochondral graft

Objective: To assess functional and aesthetic outcomes in patients having undergone dorsal nasal augmentation with costochondral graft in a tertiary care setting. Method: The single-centre, retrospective, observational study was conducted at Shifa International Hospital, Islamabad, Pakistan, and comprised data of patients who underwent dorsal nasal augmentation using costochondral graft between January 1, 2018, and December 31, 2022. Aesthetic outcomes in terms of patient satisfaction were assessed using Facial Appearance, Health-related Quality of Life and Adverse Effects scores. Data was analysed using SPSS 26. Results: Of the 46 patients, 28(61%) were males and 18(39%) were females. The overall mean age was 28.39+9.13 years. Dorsal nasal deficiency occurred secondary to congenital causes in 12(26.1%) patients, trauma 19(41.3%) and prior surgery 15(32.6%). Postoperative complication rate was 7(15%); 3(6.5%) had recipient site infection and 2(4.3%) had rib graft resorption. Besides, 1(2.2%) patient reported pain 2 months postoperatively and 1(2.2%) had hypertrophic scarring. Patient satisfaction with the outcome was noted in all the 10 parameters analysed. Most commonly reported problem was that the nose was ‘looking thick/swollen’ by 12(26.1%) patients, but the issue resolved during 1-year follow-up. Conclusion: Costochondral graft was found to be an ideal material for dorsal nasal augmentation, with high patient satisfaction rate. Key Words: Costal cartilage, Patient satisfaction, Rhinoplasty.

Effect of Incubation Time on Zone Size of Antimicrobials by Disk Diffusion Method for Pseudomonas Aeruginosa

Background: Pseudomonas aeruginosa is a prominent pathogen in healthcare settings, notorious for its rapid development of resistance to multiple antimicrobial agents. Effective susceptibility testing is critical for managing infections caused by this bacterium. This study investigates the impact of varying incubation times on the efficacy of the disk diffusion method. Objective: To evaluate the influence of incubation time on the zone sizes of antimicrobials against Pseudomonas aeruginosa using the disk diffusion method in a tertiary care setting. Methods: Conducted at the Microbiology Department of Combined Military Hospital, Lahore, from October 2022 to March 2023, this descriptive study included 71 clinical isolates of Pseudomonas aeruginosa. Samples were inoculated on Mueller Hinton Agar and incubated at 35°C ±2°C for 6, 10, and 24 hours. Antimicrobial susceptibility was tested using a panel of clinically relevant antibiotics in triplicate, with zone sizes interpreted according to Clinical and Laboratory Standards Institute guidelines. Results: Among the isolates, 59.15% were from males and 40.85% from females. The most affected age group was 15-60 years, comprising 59.52% of cases. Antimicrobial response varied with incubation times: Ceftazidime, Piperacillin-Tazobactam, and Cefepime showed increased zone sizes over time, while Tobramycin’s zones steadily enlarged. Colistin consistently produced the largest zones at all time points. Conclusion: The study highlights the significance of incubation time in disk diffusion testing for Pseudomonas aeruginosa. Adjusting incubation times can expedite results without incurring additional costs, enhancing the efficiency of antimicrobial susceptibility testing in clinical settings.

Antibiotic Susceptibility Profiling of Gram-Positive and Gram-Negative Bacterial Isolates in a Tertiary Care Hospital: Establishment of an Antibiogram.

Introduction Antimicrobial resistance poses a significant global healthcare challenge in the management of bacterial infections, which is frequently attributed to rapid bacterial adaptations. This study aims to develop an antibiogram for a tertiary care hospital, providing comprehensive antibiotic sensitivity profiles for Gram-positive and Gram-negative bacteria. It informs healthcare providers of antibiotic resistance trends, enabling informed treatment decisions and enhanced infection control measures. Methods We conducted a six-month prospective observational study, during which we gathered and analyzed data from the microbiology laboratory to identify patterns of antimicrobial sensitivity. Subsequently, the data underwent analysis and interpretation using the respected WHONET software, a readily available tool designed for this specific task. Our methodology adhered to the guidelines established by the Clinical & Laboratory Standards Institute for the standardization of antibiogram generation procedures, and these guidelines are easily integrated into the WHONET software for analytical purposes. Results There were a total of 357 isolates across various hospital departments, comprising 13 distinct bacterial species. Among them, nine were identified as Gram-negative bacteria, accounting for 262 (73.3%) isolates. Escherichia coli accounted for 131 (36.6%) isolates, while Klebsiella accounted for 62 (17.3%), emerging as the predominant species among them. The remaining four bacterial species were identified as Gram-positive bacteria, totaling 95 (26.6%) isolates, with Staphylococcus aureus being the most frequently isolated species at 51 (14.2%), followed by Enterococcus at 26 (7.2%). Subsequent analysis using the WHONET software facilitated the creation of an antibiogram. Among the Gram-negative bacteria, E. coli displayed high sensitivity (100%) to aztreonam and clindamycin, followed by nitrofurantoin (98%), imipenem (94%), and meropenem (95%). However, it exhibited decreased sensitivity to ampicillin (25%), cefuroxime (34%), and ceftriaxone (39%). Conversely, among the Gram-positive bacteria, S. aureus demonstrated 100% sensitivity to ampicillin, amoxiclav, cefazolin, teicoplanin, linezolid, rifampicin, nitrofurantoin, and cefotaxime. However, it exhibited zero sensitivity to vancomycin and only 6% sensitivity to cotrimoxazole. Conclusion This study advances the understanding of antibiotic susceptibility in a tertiary care setting and provides an invaluable tool for optimizing treatment strategies, enhancing infection control measures, and combating antibiotic resistance.

Antimicrobial Resistance and Associated Risk Factors for Clostridium difficile in Patients Attending Tertiary Care Settings.

To determine the incidence of antimicrobial-resistant emerging pathogens, Clostridium difficile, and its associated risk factors in tertiary care setups of Pakistan. This cross-sectional prospective study was conducted from January 2019 to December 2020, to determine the prevalence and antimicrobial resistance patterns of C. difficile strains isolated from 450 stool specimens of patients suffering from diarrhea hospitalized in tertiary care hospitals in Peshawar, Pakistan. The stool samples of the patients were processed for culture and detection of toxin A and toxin B by enzyme-linked immunosorbent assay (ELISA) and tpi PCR. The drug sensitivity test was performed for antibiotics including ampicillin, cefixime, cefepime, amoxicillin, nalidixic acid, sulpha/TMP (SXT), chloramphenicol, metronidazole, vancomycin, ciprofloxacin, levofloxacin, and imipenem. Of 450 stool specimens, 108 (24%) were positive for C. difficile by stool culture, whereas 115 (25.5%) were only positive for C. difficile toxins based on ELISA and PCR (128 (28.6%). Of 108, 90.7% (n = 98) isolates were resistant to one antibiotic, and 90 (83.4%) were resistant to three or more antimicrobials. The highest resistance rates were found against penicillin (83.3%) followed by amoxicillin (70%), nalidixic acid (61%), and metronidazole (38%), and the lowest resistance was found against vancomycin (6.4%) and imipenem (3.7%). CDI was statistically significantly correlated with increased age, use of antibiotics, abdominal surgeries, use of proton pump inhibitors and H2a, and presence of comorbidities. The high frequency of C. difficile in Peshawar, Pakistan, indicates that CDI is an important nosocomial infection in different hospitals. The results will be helpful for clinicians to redesign control and therapeutic strategies in hospitals.

999 telephone triage: a comparison of UK ambulance nurse and paramedic case mix, outcomes and audit compliance

PurposeMost UK ambulance services undertake remote assessments of 999 calls with nurses and paramedics to manage demand and reduce inappropriate hospital admissions. However, little is known about the differences in the types of cases managed by the two professions comparatively, their clinical outcomes, and the quality and safety they offer.Design/methodology/approachThe retrospective descriptive study analysed data collected at Welsh Ambulance Services University NHS Trust (WAST) from prioritisation, triage, and audit tools between the 17th May 2022 to 8th November 2022. A total of 21,076 cases and 728 audits were included for review.FindingsThere was little difference in the type and frequency of the presenting complaints assessed, and clinical outcomes reached in percentage terms. Whilst paramedics had more highly compliant call audits and fewer non-compliant call audits, there was, again, little difference in percentage terms between the two, indicating positive levels of safety across the two professional groups.Research limitations/implicationsThere continues to be a substantial difference between UK paramedics to those in the Middle East, the United States, and some African nations, which may limit the applicability of findings. This study also looked at a six-month window from only one UK service using one type of prioritisation and triage tool. Future research could explore longer periods from multiple services using various tools. It is important to note that this study did not link outcome data with primary, secondary or tertiary care settings. Thus, it is impossible to determine if the level of care aligned closely with the final diagnosis.Practical implicationsThe practical implications of this work include better workforce planning for agencies who have perhaps only employed one type of clinician or a reaffirmation to those who have employed both. The authors suggest that the training and education of both sets of clinicians could remain general in nature, with no overt requirement for specificity based on professional registration alone. Commissioners and stakeholders in the wider health economy should consider ensuring equitable access to alternative pathways for patients assessed by both nurses and paramedics.Social implicationsIt has been posited that UK nurses and paramedics are, by virtue of their consistency in education, skill set, licensure, and general experience, both able to achieve safe and effective remote outcomes in 999 settings. This study provides evidence to support that hypothesis. These results say more about the two professions' ability to work together rather than just the professions themselves. The multidisciplinary team approach is well-established in acute care settings, and is broadly considered to improve communication, coordination decision making, adherence to up-to-date treatment recommendations, and be positive for shared learning and development for younger colleagues.Originality/valueMost UK services use a mix of nurses and paramedics; however, little is known about the differences in the types of cases managed by the two professions comparatively, their clinical outcomes, and the quality and safety they each offer. The most recent studies of this nature were published in 2003 and 2004 and looked only at low-acuity 999 calls when remote assessment was not even an established role for UK paramedics. This study updates the literature, identifies areas for future research, and applies to the international setting for the most part.

Exploring the Multifactorial Landscape: Risk Factors for Dementia in a Tertiary Care Setting in Thailand.

Dementia poses a significant public health challenge worldwide, necessitating a deeper understanding of its risk factors to inform preventive strategies. This retrospective longitudinal study leveraged clinical data from a tertiary care database to investigate the risk factors associated with an incident dementia diagnosis. The study cohort comprised individuals aged 50 years and older. Key variables including age, income, comorbidities such as depressive disorder, osteoporosis, stroke, and metabolic conditions like type 2 diabetes and hypertension were analyzed by using Cox regression analysis. The study cohort included 127,016 adults 50 years and older. The results revealed that advancing age, with individuals aged 70-79 years having ahazard ratio (HR) of 3.9 (95% confidence interval (CI), 2.6-5.8), and those aged 80 years and above having an HR of 11.6 (95% CI, 7.7-17.3), lower income status (patients with no income or occupation had a notably higher risk of dementia diagnosis, with an HR of 2.0 (95% CI, 1.4-2.8)), depressive disorder (HR of 3.3 (95% CI, 3.3-3.7)), osteoporosis (HR of 1.2 (95% CI, 1.1-1.4)), and stroke (HR of 2.5 (95% CI, 2.3-2.7)) were significantly associated with an increased risk of incident dementia. However, no significant associations were observed for type 2 diabetes, hypertension, obesity, or underweight status managed in tertiary care. The findings underscore the importance of considering a wide range of factors in understanding dementia risk and highlight the potential utility of routinely collected clinical data for comprehensive risk assessment. Further investigation into additional variables and multi-center studies may provide deeper insights into the complex interplay of risk factors contributing to dementia onset.

Validation of postnatal growth and retinopathy of prematurity (G-ROP) screening guidelines in a tertiary care hospital of Pakistan: A report from low-middle income country.

Retinopathy of Prematurity (ROP) significantly contributes to childhood blindness globally, with a disproportionately high burden in low- and middle-income countries (LMICs) due to improved neonatal care alongside inadequate ROP screening and treatment facilities. This study aims to validate the performance of Postnatal Growth and Retinopathy of Prematurity (G-ROP) screening criteria in a cohort of premature infants presenting at a tertiary care setting in Pakistan. This cross-sectional study utilized retrospective chart review of neonates admitted to the neonatal intensive care unit (NICU) at The Aga Khan University Hospital, Pakistan from January 2018 to February 2022. The complete G-ROP criteria were applied as prediction tool for infants with type 1 ROP, type 2 ROP, and no ROP outcomes. Out of the 166 cases, 125 cases were included in the final analysis, and remaining cases were excluded due to incomplete data. ROP of any stage developed in 83 infants (66.4%), of whom 55 (44%) developed type 1 ROP, 28 (22.4%) developed type 2 ROP, and 19 (15.2%) were treated for ROP. The median BW was 1060 gm (IQR = 910 to 1240 gm) and the median gestational age was 29 wk (IQR = 27 to 30 wk). The G-ROP criteria demonstrated a sensitivity of 98.18% (95% CI: 90.28-99.95%) for triggering an alarm for type 1 ROP. The G-ROP criteria achieved 100% sensitivity (95% CI: 87.66 to 100%) for type 2 ROP. The overall sensitivity of G-ROP criteria to trigger an alarm for any type of ROP was 98.8% (95% CI: 93.47 to 99.97%). Thus, the G-ROP screening model is highly sensitive in detecting at-risk infants for ROP in a Pakistani tertiary care setting, supporting its use in LMICs where standard screening criteria may not suffice.