Tertiary Referral Hospital Research Articles

Association of LVV-Hemorphin-7 with Sepsis and Shock: Roles of Cathepsin D and G in Hemoglobin Metabolism in a Prospective ICU Cohort Study

Background: Sepsis is a leading cause of mortality in intensive care units (ICUs). Cell-free hemoglobin (CFH) released during sepsis interacts with lysosomal enzymes from neutrophils and macrophages. This study aims to examine the association of LVV-hemorphin-7 (LVV-H7), cathepsin D, and cathepsin G with sepsis and shock in ICU patients. Methods: A prospective observational cohort study was conducted in the medical ICU of a tertiary referral hospital in Taiwan. The patients with an acute increasing sequential organ failure assessment (SOFA) score ≥ 2 between 2022 and 2023. Blood samples from 40 healthy controls were obtained from the hospital biobank. CFH metabolites, including LVV-H7 and lysosomal enzyme cathepsin D and cathepsin G, were compared between the sepsis (definite and probable) and non-sepsis (possible sepsis) groups. Multivariate logistic regression analyzed factors associated with sepsis and shock. Results: Among 120 patients, 75 were classified as septic and 45 as non-septic. Significant differences were observed in CFH, cathepsin D, cathepsin G, and LVV-H7 levels between sepsis and non-sepsis groups. LVV-H7 was a significant predictor for sepsis (adjusted OR [aOR] 1.009, 95% CI 1.005–1.013; p < 0.001) and shock (aOR 1.005, 95% CI 1.002–1.008; p < 0.05). Cathepsin G predicted non-shock (aOR 0.917, 95% CI 0.848–0.991; p < 0.05), while cathepsin D predicted septic shock (aOR 1.001, 95% CI 1.000–1.002; p < 0.05). Conclusions: LVV-H7, cathepsin D, and cathepsin G are associated with the classification of sepsis and shock episodes in critically ill patients with elevated SOFA scores.

Mass-forming intrahepatic cholangiocarcinoma: treatment outcomes after curative-intent resection in an Australian tertiary referral hospital.

Mass-forming intrahepatic cholangiocarcinoma (MF-ICC) is the second most common primary liver cancer and liver resection offers the best chance of possible cure. This study aimed to assess treatment outcomes and prognostic factors for long-term survival in patients who underwent curative-intent liver resection. A retrospective analysis was conducted on prospectively collected data from patients with MF-ICC managed at the Royal North Shore/North Shore Private Hospital from January 1998 to October 2023. Baseline, peri-operative and long-term outcomes have been analysed, including an overall survival (OS) and disease-free survival (DFS) analysis. During the 25-year study period, 47 patients underwent curative-intent liver resection for primary MF-ICC at a median age of 70 years. The median OS was 36 months, with a 5-year OS of 33%. Multiple liver tumours (HR = 2.84; 95% CI = 1.24-6.48; P = 0.013) and a positive resection margin (HR = 2.46; 95% CI = 1.10-5.52; P = 0.029) were identified as independent predictors of poor long-term OS. Recurrence occurred in 62% of patients after a median DFS of 16 months, with poor tumour differentiation (HR = 3.93; 95% CI = 1.62-9.54; P = 0.002) and elevated tumour markers (HR = 3.47; 95% CI = 1.53-7.87; P = 0.003) as independent predictors of poor DFS. Liver resection can offer a significant chance for prolonged survival in a highly selected population of patients with MF-ICC. However, the surgical challenges inherent in treating this rare disease are evident, emphasizing the need for a multimodal approach and continued exploration of additional therapies to enhance personalized treatment strategies.

Development and validation of the MRI-based deep learning classifier for distinguishing perianal fistulizing Crohn’s disease from cryptoglandular fistula: a multicenter cohort study

A singular reliable modality for early distinguishing perianal fistulizing Crohn's disease (PFCD) from cryptoglandular fistula (CGF) is currently lacking. We aimed to develop and validate an MRI-based deep learning classifier to effectively discriminate between them. The present study retrospectively enrolled 1054 patients with PFCD or CGF from three Chinese tertiary referral hospitals between January 1, 2015, and December 31, 2021. The patients were divided into four cohorts: training cohort (n=800), validation cohort (n=100), internal test cohort (n=100) and external test cohort (n=54). Two deep convolutional neural networks (DCNN), namely MobileNetV2 and ResNet50, were respectively trained using the transfer learning strategy on a dataset consisting of 44871MR images. The performance of the DCNN models was compared to that of radiologists using various metrics, including receiver operating characteristic curve (ROC) analysis, accuracy, sensitivity, and specificity. Delong testing was employed for comparing the area under curves (AUCs). Univariate and multivariate analyses were conducted to explore potential factors associated with classifier performance. A total of 532 PFCD and 522 CGF patients were included. Both pre-trained DCNN classifiers achieved encouraging performances in the internal test cohort (MobileNetV2 AUC: 0.962, 95% CI 0.903-0.990; ResNet50 AUC: 0.963, 95% CI 0.905-0.990), as well as external test cohort (MobileNetV2 AUC: 0.885, 95% CI 0.769-0.956; ResNet50 AUC: 0.874, 95% CI 0.756-0.949). They had greater AUCs than the radiologists (all p≤0.001), while had comparable AUCs to each other (p=0.83 and p=0.60 in the two test cohorts). None of the potential characteristics had a significant impact on the performance of pre-trained MobileNetV2 classifier in etiologic diagnosis. Previous fistula surgery influenced the performance of the pre-trained ResNet50 classifier in the internal test cohort (OR 0.157, 95% CI 0.025-0.997, p=0.05). The developed DCNN classifiers exhibited superior robustness in distinguishing PFCD from CGF compared to artificial visual assessment, showing their potential for assisting in early detection of PFCD. Our findings highlight the promising generalized performance of MobileNetV2 over ResNet50, rendering it suitable for deployment on mobile terminals. National Natural Science Foundation of China.

Whole genome-based characterization of extended-spectrum β-lactamase-producing Enterobacter cloacae from orthopedic patients and environment of a tertiary referral hospital in Tanzania

ObjectivesWe investigated the genomic epidemiology of extended-spectrum β-lactamase-producing Enterobacter cloacae (ESBL-Ec) isolates from patients and hospital environment to better understand their distribution to help devising effective strategies for infection prevention and control. MethodsWe screened ESBL-Ec at Bugando Medical Center (BMC) in Mwanza, Tanzania. Rectal swabs from orthopedic patients on admission and swabs from the neighboring inanimate environment were collected. Following microbial culture, DNA was extracted from pure ESBL-Ec, and whole-genome sequencing was done. Sequence typing (ST), plasmid replicons, drug resistance, and virulence genes were deciphered using the Rapid Microbial Analysis Pipeline (rMAP). ResultsWe obtained 209 ESBL isolates, of which 15 (7.2%) were ESBL-Ec [8 (53.30%) from patients and 7 (46.7%) from the environment]. Seven isolates were novel and eight were diverse each with a unique ST. All isolates harbored two to five β-lactamase genes, with the predominance of blaCTX-M-15(15/15), blaOXA-1(14/15), blaTEM(14/15) and blaACT(12/15). The most common non β-lactam drug resistance genes were aac(3)-IIa (14/15), aac(6’)-Ib-cr (14/15), fosA (14/15), and qnrB1 (12/15), aph(3’’)-Ib (10/15) and aph(6)-Id (10/15). Eleven different types of plasmid replicons were identified in 14/15 of the isolates, harboring one to five plasmids, with the most common plasmids being IncFII (11/15) and IncFIB (10/15). All isolates harbored the outer membrane protein (ompA), and curli protein (csg) was in 14/15 isolates. ConclusionAdmitted orthopedic patients and the hospital environment act as a reservoir of ESBL-Ec with diverse STs and endowed with drug resistance and arsenals of virulence genes, calling for their routine screening on admission for mitigation of potential subsequent infections.

Clinical and surgical outcomes of tectonic corneal patch grafts : insights from a tertiary referral hospital

PurposeThis study aimed to report the clinical characteristics, surgical indications, outcomes and long-term complications of full-thickness or lamellar corneal patch grafts for various indications.Material-methodThis retrospective study included 48 eyes of 47 patients who underwent full-thickness or lamellar corneal patch keratoplasty for treatment of corneal perforation, melting and descemetocele. Patient demographics, preoperative features, best-corrected visual acuity before and after surgery, mean follow-up time, corneal graft type, long-term complications, need for additional surgery, and anatomical success were analyzed.ResultsOf the 48 eyes, 21 had corneal perforation, 21 had severe corneal melting, and six had descemetocele. Sjögren’s syndrome (eight eyes, 16.7%), trauma (eight eyes, 16.7%), and limbal stem cell deficiency (eight eyes, 16.7%) were the most common indications for corneal patch grafting. The most common complications after surgery were graft melting (11 eyes, 22.9%) and glaucoma (5 eyes, 10.4%). One eye developed phthisis bulbi. Penetrating keratoplasty was performed in 8 of the 11 eyes with recurrent graft melting. All descemetocele cases were central and corneal melts were more frequently located paracentrally (p = 0.0001). Anatomical success was achieved in 39 eyes (81.2%).ConclusionCorneal patch grafting is a safe and effective method for maintaining ocular integrity in corneal melting and perforation that can not be closed using conventional methods. With a success rate of over 80%, corneal patch grafts can delay a larger full-thickness graft, especially in eyes with acute inflammation, until systemic therapy is effective.

The Morbidity and Mortality Review: A crucial tool for improving patient safety and quality

Institutional mortality rates can be used to monitor the quality of hospital care. Morbidity and Mortality (M&M) review is crucial to the hospital’s quality and patient safety initiatives. A multi-disciplinary forum to discuss M&M better lends itself to the discussion that balances physician error and system failure. It is crucial to afford attendees opportunities for introspection/reflection while holding those responsible accountable without apportioning blame. This review was undertaken at the M&M conference conducted by the Department of Surgery at The Aga Khan University Hospital Nairobi, a tertiary teaching and referral hospital. All surgical residents and faculty attend the M&M conference. A standard reporting format is used for every case discussed at the departmental level and shared at the institutional level. Morbidities and Mortalities that are analyzed as being due to a system or administrative process failure or having potential medico-legal implications are subjected to a Root Cause Analysis. Recommendations from individual cases focus on measures that can prevent similar outcomes or adverse incidents or improve the care processes provided to this group of patients. These recommendations should resist the temptation to apportion blame to individuals. The department needs to construct the meetings to integrate the system and administrative issues underlying unexpected outcomes and discuss technical/clinical-related issues. Physicians who feel they work in a ‘safe’ environment are likelier to self-report events and offer them for discussion.

Ultra-low-dose chest computed tomography with model-based iterative reconstruction in the analysis of solid pulmonary nodules: A prospective study.

Incidental pulmonary nodules are an increasingly common finding on computed tomography (CT) scans of the thorax due to the exponential rise in CT examinations in everyday practice. The majority of incidental pulmonary nodules are benign and correctly identifying the small number of malignant nodules is challenging. Ultra-low-dose CT (ULDCT) has been shown to be effective in diagnosis of respiratory pathology in comparison with traditional standard dose techniques. Our hypothesis was that ULDCT chest combined with model-based iterative reconstruction (MBIR) is comparable to standard dose CT (SDCT) chest in the analysis of pulmonary nodules with significant reduction in radiation dose. To prospectively compare ULDCT chest combined with MBIR with SDCT chest in the analysis of solid pulmonary nodules. A prospective cohort study was conducted on adult patients (n = 30) attending a respiratory medicine outpatient clinic in a tertiary referral university hospital for surveillance of previously detected indeterminate pulmonary nodules on SDCT chest. This study involved the acquisition of a reference SDCT chest followed immediately by an ULDCT chest. Nodule identification, nodule characterisation, nodule measurement, objective and subjective image quality and radiation dose were compared between ULDCT with MBIR and SDCT chest. One hundred solid nodules were detected on ULDCT chest and 98 on SDCT chest. There was no significant difference in the characteristics of correctly identified nodules when comparing SDCT chest to ULDCT chest protocols. Signal-to-noise ratio was significantly increased in the ULDCT chest in all areas except in the paraspinal muscle at the maximum cardiac diameter level (P < 0.001). The mean subjective image quality score for overall diagnostic acceptability was 8.9/10. The mean dose length product, computed tomography volume dose index and effective dose for the ULDCT chest protocol were 5.592 mGy.cm, 0.16 mGy and 0.08 mSv respectively. These were significantly less than the SDCT chest protocol (P < 0.001) and represent a radiation dose reduction of 97.6%. ULDCT chest combined with MBIR is non-inferior to SDCT chest in the analysis of previously identified solid pulmonary nodules and facilitates a large reduction in radiation dose.

Value of Computed Tomography Scan for Detecting Lymph Node Metastasis in Early Esophageal Squamous Cell Carcinoma.

The necessity of computed tomography (CT) scan for detecting potential lymph node metastasis (LNM) in early esophageal squamous cell carcinoma (ESCC) before endoscopic and surgical treatments is under debate. Patients with histologically proven ESCC limited to the mucosa or submucosa were examined retrospectively. Diagnostic performance of CT for detecting LNM was analyzed by comparing original CT reports with pathology reports. The sensitivity, specificity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) were calculated. A total of 625 patients from three tertiary referral hospitals were included. The rate of pathologically confirmed LNM was 12.5%. Based on original CT reports, the sensitivity, specificity, accuracy, PPV, and NPV of CT to determine LNM in T1 ESCC were 41.0%, 83.2%, 77.9%, 25.8%, and 90.8% respectively. For mucosal cancers (T1a), these parameters were 50.0%, 81.7%, 80.9%, 6.8%, and 98.4%, respectively. For submucosal cancers (T1b), they were 40.0%, 85.0%, 75.0%, 43.0%, and 83.3%, respectively. Additionally, the diagnostic performance of CT for LNM was relatively better for ESCC in the lower esophagus. Pathologically, 69.2% of patients with LNM did not exhibit lymphovascular invasion (LVI), and the sensitivity of CT for recognizing LNM in these patients (33.3%) was lower than those with LVI (58.3%). Computed tomography can detect nearly half of the LNM cases in early ESCC with high specificity. The performance of CT further improved in LNM cases with LVI. Therefore, we conclude that routine preoperative CT for the assessment of potential LNM risk in patients with early ESCC is necessary.

Intrauterine Fetal Death and the COVID-19 Pandemic: Looking beyond SARS- CoV-2 Infection

Background: COVID-19 pandemic has caused high numbers of deaths and complications since 2020. Though the risk is the same as in the general population, pregnant women with COVID-19 are especially susceptible to developing complications because of their altered physiology. The objective of this retrospective study is to investigate the relationship betweenthe COVID-19 pandemic period and intrauterine fetal death, which can help to take steps to reduce intrauterine fetal death during the pandemic. Materials and methods: This retrospective study compared the intrauterine fetal death rate during the pre-pandemic (March 01, 2019 to February 29, 2020) and the pandemic period (March 01, 2020, to February 28, 2021) in a tertiary referral hospital in Bangladesh. Patient data were collected from the record-keeping register of the Department of Obstetrics and Gynecology and analyzed by computer-based software presented in graph, chart and table. Results: Out of 21717 obstetric patients admitted patients,821 (3.78%) were documented as cases of intrauterine fetal death in the pre-pandemic period, whereas in the pandemic period, the number was 895 (4.86%) out of 18424. Due to inadequate data records and considering the exclusion criteria, a total of 790 IUFD patients of the pre-pandemic period and 860 IUFD patients of the pandemic period were included in this study. Conclusion: The percentage of IUFD on obstetric admission showed significantly (p&lt;0.001) higher in the pandemic period compared to that in the pre-pandemic period. This result is important for providing insights to the policy makers for future planning, counseling of women wishing to become pregnant, and prioritizing their safety, including their vaccination. Chatt Maa Shi Hosp Med Coll J; Vol.22 (2); July 2023; Page 47-50

Identifying clustering of cholera cases using geospatial analysis in Kolkata and surrounding districts: data from patients at tertiary care referral hospitals

Cholera cases have increased globally across the Eastern Mediterranean, Africa, Southeast Asia, and parts of Europe since early 2024. This study aims to identify cholera hotspots and understand the spatial distribution of cholera in Kolkata and surrounding regions, a key cholera reservoir. Additionally, we examine sociodemographic factors and aspects related to water, sanitation, and hygiene (WASH). Cholera clusters were detected using kernel density estimation and spatial autocorrelation through Global Moran's-I statistics, with local cluster patterns examined using Local Moran's-I statistics. Cholera cases from August 2021 to December 2023, treated at two tertiary care facilities in Kolkata: Infectious Diseases and Beleghata General Hospital and Dr. B C Roy Post Graduate Institute of Paediatric Sciences Hospital were included. Additionally, through a case-control study, 196 culture-confirmed cholera cases and 764 age/sex-matched neighborhood controls were enrolled, to investigate cholera risk factors. Spatial analysis revealed a concentration of 196 cholera cases in Kolkata and its surrounding regions of Howrah, Hooghly, and North and South 24 Parganas. Hotspot analysis showed significant clustering in several Kolkata wards (31, 33, 56, 46, 57, 58, 59, 61, 66, 71, and 107), particularly in the northern, central, and east Kolkata wetlands areas (Global Moran's I statistic=0.14, p<0.001). These clusters had proximity between cases, with a median distance of 187.7m, and 25.5% of cases as close as 73.9m apart, suggesting localized transmission. Hotspots were identified with an average distance of 1600m between them. Local Moran's I analysis found dense "high-high" clusters in these areas (p<0.01), with a mean Moran's I index of 0.3, (range 0.1-4.6). The case-control study revealed that males were more likely to contract cholera, with an adjusted odds ratio of 2.4 (p<0.01). There was no significant association found between cholera infection and sociodemographic factors or various WASH practices. The findings emphasize the importance of targeted interventions, especially in identified hotspots, to mitigate cholera transmission. Addressing Socio-economic, and environmental factors especially improvement in WASH practices may further enhance prevention effects. The author KK, received funding from the program of the Japan Initiative for Global Research Network on Infectious Diseases, (grant id: JP23wm0125004), from the Ministry of Education, Culture, Sports, Science and Technology in Japan, and Japan Agency for Medical Research and Development.

Impact of encounters on patient app use: results of a tethered mobile personal health record usage pattern analysis.

The adoption of tethered mobile personal health records provides not only medical information to patients but also various convenience functions related to hospital use, thereby increasing accessibility to healthcare services and promoting patient engagement. We analyse the tethered mobile personal health records app's usage logs to determine how it can contribute to improving medical service accessibility and patient engagement. Log data, that comprised menu type, log time, and date, were collected from the mobile personal health records app of a tertiary referral hospital. Clinical information, including patients' demographics and visit type, was collected from the clinical research warehouse system. The usage log was analysed in terms of the type of visit, service function, and time period. Outpatients accounted for 34% of the total app usage and was the most app-accessed visit type. The most utilized menu functions were lab test and visit schedule for visits or non-visits. For Inpatient and Health check-ups, menu usage patterns showed a focus on lab test results. While investigations and other menu usage showed double peaks in the morning and afternoon, peak usage of lab test results correlated with inpatient blood sampling times, which was around 9 am. App menus to access health information, particularly blood tests, emerged as the most accessed menu. Hence, when compared with blood sampling times and hospital information system usage patterns, encounters occurring in the hospital majorly impacted patient app use. For improved patient engagement, improving lab test function should be the priority.

Acute fatty liver of pregnancy: An atypical case report

HIGHLIGHTS Acute Fatty Liver of Pregnancy (AFLP) is an uncommon condition but life-threatening obstetric emergency, that increases the risk of fetal death due to preterm birth. AFLP can be challenging for primary health workers (especially for general practitioners (GP) and midwives) since it mimics preeclampsia, viral hepatitis, intrahepatic cholestasis of pregnancy, and HELLPS syndrome, so more concern is needed in this case. ABSTRACT Objective: To present an atypical case of acute fatty liver of pregnancy. Case Report: A 33-year-old woman was referred to the Emergency department of Dr. Soedarso Tertiary Referral Hospital, Pontianak, Indonesia, previously from the district hospital over 580 KM with diagnosis of multigravida (gravida 3 para 2) at 31 weeks gestation, suspected acute fatty liver disease (AFLP), severe oligohydramnios, and intrauterine growth restriction (IUGR). The patient had a history of nausea, vomiting, epigastric pain, polydipsia and polyuria, and seizure for less than 5 minutes with loss of consciousness. The patient originally did not know she was pregnant and using a contraceptive implant. She missed her period in the last six months ago, which was the first onset of epigastric pain. Further clinical examination resulted in pitting oedema but jaundice as a cardinal sign was not present. Laboratory data showed leukocytosis, normal haemoglobin level, normal blood glucose, hyperuricemia, increased function liver test with high transaminase and bilirubin, normal coagulation profile. Urinalysis showed proteinuria. The viral hepatitis and HIV tests were negative. Transabdominal ultrasound demonstrated a single intrauterine pregnancy with no echogenic liver features. Cardiotocography (CTG) showed category 2. This patient was diagnosed with AFLP based on Swansea Criteria (7 out of 10) and terminated pregnancy two days after diagnosis. A baby boy was born with birth weight 1.100 gr, birth length 34 cm, apgar score (AS) 9 and 10 at 1 and 5 minutes. The mother had a good prognosis, while the baby died on day 23 of life. Conclusion: Acute Fatty Liver during Pregnancy is an uncommon but life-threatening obstetric emergency. Early screening, diagnosis, timely handling delivery, and intensive supportive care are essential to decrease morbidity and mortality for both mother and fetus. Multidisciplinary opinion needed for the best management of this case.

Textbook oncological outcome of locally advanced gastric cancer patients with preoperative sarcopenia: a multicenter clinical study.

The impact of postoperative sarcopenia on the Textbook Oncological Outcome (TOO) in locally advanced gastric cancer (LAGC) remains uncertain. This study investigates the relationship between sarcopenia and TOO, explores its long-term prognostic value, and develops a prognostic model incorporating sarcopenia and TOO for survival prediction. We performed a retrospective analysis of clinical and pathological data from patients with LAGC who underwent radical surgery at two Chinese tertiary referral hospitals. Sarcopenia was defined as an SMI < 36.4 cm2/m2 in males and < 28.4 cm2/m2 in females. TOO was defined as the addition of perioperative chemotherapy to the textbook outcomes (TO). A nomogram was developed to predict postoperative overall survival (OS) and recurrence-free survival (RFS) in LAGC patients. The study included 972 patients with LAGC. The overall TOO achievement rate was 67.1%. The TOO achievement rate was significantly higher in patients non-sarcopenia compared to those with sarcopenia (68.9% vs. 61.1%, P = 0.031). Logistic regression revealed that age ≥ 65, high ASA score, and sarcopenia were independent risk factors for TOO failure. Cox regression analysis identified TOO, sarcopenia, tumor size, differentiation, vascular invasion, pT stage, and pN stage as independent predictors of OS and RFS. Nomogram models based on sarcopenia and TOO accurately predicted the 3-year and 5-year OS and RFS. Preoperative sarcopenia was an independent predictor of TOO implementation. A prognostic prediction model that integrates preoperative sarcopenia and TOO, which outperforms the current staging system, can aid clinicians in effectively assessing the prognosis of patients with LAGC.

Diversity, Distribution, and Resistance Profiles of Bacterial Bloodstream Infections in Three Tertiary Referral Hospitals in Rwanda Between 2020 and 2022.

Background: The burden of bacterial bloodstream infections (BSIs) is rapidly increasing in Africa including Rwanda. Methods: This is a retrospective study that investigates the diversity, distribution, and antimicrobial susceptibility profiles of BSI bacteria in three tertiary referral hospitals in Rwanda between 2020 and 2022. Results: A total of 1532 blood culture tests were performed for visiting patients. Overall, the proportions of Gram-negative and Gram-positive bacteria were 48.2% and 51.8, respectively. Staphylococcus aureus was the predominant species accounting for 25% of all Gram-positive BSI species, and Klebsiella species represented 41% of all Gram-negative BSI species. Antimicrobial susceptibility testing revealed that Amikacin exhibited the highest activity against Enterobacter spp., Serratia spp., and Escherichia coli in >92% of cases and Klebsiella spp. in 75.7%. Meropenem and Imipenem were highly efficacious to Salmonella spp. (100% susceptibility), Enterobacter spp. (96.2% and 91.7%, respectively), and Escherichia coli (94.7% and 95.5%, respectively). The susceptibility of Enterococcus spp., S. aureus, and Streptococcus spp. to Vancomycin was 100%, 99.5%, and 97.1%, respectively. Klebsiella spp. was highly sensitive to Colistin (98.7%), Polymyxin B (85.6%), Imipenem (84.9%), and Meropenem (78.5%). Conclusions: We recommend strengthening the implementation of integrated transdisciplinary and multisectoral One Health including AMR stewardship for the surveillance, prevention, and control of AMR in Rwanda.

Psychosocial Factors Influencing Breastmilk Production in Mothers After Preterm Birth: The Role of Social Support in Early Lactation Success-A Cross-Sectional Study.

Preterm birth is a major global health issue, associated with increased neonatal morbidity and mortality. Mothers of preterm infants face unique challenges, particularly with regard to lactation, due to the complexities of preterm neonatal care. Social support has been recognized as a factor in promoting successful breastfeeding, especially in vulnerable groups such as mothers of preterm infants. This study aimed to explore the psychosocial factors influencing breastfeeding in mothers following preterm birth, with a particular focus on the role of social support in early lactation success. A cross-sectional observational study was conducted between December 2022 and March 2023 at a tertiary referral hospital in Poland. The study included 130 women (71 mothers of preterm infants and 59 mothers of full-term infants) in the early postpartum period. Data were collected through a self-administered questionnaire and the Polish version of the Berlin Social Support Scales (BSSS). Lactation success was assessed based on the mother's ability to initiate and maintain breastfeeding or expressed milk production. Statistical analyses included Mann-Whitney U tests, Pearson's Chi-Square, and logistic regression to determine the association between social support and lactation outcomes. The study revealed that mothers of preterm infants exhibited a greater need for social support compared with those who delivered at term. Social support, particularly perceived emotional and practical support, appeared to be significantly associated with successful early lactation. Women who received adequate social support were more likely to initiate breastfeeding early and maintain lactation. Psychosocial factors, particularly social support, play a critical role in the success of lactation among mothers of preterm infants. These findings underscore the need for comprehensive support systems for mothers of preterm infants to promote breastfeeding and improve neonatal health outcomes.

Understanding the Experience of Workplace Violence in Hospitals as Documented by Nursing Staff: Using the READ Approach.

Background: Workplace violence has a significant impact on patients, families, and staff safety. Workplace violence can produce traumatic results for those involved; the importance of preventive measures needs to be paramount in health service policy and process. Health care staff are required to document their experiences of violent incidents after every occasion, usually via an incident reporting system, which allows for a free text description of the event. There is a lack of understanding of how health care staff document reports of violence and how they explain the events. Methods: This study aims to determine the circumstances surrounding workplace violent events as documented by health care staff. The four-step Review, Extract, Analyze, and Document (READ) approach to document analysis was used to examine workplace violence incident reports over 12 months (September 2021-September 2022) in a tertiary referral hospital. Findings: Six categories of workplace violence were found: (a) "Escalation Dynamics"-patterns and progression of how violence incidents intensify; (b) "Warning Behaviors"-verbal or non-verbal signals that may foreshadow physical violence if not addressed; (c) "Authoritative Institutional Interventions"-how aggression correlates to protocols involving security personnel or law enforcement; (d) "Care Delivery Methods"-how certain treatment procedures and approaches might inadvertently elicit violence; (e) "Situational Stressors"-external circumstances or changes that act as triggers for violence; and (f) "Unprovoked triggers"-sudden and seemingly unprovoked violent outbursts. Conclusions and application to practice: Workplace violence in health care is a multifaceted interplay of events with the nurse involved in all aspects of the process. These findings can be used by occupational health nurses in education and policy development. The findings can be used to focus education on how violent incidents may escalate and provide more opportunities for de-escalation by health care staff.

Analysis of wrong blood in tube events at a hospital-based blood centre in a tertiary care referral hospital: A perspective from a lower middle-income country.

Wrong blood in tube (WBIT) continues to be a preventable cause of unintended harm to the patient. The literature describing extent of the problem, its consequences and factors leading to WBIT from the perspective of lower middle-income countries (LMICs) is limited. The present study describes WBIT and its outcome in a hospital-based blood centre from an LMIC. WBIT events occurring during the study period were analysed to identify the root cause. In addition, they were analysed according to discipline, department and time of sample draw. Root causes were divided and compared with standard operating procedure (SOP) for sample collection for blood requests. All WBIT events were followed and their outcomes analysed. WBIT events occurred at a rate of 4.8/10,000 blood requests, with a higher rate in urgent requests (5.2/10,000 requests). The average rate of WBIT was higher in surgical disciplines compared to medical and acute care services (6.58 vs. 4.43 vs. 3/10,000 requests). The highest rate of WBIT was observed when requests were received during 8:00 PM-2:00 AM (p = 0.02). Deviations from SOP with contribution from human and organizational elements were identified as the root cause. The consequences ranged from delay in providing blood to acute haemolytic transfusion reactions. We found that WBITs occurred at a rate comparable to that reported from developed countries. Use of software and automation may reduce the rate of WBIT but not eliminate it completely. Strict adherence to SOPs and continuous training of phlebotomy staff would help reduce it to a minimum. Blood centres need to develop specific strategies with respect to their root causes.

A case series on parathyroid carcinoma: Diagnostic challenges and therapeutic approaches

IntroductionParathyroid carcinoma is an exceptionally rare endocrine malignancy, constituting <1 % of primary hyperparathyroidism (PHPT) cases. It presents with more severe hypercalcemia and higher PTH levels than benign parathyroid diseases, requiring increased clinical awareness for accurate identification and specialized management. The results of this case series may provide insight into the clinical presentation, diagnostic workup, surgical management, and prognosis of parathyroid carcinoma, supplemented by a comprehensive review of current diagnostic and therapeutic approaches. MethodsWe retrospectively reviewed three cases of parathyroid carcinoma treated at a tertiary referral hospital. We analyzed patient demographics, clinical presentation, imaging studies, surgical interventions, histopathological findings, and follow-up data. We emphasized intraoperative decisions, criteria for achieving sustained hormonal control, and long-term monitoring protocols. ResultsPatient 1: An 84-year-old male patient presented with severe hypercalcemia and elevated PTH levels. Preoperative imaging, including 4D CT and sestamibi scan, identified a 3.7 cm, 9.32-gram parathyroid mass, which was surgically resected. Despite removing the mass and normalizing calcium levels, PTH levels remained elevated, suggesting residual disease.Patient 2: A 77-year-old male patient with osteoporosis and a history of kidney stones underwent presurgical parathyroid scintigraphy, which indicated a right superior parathyroid adenoma. A 3 cm, 3.55-gram parathyroid carcinoma was successfully removed, normalizing calcium and PTH levels. Follow-up imaging and labs confirmed no recurrence.Patient 3: A 61-year-old female patient with end-stage renal disease presented with a 5 cm hypervascular neck mass. Preoperative 4D CT and ultrasound suggested an adenoma. After surgery, PTH levels normalized, but the patient died five years later from an unrelated stroke. ConclusionParathyroid carcinoma is a rare malignancy that demands thorough diagnostic procedures, imaging techniques, precise surgical intervention, and vigilant long-term follow-up to manage the risk of recurrence. Elevated PTH and calcium levels should raise suspicion of malignancy, especially in severe hypercalcemia. This case series illustrates how the disease can present variably, with unique challenges in each patient. Despite the limitations of current adjuvant therapies, advancements in genetic and molecular research hold promise for future therapeutic options.

Postoperative rhinosinusitis and microbiological outcomes following endoscopic endonasal approaches: A retrospective analysis of 300 patients.

Endoscopic endonasal approaches (EEAs) are an efficient way to manage skull base lesions; however, studies regarding postoperative rhinosinusitis are limited. This study analyzed the incidence of postoperative rhinosinusitis, the associated risk factors, microbial species, and antibiotic usage in patients who underwent EEA. Patients who underwent EEAs at a tertiary referral hospital between July 2015 and May 2019 were retrospectively evaluated. Postoperative rhinosinusitis was defined as the presence of a purulent nasal discharge on postoperative endoscopic examination. The mucopus was aspirated and subjected to bacterial culture analysis. The culture results of various groups were analyzed. This study included 300 patients, and the incidence of post-EEA rhinosinusitis was 59.7%. History of endonasal surgery was an independent predictive factor for post-EEA rhinosinusitis [OR 2.547 (1.284-5.052), p= 0.007]. Lesions in the anterior skull base were associated with prolonged use of antibiotics for rhinosinusitis during postoperative care [OR 3.914 (1.329-11.524), p=0.013]. Staphylococcus aureus was the most common causative pathogen, followed by methicillin-resistant Staphylococcus aureus (MRSA) (20.7%), Pantoea dispersa (14.4%), and Pseudomonas aeruginosa (11.7%). P. aeruginosa was more significant in the complex reconstruction group than in the control group. While most patients with post-EEA rhinosinusitis experienced a transient clinical course, one female patient underwent ESS for prolonged rhinosinusitis. Rhinosinusitis is common in the postoperative stage of the EEA. As it usually lasts for a short duration and is treatable with proper medication, aggressive nasal care during the postoperative period is required to prevent related nasal morbidities.

ArtiSentialⓇ versus conventional laparoscopic colorectal cancer surgery: a multicenter retrospective matched cohort study

Background: This study aims to compare outcomes of colorectal cancer surgeries performed using the newly developed articulating laparoscopic instrument, ArtiSential®, with those using conventional non-articulating or rigid laparoscopic instruments. Methods: This multicenter, retrospective, matched cohort study enrolled patients with colorectal cancer undergoing laparoscopic surgery in seven tertiary referral hospitals from January 2021 to October 2022. A 1:1 propensity score matching was performed between the articulating (Arti-LAP) and conventional (Rigid-LAP) laparoscopic groups. The primary outcome was the overall incidence of short-term complications. Results: The study initially comprised 694 and 2008 patients in the Arti-LAP and Rigid-LAP groups, respectively. After matching, each group consisted of 694 patients, with no significant differences in baseline clinical characteristics. Mean operation time was 161 ± 32 min in Arti-LAP and 152 ± 25 min in Rigid-LAP groups (P=0.105). Open conversion rates were 0% (0/694) in Arti-LAP and 1.0% (7/694) in Rigid-LAP groups (P=0.024). Overall morbidity rates were 9.5% (66/694) in Arti-LAP and 12.8% (89/694) in Rigid-LAP (P=0.061), with similar rates of severe morbidities. Specimen quality was acceptable in both groups. Multivariable regression analysis showed that the choice of instrument type (articulating or rigid) was not associated with perioperative morbidity. Despite a short median follow-up period of 19.5 months, no significant difference in disease-free survival was observed between the groups. Conclusion: Laparoscopic surgery using ArtiSential® was performed safely and effectively for patients with colorectal cancer. Articulating laparoscopic instruments may offer an advantage in reducing open conversion rates.