Tertiary Referral Teaching Hospital Research Articles

Retrospective observational study of the association of peak blood glucose during the second 24 hours of admission with hospital-acquired complications in non-critical care admissions to a tertiary referral teaching hospital

IntroductionStress hyperglycaemia at hospital presentation is associated with poorer outcomes. Less is known about the risk of poorer outcomes according to achieved glycaemia early in the admission.Research design/methodsThis was a...

Exploring Antibacterial Usage and Pathogen Surveillance over Five Years in a Tertiary Referral Teaching Hospital Adult General Intensive Care Unit (ICU).

Antimicrobial resistance is a globally recognised health emergency. Intensive care is an area with significant antimicrobial consumption, particularly increased utilisation of broad-spectrum antibacterials, making stewardship programmes essential. We aimed to explore antibacterial consumption, partnered with pathogen surveillance, over a five-year period (2018 to 2023) in a tertiary referral adult general intensive care unit (ICU). The mean number of admissions was 1645 per annum. A comparison between the ICU populations admitted before and after the COVID-19 pandemic peak (2020/21) identified several notable differences with increased average daily unit bed occupancy (21.6 vs. 25.2, respectively) and a higher proportion of admissions with sepsis (28.4% vs. 32.5%, respectively) in the post-pandemic period. Over the entire five years, the overall proportion of antibacterial use by the WHO AWaRe classification was 42.6% access, 54.7% watch and 2.6% reserve. One hundred and forty-seven positive blood culture isolates were reported, with the most concerning antibacterial resistance identified in 7.5% (9 Escherichia coli and 2 Klebsiella pneumoniae isolates). The COVID-19 pandemic peak year was associated with increased ICU bed occupancy, as well as a greater number of positive blood cultures but lower antibacterial consumption. Despite an increasingly complex workload, a large proportion of overall antibacterial consumption remained within the access category. However, the mortality rate and the incidence of most concerning antimicrobial resistance with respect to pathogens remained satisfyingly consistent, suggesting the positive consequences of real-world antibiotic stewardship in an intensive care setting.

Prescription Practices and Usage of Antimicrobials in a Tertiary Teaching Hospital in Rwanda: A Call for Antimicrobial Stewardship.

Background: Antimicrobial resistance (AMR) is a global problem that results in high morbidity and mortality, particularly in low- and middle-income countries. Inappropriate use of antimicrobials is a major driver of AMR. This study aimed to evaluate the rate and quality of antimicrobial prescription and use at the University Teaching Hospital of Kigali (CHUK), a tertiary-referral teaching hospital. Methodology: A point prevalence survey (PPS) of antimicrobial prescription was conducted using the Global PPS tool, including a healthcare-acquired infection (HAI) module. Results: On the day of the PPS, 39.3% (145/369) of inpatients were prescribed at least one antimicrobial. Out of the 259 prescribed antimicrobials, 232 (89.6%) were antibacterials, of which 151 (65.1%) belonged to the watch group of the WHO AWaRe classification. The top three antibiotics prescribed were cefotaxime (87; 37.5%), parenteral metronidazole (31; 13.4%), and meropenem (23; 9.9%). Stop or review dates for the prescribed antimicrobials were documented in 27/259 prescriptions (10.4%). Surgical prophylaxis (SP) was prescribed for longer than one day in 83.3% of 61 patients. Samples for culture were sent for 27.1% (63/232) of all the patients prescribed antibiotics. Conclusion: This PPS demonstrates multiple indicators of the poor use of antimicrobials, including the high prevalence usage of watch antibiotics and prolonged surgical prophylaxis and other poor-quality indicators. Thus, there is an urgent need for intervention to improve antimicrobial stewardship.

Fat Mass Index Predicts the Effect of Weight Loss and Quality of Life Early After Laparoscopic Sleeve Gastrectomy.

Fat mass index (FMI) is a body composition indicator that reflects body fat content. Laparoscopic sleeve gastrectomy (LSG) is widely performed in patients with obesity. This study aimed to evaluate the value of the FMI in predicting weight loss effect and quality of life early after LSG. From January 2014 to July 2022, the clinical data and computed tomography (CT) images of patients who underwent LSG at a tertiary referral teaching hospital were analyzed. Body composition indicators were calculated using the SliceOmatic software. Achieving initial body mass index within 6months postoperatively was defined as early eligible weight loss (EEWL). The relationship between body composition and EEWL was analyzed. A total of 243 patients were included. Receiver operating characteristic (ROC) curve analysis showed that the predictive value of the FMI for EEWL in patients after LSG was higher than that of other indicators (all P < 0.05; area under the curve = 0.813). The best FMI cut-off point was 13.662. Accordingly, the patients were divided into the high-FMI group and low-FMI group. The %EWL and BMI of patients in the low-FMI group at 1, 3, 6, 9, 12, and 24months after surgery were better than those in the high-FMI group (all P < 0.001). Patients in the low-FMI group had higher BAROS (Bariatric Analysis and Reporting Outcome System) scores than those in the high-FMI group (P < 0.001). Compared with other body composition indicators, FMI can effectively predict the early effect of weight loss and quality of life after LSG.

Association of body composition and systemic inflammation for patients with locally advanced cervical cancer following concurrent chemoradiotherapy

Systemic inflammation and body composition are associated with survival outcomes of cancer patients. This study aimed to examine the combined prognostic value of systemic inflammatory markers and body composition parameters in patients with locally advanced cervical cancer (LACC). Patients who underwent concurrent chemoradiotherapy (CCRT) for LACC at a tertiary referral teaching hospital between January 2010 and January 2018 were enrolled. A predictive model was established based on systemic immune-inflammation index (SII) and computer tomography-derived visceral fat-to-muscle ratio (vFMR). Overall survival (OS) and progression-free survival (PFS) were assessed using the Kaplan-Meier method and Cox regression models. The model performance was assessed using discrimination, calibration, and clinical usefulness. In total, 212 patients were enrolled. The SII and vFMR were closely related, and both independently predicted survival (P < 0.05). A predictive model was established based on the above biomarkers and included three subgroups: high-risk [both high SII (>828) and high vFMR (>1.1)], middle-risk (either high SII or high vFMR), and low-risk (neither high SII nor high vFMR). The 3-year OS (PFS) rates for low-, middle-, and high-risk patients were 90.5% (86.0%), 73.9% (58.4%), and 46.8% (36.1%), respectively (P < 0.05). This model demonstrated satisfactory predictive accuracy (area under the curve values for predicting 3-year OS and PFS were 0.704 and 0.718, respectively), good fit (Hosmer-Lemeshow tests: P > 0.05), and clinical usefulness. Systemic inflammatory markers combined with body composition parameters could independently predict the prognosis of patients with LACC, highlighting the utilization of commonly collected indicators in decision-making processes. The SII and vFMR, as well as their composite indices, were promising prognostic factors in patients with LACC who received definitive CCRT. Future studies are needed to explore novel therapies to improve the outcomes in high-risk patients.

Clinical characteristics and outcome of critically ill children referred to a tertiary hospital in Indonesia: a prospective observational study

BackgroundThe clinical characteristics of pediatric critically ill patients who need referral to a tertiary hospital is often unknown in resource limited settings where constraints in diagnosis capacity, resources, and infrastructures are common. There is a need to increase insight in the characteristics of these patients for capacity building strengthening and appropriate resource allocation. The aim of this study was to describe the clinical characteristics and outcomes of critically ill children who are referred to a tertiary referral teaching hospital in Yogyakarta.MethodsA prospective observasional study was carried out from July 1st, 2022 -January 31st, 2023 which included all critically ill pediatric patients who were referred through the Integrated Referral System (SISRUTE) to the Pediatric Intensive Care Unit (PICU) of dr. Sardjito hospital. We excluded patients who were referred with a request for admission to the PICU, but were not admitted to the PICU due to their stable condition and lack of the need for intensive care.ResultDuring the study period, we received 1046 emergency referral requests for pediatric patients via SISRUTE, of those, 562 (53.7%) patients were critically ill. The reasons of PICU referral request were the need of solely intensive care 504 (89.7%), the need of multidisciplinary team care, including intensive care 57 (10.1%) and parents request 1 (0.3%). The pre-referral emergency diagnosis was shock 226 (40.3%), respiratory distress/failure 151 (26.7%), central nervous system (CNS) dysfunction 135 (24.1%), trauma 33 (5.9%) and sepsis 17 (3%). Of the 562 critically ill PICU referral requests, 473 (84.2%) requests were accepted. One hundred and eighty-one (58.7%) patients were finally admitted to the PICU, 125 (40.3%) admitted to our regular ward due to stable condition, 4 (1.3%) patients died in Emergency Departement (ED). The remaining accepted patients on request did not arrive in our facility due to various reasons. The mean (SD) response time was 9.1 (27.6) minutes. The mean (SD) transfer time was 6.45 (4.73) hours. Mean (SD) PICU and hospital length of stay was 6.7 (8.3) days and 10.2 (9.2) days respectively. PICU and hospital mortality was 24.3% and 29.7%, respectively.ConclusionThe mortality rate for critically ill pediatric patients referred to a tertiary PICU still high, with shock being the most common pre-referral emergency diagnosis. There is a discrepancy between the referring hospital’s and the referral hospital’s indication for PICU admission. The time required to reach the referral hospital is quite lengthy.

The safety and efficacy of neoadjuvant immunochemotherapy following laparoscopic gastrectomy for gastric cancer: a multicentre real-world clinical study.

The safety and efficacy of neoadjuvant immunochemotherapy (nICT) for locally advanced gastric cancer (LAGC) remain controversial. Patients with LAGC who received either nICT or neoadjuvant chemotherapy (nCT) at 3 tertiary referral teaching hospitals in China between January 2016 and October 2022 were analyzed. After propensity-score matching (PSM), comparing the radiological response, pathological response rate, perioperative outcomes, and early recurrence between the two groups. After PSM, 585 patients were included, with 195 and 390 patients comprising the nICT and nCT groups, respectively. The nICT group exhibited a higher objective response rate (79.5% vs. 59.0%; P <0.001), pathological complete response rate (14.36% vs. 6.41%; P =0.002) and major pathological response rate (39.49% vs. 26.15%; P =0.001) compared with the nCT group. The incidence of surgical complications (17.44% vs. 16.15%, P =0.694) and the proportion of perioperative textbook outcomes (80.0% vs. 81.0%; P =0.767) were similar in both groups. The nICT group had a significantly lower proportion of early recurrence than the nCT group (29.7% vs. 40.8%; P =0.047). Furthermore, the multivariable logistic analysis revealed that immunotherapy was an independent protective factor against early recurrence [odds ratio 0.62 (95% CI 0.41-0.92); P =0.018]. No significant difference was found in neoadjuvant therapy drug toxicity between the two groups (51.79% vs. 45.38%; P =0.143). Compared with nCT, nICT is safe and effective, which significantly enhanced objective and pathological response rates and reduced the risk for early recurrence among patients with LAGC. Clinical Trials.gov.

[Artículo traducido] Experiencia con bexaroteno en linfoma cutáneo de células T: un estudio del Grupo Español de Linfomas Cutáneos (GELC)

Background and objectivesBexarotene has been approved to treat advanced stage cutaneous T-cell lymphomas (CTCL) since 1999. However, very few data have been published on its long-term safety and efficacy profile. The aim of this study is to determine the tolerability to bexarotene and outcomes by collecting the 2nd largest case series to date on its long-term use vs CTCL. Material and methodThis was a multicenter retrospective review of 216 patients with mycosis fungoides (174), or Sézary syndrome (42) on a 10-year course of bexarotene alone or in combination with other therapies at 19 tertiary referral teaching hospitals. ResultsA total of 133 men (62%) and 83 women (38%) were included, with a mean age of 63.5 year (27–95). A total of 45% were on bexarotene monotherapy for the entire study period, 22% started on bexarotene but eventually received an additional therapy, 13% were on another treatment but eventually received bexarotene while the remaining 20% received a combination therapy since the beginning. The median course of treatment was 20.78 months (1–114); and the overall response rate, 70.3%. Complete and partial response rates were achieved in 26% and 45% of the patients, respectively. Treatment was well tolerated, being the most common toxicities hypertriglyceridemia (79%), hypercholesterolemia (71%), and hypothyroidism (52%). No treatment-related grade 5 adverse events were reported. ConclusionsOur study confirms bexarotene is a safe and effective therapy for the long-term treatment of CTCL.

Long-term survival outcomes of robotic total gastrectomy for locally advanced proximal gastric cancer: a prospective study.

Robotic gastrectomy is a safe and feasible approach for gastric cancer (GC); however, its long-term oncological efficacy remains unclear. We evaluated the long-term survival outcomes and recurrence patterns of patients with locally advanced proximal GC who underwent robotic total gastrectomy (RTG). This prospective study (FUGES-014 study) enrolled 48 patients with locally advanced proximal GC who underwent RTG between March 2018 and February 2020 at a tertiary referral teaching hospital. Patients who underwent laparoscopic total gastrectomy (LTG) in the FUGES-002 study were enrolled in a 2:1 ratio to compare the survival outcomes between RTG and LTG. The primary endpoint of the FUGES-014 study was postoperative 30-day morbidity and has been previously reported. Here we reported the results of 3-year disease-free survival (DFS), 3-year overall survival (OS), and recurrence patterns. After propensity score matching, 48 patients in the RTG and 96 patients in the LTG groups were included. The 3-year DFS rates were 77.1% (95% confidence interval [CI] 66.1-89.9%) for the RTG and 68.8% (95% CI 60.1-78.7%) for the LTG groups ( P =0.261). The 3-year OS rates were not significantly different between the groups (85.4% vs. 74.0%, P =0.122). Recurrence occurred in nine patients (18.8%) in the RTG and 27 (28.1%) patients in the LTG groups ( P =0.234). Recurrence patterns and causes of death were similar between the groups ( P >0.05). The oncological outcome of RTG was non-inferior to that of LTG. Thus, RTG might be an alternative surgical treatment for locally advanced proximal GC.

Satisfaction levels and associated influencing factors among inpatients and outpatients with breast cancer at a tertiary health facility in Ghana.

To uncover variables linked to breast cancer patient satisfaction in order to improve policy choices and actions for breast cancer care in Ghana. We employed a cross-sectional design using a quantitative approach. The Radiotherapy, Oncology and Surgery Departments of the Korle Bu Teaching Hospital, Accra. Inpatient and outpatient breast cancer patients. The level of inpatient and outpatient satisfaction was measured using descriptive and inferential statistical analyses. The Shapiro-Wilk test was employed to assess normality, while the Heckman selection model assessed significance with outcomes of interest. A total of 636 participants, with a mean age of 52.64±14.07 years, were recruited. The measured inpatient and outpatient levels of satisfaction out of 100 were 74.06±7.41 and 49.99±1.00 respectively, while the self-reported satisfaction levels out of 5 were 4.22±0.63 and 4.11±0.85 respectively. The level of inpatient satisfaction was significantly influenced by age, marital status, income level, and number of previous facilities visited (p<0.05). Outpatient satisfaction level was significantly associated with place of residence and income level (p<0.05). The study offers insight into the satisfaction levels of breast cancer patients receiving inpatient and outpatient services at the largest tertiary referral centre and teaching hospital in Ghana, as well as the factors influencing attendance and satisfaction levels. Understanding and improving breast cancer patients' levels of satisfaction is a way that providers can safeguard their emotional well-being. Improvement in patient satisfaction at our institution among outpatients is an area for future growth. Gardner-Holt Women's Health Grant program, Centre for Global Surgery 2021.

Experience With Bexarotene to Treat Cutaneous T-Cell Lymphomas: A Study of the Spanish Working Group of Cutaneous Lymphomas

Background and objectivesBexarotene has been approved to treat advanced stage cutaneous T-cell lymphomas (CTCL) since 1999. However, very few data have been published on its long-term safety and efficacy profile. The aim of this study is to determine the tolerability to bexarotene and outcomes by collecting the 2nd largest case series to date on its long-term use vs CTCL. Material and methodThis was a multicenter retrospective review of 216 patients with mycosis fungoides (174), or Sézary syndrome (42) on a 10-year course of bexarotene alone or in combination with other therapies at 19 tertiary referral teaching hospitals. ResultsA total of 133 men (62%) and 83 women (38%) were included, with a mean age of 63.5 year (27–95). A total of 45% were on bexarotene monotherapy for the entire study period, 22% started on bexarotene but eventually received an additional therapy, 13% were on another treatment but eventually received bexarotene while the remaining 20% received a combination therapy since the beginning. The median course of treatment was 20.78 months (1–114); and the overall response rate, 70.3%. Complete and partial response rates were achieved in 26% and 45% of the patients, respectively. Treatment was well tolerated, being the most common toxicities hypertriglyceridemia (79%), hypercholesterolemia (71%), and hypothyroidism (52%). No treatment-related grade 5 adverse events were reported. ConclusionsOur study confirms bexarotene is a safe and effective therapy for the long-term treatment of CTCL.

Estimation of ABO Anti-A and Anti-B Agglutinin Titers among Blood Donors at a Tertiary Care Referral Teaching Hospital Blood Centre in Southern India: A Cross-sectional Study

Introduction: Transfusion of blood Group O and its components with high ABO antibody titers to non O recipients has been shown to cause acute transfusion reactions, especially in platelet transfusions, as platelets contain significant amounts of ABO antigen on their surface as well as Anti-ABO alloisogglutinins in plasma. Aim: To estimate the ABO Anti-A and Anti-B agglutinin titers among blood donors at a tertiary care referral teaching hospital blood centre. Materials and Methods: This cross-sectional observational study was conducted at the Immunohaematology laboratory of the Department of Transfusion Medicine, Sri Venkateswara Institute of Medical Sciences, Tirupati, Andhra Pradesh, India, from March 2021 to June 2022. All blood donors presenting to the blood centre were screened for eligibility for blood donation. Donors who fulfilled the eligibility criteria as per the Drugs and Cosmetics Act, 1940, and Rules, 1945 were included. Anti-A and Anti-B titers were determined by the conventional tube method with dilutions of 1 in 2, 1 in 4, 1 in 8, 1 in 16, 1 in 32, 1 in 64, 1 in 128, 1 in 256, 1 in 512, and 1 in 1024. A titer of &lt;64 was considered as a low titer, while a titer of &gt;64 was considered as a high titer. Results: A total of 399 donors were included in the study, with 393 (98.5%) being males and 6 (1.5%) being females. The mean age of the study population was 28.49 years. Among blood group A, the percentage of individuals with an IgM anti-B titer of &lt;64 was 85.44% (88) and &gt;64 was 14.56% (15), whereas in blood group B, IgM anti-A titers of &lt;64 were 65.5% (93) and &gt;64 were 34.5% (49). In blood group O, the percentage of individuals with &lt;64 and &gt;64 titers of IgM anti-A were 52.60% (81) and 47.40% (73), respectively, whereas for anti-B, &lt;64 and &gt;64 titers were 77.92% (120) and 22.08% (34), respectively. Conclusion: It is recommended that a database be maintained in all institutes by estimating antibody titers for every A, B, O blood group donors. Whole blood or platelets from group O donors with IgM Anti-A and Anti-B antibody titers &lt;64 can only be transfused across the ABO barrier. As the majority of group A donors had titers &lt;64, group A platelets may be transfused across the ABO barrier in emergency situations.

Beyond the boundaries of ward-based services – exploring the scope of “non-traditional” clinical pharmacy practice in a tertiary referral teaching hospital

Abstract Introduction Hospital clinical pharmacy practice in the UK has developed beyond traditional boundaries of ward-based inpatient services. Royal Pharmaceutical Society Hospital Pharmacy Standards recommend pharmacy team members are integrated into multidisciplinary teams across the organisation to ensure safe and appropriate medicines use whatever the setting1. Pharmacy professionals provide pharmaceutical care and specialist services in outpatient and ambulatory settings and through participation in multidisciplinary team (MDT) meetings. Within the outpatient setting, research typically focusses on single outpatient clinics within specific disciplines, little evidence describes the overall contribution to patient care across whole pharmacy services2. Aim To describe the scope of clinical pharmacy services occurring beyond traditional ward-based services in a tertiary hospital; including quantification of outpatient clinics and MDT meetings provided by pharmacy professionals. Methods The Deputy Chief Pharmacist invited clinical Principal Pharmacists to participate in semi-structured interviews exploring the scope of “non-traditional” services across the Trust during March 2023. Non-traditional services were defined as direct clinical care outside of ward-based inpatient clinical pharmacy services. Indirect clinical care activities such as guideline writing, drug expenditure and governance activities were excluded. Inpatient board rounds/ward rounds and any service not currently provided due to vacancy were excluded. Participants were asked to quantify services provided, advise who provided the services and to describe contributions provided by the pharmacy team. The study was deemed service evaluation and ethical approval waived. Results 100% invited pharmacists participated. Pharmacists attended and contributed to over 150 MDT meetings monthly across 24 sub-specialities; 80% were for outpatients. In tertiary/quaternary services, these frequently covered patients beyond local geography. MDT meetings were typically attended by specialist, principal or consultant pharmacists. Common contributions included: provision of pro-active advice/responding to queries; medicines optimisation; monitoring; income or compliance assurance; prescribing/deprescribing. Specialist pharmacists provided 80-100 outpatient clinic sessions across 17 sub-specialities through a mix of face-to-face and virtual appointments, advanced pharmacy technicians provided on-treatment and counselling clinics. Activities included: initiation, monitoring, adjustment and cessation of medicines; patient counselling and MDT referral. Medicines prescribed were typically high cost, complex and higher risk. Pharmacists prescribed and clinically verified homecare medicines and provided ongoing annual review of outpatient medicines, including prescribing/deprescribing. Teams described medicines reconciliation and counselling in ambulatory haematology settings, off-site units and infusion suites. The team organised, optimised and provided advice and counselling for patients requiring antimicrobial therapies at home. Clinical pharmacists and pharmacy technicians provided medicines information to patients, internal and external healthcare professionals. Discussion/Conclusion This study provides evidence of the broad scope of clinical pharmacy practice beyond the boundaries of traditional ward-based services in a tertiary teaching hospital. This study was limited to a single organisation, specific clinical pharmacy activities and outcomes of these services were not fully quantified. Formal collation of clinical pharmacy activities within “non-traditional” outpatient and ambulatory settings is limited because activity data collection forms in hospital pharmacy are typically validated in traditional ward-based pharmacy services. We recommend further studies to validate activity collection tools to benchmark the activities of clinical pharmacy professionals providing services in outpatient and ambulatory settings both within and between hospital Trusts.

272 Advanced nurse practitioner -supported nursing home liaison service

Abstract Background Nursing Home Residents (NHR) are the frailest group of older people in society and require a gerontologically attuned approach to address multiple challenges presented to the practitioner. In 2018 we commenced an advanced nurse practitioner (ANP) specialist liaison service with bespoke comprehensive geriatric assessment (CGA) to support NHR admitted to a tertiary referral university teaching hospital. Given the impact of COVID-19 on NHR in particular, in 2020 this service was expanded to include a consultant physician and specialist registrar in geriatric medicine, when full care of NHRs came under geriatric medicine services. This includes a two-week post-discharge virtual clinic with the Nursing Home director of nursing and/or GP. Methods Information on all NHRs attending a tertiary referral university teaching hospital was collected from 2018–2023. Data on demographics, presenting complaints, CGA, and outcomes of Length of Stay (LoS), emergency department (ED) recidivism, and mortality were collected. Impact on clinical outcomes of liaison versus full geriatric medicine care are presented in this abstract. Results In 2018 there were 353 NHRs admitted from ED who represented 4,170 total hospital bed days. In 2019 there were 329 NHRs admitted with 3,991 total bed days. In 2021, 251 NHRs were admitted representing 2,582 total bed days. As result of the enhanced care model, where full inpatient governance came under the geriatric medicine services, we observed: (1) Readmission rate 37% (2018) vs 12.7% (2021), (2) Reduction in LoS from 2018–2021 from 11.8 to 10.0 days, (3) Halved the overall bed-usage days from 2018–2021. Conclusion The high complexity of this cohort of patients requires a timely, comprehensive gerontological approach in order to provide holistic care. Better care with CGA embedded also translates to better use of acute hospital resource.

Etiological Profile, Targeted Levothyroxine Dosing and Impact of Partial Newborn Screening in Congenital Hypothyroidism-A Single Centre Experience.

Congenital hypothyroidism (CH) is the most common cause of preventable intellectual disability. Newborn screening (NBS) for CH has been in vogue in many parts of the world since 1970, but despite its well-known benefits, many developing countries including India have not been able to establish universal NBS for CH till date. The aim of this study was to review the clinical aspects of congenital hypothyroidism in a tertiary care university referral teaching hospital, focusing on aetiology of CH, predictors of permanence, optimal targeted dose strategies based on aetiology and the effect of newborn screening on the time to diagnosis. The electronic medical records of 233 children with CH referred to our centre between January 2009 and December 2019 were analysed. A partial NBS was established in the state in 2012. Dyshormonogenesis (57.5%) was the most common aetiology of CH. The incidence of transient CH in children with a gland in situ (GIS) was 35%. Levothyroxine (LT-4) dose of >2.75 μg/kg/day (sensitivity 76.5, specificity 72), >2.15 μg/kg/day (sensitivity 82.4, specificity 61.9) and >1.85 μg/kg/day (sensitivity 76.5, specificity 61.9) at years 1, 2 and 3, respectively, were predictors of permanent CH. An initial LT-4 dose ≥8 μg/kg was sufficient and very seldom led to undertreatment in children with dyshormonogenesis. On the contrary, even doses ≥13 mcg/kg/day led to frequent undertreatment in children with thyroid dysgenesis. After the introduction of newborn screening, the median age at diagnosis came down from 45 days (IQR 14-180 days) to ten days (IQR 3-12 days). Targeted dosing based on aetiology of CH may be more appropriate to optimise outcomes. The time to diagnosis of CH reduced significantly after the adoption of even a partial NBS program highlighting the urgent need for implementation of the same in resource poor settings.

External validation of the FAMISH predicting score for early gastric cancer with endoscopic submucosal dissection.

To externally validate the robustness of the FAMISH predicting score designed to estimate the risk of metachronous gastric lesions (MGLs) after endoscopic submucosal dissection (ESD) for early gastric cancer (EGC). This multicenter, retrospective study included 618 patients with EGC who underwent curative ESD at two tertiary referral teaching hospitals between January 2014 and December 2019. FAMISH score was a composite indicator of age, sex, family history, corpus intestinal metaplasia, synchronous lesions, and H. pylori infection. Discrimination, calibration, and risk stratification of these scores were assessed. Associations between MGL characteristics and FAMISH scores were also explored. After a median follow-up period of 60 months, 83 of 618 patients (13.4%) developed MGL. The discrimination ability according to the area under the curve was 0.708 (95% CI, 0.645-0.772) for predicting the 5-year MGL. The calibration results showed good consistency between the predicted and actual MGL (Hosmer-Lemeshow, P > 0.05). In terms of risk stratification, the 5-year MGL rates were 4.1% (95% CI, 1.6%-6.5%), 10.8% (95% CI, 7.2%-14.3%), and 32.1% (95% CI, 20.9%-41.7%) in the low-, intermediate-, and high-risk groups, respectively (P < 0.001). For patients with MGL, the curative resection rate of ESD was significantly higher in the low- and intermediate-risk groups than in the high-risk group (100% vs. 80%, P = 0.037). The FAMISH predicting score was externally validated and can be generalized to an independent patient population. This adjuvant tool can assist in individual clinical decision-making.

E50 Central Nervous System manifestation of Systemic Lupus Erythematosus: A case presentation

Abstract Background Systemic Lupus Erythematosus (SLE) is a complex, chronic, multisystem autoimmune disease with clinical manifestations in all organ systems. It is characterized by production of autoantibodies to components of the cell nucleus. Pediatric patients tend to have more severe disease and widespread organ involvement. If untreated, the 5-year mortality rate is almost 95%. Literature on SLE, more so pediatric SLE in Sub-Saharan Africa is scarce. Aim To describe the diagnostic journey of a child with CNS lupus in our setting. Method Retrospective chart review of a child with CNS Lupus at a tertiary referral teaching hospital in Nairobi, Kenya. Results We present a case of a 14-year-old boy who was diagnosed with CNS Lupus. He was known to have a convulsive disorder, with a recent history of mutism and was on Lamictal and rivotril for approximately one year. He presented to our facility in status epilepticus, having complained of a sudden onset of headache prior to the onset of the convulsions. He had had an uneventful birth and developmental history with no family history of chronic ailments. On examination, he was found to have bilateral ptosis with no other neurological deficits and otherwise normal systemic examination. Complete blood count initially showed a slight neutrophilia and thrombocytosis. Kidney function was normal and the CSF workup was negative for infection. Chest X ray showed features of aspiration pneumonia for which he received Augmentin, nebulization with hypertonic saline and chest physiotherapy. EEG showed generalized electrical seizures. CT/MRI brain showed acute infarcts in the superior frontal gyrus, post central gyrus and in the right insular cortex. He was managed in the Intensive Care Unit until cessation of the seizures. Post extubation, he was noted to have reduced lower limb power and bulbar dysfunction. A rheumatology consult was requested and revealed speech regression, a prior episode of conjunctivitis, a vasculitic palmar rash, palatial petechiae and suspected right knee arthritis. Urinalysis was suggestive of glomerulonephritis. ANA Antibodies were positive (titers of 1:160), positive anti-Ro antibodies. Anti-Ds DNA, P and C ANCA were negative. Renal histopathology was unremarkable. He was pulsed with IV methylprednisolone for 3 days with improvement and thereafter on follow up as an outpatient in the Pediatric Rheumatology clinic. Conclusion Pediatric SLE has significant morbidity and mortality therefore early intervention is crucial to retard disease progression. Given the vast array of clinical manifestations, it requires a high index of suspicion to enable early, accurate diagnosis and prompt treatment.

OA01 A case report of a patient with Type 1 diabetes mellitus and systemic lupus erythematosus: a management dilemma

Abstract Background Systemic lupus erythematosus (SLE) is a chronic autoimmune disease affecting multiple organs. Up to 30% of patients with SLE will develop other autoimmune conditions. A few cases of SLE and Type 1 Diabetes Mellitus (T1DM) have been reported in literature. Corticosteroids which is key in induction therapy increases the risk of hyperglycemia and hypertension. Other immunosuppressive agents such as mycophenolate mofetil used in management of lupus nephritis increase the risk of hyperglycemia. This poses a challenge in the management of SLE in a patient with T1DM. Aim To describe a management dilemma in caring for a child with T1DM and SLE at a tertiary referral teaching hospital in Nairobi, Kenya. Method Retrospective chart review of a child with T1DM and SLE at Aga Khan University Medical College East Africa, Nairobi, Kenya. Results We discuss a 16-year-old male patient with T1DM since nine years of age on insulin and on follow up in the endocrine clinic. He presented with complaints of facial and lower limb swelling of three days and severe frontal headache associated with nausea for one day. He was also noted to have a strong family history of Sjogren’s disease and diabetes. His initial examination revealed hypertension with a blood pressure of 184/118 mmHg, facial and lower limb oedema. He was commenced on labetalol infusion and amlodipine for blood pressure control, and was to continue with his insulin regimen. Initial urinalysis showed proteinuria and hematuria. An impression of hypertensive emergency with nephropathy was made. Rheumatology review was requested. Investigations revealed an ANA titer of &amp;gt; 1:1280; anti-smith and anti dsDNA antibodies were positive; low C3 and low C4. Echo showed pleural effusion. The kidney biopsy showed features of proliferative lupus nephritis class IV with no features of diabetic nephropathy. A diagnosis of SLE was made and management initiated with hydroxychloroquine, methylprednisolone for three days then oral prednisolone and mycophenolate mofetil. During methylprednisolone therapy, the patient was noted to have unrecordably high blood glucose necessitating an insulin infusion for six days and close adjustment of insulin doses by the endocrinologist. Initially, after the 1st dose of methylprednisolone, his blood pressure seemed to improve. During the course of treatment, his blood pressure was elevated and difficult to control despite being on labetalol infusion, amlodipine, enalapril and carvedilol. Adjustment of antihypertensive drug doses and addition of hydralazine were made by the nephrologist, cardiologist and critical care specialist. He was eventually discharged with controlled blood glucose and blood pressure. He is currently doing well and is on follow up in the nephrology, rheumatology and endocrinology clinics. Conclusion Our case report highlights the challenges that arise while managing patients with SLE and other illnesses such as T1DM. It also points out the necessity of multi-disciplinary care. This may be a challenge in many African health facilities due to a low number of specialized doctors.

Pattern of Liver Function Test in Scrub Typhus Cases: A Hospital Based Observational Study in a Tertiary Care Center in Nepal

Background and Aim: Scrub typhus, a potentially severe but treatable infection is a major cause of acute non-malarial febrile illness in children in the rural tropics. The present study aims to explore the association between the liver function tests in the cases of scrub typhus and correlate the levels of these parameters with the severity of the scrub typhus infections, their clinical risk characteristics that may be used to forecast disease severity under routine clinical practice.&#x0D; Methodology: This prospective observational study, conducted at National Medical College Teaching Hospital, a tertiary care referral teaching hospital situated in province two of Nepal over a period of 7 months (November, 2021- May 2022) enrolled 75 scrub typhus cases and their liver function tests were done following standard guidelines.&#x0D; Results:There were deranged liver function tests in the participants. The mean Aspartate Transaminase, Alanine Transaminase, Total Bilirubin and Albumin were425.48 ± 505.56 U/L, 368.54 ± 402.22 U/L, 3.8 ± 3.1 mg/dL and 3.10 ± 0.8 g/dL, respectively. Most of the cases presented with hypoalbuminemia (66.7%), cardiac dysfunction (64%), acute kidney injury (61%) and hepatitis (60%). About 9 % of the subjects presented as multiorgan dysfunction syndrome (MODS).&#x0D; Conclusion: Scrub typhus cases presents with deranged liver function tests results and the values can be helpful in assessment of the disease severity and outcome.

Volunteers, religious communities and users representatives as an alternative for visiting hospitalized patients: The importance of an infection control training.

During the COVID-19 pandemic, the suspension of relatives' visits was a common measure in healthcare facilities to prevent the spread of the virus among patients. This measure caused significant adverse consequences for hospitalized patients. Volunteers' intervention was an alternative but could also lead to cross transmission events. in order to secure their intervention with patients, we implemented an infection control training to evaluate and to improve the knowledge of volunteers about infection control measures. We performed a before-after study in a group of five tertiary referral teaching hospitals in the suburbs of Paris. A total of 226 volunteers from three groups (religious representatives, civilian volunteers and users' representatives) were included. Basic theoretical and practical knowledge about infection control, hand hygiene, and glove and mask use were evaluated just before and immediately after a three-hour training program. The contribution of the characteristics of the volunteers to the results was studied. The initial conformity rate for theoretical and practical infection control measures ranged from 53% to 68%, depending on the participants' activity status and education level. Some critical shortcomings in hand hygiene as well as mask and glove wearing putatively endangered the patients and volunteers. Surprisingly, serious gaps were also identified among volunteers who experienced care activities. Regardless of their origin, the program significantly improved both their theoretical and practical knowledge (p<0.001). Real-life observance and long-term sustainability should be monitored. To become a secure alternative to relatives' visits, volunteers' interventions must be preceded by the assessment of their theoretical knowledge and practical skills in infection control. Additional study, including practice audit, must confirm the implementation of the acquired knowledge in the real-life.