Patient Turnover Research Articles

Exploring antibiotic prescribing in public and private primary care settings in Singapore: a qualitative analysis informing theory and evidence-based planning for value-driven intervention design

BackgroundSingapore’s healthcare system presents an ideal context to learn from diverse public and private operational models and funding systems.AimTo explore processes underpinning decision-making for antibiotic prescribing, by considering doctors’ experiences in different primary care settings.MethodsThirty semi-structured interviews were conducted with 17 doctors working in publicly funded primary care clinics (polyclinics) and 13 general practitioners (GP) working in private practices (solo, small and large). Data were analysed using applied thematic analysis following realist principles, synthesised into a theoretical model, informing solutions to appropriate antibiotic prescribing.ResultsGiven Singapore’s lack of national guidelines for antibiotic prescribing in primary care, practices are currently non-standardised. Themes contributing to optimal prescribing related first and foremost to personal valuing of reduction in antimicrobial resistance (AMR) which was enabled further by organisational culture creating and sustaining such values, and if patients were convinced of these too. Building trusting patient-doctor relationships, supported by reasonable patient loads among other factors were consistently observed to allow shared decision-making enabling optimal prescribing. Transparency and applying data to inform practice was a minority theme, nevertheless underpinning all levels of optimal care delivery. These themes are synthesised into the VALUE model proposed for guiding interventions to improve antibiotic prescribing practices.These should aim to reinforce intrapersonal Values consistent with prioritising AMR reduction, and Aligning organisational culture to these by leveraging standardised guidelines and interpersonal intervention tools. Such interventions should account for the wider systemic constraints experienced in publicly funded high patient turnover institutions, or private clinics with transactional models of care. Thus, ultimately a focus on Liaison between patient and doctor is crucial. For instance, building in adequate consultation time and props as discussion aids, or quick turnover communication tools in time-constrained settings. Message consistency will ultimately improve trust, helping to enable shared decision-making. Lastly, Use of monitoring data to track and Evaluate antibiotic prescribing using meaningful indicators, that account for the role of shared decision-making can also be leveraged for change.ConclusionsThese VALUE dimensions are recommended as potentially transferable to diverse contexts, and the model as implementation tool to be tested empirically and updated accordingly.

Assessment of Sacsin Turnover in Patients With ARSACS: Implications for Molecular Diagnosis and Pathogenesis.

Background and ObjectivesAutosomal recessive spastic ataxia of Charlevoix-Saguenay (ARSACS) is caused by variations in SACS gene encoding sacsin, a huge multimodular protein of unknown function. More than 200 SACS variations have been described worldwide to date. Because ARSACS presents phenotypic variability, previous empirical studies attempted to correlate the nature and position of SACS variations with the age at onset or with disease severity, although not considering the effect of the various variations on protein stability. In this work, we studied genotype-phenotype correlation in ARSACS at a functional level.MethodsWe analyzed a large set of skin fibroblasts derived from patients with ARSACS, including both new and already published cases, carrying variations of different types affecting diverse domains of the protein.ResultsWe found that sacsin is almost absent in patients with ARSACS, regardless of the nature of the variation. As expected, we did not detect sacsin in patients with truncating variations. We found it strikingly reduced or absent also in compound heterozygotes carrying diverse missense variations. In this case, we excluded SACS mRNA decay, defective translation, or faster posttranslational degradation as possible causes of protein reduction. Conversely, our results demonstrate that nascent mutant sacsin protein undergoes cotranslational ubiquitination and degradation.DiscussionOur results provide a mechanistic explanation for the lack of genotype-phenotype correlation in ARSACS. We also propose a new and unambiguous criterion for ARSACS diagnosis that is based on the evaluation of sacsin level. Last, we identified preemptive degradation of a mutant protein as a novel cause of a human disease.

Impact of Permissive Hypoxia and Hyperoxia Avoidance on Clinical Outcomes in Septic Patients Receiving Mechanical Ventilation: A Retrospective Single-Center Study.

Background Septic patients often require mechanical ventilation due to respiratory dysfunction, and effective ventilatory strategies can improve survival. The effects of the combination of permissive hypoxia and hyperoxia avoidance for managing mechanically ventilated patients are unknown. This study examines these effects on outcomes in mechanically ventilated septic patients. Methods In a retrospective before-and-after study, we examined adult septic patients (aged ≥18 years) requiring mechanical ventilation at a university hospital. On April 1, 2017, our mechanical ventilation policy changed from a conventional oxygenation target (SpO2: ≥96%) to more conservative targets with permissive hypoxia (SpO2: 88-92% or PaO2: 60 mmHg) and hyperoxia avoidance (reduced oxygenation for PaO2 > 110 mmHg). Patients were divided into a prechange group (April 2015 to March 2017; n = 83) and a postchange group (April 2017 to March 2019; n = 130). Data were extracted from clinical records and insurance claims. Using a multiple logistic regression model, we examined the association of the postchange group (permissive hypoxia and hyperoxia avoidance) with intensive care unit (ICU) mortality after adjusting for variables such as Sequential Organ Failure Assessment (SOFA) score and PaO2/FiO2 ratios. Results The postchange group did not have significantly lower adjusted ICU mortality (0.67, 0.33-1.43; P = 0.31) relative to the prechange group. However, there were significant intergroup differences in mechanical ventilation duration (prechange: 11.0 days, postchange: 7.0 days; P = 0.01) and ICU stay (prechange: 11.0 days, postchange: 9.0 days; P = 0.02). Conclusions Permissive hypoxia and hyperoxia avoidance had no significant association with reduced ICU mortality in mechanically ventilated septic patients. However, this approach was significantly associated with shorter mechanical ventilation duration and ICU stay, which can improve patient turnover and ventilator access.

56 ‘A Closed-Loop Audit on The Appropriateness of Urine Testing Carried Out on Surgical Patients in The Acute Surgical Unit in University Hospital Limerick as Compared with Hospital Guidelines’

Abstract Aim The acute surgical unit (ASU) in University Hospital Limerick (UHL) has a high turnover of patients of all surgical specialties, many of whom are sent home without the need for admission or follow-up. Urinalysis is very accessible, and is carried out on many patients, prior to them being seen by a doctor. Inappropriate urinalysis sets off a cascade of inappropriate urine culture, antimicrobial treatment and a waste of resources and time of nursing, medical and laboratory staff. We aim to identify and reduce inappropriate testing. Method The notes of all ASU patients during a one-week period were analysed using the ‘Therefore Navigator’ application, where all patient notes are scanned on leaving the ASU. Data relating to presenting complaint, presence or absence of urinary symptoms and abdominal pain, and urine dipstick and culture results (if performed) was collected for each patient. The results were compared with UHL guidelines on testing, an information sheet was designed and placed in ASU, and an education session for nursing staff was carried out. The second cycle was performed one month later. Results In the first cycle, 68% of the 99 ASU patients had urinalysis, and 48% had urine culture performed. Of cultures performed, only 23 of 47 (49%) were deemed indicated according to the guidelines. In the second cycle, 39% had urinalysis. 28% had urine cultured, 79% of these were deemed to have been indicated. Conclusions Inappropriate urine testing in the ASU decreased following teaching for nursing staff, together with an information leaflet being placed in the ASU.

1541 Treating Patients with Respect: Assessing the Completion Rate of The ReSPECT Form for Patients Admitted to Hospital

AimTo assess the current completion rate of the Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) form, and to identify ways to improve the completion rate for all inpatients under our care.MethodAll notes of admitted patients were reviewed for a completed ReSPECT form over a two-week period. Data was collected on whether a form had been completed and its respective fields. This was repeated in three cycles, introducing interventions between each cycle – trainee education and reminders were sent through our WhatsApp messenger group between cycles 1 and 2, and posters implemented between cycles 2 and 3.ResultsFor cycle 1, out of 40 patient notes, 9 (22.5%) had a completed ReSPECT form. This increased to 25 out of 57 patients (43.9%) for cycle 2. Cycle 3 found 1 out of 16 patients (6.7%) had a completed ReSPECT form.ConclusionsOur data demonstrated a significant deterioration in our compliance as a department. This could be due to a number of factors ranging from the coronavirus pandemic and staff redeployment to increased workloads, higher patient turnover, and new staff. In any outcome, the poster has proven to be ineffective. Whilst we identified that reminders via electronic message appear to have had an improvement, this has shown to be temporary, and may not be effective in busier times. As such, this audit has revealed a significant need for departmental change and to develop new strategies to improve compliance.

347 Read the First Page: An Audit on Medicine Reconciliation in General Surgery Inpatients at London District General Hospital

Abstract Aim Medication-related incidents occur more frequently when medicine reconciliation happens more than 24 hours after admission. The National Institute for Health and Care Excellence recommends a complete reconciliation within 24 hours of admission. General Surgery is a busy specialty with a high patient turnover rate. Hence, this audit was conducted to assess the extent of a problem and mitigate it. Method Every adult General Surgery inpatient who were admitted for over 24 hours were included. Patients on intensive care or high dependency unit were excluded. Drug charts were reviewed every Thursday for nine weeks between October and December 2020. Data from the first three weeks were used to establish baseline. Three interventions were introduced, each lasting two weeks. Any significant harm to patients due to incomplete reconciliation was recorded. Results At baseline (n = 100), 38.0% of patients had incomplete reconciliation. This significantly reduced to 23.4% (n = 64, p-value=0.037) between Weeks 4 and 5 after baseline data was presented at a team meeting and posters were put up. Allowing pharmacists to flag up missing medications on a daily job’s list did not significantly reduce the incompletion rate (23.0%, n = 74, p-value>0.999). Finally, performing a medicine reconciliation ward round on Weeks 8 and 9 further reduced the incompletion rate to 2.8% (n = 74, p-value=0.001). One significant harm was noted on Week 1. Conclusions Medicine reconciliation is a vital aspect of patient safety. Raising awareness of the issue significantly reduced the incompletion rate. However, the most effective intervention is conducting a medicine reconciliation ward round.

ICU Nurses—An Impact Factor on Patient Turnover in Cardiac Surgery in Western Denmark?

The aim of this study was to describe changes in performance indicators such as length of stay [LOS] in the intensive care unit [ICU] and ventilation time, during the last six years in an attempt to identify associations between patient and systemic performance indicators, including the impact of nurse turnover. A retrospective study of prospectively registered data (2013-2018). Propensity- score matching was performed to establish comparable groups. Three Danish university hospitals. The study included a total of 12,404 adult cardiac surgical patients registered in the Western Denmark Heart Registry. The cohort was divided into an "early" group (2013-2016) and a "late" group (2017-2018). An analysis of dynamics in patient indicators and systemic performance indicators, including the impact from selected performance parameters and nurse turnover. Comorbidity, calculated from the European System for Cardiac Operative Risk Evaluation, and the mean age were stable in the study period. Strong predictors of long LOS in the ICU included postoperative use of inotropes, re-exploration surgery, high postoperative drainage, and the "late" time group. Time parameters (relative risks) were all significantly longer in the "late" time group": ventilation time 1.21 (1.05-1.39), length of stay ICU 1.28 (1.11-1.48), and in-hospital time 1.36 (1.19-1.57). ICU nurse turnover increased from four (2013-2014) to 52 (2017-2018). No single patient factor, such as age or comorbidity, could explain the decrease in patient turnover in the ICU. In the same period, the turnover of ICU nurses increased. Patient turnover is complex and affected by a mix of patient and systemic performance factors.

Enhanced recovery after surgery in bariatric and metabolic surgery

: Enhanced recovery after surgery (ERAS) protocol is an extensive, evidence based, multimodal and multidisciplinary protocol for surgery. ERAS aims to enhance pre-intra and postoperative physiology and optimization of recovery after surgery. The concept of this approach showed us, multidisciplinary instrument integrating several perioperative elements, with the use of minimally invasive surgery, could be adopted various surgical procedures. Recently, principles of these protocols and their advantages are extended into bariatric and metabolic surgery. In this review, we summarize the components of ERAS protocols for bariatric and metabolic surgery according to ERAS Society guidelines and present the evidence on the emerging role of ERAS principles in obese patients. Many recent trials have evaluated ERAS protocols for bariatric surgery. Studies demonstrate that using ERAS protocols requires evidence-based modifications in all perioperative phase. The benefits of ERAS in this group of patients, including decreased length of hospital stay, rapid patient turnover, shorter operating room times and lower healthcare costs have been well demonstrated repeatedly. Despite the role of ERAS protocols in bariatric surgery is in its early phase, literature supports its role in improving perioperative outcomes compared with conventional care. Evidence-based protocols and multidisciplinary teamwork seem to be the key factors for success in ERAS.

Variation of Daily Care Demand in Swiss General Hospitals: Longitudinal Study on Capacity Utilization, Patient Turnover and Clinical Complexity Levels.

BackgroundVariations in hospitals’ care demand relies not only on the patient volume but also on the disease severity. Understanding both daily severity and patient volume in hospitals could help to identify hospital pressure zones to improve hospital-capacity planning and policy-making.ObjectiveThis longitudinal study explored daily care demand dynamics in Swiss general hospitals for 3 measures: (1) capacity utilization, (2) patient turnover, and (3) patient clinical complexity level.MethodsA retrospective population-based analysis was conducted with 1 year of routine data of 1.2 million inpatients from 102 Swiss general hospitals. Capacity utilization was measured as a percentage of the daily maximum number of inpatients. Patient turnover was measured as a percentage of the daily sum of admissions and discharges per hospital. Patient clinical complexity level was measured as the average daily patient disease severity per hospital from the clinical complexity algorithm.ResultsThere was a pronounced variability of care demand in Swiss general hospitals. Among hospitals, the average daily capacity utilization ranged from 57.8% (95% CI 57.3-58.4) to 87.7% (95% CI 87.3-88.0), patient turnover ranged from 22.5% (95% CI 22.1-22.8) to 34.5% (95% CI 34.3-34.7), and the mean patient clinical complexity level ranged from 1.26 (95% CI 1.25-1.27) to 2.06 (95% CI 2.05-2.07). Moreover, both within and between hospitals, all 3 measures varied distinctly between days of the year, between days of the week, between weekdays and weekends, and between seasons.ConclusionsWhile admissions and discharges drive capacity utilization and patient turnover variation, disease severity of each patient drives patient clinical complexity level. Monitoring—and, if possible, anticipating—daily care demand fluctuations is key to managing hospital pressure zones. This study provides a pathway for identifying patients’ daily exposure to strained hospital systems for a time-varying causal model.

Bone Nanomechanical Properties and Relationship to Bone Turnover and Architecture in Patients With Atypical Femur Fractures: A Prospective Nested Case-Control Study.

ABSTRACTAtypical femur fractures (AFFs) are well‐established serious complication of long‐term bisphosphonate and denosumab therapy in patients with osteopenia or osteoporosis. To elucidate underlying mechanism(s) for the development of AFF, we performed a nested case‐control study to investigate bone tissue nanomechanical properties and prevailing bone microstructure and tissue‐level remodeling status as assessed by bone histomorphometry. We hypothesized that there would be differences in nanomechanical properties between patients with and without AFF and that bone microstructure and remodeling would be related to nanomechanical properties. Thirty‐two full‐thickness transiliac bone biopsies were obtained from age‐ and sex‐matched patients on long‐term bisphosphonate therapy with (n = 16) and without an AFF (n = 16). Standard histomorphometric measurements were made in each sample on three different bone envelopes (cancellous, intracortical, and endosteal). Iliac bone wall thickness was significantly lower on all three bone surfaces in patients with AFF than in those without AFF. Surface‐based bone formation rate was suppressed similarly in both groups in comparison to healthy premenopausal and postmenopausal women, with no significant difference between the two groups. Nanoindentation was used to assess material properties of cortical and cancellous bone separately. Elastic modulus was higher in cortical than in cancellous bone in patients with AFF as well as compared to the elastic modulus of cortical bone from non‐AFF patients. However, the elastic modulus of the cancellous bone was not different between AFF and non‐AFF groups or between cortical and cancellous bone of non‐AFF patients. Resistance to plastic deformation was decreased in cortical bone in both AFF and non‐AFF groups compared to cancellous bone, but to a greater extent in AFF patients. We conclude that long‐term bisphosphonate therapy is associated with prolonged suppression of bone turnover resulting in altered cortical remodeling and tissue nanomechanical properties leading to AFF. © 2021 The Authors. JBMR Plus published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research.

Healthcare Safety Nets during the COVID-19 Pandemic Based on Double Diamond Model: A Concept Analysis.

The purpose of this study was to analyze the concept of the “healthcare safety net” during the COVID-19 pandemic. Walker and Avant’s process of concept analysis was used in this systematic literature review. The attributes of the concept of a healthcare safety net during the COVID-19 pandemic were found to be: (a) capacity, (b) accessibility, (c) health equality, and (d) education. In consideration of these defining criteria, antecedents to the concept were identified as: (a) the COVID-19 pandemic, (b) health inequalities (internal factors and external factors), and (c) healthcare systems (health insurance, screening, protective equipment, medicine, and medical services). Consequences of the concept were: (a) meeting healthcare needs, (b) quality of life, and (c) a decrease in morbidity and mortality. A healthcare safety net is an important concept during the COVID-19 pandemic. In situations like COVID-19, healthcare safety nets are designed to meet safety needs, improve quality of life, and reduce patient turnover and mortality. Based on the results of this study, the development of standardized tools for measuring a healthcare safety net as well as that of policies and systems for resolving a healthcare safety net in the COVID-19 situation is recommended.

Quantifying paediatric intensive care unit staffing levels at a paediatric academic medical centre: A mixed-methods approach.

To identify, simulate and evaluate the formal and informal patient-level and unit-level factors that nurse managers use to determine the number of nurses for each shift. Nurse staffing schedules are commonly set based on metrics such as midnight census that do not account for seasonality or midday turnover, resulting in last-minute adjustments or inappropriate staffing levels. Staffing schedules at a paediatric intensive care unit (PICU) were simulated based on nurse-to-patient assignment rules from interviews with nursing management. Multivariate regression modelled the discrepancies between scheduled and historical staffing levels and constructed rules to reduce these discrepancies. The primary outcome was the median difference between simulated and historical staffing levels. Nurse-to-patient ratios underestimated staffing by a median of 1.5 nurses per shift. Multivariate regression identified patient turnover as the primary factor accounting for this difference and subgroup analysis revealed that patient age and weight were also important. New rules reduced the difference to a median of 0.07 nurses per shift. Measurable, predictable indicators of patient acuity and historical trends may allow for schedules that better match demand. Data-driven methods can quantify what drives unit demand and generate nurse schedules that require fewer last-minute adjustments.

Regional Anaesthesia in Enhanced Recovery After Surgery Pathways – A Quintessential Component

Enhanced recovery after surgery (ERAS) is a multimodal, perioperative care pathway designed to achieve early recovery for patients undergoing major surgery. [1] Initially described by Henry Kehlet in 1995 for colonic surgeries, the enhanced recovery pathways have now evolved and are now validated for more than 30 different types of surgery which include but are not limited to emergency laparotomy, neonatal surgeries, and lower segment cesarean sections. [2] Not only is the patient benefited from this by having an enhanced recovery and early discharge from the hospital, the cost of treatment is reduced and also leads to more turnover of patients thereby reducing the waiting list of patients scheduled for various surgeries. [3]

Bone marrow adiposity inversely correlates with bone turnover in pediatric renal osteodystrophy

Bone marrow adiposity is associated with bone disease in the general population. Although chronic kidney disease (CKD) is associated with increased bone fragility, the correlation between marrow adiposity and bone health in CKD is unknown. We evaluated the relationship between bone marrow adipocytes and bone histomorphometry in 32 pediatric patients. We also evaluated the effects of growth hormone and calcitriol (1,25(OH)2D3)—two therapies commonly prescribed for pediatric bone disease—on marrow adiposity and bone histomorphometry. Finally, the adipogenic potential of primary human osteoblasts from CKD patients was assessed in vitro, both alone and in the presence of 1,25(OH)2D3. In cross-sectional analysis, marrow adipocyte number per tissue area (Adi.N/T.Ar) correlated with bone formation rate/bone surface (BFR/BS) in patients with high bone turnover (r = −0.55, p = 0.01) but not in those with low/normal bone turnover. Changes in bone formation rate correlated with changes Adi.N/T.Ar on repeat bone biopsy(r = −0.48, p = 0.02). In vitro, CKD and control osteoblasts had a similar propensity to transition into an adipocyte-like phenotype; 1,25(OH)2D3 had very little effect on this propensity. In conclusion, marrow adiposity correlates inversely with bone turnover in pediatric patients with high turnover renal osteodystrophy. The range of adiposity observed in pediatric patients with low/normal bone turnover is not explained by intrinsic changes to precursor cells or by therapies but may reflect the effects of circulating factors on bone cell health in this population.

Bone turnover and mineral metabolism in adult patients with hypophosphatasia treated with asfotase alfa

SummaryThere is limited understanding of how asfotase alfa affects mineral metabolism and bone turnover in adults with pediatric-onset hypophosphatasia. This study showed that adults with hypophosphatasia treated with asfotase alfa experienced significant changes in biochemical markers of bone and mineral metabolism, possibly reflecting enhanced bone remodeling of previously osteomalacic bone.IntroductionHypophosphatasia (HPP), due to a tissue nonspecific alkaline phosphatase (TNSALP) deficiency, can cause impaired bone mineralization and turnover. Although HPP may be treated with asfotase alfa, an enzyme replacement therapy, limited data are available on how treatment with asfotase alfa affects mineral metabolism and bone turnover in adults with HPP.MethodsALP substrates, bone turnover and mineral metabolism markers, and bone mineral density (BMD) data from EmPATHY, a single-center, observational study of adults (≥ 18 years) with pediatric-onset HPP treated with asfotase alfa (NCT03418389), were collected during routine clinical care and analyzed from baseline through 24 months of treatment.ResultsData from 21 patients showed significantly increased ALP activity and reduced urine phosphoethanolamine (PEA)/creatinine (Cr) ratios after baseline through 24 months of asfotase alfa treatment. There were significant transient increases in parathyroid hormone 1-84 (PTH), osteocalcin, and procollagen type 1 N-propeptide (P1NP) levels at 3 and 6 months and in tartrate-resistant acid phosphatase 5b (TRAP5b) levels at 3 months, with a significant decrease in N-terminal telopeptide of type 1 collagen (NTX) levels at 24 months. Lumbar spine BMD T scores continuously increased during treatment.ConclusionSignificant changes in bone turnover and mineral metabolism markers after asfotase alfa treatment suggest that treatment-mediated mineralization may enable remodeling and bone turnover on previously unmineralized surfaces. Urine PEA/Cr ratios may be a useful parameter in monitoring treatment during routine care.

Lower Antiplatelet Effect of Aspirin in Essential Thrombocythemia than in Coronary Artery Disease.

Background Patients with essential thrombocythemia (ET) and coronary artery disease (CAD) have increased risk of thromboembolic complications. In addition, a reduced antiplatelet effect of aspirin has been demonstrated in both patient groups. As ET is a platelet disorder, platelets may be more important for the thromboembolic risk in ET than in CAD. We aimed to investigate the antiplatelet effect of aspirin and platelet turnover in ET versus CAD patients. Methods We included 48 ET patients and an age-matched group of 48 CAD patients. The effect of aspirin was evaluated by thromboxane B 2 (TXB 2 ) levels and platelet aggregation. Platelet turnover was assessed by immature platelet count (IPC) and immature platelet fraction (IPF). Results ET patients had reduced effect of aspirin compared with CAD patients, demonstrated by significantly higher TXB 2 levels (median of differences = 22.3 ng/mL, p < 0.0001) and platelet aggregation (median of differences = 131.0 AU*min, p = 0.0003). Furthermore, ET patients had significantly higher IPC ( p < 0.0001) and IPF ( p = 0.0004) than CAD patients. Conclusion ET patients have lower 24-hour antiplatelet effect of aspirin than CAD patients. This may be explained by an increased platelet production and turnover counteracting the antiplatelet effect of aspirin. These findings strengthen the rationale for exploring novel antiplatelet regimens in ET patients to reduce the risk of cardiovascular events.

Different Techniques for Rubber Dam Isolation: A Cross-Sectional Study

Objective: To assess knowledge, regarding use of rubber dam during root canal treatment among dentists in Rawalpindi and Islamabad.Study Design: Descriptive cross-sectionPlace and Duration of Study: Operative Department Armed Forces Institute of Dentistry (AFID) Rawalpindi from 1st March 2020 to 31st May 2020. Materials and Methods: A web-based questionnaire, comprising of close-ended questions in the categories of demographics, clinical experience, usage of isolation techniques and knowledge regarding rubber dam (RD) use, procedures, and contraindications was sent through internet to 387 dentists of Rawalpindi and Islamabad. The response rate was 77.5%. Data was analyzed using SPSS version 20, and was displayed as numbers and percentages.Results: 79 out of 300 i.e. 26.33% respondents used rubber dam in restorative and endodontic procedures. 73.3% were using other methods of isolation such as cotton rolls, saliva ejectors and high volume suction. All the respondents were aware about the importance of rubber dam. The most challenging factor for dentists (57.3%) was high influx of patients per day.Conclusion: Rubber dam is not being used commonly by participating dentists of tertiary dental hospitals of Rawalpindi and Islamabad mainly because of high patient turnover per day, combination of cotton rolls and saliva high-volume ejector or gauze is the most common alternative to rubber dam isolation. Rubber dam isolation is highly recommended.&#x0D;

Effect of cachexia on bone turnover in cancer patients: a case-control study

BackgroundIncreased bone turnover is frequently observed in advanced cancer and predominantly related to bone metastases or therapy. Cachexia represents an important cause of morbidity and mortality in cancer patients. Key features are weight loss, muscle wasting and chronic inflammation, which induce profound metabolic changes in several organs, including the bone. However, whether cachexia contributes to abnormal bone metabolism in cancer patients is unknown. Aim of the present study was to determine the potential correlation of bone turnover markers with body composition and laboratory parameters in treatment-naïve cancer patients.MethodsIn this cross-sectional study we measured the levels of carboxy terminal telopeptide of collagen (CTX), an indicator of bone resorption, as well as osteocalcin (Ocn) and procollagen type I N-terminal propeptide (PINP), indicators of bone formation, in 52 cancer patients and correlated with body composition and laboratory parameters. Univariate and multivariate logistic analysis were performed to identify determinants of negative bone remodeling balance, estimated by CTX/Ocn and CTX/PINP ratio.ResultsBased on weight loss, body mass index and muscle mass, patients were divided into a cachectic (59.6%) and a control (40.4%) group. After correcting for the presence of bone metastases, our results showed a significant upregulation of CTX in cachectic patients compared to non-cachectic cancer patients (median 0.38 vs 0.27 ng/mL, p < 0.05), with no difference in Ocn and PINP levels (mean 14 vs. 16 ng/ml, p = 0.2 and median 32 vs. 26 μg/L, p = 0.5, respectively). In addition, the CTX/Ocn and the CTX/PINP ratio were indicative of bone resorption in 68% and 60% of cachexia patients, respectively (vs. 20% and 31% in the control group, p = 0.002 and p = 0.06). The main determinants of the unbalanced bone turnover were hypoalbuminemia for the CTX/Ocn ratio (OR 19.8, p < 0.01) and high CRP for the CTX/PINP ratio (OR 5.3, p < 0.01) in the multivariate regression analysis.ConclusionsCTX is substantially higher in cachectic patients compared to non-cachectic oncological patients and hypoalbuminemia as well as elevated CRP concentrations are independent predictors of a negative bone remodeling balance in cancer patients. These results strongly indicate that cachexia correlates with exacerbated bone turnover in cancer.

Baseline N-Telopeptide Levels Correlate with Risk of Skeletal Morbidity in Patients with Multiple Myeloma during Zoledronic Acid Therapy.

BACKGROUND: Biochemical markers of bone metabolism provide valuable information about rates of bone turnover in patients with malignant bone disease. N-telopeptide of type I collagen (NTX) is released during osteolysis and is indicative of pathologic increases in bone resorption. Elevated NTX levels recently have been correlated with increased risks of skeletal-related events (SREs, defined as pathologic fracture, surgery to bone, spinal cord compression, hypercalcemia of malignancy, and the requirement for palliative radiotherapy), disease progression, and death in patients with bone metastases from solid tumors (Coleman RE, et al. J Clin Oncol. 2005; 23:4925–4935; Brown J, et al. J Natl Cancer Inst . 2005; 97:59–69).METHODS: The current univariate analysis investigated the correlation between NTX levels at baseline and SREs (including palliative radiotherapy to bone) in patients with multiple myeloma who were treated with 4 mg zoledronic acid in a phase III clinical trial (Rosen LS, et al. Cancer J. 2001; 7:377–387).RESULTS: Forty-three patients had low NTX (< 50 nmol/mmol creatinine), 45 had moderate NTX (50 to < 100 nmol/mmol creatinine), and 18 had high NTX (≥ 100 nmol/mmol creatinine) at baseline. Patients with either moderate or high NTX at baseline had significantly increased risks of on-study SREs and significantly increased risks of experiencing their first SRE while on-study compared with patients with low NTX (Table). A similar correlation was also observed for pathologic fractures alone. The risk of first events was especially high in the high NTX group. There were no significant correlations between NTX levels and the requirement for palliative radiotherapy alone.Hazard Ratios for Time to Onset and Occurrence of On-Study SRE Compared With Low (< 50 nmol/mmol creatinine) NTX (P Value)SREPathologic fracturePalliative radiotherapyBaseline NTX levelOnset of first SREAny eventOnset of first eventAny eventOnset of first eventAny eventModerate*2.76 (.012)2.26 (.003)3.78 (.001)2.98 (< .001)1.21 (.777)1.61 (.386)High†6.80 (< .001)4.01 (.001)8.87 (< .001)5.35 (< .001)3.23 (.095)3.44 (.124)*50 to < 100 nmol/mmol creatinine.; † ≥ 100 nmol/mmol creatinine.Conclusions: Multiple myeloma patients with elevated baseline NTX levels have a significantly increased risk of experiencing SREs.

PERSEPSI PERAWAT MENGENAI KEBUTUHAN SPIRITUAL DAN PEMENUHAN KEBUTUHAN SPIRITUAL PASIEN DI INSTALASI GAWAT DARURAT

Patient overcrowding and rapid patient turnover in emergency department cause nurses to be less than optimal in providing patients spiritual needs. This condition can affect the emergency nurses' perceptions of spirituality and fulfill the patient's spiritual needs. A good fulfillment of the emergency patients spiritual needs can also improved a good treatment results. Nurses who have a good spiritual perception will have the ability to fulfill the patient's spiritual needs. Objective: describe nurses’ perception of spiritual needs and fulfill the spiritual needs of patients in the emergency department. Methods: This study was used descriptive survey research. Samples were taken using total sampling technique and obtained 75 participants. Data were taken using the Spiritual Care Giving Scale (SCGS) questionnaire and analyzed by univariate analysis. Results: more than a half of emergency nurses considered spiritual needs and fulfilled the patient’s spiritual needs as very important (57,3%). Every aspect of fulfilling spiritual needs is also perceived to be very important by emergency nurses. Conclusion: An aspect that need to be improved are values in fulfilling spiritual needs. The value of spirituality is interpreted as a very important part of holistic nursing. Consequently, emergency nurses need to improve their understanding of spirituality so that the implementation of fulfilling patients spiritual needs in emergency department can be positively reinforced.