Prevalence of Clostridium difficile infection among the patients attending a tertiary care teaching hospital.

PubMed

Segar, Lavanya; Easow, Joshy M; Srirangaraj, Sreenivasan; Hanifah, Mohammad; Joseph, Noyal M; Seetha, K S

2017-01-01

Clostridium difficile, a most important nosocomial enteric pathogen, is recognized globally as responsible for antibiotic-associated diarrhea and colitis. It is associated with considerable morbidity and mortality due to widespread use of antibiotics. The study was done to determine the prevalence of C. difficile infection (CDI) among the patients attending a tertiary care teaching hospital in Puducherry. We performed a prospective cohort study in Mahatma Gandhi Medical College and Research Institute. Around 150 patients were evaluated along with the patient details. C. difficile toxin detection was done as per the standard algorithm using the C. Diff Quik Chek Complete® assay (TECHLAB, Blacksburg, VA, USA). Analysis was done using statistics software (SPSS 16.0, SPSS Inc., Chicago, IL, USA). The prevalence of CDI was found to be 4%. More toxin-positive cases were between 50 and 60 years of age, and there was no difference in gender. Intensive Care Unit showed more toxin-positive cases; however, there was no significant association between the occurrence of CDI and the primary diagnosis of the patients. The prevalence of CDI in our hospital was found to be 4%, which was relatively lower compared to other Indian studies. However, awareness of the risk factors may assist in identifying patients at higher risk for CDI, guide implementation of appropriate preventive measures, and modulate potential intervention measure during management.

Into the abyss: diabetes process of care indicators and outcomes of defaulters from a Canadian tertiary care multidisciplinary diabetes clinic

PubMed Central

2013-01-01

Background Continuity of care is essential for good quality diabetes management. We recently found that 46% of patients defaulted from care (had no contact with the clinic for 18 months after a follow-up appointment was ordered) in a Canadian multidisciplinary tertiary care diabetes clinic. The primary aim was to compare characteristics, diabetes processes of care, and outcomes from referral to within 1 year after leaving clinic or to the end of the follow-up period among those patients who defaulted, were discharged or were retained in the clinic. Methods Retrospective cohort study of 193 patients referred to the Foustanellas Endocrine and Diabetes Center (FEDC) for type 2 diabetes from January 1, 2005 to June 30, 2005. The FEDC is the primary academic referral centre for the Ottawa Region and provides multidisciplinary diabetes management. Defaulters (mean age 58.5 ± 12.5 year, 60% M) were compared to patients who were retained in the clinic (mean age 61.4 ± 10.47 years, 49% M) and those who were formally discharged (mean age 61.5 ± 13.2 years, 53.3% M). The chart audit population was then individually linked on an individual patient basis for laboratory testing, physician visits billed through OHIP, hospitalizations and emergency room visits using Ontario health card numbers to health administrative data from the Ministry of Health and Long-Term Care at the Institute for Clinical and Evaluative Sciences (ICES). Results Retained and defaulted patients had significantly longer duration of diabetes, more microvascular complications, were more likely to be on insulin and less likely to have a HbA1c < 7.0% than patients discharged from clinic. A significantly lower proportion of patients who defaulted from tertiary care received recommended monitoring for their diabetes (HbA1c measurements, lipid measurements, and periodic eye examinations), despite no difference in median number of visits to a primary care provider (PCP). Emergency room visits were numerically higher in the defaulters group. Conclusions Patients defaulting from a tertiary care diabetes hospital do not receive the recommended monitoring for their diabetes management despite attending PCP appointments. Efforts should be made to minimize defaulting in this group of individuals. PMID:23938105

C. trachomatis in female reproductive tract infections and RFLP-based genotyping: a 16-year study from a tertiary care hospital.

PubMed

Gita, Satpathy; Suneeta, Mittal; Anjana, Sharma; Niranjan, Nayak; Sujata, Mohanty; Pandey, R M

2011-01-01

Presence of Chlamydia trachomatis in endocervix was determined in 2466 women attending a tertiary care hospital in New Delhi, India over a period of 16 years, using a monoclonal-based direct immunofluorescence assay, tissue culture isolation, and a conventional PCR assay. Chlamydia antigen could be detected in 391 out of 2466 (15.85%) of patients studied; in 27.27% women with PID, 16.74% women with cervicitis, 16.03% women with infertility, and 12.06% women with adverse pregnancy outcomes, respectively. There was a statistically significant decreasing trend in Chlamydia antigen positivity between the years 1994-1999 and 2000-2004; the apparent decline in antigen positivity between the years 2000-2004 and 2005-2010 was not statistically significant. Antigen detection assay detected equal number of positives as the PCR assay; tissue culture isolation demonstrated lower positivity. In a few representative specimens from cervicitis patients, genotyping was done using RFLP pattern analysis of C. trachomatis MOMP gene amplified by PCR assay, all of these belonged to Chlamydia trachomatis serovar E.

C. trachomatis in Female Reproductive Tract Infections and RFLP-Based Genotyping: A 16-Year Study from a Tertiary Care Hospital

PubMed Central

Gita, Satpathy; Suneeta, Mittal; Anjana, Sharma; Niranjan, Nayak; Sujata, Mohanty; Pandey, R. M.

2011-01-01

Presence of Chlamydia trachomatis in endocervix was determined in 2466 women attending a tertiary care hospital in New Delhi, India over a period of 16 years, using a monoclonal-based direct immunofluorescence assay, tissue culture isolation, and a conventional PCR assay. Chlamydia antigen could be detected in 391 out of 2466 (15.85%) of patients studied; in 27.27% women with PID, 16.74% women with cervicitis, 16.03% women with infertility, and 12.06% women with adverse pregnancy outcomes, respectively. There was a statistically significant decreasing trend in Chlamydia antigen positivity between the years 1994–1999 and 2000–2004; the apparent decline in antigen positivity between the years 2000–2004 and 2005–2010 was not statistically significant. Antigen detection assay detected equal number of positives as the PCR assay; tissue culture isolation demonstrated lower positivity. In a few representative specimens from cervicitis patients, genotyping was done using RFLP pattern analysis of C. trachomatis MOMP gene amplified by PCR assay, all of these belonged to Chlamydia trachomatis serovar E. PMID:21747643

Prevalence of Clostridium difficile toxinotypes in infected patients at a tertiary care center in Lebanon.

PubMed

Moukhaiber, Romy; Araj, George F; Kissoyan, Kohar Annie B; Cheaito, Katia A; Matar, Ghassan M

2015-07-30

Due to the increase in the incidence of Clostridium difficile associated diseases at a tertiary care center in Lebanon, this study was undertaken to determine the prevalent C. difficile toxinotypes. The immunocard method was used to test for toxins A and B in 88 collected stool samples, followed with API 20A to confirm for C. difficile. PCR amplification of the triose phosphate isomerase (tpi) gene, the toxin encoding genes tcdA, and tcdB, followed by toxinotyping, were performed on recovered isolates and stool specimens. Out of the 88 stool samples obtained, 30 (65.2%) were Immunocard positive, culture and or tpi positive for C. difficile. Of the 30 isolates, 4 were PCR negative for the tcdA and tcdB genes (A-B-), and 26 were PCR positive for the tcdA and / or tcdB genes with 4 being A+B+, 1 A+B-, and 21 A-B+. The results of toxinotyping showed that 2 isolates belonged to toxinotype 0, 4 to toxinotype XI, 2 to toxinotype XII, 1 to toxinotype XVI, 1(A+B-) and twenty (A-B+) designated as toxinotype 0-like. C. difficile was detected in 65.2% of patients' stools with prevalence of toxinotype 0-like. Identification of toxinotypes of C. difficile is important to determine the virulence potential of strains and control their spread.

Disaster resilience in tertiary hospitals: a cross-sectional survey in Shandong Province, China

PubMed Central

2014-01-01

Background Hospital disaster resilience can be defined as a hospital’s ability to resist, absorb, and respond to the shock of disasters while maintaining critical functions, and then to recover to its original state or adapt to a new one. This study aims to explore the status of resilience among tertiary hospitals in Shandong Province, China. Methods A stratified random sample (n = 50) was derived from tertiary A, tertiary B, and tertiary C hospitals in Shandong Province, and was surveyed by questionnaire. Data on hospital characteristics and 8 key domains of hospital resilience were collected and analysed. Variables were binary, and analysed using descriptive statistics such as frequencies. Results A response rate of 82% (n = 41) was attained. Factor analysis identified four key factors from eight domains which appear to reflect the overall level of disaster resilience. These were hospital safety, disaster management mechanisms, disaster resources and disaster medical care capability. The survey demonstrated that in regard to hospital safety, 93% had syndromic surveillance systems for infectious diseases and 68% had evaluated their safety standards. In regard to disaster management mechanisms, all had general plans, while only 20% had specific plans for individual hazards. 49% had a public communication protocol and 43.9% attended the local coordination meetings. In regard to disaster resources, 75.6% and 87.5% stockpiled emergency drugs and materials respectively, while less than a third (30%) had a signed Memorandum of Understanding with other hospitals to share these resources. Finally in regard to medical care, 66% could dispatch an on-site medical rescue team, but only 5% had a ‘portable hospital’ function and 36.6% and 12% of the hospitals could surge their beds and staff capacity respectively. The average beds surge capacity within 1 day was 13%. Conclusions This study validated the broad utility of a framework for understanding and measuring the level of hospital resilience. The survey demonstrated considerable variability in disaster resilience arrangements of tertiary hospitals in Shandong province, and the difference between tertiary A hospitals and tertiary B hospitals was also identified in essential areas. PMID:24661641

Disaster resilience in tertiary hospitals: a cross-sectional survey in Shandong Province, China.

PubMed

Zhong, Shuang; Hou, Xiang-Yu; Clark, Michele; Zang, Yu-Li; Wang, Lu; Xu, Ling-Zhong; FitzGerald, Gerard

2014-03-25

Hospital disaster resilience can be defined as a hospital's ability to resist, absorb, and respond to the shock of disasters while maintaining critical functions, and then to recover to its original state or adapt to a new one. This study aims to explore the status of resilience among tertiary hospitals in Shandong Province, China. A stratified random sample (n = 50) was derived from tertiary A, tertiary B, and tertiary C hospitals in Shandong Province, and was surveyed by questionnaire. Data on hospital characteristics and 8 key domains of hospital resilience were collected and analysed. Variables were binary, and analysed using descriptive statistics such as frequencies. A response rate of 82% (n = 41) was attained. Factor analysis identified four key factors from eight domains which appear to reflect the overall level of disaster resilience. These were hospital safety, disaster management mechanisms, disaster resources and disaster medical care capability. The survey demonstrated that in regard to hospital safety, 93% had syndromic surveillance systems for infectious diseases and 68% had evaluated their safety standards. In regard to disaster management mechanisms, all had general plans, while only 20% had specific plans for individual hazards. 49% had a public communication protocol and 43.9% attended the local coordination meetings. In regard to disaster resources, 75.6% and 87.5% stockpiled emergency drugs and materials respectively, while less than a third (30%) had a signed Memorandum of Understanding with other hospitals to share these resources. Finally in regard to medical care, 66% could dispatch an on-site medical rescue team, but only 5% had a 'portable hospital' function and 36.6% and 12% of the hospitals could surge their beds and staff capacity respectively. The average beds surge capacity within 1 day was 13%. This study validated the broad utility of a framework for understanding and measuring the level of hospital resilience. The survey demonstrated considerable variability in disaster resilience arrangements of tertiary hospitals in Shandong province, and the difference between tertiary A hospitals and tertiary B hospitals was also identified in essential areas.

Nurses’ Perceptions of Spirituality and Spiritual Care at Five Tertiary Care Hospitals in Riyadh, Saudi Arabia: A Cross-Sectional Study

PubMed Central

Kaddourah, Bayan; Abu-Shaheen, Amani; Al-Tannir, Mohamad

2018-01-01

Objectives To identify the perceptions towards spirituality and spiritual care among nurses at tertiary care hospitals in Riyadh, Saudi Arabia. Methods A cross-sectional study was conducted on nurses at five tertiary care hospitals in Riyadh. The data were collected using the Spirituality and Spiritual Care Rating Scale (SSCRS). Results We recruited 978 nurses, of which 896 (91.6%) were female. The mean SSCRS score was 3.8±0.5 (the spirituality and spiritual care statements fell within the ‘agree’ category). A statistically significant difference was found only between perceptions of spirituality and spiritual care among nurses and their nursing experience duration. Conclusions The findings of this study revealed that nurses were oriented to spirituality, and respected the importance of providing spiritual care to their patients. The nurses believed that spirituality exists in all religions and spiritual care means showing concern while treating the patients by focusing on respecting patients’ religious beliefs. PMID:29657685

Fungal Profile of Vulvovaginal Candidiasis in a Tertiary Care Hospital.

PubMed

Kalaiarasan, Krishnapriya; Singh, Rakesh; Chaturvedula, Latha

2017-03-01

Vulvovaginal Candidiasis (VVC) is a common medical health problem of adult women. It is most commonly caused by Candida albicans . But there is a change in fungal profile. Sabouraud's Dextrose Agar (SDA) is the most common culture medium used where mixed fungal infection may be missed. It can be detected easily by using chromogenic culture medium. To know the fungal profile of vulvovaginal candidiasis using Candida CHROMagar and antifungal susceptibility pattern in patients attending tertiary care hospital. Culture confirmed cases of VVC presented at Department of Obstetrics and Gynaecology of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, India, from July 2015 to December 2015 were included in the cross-sectional study. Two high vaginal swabs were collected and inoculated on SDA and Candida CHROMagar (Hi-Media, Mumbai, India). After overnight incubation the colonies were counted and colour of the colonies were recorded from Candida CHROMagar. Candida spp. were identified by sugar fermentation and assimilation tests and other conventional tests. Antifungal susceptibility tests were performed by the disc diffusion method using fluconazole (25 μg) and voriconazole (1μg) as per the Clinical and Laboratory Standards Institute (CLSI - M44-A2) guidelines. A total of 50 culture confirmed (23.7%) cases were detected from 211 clinically suspected VVC cases. Candida glabrata (45.1%) was the most common isolate, followed by Candida tropicalis (23.5%) , Candida albicans (17.6%) , Candida krusei (9.8%) and Candida parapsilosis (3.9%) . One mixed infection of C. glabrata and C. albicans was identified on Candida CHROMagar. Mixed fungal infection was observed in 2% of positive culture and 0.5% of VVC cases. The antifungal susceptibility testing revealed that 15.7% and 9.8% isolates of Candida spp. were resistant and Susceptible Dose Dependent (S-DD) respectively to fluconazole. The increase resistant against fluconazole was because of increased isolation of C. glabrata strains. All strains of Candida spp. were susceptible to voriconazole. C. glabrata was the most common causative agent of VVC in a tertiary care hospital. Chromogenic culture medium facilitates detection of mixed fungal infection. In vitro susceptibility testing should be used to guide the treatment especially in cases of non- albicans Candidiasis.

Geography does not limit optimal diabetes care: use of a tertiary centre model of care in an outreach service for type 1 diabetes mellitus.

PubMed

Simm, Peter J; Wong, Nicole; Fraser, Lynne; Kearney, John; Fenton, Judy; Jachno, Kim; Cameron, Fergus J

2014-06-01

Young people with type 1 diabetes mellitus living in rural and regional Australia have previously been shown to have limited access to specialised diabetes services. The Royal Children's Hospital Melbourne has been running diabetes outreach clinics to Western Victoria, Australia, for over 13 years. We aim to evaluate this service by comparing the outcomes of three outreach clinics with our urban diabetes clinic at the Royal Children's Hospital Melbourne. We examine our tertiary, multidisciplinary team-based model of care, where visiting specialist medical staff work alongside local allied health teams. The local teams provide interim care between clinics utilising the same protocols and treatment practices as the tertiary centre. Longitudinal data encapsulating the years 2005-2010, as a cohort study with a control group, are reviewed. A total of 69 rural patients were compared with 1387 metropolitan patients. Metabolic control was comparable, with no difference in mean HbA1c (8.3%/67 mmol/mol for both groups). Treatment options varied slightly at diagnosis, while insulin pump usage was comparable between treatment settings (20.3% rural compared with 27.6% urban, P = 0.19). Of note was that the number of visits per year was higher in the rural group (3.3 per year rural compared with 2.7 urban, P < 0.001). We conclude that the outreach service is able to provide a comparable level of care when the urban model is translated to a rural setting. This model may be further able to be extrapolated to other geographic areas and also other chronic health conditions of childhood. © 2014 The Authors. Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Identification of extended spectrum beta lactamases, AmpC and carbapenemase production among isolates of Escherichia coli in North Indian tertiary care centre

PubMed Central

Chaudhary, Uma; Agarwal, Shipra; Raghuraman, Kausalya

2018-01-01

Introduction: Identification of Extended spectrum beta lactamases (ESBL), AmpC production and carbapenemase production among isolates of Escherichia coli, helps clinician to rationalize the choice of antibiotics. However, there is a lack of simple and effective method for simultaneous identification of these beta lactamases. Aim: To determine the concurrent production of beta lactamases using twelve disc method on E. coli isolates. Materials and Methods: A total of 200 multidrug resistant E. coli were screened using twelve disc method. The isolates of ESBL were confirmed by ceftazidime/clavulanic acid and cefotaxime/clavulanic acid method. Metallo-beta-lactamases (MBL) were confirmed by imipenem EDTA combined disc method. Results: Among the 200 isolates, 42.5% were ESBL producers, 9% were MBL and 6.5% were Klebsiella pneumoniae carbapenemase (KPC) and AmpC each respectively. Coproduction was seen in 54 (27%). A significant difference in sensitivity was seen in cefuroxime, aztreonam, cefoxitin and ceftriaxone among inpatient and outpatients. Conclusion: The present study highlights burden of ESBL, AmpC, KPC and MBL along with their coproduction in a tertiary care hospital. In-house antibiotic policy, infection control and epidemiological surveys will help us in controlling these resistant bugs. We believe, the twelve disc method is a simple, inexpensive screening method for beta lactamase production. PMID:29682477

The algebra of healthcare reform: hospital-physician economic alignment.

PubMed

Goodroe, J H; Murphy, D A

1999-01-01

In summary the tertiary care programs in this nation are trapped in a difficult dilemma. On one side is the ongoing reduction in provider revenue driven by real and powerful market forces. On the other side is a traditional payment system governed by necessary laws that inhibit meaningful re-engineering of tertiary care delivery. If a remedy to this situation cannot be created then it is very likely that all aspects of quality as defined earlier will suffer. It is our hope that by very careful construction of a relationship, with attention to applicable statutes and careful measurement of utilization and quality, a limited business alignment of a hospital and a group of tertiary physicians can be approved in the care of Medicare, Medicaid and all federally funded patients.

Monitoring political decision-making and its impact in Austria.

PubMed

Stepan, Adolf; Sommersguter-Reichmann, Margit

2005-09-01

The range of services provided by the Austrian health care system has been greatly extended over the last few decades. The accompanying measures for long-term care bring the situation closer to the ideal concept of a 'seamless web' between primary, secondary and tertiary care. Due to the expansion in services it has become increasingly difficult to ensure the balance between the financing and degree of usage of the services. The reiterated political aim has been to achieve balanced financing via legally fixed social health insurance (SHI) contributions and taxation. A steadily expanding part is contributed by the private sector. In the 1980s, measures for SHI expenditure containment were implemented; in 1997 a new hospital financing system based on flat rates was introduced. In order to guarantee hospital financing, the historical financing shares of the SHI for the hospitals were introduced in the form of valorised global budgets. The contradictory incentives arising from the flat rates and global budgets lead hospitals to shift services to the primary and tertiary care sector, causing additional expenditure for SHI. Currently, attempts are being made to secure the financing by increasing the SHI contribution rates and patients' co-payments. Copyright (c) 2005 John Wiley & Sons, Ltd.

Sustained Reduction in Bloodstream Infections in Infants at a Large Tertiary Care Neonatal Intensive Care Unit

PubMed Central

Neill, Sara; Haithcock, Sarah; Smith, P. Brian; Goldberg, Ronald; Bidegain, Margarita; Tanaka, David; Carriker, Charlene; Ericson, Jessica E.

2015-01-01

Purpose Reduction of bloodstream infections (BSI) has emerged as an important patient safety goal. Implementation of central line insertion bundles, standardized line care protocols, and health care provider education programs have reduced BSI in neonatal intensive care units (NICUs) around the country. The ability of large tertiary care centers to decrease nosocomial infections, including BSI, has been demonstrated. However, long-term BSI reductions in infants are not well documented. We sought to demonstrate that a low incidence of BSI can be maintained over time in a tertiary care NICU. Subjects 6,790 infants admitted to a large, tertiary care NICU between 2005 and 2013. Design Retrospective intervention study. Methods A staged, multifaceted infection prevention plan was implemented beginning in October 2007 under nursing leadership. The incidence of BSI was determined annually for 2005-2013. Results Baseline BSI incidence for infants admitted to the NICU was 5.15 and 6.08 episodes per 1,000 infant-days in 2005 and 2006, respectively. After protocol implementation, the incidence of BSI decreased to 2.14/1,000 infant-days and 2.44/1,000 infant-days in 2008 and 2009, respectively. Yearly incidence remained low over the next 4 years and decreased even further to 0.20-0.45 infections/1,000 infant days. This represents a 92% decrease in BSI over a period of >5 years. Conclusions Implementation of a nursing-led comprehensive infection control initiative can effectively produce and maintain a reduction in the incidence of BSI in infants at a large tertiary care NICU. What this study adds Long term reductions in neonatal BSI are possible with implementation of a multidisciplinary team approach and strong nursing leadership. PMID:25915573

Factors Associated with Failure to Achieve SVR in Hepatitis C Genotype 3 Patients Within an Integrated Care Delivery System.

PubMed

Cheetham, T Craig; Niu, Fang; Chiang, Kevin; Yuan, Yong; Kalsekar, Anu; Hechter, Rulin; Hay, Joel W; Nyberg, Lisa

2015-08-01

Achievement of sustained virologic response (SVR) and factors associated with treatment failure in hepatitis C virus (HCV) genotype 3 have been described in tertiary and referral care settings, with rates of SVR reported to range between 72% and 89%. Fewer data exist on SVR outside of these settings. To describe rates of SVR and characterize factors associated with achievement of SVR within an integrated health care delivery system. A retrospective cohort study of genotype 3 HCV patients treated with dual therapy (pegylated interferon-alpha plus ribavirin) was conducted at Kaiser Permanente Southern California. Adult patients diagnosed with HCV and testing positive for HCV-RNA genotype 3 were identified from electronic medical records. Data were collected on patient demographics, baseline health status, and comorbid conditions. A multivariate logistic regression model was used to determine the association between baseline patient factors and SVR. A total of 484 HCV genotype 3 patients met the eligibility criteria. The median age was 49 years, and 65.7% were male. Overall, 252 (52.1%) achieved SVR. Aged ≥ 45 years and male gender were associated with lower rates of SVR; cirrhosis and chronic diseases (diabetes and chronic obstructive pulmonary disease) were also associated with lower rates of SVR. SVR was lower in patients within an integrated care delivery system than in those in tertiary and referral centers. Males and older patients had lower rates of SVR, as well as patients with cirrhosis, diabetes, and chronic obstructive pulmonary disease.

Good and Caring Teaching Behaviours as Perceived by Business Education Students in Tertiary Institutions in the North Eastern Nigeria

ERIC Educational Resources Information Center

Udo, Magnus P.; Samson, Agatha; Baraya, Abdulmutallib Umar

2016-01-01

This study investigated good and caring teaching behaviours as perceived by Business Education students in Tertiary Institutions in the North Eastern Nigeria. The latter needed good and caring teaching behaviours to reform the education sector that had been devastated by Boko Haram insurgency. The design of the study was survey. The research…

Availability of antidotes and key emergency drugs in tertiary care hospitals of Punjab and assessment of the knowledge of health care professionals in the management of poisoning cases.

PubMed

Arslan, Naheed; Khiljee, Sonia; Bakhsh, Allah; Ashraf, Muhammad; Maqsood, Iram

2016-03-01

This study was conducted to evaluate the availability of antidotes/key emergency drugs in tertiary care hospitals of the Punjab province, and to assess the knowledge of health care professionals in the stocking and administration of antidotes in the proper management of poisoning cases. Seventeen (n=17) tertiary care hospitals of Punjab Pakistan were selected. Two performas (A and B) were designed for 26 antidotes/key emergency drugs and given to the hospital pharmacists and physicians respectively. It was observed that Activated Charcoal, being the universal antidote was found only in 6 hospitals (41%). Digoxin Immune Fab, Edentate Calcium disodium and Glucagon were not available in emergency department of any hospital and even not included in the formulary of any hospital. About 80% pharmacists were aware of the method of preparation of Activated Charcoal and 85% physicians were familiar with its route of administration. Data showed that tertiary care hospitals of Punjab do not stock antidotes according to national drug policy. Moreover the study strongly suggests the development of health care centers and professional by organizing antidote awareness programs, continuous education and record keeping of poisonous cases and availability of emergency drugs around the clock.

Epilepsy in Ireland: towards the primary-tertiary care continuum.

PubMed

Varley, Jarlath; Delanty, Norman; Normand, Charles; Coyne, Imelda; McQuaid, Louise; Collins, Claire; Boland, Michael; Grimson, Jane; Fitzsimons, Mary

2010-01-01

Epilepsy is a chronic neurological disease affecting people of every age, gender, race and socio-economic background. The diagnosis and optimal management relies on contribution from a number of healthcare disciplines in a variety of healthcare settings. To explore the interface between primary care and specialist epilepsy services in Ireland. Using appreciative inquiry, focus groups were held with healthcare professionals (n=33) from both primary and tertiary epilepsy specialist services in Ireland. There are significant challenges to delivering a consistent high standard of epilepsy care in Ireland. The barriers that were identified are: the stigma of epilepsy, unequal access to care services, insufficient human resources, unclear communication between primary-tertiary services and lack of knowledge. Improving the management of people with epilepsy requires reconfiguration of the primary-tertiary interface and establishing clearly defined roles and formalised clinical pathways. Such initiatives require resources in the form of further education and training and increased usage of information communication technology (ICT). Epilepsy services across the primary-tertiary interface can be significantly enhanced through the implementation of a shared model of care underpinned by an electronic patient record (EPR) system and information communication technology (ICT). Better chronic disease management has the potential to halt the progression of epilepsy with ensuing benefits for patients and the healthcare system. Copyright 2009 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

Patients' assessment of quality of care in public tertiary hospitals with and without accreditation: comparative cross-sectional study.

PubMed

Aboshaiqah, Ahmad E; Alonazi, Wadi B; Patalagsa, Joel Gonzales

2016-11-01

To compare patients' assessment of quality of care provided by public tertiary hospitals grouped according to accreditation status. Healthcare institutions worldwide are increasingly adopting accreditation as continuing initiative aimed at improving structures, processes and outcomes associated with quality of care. Patients being recipients of health care need to participate in assessing the quality of care they experienced while confined for therapeutic management. Comparative, cross-sectional. Data were collected from patients confined in public tertiary hospitals (n = 517 in four with accreditation and n = 542 in four without accreditation) in Riyadh, Saudi Arabia between February 2011-June 2011. Patients rated key performance indicators grouped under the dimensions of structure, process and outcome. Mann-Whitney U-test, Spearman Correlation Coefficient and coefficient of determination were used in analysing data. Patients in accredited public tertiary hospitals perceived structure, outcome and overall quality of care statistically higher than patients in non-accredited hospitals. No statistical differences were found in process (access and communication) indicators. Accreditation status is marginally associated with structure; outcome; and overall quality of care. The proportion of variance in the ranks of accreditation status explained the proportion of variance in the ranks of structure; outcome; and overall quality of care. The results apparently showed better structure, outcome and overall quality of care in accredited hospitals. Accreditation's association in the overall quality of care apparently remained unclear. Further studies are needed to appreciate the contribution of accreditation. © 2016 John Wiley & Sons Ltd.

Reducing inpatient heritable thrombophilia testing using a clinical decision-making tool.

PubMed

Smith, Tyler W; Pi, David; Hudoba, Monika; Lee, Agnes Y Y

2014-04-01

To evaluate the impact of a clinical decision-making tool, designed to educate physicians regarding heritable thrombophilia (HT) testing, on the volume of testing in hospitalised patients in the tertiary care setting. We performed a retrospective cohort study over a 6-year period (2007-2012) at a single tertiary care centre intervention site and two regional control sites. In January 2010, the intervention site instituted a policy change whereby physicians ordering HT testing on inpatients needed to complete a pre-preprinted order (PPO) form that outlined the limitations of HT testing in the hospitalised setting. Failure to complete the PPO within 24 h resulted in test cancellation. Our main outcome measure was the volume of HT testing performed at the three study sites. Introduction of the PPO resulted in a 79.4% (95% CI 71.2% to 87.6%) reduction in factor V Leiden (FVL) testing at the intervention site. This decrease was significantly greater compared with those in the two control teaching hospitals over the same time periods (33.7% and 43.6%; both p<0.001). Reductions in FVL testing postintervention were observed among all ordering specialists. Similar postintervention reductions in testing volumes were observed for antithrombin (57.4%), protein C (61.9%) and protein S (62.2%) activity assays. In a large tertiary care hospital, the introduction of a clinical decision-making tool significantly reduced HT testing in inpatients across clinical specialties. The impact on patient outcome should be assessed in further studies.

Interhospital paediatric intensive care transport: a novel transport unit based on a standard ambulance trolley.

PubMed

Vos, Gijs D; Buurman, Wim A; van Waardenburg, Dick A; Visser, Timo P L; Ramsay, Graham; Donckerwolcke, Raymond A M G

2003-09-01

A recent development in providing intensive care for children is that it is more and more centralized in tertiary centres. The centralization of intensive care facilities for children in tertiary centres demands a safe and well-organized transport system. The transfer of critically ill children from a referring general hospital to a tertiary paediatric intensive care centre should be performed by a specially trained and fully equipped transport team. During the transfer of these children continuous intensive care facilities should be provided. The minimal requirements of equipment and materials for transport that allow such care have been determined. The equipment consists of a monitor allowing continuous measurement of vital signs, a defibrillator, tools for airway and ventilatory management, an oxygen source, suction unit, fluid and electrolyte management, medication, resuscitation chart and a communication system. A mobile paediatric intensive care unit was constructed in order to store this equipment, including easily accessible ventilator and materials optimized for close patient observation and ventilator control.

Quality of life outcomes in women with endometriosis are highly influenced by recruitment strategies.

PubMed

De Graaff, A A; Dirksen, C D; Simoens, S; De Bie, B; Hummelshoj, L; D'Hooghe, T M; Dunselman, G A J

2015-06-01

To what extent are outcome measures in endometriosis-related quality of life studies influenced by the setting in which patient recruitment is performed? Quality of life outcomes in women with endometriosis are highly influenced by recruitment strategies. Most studies on quality of life in women with endometriosis are conducted in tertiary care centres or patient associations. It is conceivable that the setting in which patient recruitment is performed influences the quality of life results. This has not been investigated before. Retrospective questionnaire based cohort study (part of the World Endometriosis Research Foundation (WERF) EndoCost study). The investigated women were recruited in three settings: a tertiary care centre for endometriosis (n = 135); five secondary care centres (n = 63); an endometriosis patient association (n = 291). The secondary and tertiary care population included women with a laparoscopic and/or histological diagnosis of endometriosis. The patient association population consisted of women with a self-reported diagnosis of surgically confirmed endometriosis. The populations did not differ in terms of age, co-morbidities and education level. Delay of diagnosis was the longest in the patient association (median 7 years) (tertiary care 2 years; secondary care 1.5 years) (P < 0.001). The tertiary care population reported more laparotomies (64%) than the other populations (secondary care 43%; patient association 47%) (P = 0.002). Affected job was least prevalent in the secondary care setting (35%) (patient association 64%; tertiary care 56%) (P < 0.001). Affected relationships were most prevalent in the patient association setting (52%) (tertiary care 38%; secondary care 22%) (P < 0.001). Chronic pain was least prevalent in patients in secondary care (44%) (tertiary care 65%; patient association 61%) (P = 0.009). Substantial differences in quality of life were detected between secondary care (median physical component 50.4, mental component 49.6); tertiary care (physical component 46.2, mental component 46.2) and the patient association (physical component 45.0, mental component 44.6) (P < 0.001, P = 0.018). The response rate was relatively low (35%). Analysis of the hospital populations revealed that non-responders and responders did not differ with respect to age or revised American Fertility Society classification, indicating that the non-responder bias is limited. However, other factors, such as social and marital status or symptomatology, might be different for non-responders. Missing values were analysed as if the symptom was not present. Missing values never exceeded 10%, except for one value. Therefore, it can be expected that the effect of missing data on the outcome is negligible. Twenty-five patients belonged to more than one category. A sensitivity analysis showed that the influence of assigning patients to another category was limited. Outcomes regarding quality of life are highly influenced by recruitment strategy. None of the groups appeared to be a representative selection of the total population of women with endometriosis. An alternative strategy for creating a representative population for cost and quality of life studies is probably to recruit women who live in a specific geographic area rather than women that visit a specific hospital or are a member of a patient association. The WERF EndoCost study was funded by the World Endometriosis Research Foundation. The sponsors did not have a role in the design and conduct of this study: collection, management, analysis, interpretation of the data; preparation, review, approval of the manuscript. L.H. is the chief executive and T.M.D. was a board member of WERF at the time of funding. T.M.D holds the Merck-Serono Chair and the Ferring Chair in Reproductive Medicine in Leuven, Belgium and has served as consultant for Merck-Serono, Schering-Plough, Astellas, and Arresto. Not applicable. © The Author 2015. Published by Oxford University Press on behalf of the European Society of Human Reproduction and Embryology. All rights reserved. For Permissions, please email: journals.permissions@oup.com.

Interhospital transfers of acute care surgery patients: should care for nontraumatic surgical emergencies be regionalized?

PubMed

Santry, Heena P; Janjua, Sumbal; Chang, Yuchiao; Petrovick, Laurie; Velmahos, George C

2011-12-01

Patients with major nontraumatic surgical emergencies (NTSEs) are commonly transferred from small hospitals to tertiary care centers. We hypothesized that transferred patients (TRANS) have worse outcomes than patients with similar diagnoses admitted directly to a tertiary center (DIRECT). We reviewed all patients admitted to the acute care surgery service of our tertiary center (September 1, 2006-October 31, 2009) with one of eight diagnoses indicating a major NTSE. Patients transferred for reasons other than the severity of illness were excluded. Univariate and multivariable analyses compared TRANS and DIRECT patients. Of 319 patients eligible for analysis, 103 (34%) were TRANS and averaged 3.8 days in the referring hospital before transfer. Compared to DIRECT patients, TRANS patients were more likely to be obese (18.5 vs. 8.0%, P = 0.006) and have cardiac (24 vs. 14%, P = 0.022) or pulmonary (25 vs. 12%, P = 0.003) co-morbidities. TRANS patients were also more likely to present to the tertiary center with hypotension (9 vs. 2%, P = 0.021), tachycardia (20 vs. 13%, P = 0.036), anemia (83 vs. 58%, P < 0.001), and hypoalbuminemia (50 vs. 14%, P < 0.001). TRANS patients had higher mortality (4.9 vs. 0.9%, P = 0.038) and longer hospital stay (8 with 5-13 days vs. 5 with 3-8 days, P < 0.001). TRANS patients comprised a significant portion of the population with major NTSEs admitted to the acute care surgery service of our tertiary center. They presented with greater physiologic derangement and had worse outcomes than DIRECT patients. As is currently established for trauma care, regionalization of care for NTSEs should be considered.

Models of care for the management of hepatitis C virus among people who inject drugs: one size does not fit all.

PubMed

Bruggmann, Philip; Litwin, Alain H

2013-08-01

One of the major obstacles to hepatitis C virus (HCV) care in people who inject drugs (PWID) is the lack of treatment settings that are suitably adapted for the needs of this vulnerable population. Nevertheless, HCV treatment has been delivered successfully to PWID through various multidisciplinary models such as community-based clinics, substance abuse treatment clinics, and specialized hospital-based clinics. Models may be integrated in primary care--all under one roof in either addiction care units or general practitioner-based models--or can occur in secondary or tertiary care settings. Additional innovative models include directly observed therapy and peer-based models. A high level of acceptance of the individual life circumstances of PWID rather than rigid exclusion criteria will determine the level of success of any model of HCV management. The impact of highly potent and well-tolerated interferon-free HCV treatment regimens will remain negligible as long as access to therapy cannot be expanded to the most affected risk groups.

Placenta previa. A 13 years experience at a tertiary care center in Western Saudi Arabia.

PubMed

Abduljabbar, Hassan S; Bahkali, Nedaa M; Al-Basri, Samera F; Al Hachim, Estabrq; Shoudary, Ibrahim H; Dause, Wesam R; Mira, Mohammed Y; Khojah, Mohammed

2016-07-01

To review cases of placenta previa in the last 13 years in a tertiary teaching hospital to identify risk factors for maternal morbidity.  A retrospective analysis of all cases of placenta previa managed at King Abdulaziz University Hospital (KAUH), Jeddah, Kingdom of Saudi Arabia from January 2001 to December 2013.    The total number of deliveries was 55,862 deliveries, and 11,412 (20.3%) delivered by cesarean section (C/S). The charts of 230 cases diagnosed with placenta previa was reviewed, and different variables were collected and analyzed. Diagnoses were achieved in 94% of them using ultrasound. The prevalence rate of placenta previa was 4.1 per 1000 births. Cesarean section was carried out as an emergency procedure in 130 (56.5%) women and as elective in 100 (43.5%) women. Of them, 26 patients were admitted to the intensive care unit (ICU) (11.3%), all of which received blood transfusion >6 units and 22 patients had a hysterectomy for uncontrollable bleeding.   Placenta previa is one of the leading causes of maternal morbidity and mortality. Every hospital must have a protocol, or algorithm for the management of placenta previa. Risk factors for maternal morbidity included complete previa, history of previous C/S, emergency C/S at a gestational age of less than 36 weeks, and estimated blood loss more than 2000 ml.

Deliberate Self-Harm among Children in Tertiary Care Residential Treatment: Prevalence and Correlates

ERIC Educational Resources Information Center

Stewart, Shannon L.; Baiden, Philip; Theall-Honey, Laura; den Dunnen, Wendy

2014-01-01

Background: Few studies have examined deliberate self-harm (DSH) among children in residential treatment in Canada. Most of the existing studies examined adolescent students or children from pediatric emergency departments. Objectives: The objectives of this study were to examine the prevalence of DSH among children in tertiary care residential…

Pediatric manpower in Canada: a cross-country survey.

PubMed Central

Rieder, M J; Hanmer, S J; Haslam, R H

1989-01-01

Health care costs and government cutbacks in Canadian training posts have caused concerns about physician manpower. To determine the present pediatric manpower situation a cross-country survey was undertaken of all pediatricians and their practice patterns. Of the 2060 recipients of a questionnaire 5% were found to not be pediatricians. Of the remaining 1960, 69% returned a completed questionnaire. Overall, 70% of the pediatricians were men, although among those less than 35 years of age 49% were women. Across Canada 37% of the pediatricians practised primary care, 25% secondary care and 38% tertiary care. There were wide regional differences in practice patterns, with large numbers of primary care pediatricians in Winnipeg, Toronto, Ottawa and the province of Quebec; few pediatricians in the Maritimes and the remainder of western Canada practised primary care. Non-Canadian graduates accounted for 33% of the pediatricians and represented a considerable proportion of tertiary care pediatricians. Cutbacks in numbers of pediatric training positions and restrictions on immigration of foreign pediatricians may lead to unexpected deficiencies in the availability of some types of pediatric practitioners, especially those in tertiary care. PMID:2910397

Summary of recommendations for the management of infantile seizures: Task Force Report for the ILAE Commission of Pediatrics.

PubMed

Wilmshurst, Jo M; Gaillard, William D; Vinayan, Kollencheri Puthenveettil; Tsuchida, Tammy N; Plouin, Perrine; Van Bogaert, Patrick; Carrizosa, Jaime; Elia, Maurizio; Craiu, Dana; Jovic, Nebojsa J; Nordli, Doug; Hirtz, Deborah; Wong, Virginia; Glauser, Tracy; Mizrahi, Eli M; Cross, J Helen

2015-08-01

Evidence-based guidelines, or recommendations, for the management of infants with seizures are lacking. A Task Force of the Commission of Pediatrics developed a consensus document addressing diagnostic markers, management interventions, and outcome measures for infants with seizures. Levels of evidence to support recommendations and statements were assessed using the American Academy of Neurology Guidelines and the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system. The report contains recommendations for different levels of care, noting which would be regarded as standard care, compared to optimal care, or "state of the art" interventions. The incidence of epilepsy in the infantile period is the highest of all age groups (strong evidence), with epileptic spasms the largest single subgroup and, in the first 2 years of life, febrile seizures are the most commonly occurring seizures. Acute intervention at the time of a febrile seizure does not alter the risk for subsequent epilepsy (class 1 evidence). The use of antipyretic agents does not alter the recurrence rate (class 1 evidence), and there is no evidence to support initiation of regular antiepileptic drugs for simple febrile seizures (class 1 evidence). Infants with abnormal movements whose routine electroencephalography (EEG) study is not diagnostic, would benefit from video-EEG analysis, or home video to capture events (expert opinion, level U recommendation). Neuroimaging is recommended at all levels of care for infants presenting with epilepsy, with magnetic resonance imaging (MRI) recommended as the standard investigation at tertiary level (level A recommendation). Genetic screening should not be undertaken at primary or secondary level care (expert opinion). Standard care should permit genetic counseling by trained personal at all levels of care (expert opinion). Genetic evaluation for Dravet syndrome, and other infantile-onset epileptic encephalopathies, should be available in tertiary care (weak evidence, level C recommendation). Patients should be referred from primary or secondary to tertiary level care after failure of one antiepileptic drug (standard care) and optimal care equates to referral of all infants after presentation with a seizure (expert opinion, level U evidence). Infants with recurrent seizures warrant urgent assessment for initiation of antiepileptic drugs (expert opinion, level U recommendation). Infantile encephalopathies should have rapid introduction and increment of antiepileptic drug dosage (expert opinion, level U recommendation). There is no high level evidence to support any particular current agents for use in infants with seizures. For focal seizures, levetiracetam is effective (strong evidence); for generalized seizures, weak evidence supports levetiracetam, valproate, lamotrigine, topiramate, and clobazam; for Dravet syndrome, strong evidence supports that stiripentol is effective (in combination with valproate and clobazam), whereas weak evidence supports that topiramate, zonisamide, valproate, bromide, and the ketogenic diet are possibly effective; and for Ohtahara syndrome, there is weak evidence that most antiepileptic drugs are poorly effective. For epileptic spasms, clinical suspicion remains central to the diagnosis and is supported by EEG, which ideally is prolonged (level C recommendation). Adrenocorticotropic hormone (ACTH) is preferred for short-term control of epileptic spasms (level B recommendation), oral steroids are probably effective in short-term control of spasms (level C recommendation), and a shorter interval from the onset of spasms to treatment initiation may improve long-term neurodevelopmental outcome (level C recommendation). The ketogenic diet is the treatment of choice for epilepsy related to glucose transporter 1 deficiency syndrome and pyruvate dehydrogenase deficiency (expert opinion, level U recommendation). The identification of patients as potential candidates for epilepsy surgery should be part of standard practice at primary and secondary level care. Tertiary care facilities with experience in epilepsy surgery should undertake the screening for epilepsy surgical candidates (level U recommendation). There is insufficient evidence to conclude if there is benefit from vagus nerve stimulation (level U recommendation). The key recommendations are summarized into an executive summary. The full report is available as Supporting Information. This report provides a comprehensive foundation of an approach to infants with seizures, while identifying where there are inadequate data to support recommended practice, and where further data collection is needed to address these deficits. Wiley Periodicals, Inc. © 2015 International League Against Epilepsy.

Determinants of career satisfaction among pediatric hospitalists: a qualitative exploration

PubMed Central

Leyenaar, JoAnna K.; Capra, Lisa A.; O'Brien, Emily R.; Leslie, Laurel K.; Mackie, Thomas I.

2014-01-01

Objectives To characterize determinants of career satisfaction among pediatric hospitalists working in diverse practice settings, and to develop a framework to conceptualize factors influencing career satisfaction. Methods Semi-structured interviews were conducted with community and tertiary care hospitalists, using purposeful sampling to attain maximum response diversity. We employed close- and open-ended questions to assess levels of career satisfaction and its determinants. Interviews were conducted by telephone, recorded, and transcribed verbatim. Emergent themes were identified and analyzed using an inductive approach to qualitative analysis. Results A total of 30 interviews were conducted with community and tertiary care hospitalists, representing 20 hospital medicine programs and 7 Northeastern states. Qualitative analysis yielded 657 excerpts which were coded and categorized into four domains and associated determinants of career satisfaction: (i) professional responsibilities; (ii) hospital medicine program administration; (iii) hospital and healthcare systems; and (iv) career development. While community and tertiary care hospitalists reported similar levels of career satisfaction, they expressed variation in perspectives across these four domains. While the role of hospital medicine program administration was consistently emphasized by all hospitalists, community hospitalists prioritized resource availability, work schedule and clinical responsibilities while tertiary care hospitalists prioritized diversity in non-clinical responsibilities and career development. Conclusions We illustrate how hospitalists in different organizational settings prioritize both consistent and unique determinants of career satisfaction. Given associations between physician satisfaction and healthcare quality, efforts to optimize modifiable factors within this framework, at both community and tertiary care hospitals, may have broad impacts. PMID:24976348

Congestive heart failure patients report conflict with their physicians.

PubMed

Zickmund, Susan L; Blasiole, Julie A; Brase, Venture; Arnold, Robert M

2006-09-01

Given the importance of the doctor-patient relationship, we examined the prevalence and nature of patients' perceived conflicts with the physicians caring for their congestive heart failure (CHF). This cross-sectional study recruited patients with CHF in the outpatient and inpatient service of a tertiary referral hospital. Patients completed demographics, semistructured interviews, and surveys of emotional and health status. CHF physiologic measures and comorbidities were abstracted from the medical record. A team of 2 blinded coders analyzed the interviews. Thirty-one percent of the 289 patients reported difficulties with physicians. In the bivariate analysis, only marital status was significantly associated with conflict. Major problems included the providers' poor communication skills (20%), trust in the physicians' competence (18%), and insufficient medical information (16%). Patients identified care outside the tertiary referral hospital (13%) and inadequate communication between physicians (9%) as additional sources of difficulty. Perceived conflict with providers is common in patients with CHF. Patient-level factors, however, did not predict conflict, which differs from our previous findings with hepatitis C patients. Perceived conflict is troubling because it can undermine the trust in the doctor-patient relationship, thereby weakening the therapeutic bond necessary to care for this sick and often vulnerable population.

Clinical Profile of Children and Adolescents Attending the Behavioural Paediatrics Unit OPD in a Tertiary Care Set up

ERIC Educational Resources Information Center

Jayaprakash, R.

2012-01-01

Background: There are limited studies on the clinical profile of children attending child guidance clinic under Paediatric background. Aims: To study clinical profile of Children & adolescents attending the Behavioural Paediatrics Unit (BPU) OPD under department of Paediatrics in a tertiary care set up. Methods: Monthly average turnover in the…

Abusive Head Trauma at a Tertiary Care Children's Hospital in Mexico City. A Preliminary Study

ERIC Educational Resources Information Center

Diaz-Olavarrieta, Claudia; Garcia-Pina, Corina A.; Loredo-Abdala, Arturo; Paz, Francisco; Garcia, Sandra G.; Schilmann, Astrid

2011-01-01

Objectives: Determine the prevalence, clinical signs and symptoms, and demographic and family characteristics of children attending a tertiary care hospital in Mexico City, Mexico, to illustrate the characteristics of abusive head trauma among this population. Methods: This is a cross-sectional descriptive study of infants and children under 5,…

Pain symptoms and stooling patterns do not drive diagnostic costs for children with functional abdominal pain and irritable bowel syndrome in primary or tertiary care.

PubMed

Lane, Mariella M; Weidler, Erica M; Czyzewski, Danita I; Shulman, Robert J

2009-03-01

The objectives of this study were to (1) compare the cost of medical evaluation for children with functional abdominal pain or irritable bowel syndrome brought to a pediatric gastroenterologist versus children who remained in the care of their pediatrician, (2) compare symptom characteristics for the children in primary versus tertiary care, and (3) examine if symptom characteristics predicted the cost of medical evaluation. Eighty-nine children aged 7 to 10 years with functional abdominal pain or irritable bowel syndrome seen by a gastroenterologist (n = 46) or seen only by a pediatrician (n = 43) completed daily pain and stool diaries for 2 weeks. Mothers provided retrospective reports of their children's symptoms in the previous year. Cost of medical evaluation was calculated via chart review of diagnostic tests and application of prices as if the patients were self-pay. Child-reported diary data reflected no significant group differences with respect to pain, interference with activities, or stool characteristics. In contrast, mothers of children evaluated by a gastroenterologist viewed their children as having higher maximum pain intensity in the previous year. Excluding endoscopy costs, cost of medical evaluation was fivefold higher for children evaluated by a gastroenterologist, with higher cost across blood work, stool studies, breath testing, and diagnostic imaging. Symptom characteristics did not predict cost of care for either group. Despite the lack of difference in symptom characteristics between children in primary and tertiary care, a notable differential in cost of evaluation exists in accordance with level of care. Symptom characteristics do not seem to drive diagnostic evaluation in either primary or tertiary care. Given the lack of differences in child-reported symptoms and the maternal perspective that children evaluated by a gastroenterologist had more severe pain, we speculate that parent perception of child symptoms may be a primary factor in seeking tertiary care.

Peri-operative management of high-risk paediatric adenotonsillectomy patients: A survey of 35 UK tertiary referral centres.

PubMed

Cheong, Ryan Chin Taw; Bowles, Philippe; Moore, Andrew; Watts, Simon

2017-05-01

Peri-operative management of high-risk paediatric patients undergoing adenotonsillectomy for treatment of obstructive sleep apnoea varies between tertiary referral hospitals. 'Day of surgery cancellation' (DoSC) rates of up to 11% have been reported due to pre-booked critical care being unavailable on the day of surgery as a result of competing needs from other hospital departments. We report the results of a survey of peri-operative management in UK tertiary care centres of high-risk paediatric patients undergoing adenotonsillectomy for obstructive sleep apnoea (OSA). An 8-point questionnaire was developed using a cloud-based software platform (www.surveymonkey.com). A web-link to the survey was embedded in a customised e-mail which was sent via secure server to the Clinical Leads for Paediatric Otolaryngology at 35 United Kingdom (UK) Tertiary referral centres. The survey response rate was 60% (n = 21). Almost all (94.1%) of centres considered paediatric critical care facilities to be limited, with 70.6% (n = 12) stating that DoSC often occurred due to unavailable paediatric critical care capacity. There was variation between tertiary referral units in the practice applied for pre-booking critical care beds (our survey identifies 6 variations) (Table 1). The most frequent selection method reported (47.1%) was at the discretion of the booking clinician at the time of listing the patient for surgery. In the context of limited critical care resources, variation in practice and difficulty in accurately predicting which patients will require post-operative critical care beds, a review and consensus on best practice in the peri-operative management of high risk paediatric adenotonsillectomy patients may offer a safe means of reducing cancellations and improving patient care, resource allocation and hospital efficiency. Copyright © 2017 Elsevier B.V. All rights reserved.

Outbreak of candidemia caused by fluconazole resistant Candida parapsilosis strains in an intensive care unit.

PubMed

Pinhati, Henrique Marconi Sampaio; Casulari, Luiz Augusto; Souza, Ana Carolina Remondi; Siqueira, Ricardo Andreotti; Damasceno, Camila Maria Gomes; Colombo, Arnaldo Lopes

2016-08-20

Candidemia is an increasing problem in tertiary care hospitals worldwide. Here, we report the first outbreak of candidemia caused by fluconazole-resistant C. parapsilosis (FRCP) strains in Brazil. This was a cross-sectional study of clinical and microbiological data of all candidemic episodes diagnosed from July 2011 to February 2012 in a 200-bed tertiary care hospital. Initial yeast identification and susceptibility testing were performed using the VITEK 2 - System. Isolates of Candida spp. resistant to fluconazole were sent to a reference laboratory (LEMI-UNIFESP) for further molecular identification and confirmation of resistance by CLSI microdilution test. A multivariate analysis was conducted to identify factors associated with FRCP infection. We identified a total of 40 critically ill patients with candidemia (15 women) with a median age of 70 years. The incidence of candidemia was 6 cases/1,000 patients admissions, including 28 cases (70 %) of infection with C. parapsilosis, 21 of which (75 %) were resistant to fluconazole. In only 19 % of FRCP candidemia cases had fluconazole been used previously. The results of our study indicated that diabetes is a risk factor for FRCP candidemia (p = 0.002). Overall, mortality from candidemia was 45 %, and mortality from episodes of FRCP infections was 42.9 %. The clustering of incident cases in the ICU and molecular typing of strains suggest horizontal transmission of FRCP. Accurate vigilant monitoring for new nosocomial strains of FRCP is required.

Socioeconomic factors affecting patients’ utilization of primary care services at a Tertiary Teaching Hospital in Riyadh, Saudi Arabia

PubMed Central

Alsubaie, Abdulaziz M.; Almohaimede, Khaled A.; Aljadoa, Abdulrahman F.; Jarallah, Osamah J.; Althnayan, Yasser I.; Alturki, Yousef A.

2016-01-01

Background: Primary care services utilization is dependent on socioeconomic factors. It is proven that variation in socioeconomic factors result in discrepancies in the use of such services. Admittedly, research is limited on the socioeconomic factors affecting the utilization of primary care services in Saudi Arabia. Objectives: The aim of this research was to study the effect of the main socioeconomic factors affecting patients' utilization of primary care services at a tertiary teaching hospital, Riyadh, Saudi Arabia. Materials and Methods: A cross-sectional study was conducted from January to February 2014 in a primary care clinic of a tertiary teaching hospital in Riyadh city; subjects selected using a random consecutive sampling technique. A self-administered questionnaire in Arabic was given to the participants to collect the data which comprised sociodemographic data, utilization measures, and health needs. The data were analyzed using SPSS version 21. Results: A total of 358 subjects participated in the study. The main factors that best determine the utilization of primary health care clinic in a tertiary teaching hospital were the possession of a health insurance (P = 0.046, odds ratio [OR] = 8.333), and bad self-health-perception (P < 0.014, OR: 2.088). Chronic illness was also associated with higher utilization (OR = 2.003). Conclusion: Our results reveal that chronic health problems, self-health-perception, and health insurance are the most significant socioeconomic factors affecting the utilization of primary care services. PMID:26929723

Measuring case-mix complexity of tertiary care hospitals using DRGs.

PubMed

Park, Hayoung; Shin, Youngsoo

2004-02-01

The objectives of the study were to develop a model that measures and evaluates case-mix complexity of tertiary care hospitals, and to examine the characteristics of such a model. Physician panels defined three classes of case complexity and assigned disease categories represented by Adjacent Diagnosis Related Groups (ADRGs) to one of three case complexity classes. Three types of scores, indicating proportions of inpatients in each case complexity class standardized by the proportions at the national level, were defined to measure the case-mix complexity of a hospital. Discharge information for about 10% of inpatient episodes at 85 hospitals with bed size larger than 400 and their input structure and research and education activity were used to evaluate the case-mix complexity model. Results show its power to predict hospitals with the expected functions of tertiary care hospitals, i.e. resource intensive care, expensive input structure, and high levels of research and education activities.

Unlicensed and off-label use of drugs in pediatric surgical units at tertiary care hospitals of Pakistan.

PubMed

Aamir, Muhammad; Khan, Jamshaid Ali; Shakeel, Faisal; Asim, Syed Muhammad

2017-08-01

Background Unlicensed and off-label prescribing practice is global dilemma around the world. This pioneering study was designed to determine unlicensed and off-label use of drug in surgical wards of tertiary care hospitals of Pakistan. Objective To assess unlicensed and off-label use of drugs in pediatric surgical unit at three tertiary care hospitals in Peshawar, Pakistan. Setting Two government and one private tertiary care hospitals in Pakistan. Method Drug profiles of 895 patients from three different clinical settings were evaluated for unlicensed and off-label use of drugs using Micromedex DRUGDEX. Main outcome measure Characteristics of the unlicensed and off-label drug prescriptions. Result Total of 3168 prescribed drugs were analyzed in this study. Indication (38.7%) and dose (34.8%) were the most frequent off-label categories. In comparison with the corresponding reference categories, infants and children, male patients and having less than five prescribed drugs were significant predictors of unlicensed prescriptions. In comparison with the corresponding reference categories, significant predictors of off-label drug prescribing were children younger than two year, children between 2-12 years, patient staying at hospital less than 5 days and patients having less than five prescribed drugs. Conclusion The prevalence of unlicensed and off-label drug prescriptions are high at pediatric surgical ward of tertiary care hospitals. More awareness of the efficacy and safety of drugs are required in pediatrics. In addition, new formulations with advanced dosing for children are also required to minimize the risk of adverse outcomes.

Efficacy of sequential three-step empirical therapy for chronic cough.

PubMed

Yu, Li; Xu, Xianghuai; Hang, Jingqing; Cheng, Kewen; Jin, Xiaoyan; Chen, Qiang; Lv, Hanjing; Qiu, Zhongmin

2017-06-01

Empirical three-step therapy has been proved in just one hospital. This study aimed to demonstrate applicability of the sequential empirical three-step therapy for chronic cough in different clinical settings. Sequential empirical three-step therapy was given to patients with chronic cough in one tertiary and three secondary care respiratory clinics. Recruiters were initially treated with methoxyphenamine compound as the first-step therapy, followed by corticosteroids as the second-step therapy and the combination of a proton-pump inhibitor and a prokinetic agent as the third-step therapy. The efficacy of the therapy was verified according to the changes in cough symptom score between pre- and post-treatment, and compared among the different clinics. In total 155 patients in one tertiary clinic and 193 patients in secondary care clinics were recruited. The total dropout ratio is significantly higher in the secondary care clinics than that in the tertiary clinic (9.3% versus 3.2%, p = 0.023). The therapeutic success rate for cough was 38.7% at first-step therapy, 32.3% at second-step therapy and 20.0% at third-step therapy in the tertiary clinic, and comparable to corresponding 49.7%, 31.1% and 4.1% in secondary care clinics. Furthermore, the overall cough resolution rate was not significantly different (91.0% versus 85.0%, p = 0.091). However, the efficacy of the third-step therapy is much higher (20.0% versus 4.1%, p = 0.001) in the tertiary clinic than in the secondary care clinics. Sequential empirical three-step therapy is universally efficacious and useful for management of chronic cough in different clinical settings.

Medical tourism in India: perceptions of physicians in tertiary care hospitals.

PubMed

Qadeer, Imrana; Reddy, Sunita

2013-12-17

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding of MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians' however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy.

Medical tourism in india: perceptions of physicians in tertiary care hospitals

PubMed Central

2013-01-01

Senior physicians of modern medicine in India play a key role in shaping policies and public opinion and institutional management. This paper explores their perceptions of medical tourism (MT) within India which is a complex process involving international demands and policy shifts from service to commercialisation of health care for trade, gross domestic profit, and foreign exchange. Through interviews of 91 physicians in tertiary care hospitals in three cities of India, this paper explores four areas of concern: their understanding of MT, their views of the hospitals they work in, perceptions of the value and place of MT in their hospital and their views on the implications of MT for medical care in the country. An overwhelming majority (90%) of physicians in the private tertiary sector and 74.3 percent in the public tertiary sector see huge scope for MT in the private tertiary sector in India. The private tertiary sector physicians were concerned about their patients alone and felt that health of the poor was the responsibility of the state. The public tertiary sector physicians’ however, were sensitive to the problems of the common man and felt responsible. Even though the glamour of hi-tech associated with MT dazzled them, only 35.8 percent wanted MT in their hospitals and a total of 56 percent of them said MT cannot be a public sector priority. 10 percent in the private sector expressed reservations towards MT while the rest demanded state subsidies for MT. The disconnect between their concern for the common man and professionals views on MT was due to the lack of appreciation of the continuum between commercialisation, the denial of resources to public hospitals and shift of subsidies to the private sector. The paper highlights the differences and similarities in the perceptions and context of the two sets of physicians, presents evidence, that questions the support for MT and finally analyzes some key implications of MT on Indian health services, ethical issues emerging out of that and the need for understanding the linkages between public and private sectors for a more effective intervention for an equitable medical care policy. PMID:24345280

Estimation of Need for Palliative Care among Noncancer Patients Attending a Tertiary Care Hospital.

PubMed

Prasad, Parvathy; Sarkar, Sonali; Dubashi, Biswajit; Adinarayanan, S

2017-01-01

Palliative care services, until recently, were mainly restricted to cancer patients with incurable diseases. Hence, evaluative studies of palliative care are sparse in areas other than oncology. To estimate what proportion of patients attending the Departments of Neurology, Cardiology, and Nephrology of Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry, required palliative care and to identify the palliative care needs of those patients. This was an exploratory descriptive study conducted in the three departments of JIPMER. There was no predetermined sample size for the study. The participants were all adult inpatients and outpatients who were in need of palliative care in the departments of Cardiology, Nephrology, and Neurology on the day of study. Percentage distribution was used to analyze the categorical variables such as education, gender, age, patients in need of palliative care, and their needs. The study showed that one in ten non-cancer patients in tertiary care hospitals may require palliative care services. Apart from issues in physical domain, a substantial proportion of participants also had issues in the psychological, emotional, and financial domains. This study highlights the need for incorporation and initiation of palliative care services in other non-cancer specialties in tertiary care hospitals to ensure holistic management of such cases. Counseling service has also to be rendered as part of palliative care since a good share of the patients had psychological and emotional issues.

Impact of health insurance for tertiary care on postoperative outcomes and seeking care for symptoms: quasi-experimental evidence from Karnataka, India

PubMed Central

Sood, Neeraj; Wagner, Zachary

2016-01-01

Objectives To evaluate the effects of a government insurance programme covering tertiary care for the poor in Karnataka, India—Vajpayee Arogyashree Scheme (VAS)—on treatment seeking and postoperative outcomes. Design Geographic regression discontinuity. Setting 572 villages in Karnataka, India. Participants 3478 households in 300 villages where VAS was implemented and 3486 households in 272 neighbouring matched villages ineligible for VAS. Intervention A government insurance programme that provided free tertiary care to households below the poverty line in half of villages in Karnataka from February 2010 to August 2012. Main outcome measure Seeking treatment for symptoms, posthospitalisation well-being, occurrence of infections during hospitalisation and need for rehospitalisation. Results The prevalence of symptoms was nearly identical for households in VAS-eligible villages compared with households in VAS-ineligible villages. However, households eligible for VAS were 4.96 percentage points (95% CI 1 to 8.9; p=0.014) more likely to seek treatment for their symptoms. The increase in treatment seeking was more pronounced for symptoms of cardiac conditions, the condition most frequently covered by VAS. Respondents from VAS-eligible villages reported greater improvements in well-being after a hospitalisation in all categories assessed and they were statistically significant in 3 of the 6 categories (walking ability, pain and anxiety). Respondents eligible for VAS were 9.4 percentage points less likely to report any infection after their hospitalisation (95% CI −20.2 to 1.4; p=0.087) and 16.5 percentage points less likely to have to be rehospitalised after the initial hospitalisation (95% CI −28.7 to −4.3; p<0.01). Conclusions Insurance for tertiary care increased treatment seeking among eligible households. Moreover, insured patients experienced better posthospitalisation outcomes, suggesting better quality of care received. These results suggest that there are several pathways through which tertiary care insurance could improve health, aside from increasing utilisation of the services that the programme directly subsidises. PMID:26739744

Colorectal Cancer Safety Net: Is It Catching Patients Appropriately?

PubMed

Althans, Alison R; Brady, Justin T; Times, Melissa L; Keller, Deborah S; Harvey, Alexis R; Kelly, Molly E; Patel, Nilam D; Steele, Scott R

2018-01-01

Disparities in access to colorectal cancer care are multifactorial and are affected by socioeconomic elements. Uninsured and Medicaid patients present with advanced stage disease and have worse outcomes compared with similar privately insured patients. Safety net hospitals are a major care provider to this vulnerable population. Few studies have evaluated outcomes for safety net hospitals compared with private institutions in colorectal cancer. The purpose of this study was to compare demographics, screening rates, presentation stage, and survival rates between a safety net hospital and a tertiary care center. Comparative review of patients at 2 institutions in the same metropolitan area were conducted. The study included colorectal cancer care delivered either at 1 safety net hospital or 1 private tertiary care center in the same city from 2010 to 2016. A total of 350 patients with colorectal cancer from each hospital were evaluated. Overall survival across hospital systems was measured. The safety net hospital had significantly more uninsured and Medicaid patients (46% vs 13%; p < 0.001) and a significantly lower median household income than the tertiary care center ($39,299 vs $49,741; p < 0.0001). At initial presentation, a similar percentage of patients at each hospital presented with stage IV disease (26% vs 20%; p = 0.06). For those undergoing resection, final pathologic stage distribution was similar across groups (p = 0.10). After a comparable median follow-up period (26.6 mo for safety net hospital vs 29.2 mo for tertiary care center), log-rank test for overall survival favored the safety net hospital (p = 0.05); disease-free survival was similar between hospitals (p = 0.40). This was a retrospective review, reporting from medical charts. Our results support the value of safety net hospitals for providing quality colorectal cancer care, with survival and recurrence outcomes equivalent or improved compared with a local tertiary care center. Because safety net hospitals can provide equivalent outcomes despite socioeconomic inequalities and financial constraints, emphasis should be focused on ensuring that adequate funding for these institutions continues. See Video Abstract at http://links.lww.com/DCR/A454.

Molecular, microbiological and clinical characterization of Clostridium difficile isolates from tertiary care hospitals in Colombia.

PubMed

Salazar, Clara Lina; Reyes, Catalina; Atehortua, Santiago; Sierra, Patricia; Correa, Margarita María; Paredes-Sabja, Daniel; Best, Emma; Fawley, Warren N; Wilcox, Mark; González, Ángel

2017-01-01

In Colombia, the epidemiology and circulating genotypes of Clostridium difficile have not yet been described. Therefore, we molecularly characterized clinical isolates of C.difficile from patients with suspicion of C.difficile infection (CDI) in three tertiary care hospitals. C.difficile was isolated from stool samples by culture, the presence of A/B toxins were detected by enzyme immunoassay, cytotoxicity was tested by cell culture and the antimicrobial susceptibility determined. After DNA extraction, tcdA, tcdB and binary toxin (CDTa/CDTb) genes were detected by PCR, and PCR-ribotyping performed. From a total of 913 stool samples collected during 2013-2014, 775 were included in the study. The frequency of A/B toxins-positive samples was 9.7% (75/775). A total of 143 isolates of C.difficile were recovered from culture, 110 (76.9%) produced cytotoxic effect in cell culture, 100 (69.9%) were tcdA+/tcdB+, 11 (7.7%) tcdA-/tcdB+, 32 (22.4%) tcdA-/tcdB- and 25 (17.5%) CDTa+/CDTb+. From 37 ribotypes identified, ribotypes 591 (20%), 106 (9%) and 002 (7.9%) were the most prevalent; only one isolate corresponded to ribotype 027, four to ribotype 078 and four were new ribotypes (794,795, 804,805). All isolates were susceptible to vancomycin and metronidazole, while 85% and 7.7% were resistant to clindamycin and moxifloxacin, respectively. By multivariate analysis, significant risk factors associated to CDI were, staying in orthopedic service, exposure to third-generation cephalosporins and staying in an ICU before CDI symptoms; moreover, steroids showed to be a protector factor. These results revealed new C. difficile ribotypes and a high diversity profile circulating in Colombia different from those reported in America and European countries.

Molecular, microbiological and clinical characterization of Clostridium difficile isolates from tertiary care hospitals in Colombia

PubMed Central

Salazar, Clara Lina; Reyes, Catalina; Atehortua, Santiago; Sierra, Patricia; Correa, Margarita María; Paredes-Sabja, Daniel; Best, Emma; Fawley, Warren N.; Wilcox, Mark

2017-01-01

In Colombia, the epidemiology and circulating genotypes of Clostridium difficile have not yet been described. Therefore, we molecularly characterized clinical isolates of C.difficile from patients with suspicion of C.difficile infection (CDI) in three tertiary care hospitals. C.difficile was isolated from stool samples by culture, the presence of A/B toxins were detected by enzyme immunoassay, cytotoxicity was tested by cell culture and the antimicrobial susceptibility determined. After DNA extraction, tcdA, tcdB and binary toxin (CDTa/CDTb) genes were detected by PCR, and PCR-ribotyping performed. From a total of 913 stool samples collected during 2013–2014, 775 were included in the study. The frequency of A/B toxins-positive samples was 9.7% (75/775). A total of 143 isolates of C.difficile were recovered from culture, 110 (76.9%) produced cytotoxic effect in cell culture, 100 (69.9%) were tcdA+/tcdB+, 11 (7.7%) tcdA-/tcdB+, 32 (22.4%) tcdA-/tcdB- and 25 (17.5%) CDTa+/CDTb+. From 37 ribotypes identified, ribotypes 591 (20%), 106 (9%) and 002 (7.9%) were the most prevalent; only one isolate corresponded to ribotype 027, four to ribotype 078 and four were new ribotypes (794,795, 804,805). All isolates were susceptible to vancomycin and metronidazole, while 85% and 7.7% were resistant to clindamycin and moxifloxacin, respectively. By multivariate analysis, significant risk factors associated to CDI were, staying in orthopedic service, exposure to third-generation cephalosporins and staying in an ICU before CDI symptoms; moreover, steroids showed to be a protector factor. These results revealed new C. difficile ribotypes and a high diversity profile circulating in Colombia different from those reported in America and European countries. PMID:28902923

"I wish they could be in my shoes": patients' insights into tertiary health care for type 2 diabetes mellitus.

PubMed

Cotugno, Jacqueline D; Ferguson, Maree; Harden, Hazel; Colquist, Shoni; Stack, Annabelle A; Zimmerman, Jane I; Russell, Anthony W; Ball, Lauren E; Hickman, Ingrid J

2015-01-01

Insightful accounts of patient experience within a health care system can be valuable for facilitating improvements in service delivery. The aim of this study was to explore patients' perceptions and experiences regarding a tertiary hospital Diabetes and Endocrinology outpatient service for the management of type 2 diabetes mellitus (T2DM). Nine patients participated in discovery interviews with an independent trained facilitator. Patients' stories were synthesized thematically using a constant comparative approach. Three major themes were identified from the patients' stories: 1) understanding T2DM and diabetes management with subthemes highlighting that specialist care is highly valued by patients who experience a significant burden of diabetes on daily life and who may have low health literacy and low self confidence; 2) relationships with practitioners were viewed critical and perceived lack of empathy impacted the effectiveness of care; and 3) impact of health care systems on service delivery with lack of continuity of care relating to the tertiary hospital model and limitations with appointment bookings negatively impacting on patient experience. The patients' stories suggest that the expectation of establishing a productive, ongoing relationship with practitioners is highly valued. Tertiary clinics for T2DM are well placed to incorporate novel technological approaches for monitoring and follow-up, which may overcome many of the perceived barriers of traditional service delivery. Investing in strategies that promote patient-practitioner relationships may enhance effectiveness of treatment for T2DM by meeting patient expectations of personalized care. Future changes in service delivery would benefit from incorporating patients as key stakeholders in service evaluation.

Epidemiology and molecular typing of VRE bloodstream isolates in an Irish tertiary care hospital.

PubMed

Ryan, L; O'Mahony, E; Wrenn, C; FitzGerald, S; Fox, U; Boyle, B; Schaffer, K; Werner, G; Klare, I

2015-10-01

Ireland has the highest rate of vancomycin-resistant Enterococcus faecium (VREfm) isolated from blood of nosocomial patients in Europe, which rose from 33% (110/330) in 2007 to 45% (178/392) in 2012. No other European country had a VREfm rate from blood cultures of >25%. Our aim was to elucidate the reasons for this significantly higher rate in Ireland. The epidemiology and molecular typing of VRE from bloodstream infections (BSIs) was examined in a tertiary care referral hospital and isolates were compared with those from other tertiary care referral centres in the region. The most common source of VRE BSIs was intra-abdominal sepsis, followed by line-related infection and febrile neutropenia. Most of the isolates were positive for vanA; 52% (43/83) possessed the esp gene and 12% (10/83) possessed the hyl gene. Genotyping by SmaI macrorestriction analysis (PFGE) of isolates revealed clonal relatedness between bloodstream isolates and environmental isolates. VRE BSI isolates from two other tertiary care hospitals in the Dublin region showed relatedness by PFGE analysis. MLST revealed four STs (ST17, ST18, ST78 and ST203), all belonging to the clonal complex of hospital-associated strains. Irish VRE BSI isolates have virulence factor profiles as previously reported from Europe. Typing analysis shows the spread of individual clones within the hospital and between regional tertiary care hospitals. Apart from transmission of VRE within the hospital and transfer of colonized patients between Irish hospitals, no other explanation for the persistently high VREfm BSI rate in Ireland has been found. © The Author 2015. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oup.com.

Tertiary care centre adherence to unified guidelines for management of periprosthetic joint infections: a gap analysis

PubMed Central

Armstrong, Mitchel D.; Carli, Alberto V.; Abdelbary, Hesham; Poitras, Stephane; Lapner, Peter; Beaulé, Paule E.

2018-01-01

Background The success rate of surgical treatment for periprosthetic joint infection (PJI) remains inconsistent in the literature. Variability in PJI clinical guidelines and surgeon adherence to guidelines could affect treatment success. The objectives of this study were to appraise current recommendations for PJI management and develop a unified clinical standard of care, to perform a gap analysis of PJI cases in a tertiary institution to determine the rate of guideline adherence, and to determine if adherence to unified PJI guidelines affected 2-year treatment outcomes. Methods We appraised the PJI guidelines from 3 academic medical societies, and consistent statements were aggregated. We retrospectively reviewed all PJI cases in a tertiary care institution. We defined PJI based on Musculoskeletal Infection Society PJI criteria. Surgeon adherence to preoperative, intraoperative, surgical and medical management guidelines was calculated, and we evaluated the association between guideline adherence and 2-year treatment outcomes. Results The institutional rate of PJI was 1.13% (38 of 3368). Treatment success was 57.8% at 2 years. Unified guideline adherence percentages varied substantially: 92% of patients had preoperative erythrocyte sedimentation rate and C-reactive protein, 97% had intraoperative tissue cultures, 42% had appropriate preoperative arthrocentesis, and 74% underwent guideline-appropriate surgery. Performing appropriate preoperative arthrocentesis significantly correlated with positive treatment outcomes at 2 years (p = 0.028). Conclusion Adherence to PJI guidelines varies considerably, indicating that clinicians are either unaware of them or do not recognize their value for PJI treatment. This study shows the need for institution-based PJI treatment pathways that are consistent with published guidelines and the need to monitor adherence. PMID:29368675

The future of health care delivery and the experience of a tertiary care center in Saudi Arabia.

PubMed

Alsanea, Nasser

2012-01-01

Five major technological changes will herald a new era in health care delivery around the World: digitalization of the personal health record, sharing of health care digital data across different platforms, applications and institutions, delivery of patient services via the internet, use of the digital media and social networking as a medium for education and preventive medicine and introduction of smart applications as counselors to prevent medical errors. The implications of such changes are huge. Saudi Arabia is not isolated from such important developments. This article explores the future of health care delivery with a special focus on the experience of a tertiary care center in Saudi Arabia that has led the wave in such changes regionally.

Six-month outcome in patients with myocardial infarction initially admitted to tertiary and nontertiary hospitals. RESCATE Investigators. Recursos Empleados en el Síndrome Coronario Agudo y Tiempos de Espera.

PubMed

Marrugat, J; Sanz, G; Masiá, R; Valle, V; Molina, L; Cardona, M; Sala, J; Serés, L; Szescielinski, L; Albert, X; Lupón, J; Alonso, J

1997-11-01

The aim of the present study was to ascertain whether the degree of accessibility to coronary angiography and revascularization results in differing usages or outcomes, or both, in the setting of a high coverage national health system. The selective use of coronary angiography and revascularization procedures in the management of acute myocardial infarction (MI) remains controversial. A cohort of 1,460 consecutive patients with a first MI admitted to four referral teaching hospitals (one with tertiary facilities) were followed up for 6 months after admission. Only patients initially admitted to each of the study hospitals were retained for analysis in the original hospital's cohort. End points were 6-month mortality and readmission for reinfarction, unstable angina, heart failure or severe ventricular arrhythmia. Patients admitted to the tertiary hospital were more likely to undergo coronary angiography (adjusted relative risk 4.22, 95% confidence interval [CI] 3.37 to 5.45) than those admitted to the nontertiary sites (use rate: 22.1% for nontertiary care, 55.5% for tertiary care). Revascularization procedures were performed in 21.2% of patients in the tertiary hospital and in 8.3% in the nontertiary hospitals (p < 0.0001). Median delay for emergency coronary angiography was shorter in the tertiary hospital (within 1 vs. 2 days, p < 0.0001). Six-month mortality or readmission rates were similar (23.7% and 24.7% for tertiary and nontertiary care, respectively). After adjustment for comorbidity and disease severity, the relative risk of death or readmission for the tertiary hospital was 1.03 (95% CI 0.69 to 1.53) times that of the nontertiary hospitals. Selective use of coronary angiography and revascularization procedures may be as effective as less restricted use in the management of acute MI.

Non-physician communities in Japan: are they still disadvantaged?

PubMed

Kashima, S; Inoue, K; Matsumoto, M; Takeuchi, K

2014-01-01

Non-physician community' (NPC) is a policy term that indicates a medically underserved area in Japan. Designated NPCs are politically targeted as the foci of medical resource allocation. NPC is defined as a specified district where 50 or more persons dwell within a geographic diameter of 4 km and medical care is not easily accessible. The definition of NPC was first introduced in 1960 and has been unchanged for more than half a century despite radical social changes in rural Japan. This study examines whether designated NPCs are still more disadvantaged in terms of geographical access to healthcare in comparison to other communities. Hiroshima prefecture, which has the largest number of NPCs in terms of tertiary healthcare areas of Japan, was used as the study area. Targeted communities were all the NPCs in the prefecture, and, as controls, two community groups were selected: non-NPC adjacent to NPC, and municipal center. We measured driving time from NPCs and control communities to the nearest healthcare facilities, which were classified into the following two types: primary or secondary care facilities (n=2636) and tertiary care facilities (equal to tertiary emergency care centers; n=6). We further calculated the driving time to the nearest facilities for secondary emergency care (n=246) extracted from the 2636 primary or secondary care facilities. The median driving times to the nearest primary or secondary healthcare facility for NPC, non-NPC, and municipal center were 11 minutes, 11 minutes, and 1 minute, respectively; the times to a tertiary healthcare facility (equal to an accident and emergency care center) were 80 minutes, 84 minutes, and 68 minutes, respectively; and the times to a secondary emergency care facility were 24 minutes, 18 minutes, and 15 minutes, respectively. Although a municipal center was significantly more advantageous in driving time compared to a primary or secondary care facility, the disadvantage of a NPC in access was no more obvious than an adjacent non-NPC for any type of healthcare facility. NPCs had a disadvantage in access time to primary, secondary and tertiary medical care compared with a municipal center. NPCs, however, did not have a greater access disadvantage in comparison to adjacent rural communities for any type of medical facility. As such, future resource allocation policies in Japan need to redefine medically underserved communities.

Tension-compression-tension tertiary twins in coarse-grained polycrystalline pure magnesium at room temperature

DOE PAGES

Yu, Qin; Jiang, Yanyao; Wang, Jian

2015-04-07

Using electron backscatter diffraction, the microstructural features of tension–compression–tension (T–C–T) tertiary twins are studied in coarse-grained pure polycrystalline magnesium subjected to monotonic compression along the extrusion direction in ambient air. T–C–T tertiary twins are developed due to the formation of a compression–tension double twin inside a primary tension twin. All the observed T–C–T twin variants are of T iC jT j type. T iC i+1T i+1 (or T iC i–1T i–1) variants are observed more frequently than T iC i+2T i+2 (or T iC i–2T i–2) variants. Moreover, the number of tertiary twin lamellae increases with the applied compressive strain.

Technology complementing military psychology programs and services in the Pacific Regional Medical Command.

PubMed

Stetz, Melba C; Folen, Raymond A; Van Horn, Sandra; Ruseborn, Daniel; Samuel, Kevin M

2013-08-01

The Tripler Army Medical Center is the only federal tertiary care hospital serving the Pacific Regional Medical Command. Due to Tripler's large area of responsibility, many behavioral health professionals are starting to employ more technology during their sessions. As explained in this article, virtual reality and telepsychology efforts are proving to benefit military service members and their families in the Pacific Rim. PsycINFO Database Record (c) 2013 APA, all rights reserved.

Circulation of Highly Drug-Resistant Clostridium difficile Ribotypes 027 and 001 in Two Tertiary-Care Hospitals in Mexico.

PubMed

Martínez-Meléndez, Adrián; Tijerina-Rodríguez, Laura; Morfin-Otero, Rayo; Camacho-Ortíz, Adrián; Villarreal-Treviño, Licet; Sánchez-Alanís, Hugo; Rodríguez-Noriega, Eduardo; Baines, Simon D; Flores-Treviño, Samantha; Maldonado-Garza, Héctor Jesús; Garza-González, Elvira

2018-05-01

To assess drug susceptibility and characterize Clostridium difficile ribotypes in isolates from two tertiary-care hospitals in Mexico. Isolates were evaluated for genotyping, antimicrobial susceptibility testing and detection of mutations associated with drug resistance. PCR ribotyping was performed using a combination of gel-based and capillary electrophoresis-based approaches. MIC 50 and MIC 90 were ≥128 mg/L for ciprofloxacin, erythromycin, clindamycin, and rifampicin. There was no reduced susceptibility to metronidazole or tetracycline; however, reduced susceptibility to vancomycin (≥4 mg/L) and fidaxomicin (≥2 mg/L) was detected in 50 (40.3%) and 4 (3.2%) isolates, respectively. Furthermore, the rpoB Arg505Lys mutation was more frequently detected in isolates with high minimum inhibitory concentration (MIC) to rifampicin (≥32 mg/L) (OR = 52.5; 95% CI = 5.17-532.6; p < 0.000). Of the 124 C. difficile isolates recovered, 84 (66.7%) were of ribotype 027, 18 (14.5%) of ribotype 001, and the remainder were other ribotypes (353, 255, 220, 208, 176, 106, 076, 020, 019, 017, 014, 012, 003, and 002). Ribotypes 027 and 001 were the most frequent C. difficile isolates recovered in this study, and demonstrated higher MICs. Furthermore, we found four isolates with reduced susceptibility to fidaxomicin, raising a concern since this drug is currently unavailable in Mexican Hospitals.

Tertiary paediatric hospital health professionals' attitudes to lesbian, gay, bisexual and transgender parents seeking health care for their children.

PubMed

Nicol, Pam; Chapman, Rose; Watkins, Rochelle; Young, Jeanine; Shields, Linda

2013-12-01

To ascertain health professionals' knowledge, attitudes and beliefs towards lesbian, gay, bisexual and transgender parents seeking health care for their children in a paediatric tertiary hospital setting which practises family-centred care. Lesbian, gay, bisexual and transgender parents are often reluctant to disclose their sexual orientation to health professionals for fear of discrimination and compromised quality of care. Staff knowledge, attitudes and beliefs can influence disclosure by parents, but little is known about knowledge, attitudes and beliefs in paediatric tertiary hospital staff towards lesbian, gay, bisexual and transgender parents accessing care for their children. Descriptive comparative study of health staff using a cross-sectional survey. A set of validated anonymous questionnaires was used to assess knowledge about homosexuality, attitudes towards lesbians and gay men, and gay affirmative practice. Three open-ended questions were also used to assess beliefs about encouraging disclosure of lesbian, gay, bisexual and transgender parenting roles and how this may impact on care. Of the 646 staff surveyed, 212 (32.8%) responded. Knowledge and attitudes were significantly associated with professional group, gender, Caucasian race, political voting behaviour, presence of religious beliefs, the frequency of attendance at religious services, the frequency of praying, and having a friend who was openly lesbian, gay, bisexual and transgender. This study highlighted that staff working in a tertiary paediatric hospital setting, with family-centred care models in place, held attitudes and beliefs that may impact on the experience of hospitalisation for lesbian, gay, bisexual and transgender parents, and the quality of care received by their children. To promote equitable care to all families, organisations should ensure that family-centred care policies and guidelines are adopted and appropriately implemented. In addition to formal education, affirmative health service action and innovative methods may be required. © 2013 John Wiley & Sons Ltd.

A THIRD OF PATIENTS TREATED AT A TERTIARY LEVEL SURGICAL SERVICE COULD BE TREATED AT A SECONDARY LEVEL FACILITY.

PubMed

Van Straten, S K; Stannard, C J; Bulabula, J; Paul, K; Leong, J; Klipin, M

2017-06-01

South Africa has an overburdened public healthcare system. Some admissions to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH) may not require tertiary care. The numbers and details thereof are uncertain. Clinical research is limited by skills and access to data. A retrospective analysis of Electronic Discharge (ED) summaries from the Department of Surgery at CMJAH between 01 April 2015 and 01 April 2016. An SQL-query of the database generated a .csv file of all discharges with the fields database reference number, length of stay and level of care. The details and level of care of each record were verified by MBBCh 5 medical students using a defined level of care template with review of the full discharge summary. The data was reviewed by a senior clinician. There were 3007 discharge summaries, 97 were not classifiable, two were test records and one was a duplicate. These 100 records were excluded. There were no primary level records. Secondary level patients represented 29% (854) of patients discharged and 19% of total bed days. Tertiary and quaternary together represented 71% of the total patients and 81% of bed days. The average length of stay was 4.31 days for secondary, 6.98 days for tertiary and 9.77 days for quaternary level of care allocation. Almost a third (29%) of patients discharged from CMJAH Department of Surgery were deemed suitable for secondary level care. These admissions have a shorter length of stay and comprise 19% of total bed days. Students and electronic databases are useful research resources.

“I wish they could be in my shoes”: patients’ insights into tertiary health care for type 2 diabetes mellitus

PubMed Central

Cotugno, Jacqueline D; Ferguson, Maree; Harden, Hazel; Colquist, Shoni; Stack, Annabelle A; Zimmerman, Jane I; Russell, Anthony W; Ball, Lauren E; Hickman, Ingrid J

2015-01-01

Background Insightful accounts of patient experience within a health care system can be valuable for facilitating improvements in service delivery. Objective The aim of this study was to explore patients’ perceptions and experiences regarding a tertiary hospital Diabetes and Endocrinology outpatient service for the management of type 2 diabetes mellitus (T2DM). Method Nine patients participated in discovery interviews with an independent trained facilitator. Patients’ stories were synthesized thematically using a constant comparative approach. Results Three major themes were identified from the patients’ stories: 1) understanding T2DM and diabetes management with subthemes highlighting that specialist care is highly valued by patients who experience a significant burden of diabetes on daily life and who may have low health literacy and low self confidence; 2) relationships with practitioners were viewed critical and perceived lack of empathy impacted the effectiveness of care; and 3) impact of health care systems on service delivery with lack of continuity of care relating to the tertiary hospital model and limitations with appointment bookings negatively impacting on patient experience. Discussion The patients’ stories suggest that the expectation of establishing a productive, ongoing relationship with practitioners is highly valued. Tertiary clinics for T2DM are well placed to incorporate novel technological approaches for monitoring and follow-up, which may overcome many of the perceived barriers of traditional service delivery. Conclusion Investing in strategies that promote patient–practitioner relationships may enhance effectiveness of treatment for T2DM by meeting patient expectations of personalized care. Future changes in service delivery would benefit from incorporating patients as key stakeholders in service evaluation. PMID:26604714

Impact of health insurance for tertiary care on postoperative outcomes and seeking care for symptoms: quasi-experimental evidence from Karnataka, India.

PubMed

Sood, Neeraj; Wagner, Zachary

2016-01-06

To evaluate the effects of a government insurance programme covering tertiary care for the poor in Karnataka, India--Vajpayee Arogyashree Scheme (VAS)--on treatment seeking and postoperative outcomes. Geographic regression discontinuity. 572 villages in Karnataka, India. 3478 households in 300 villages where VAS was implemented and 3486 households in 272 neighbouring matched villages ineligible for VAS. A government insurance programme that provided free tertiary care to households below the poverty line in half of villages in Karnataka from February 2010 to August 2012. Seeking treatment for symptoms, posthospitalisation well-being, occurrence of infections during hospitalisation and need for rehospitalisation. The prevalence of symptoms was nearly identical for households in VAS-eligible villages compared with households in VAS-ineligible villages. However, households eligible for VAS were 4.96 percentage points (95% CI 1 to 8.9; p=0.014) more likely to seek treatment for their symptoms. The increase in treatment seeking was more pronounced for symptoms of cardiac conditions, the condition most frequently covered by VAS. Respondents from VAS-eligible villages reported greater improvements in well-being after a hospitalisation in all categories assessed and they were statistically significant in 3 of the 6 categories (walking ability, pain and anxiety). Respondents eligible for VAS were 9.4 percentage points less likely to report any infection after their hospitalisation (95% CI -20.2 to 1.4; p=0.087) and 16.5 percentage points less likely to have to be rehospitalised after the initial hospitalisation (95% CI -28.7 to -4.3; p<0.01). Insurance for tertiary care increased treatment seeking among eligible households. Moreover, insured patients experienced better posthospitalisation outcomes, suggesting better quality of care received. These results suggest that there are several pathways through which tertiary care insurance could improve health, aside from increasing utilisation of the services that the programme directly subsidises. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Financial impact of tertiary care in an academic medical center.

PubMed

Huber, T S; Carlton, L M; O'Hern, D G; Hardt, N S; Keith Ozaki, C; Flynn, T C; Seeger, J M

2000-06-01

To analyze the financial impact of three complex vascular surgical procedures to both an academic hospital and a department of surgery and to examine the potential impact of decreased reimbursements. The cost of providing tertiary care has been implicated as one potential cause of the financial difficulties affecting academic medical centers. Patients undergoing revascularization for chronic mesenteric ischemia, elective thoracoabdominal aortic aneurysm repair, and treatment of infected aortic grafts at the University of Florida were compared with those undergoing elective infrarenal aortic reconstruction and carotid endarterectomy. Hospital costs and profit summaries were obtained from the Clinical Resource Management Office. Departmental costs and profit summary were estimated based on the procedural relative value units (RVUs), the average clinical cost per RVU ($33.12), surgeon charges, and the collection rate for the vascular surgery division (30.2%) obtained from the Faculty Group Practice. Surgeon work effort was analyzed using the procedural work RVUs and the estimated total care time. The analyses were performed for all payors and the subset of Medicare patients, and the potential impact of a 15% reduction in hospital and physician reimbursement was analyzed. Net hospital income was positive for all but one of the tertiary care procedures, but net losses were sustained by the hospital for the mesenteric ischemia and infected aortic graft groups among the Medicare patients. In contrast, the estimated reimbursement to the department of surgery for all payors was insufficient to offset the clinical cost of providing the RVUs for all procedures, and the estimated losses were greater for the Medicare patients alone. The surgeon work effort was dramatically higher for the tertiary care procedures, whereas the reimbursement per work effort was lower. A 15% reduction in reimbursement would result in an estimated net loss to the hospital for each of the tertiary care procedures and would exacerbate the estimated losses to the department. Caring for complex surgical problems is currently profitable to an academic hospital but is associated with marginal losses for a department of surgery. Economic forces resulting from further decreases in hospital and physician reimbursement may limit access to academic medical centers and surgeons for patients with complex surgical problems and may compromise the overall academic mission.

Investigation of mutation distribution in DNA gyrase and topoisomerase IV genes in ciprofloxacin-non-susceptible Enterobacteriaceae isolated from blood cultures in a tertiary care university hospital in South Korea, 2005-2010.

PubMed

Nam, You Sun; Cho, Sun Young; Yang, Hee Young; Park, Kyung Sun; Jang, Ji-Hyun; Kim, Yun-Tae; Jeong, Joo-Won; Suh, Jin-Tae; Lee, Hee Joo

2013-02-01

This study investigated the distribution of mutations in DNA gyrase (gyrA and gyrB) and topoisomerase IV (parC and parE) genes and compared the distribution of these mutations with the distribution of plasmid-mediated quinolone resistance (PMQR) genes and extended-spectrum β-lactamase (ESBL) production in 101 ciprofloxacin-non-susceptible Enterobacteriaceae from blood culture isolates (80 Escherichia coli and 21 Klebsiella pneumoniae) isolated in Kyung Hee University Hospital, a tertiary care university hospital in Seoul, South Korea. Among the 101 isolates, 80 (79.2%) contained PMQR genes and 28 (27.7%) produced ESBL. Mutations in the gyrA and parC genes were observed more frequently than in the gyrB and parE genes as well as more frequently in E. coli than in K. pneumoniae isolates, even in the same ciprofloxacin minimum inhibitory concentration (MIC) range of the two species. In E. coli isolates, the distribution of the codon 529 mutation (Ile→Leu) in parE was increased with an increase in the ciprofloxacin MIC. An increase in high-level resistance to quinolones may occur with double mutations compared with a single mutation in gyrA as well as with additional mutations in parC. However, this finding could not be applied to ciprofloxacin-resistant K. pneumoniae. A higher level of quinolone resistance may be correlated with an additional mutation in parE, especially Ile529→Leu. Copyright © 2012 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

Emergency and trauma care in Pakistan: a cross-sectional study of healthcare levels

PubMed Central

Razzak, Junaid A; Baqir, Syed M; Khan, Uzma Rahim; Heller, David; Bhatti, Junaid; Hyder, Adnan A

2015-01-01

Background The importance of emergency medical care for the successful functioning of health systems has been increasingly recognised. This study aimed to evaluate emergency and trauma care facilities in four districts of the province of Sindh, Pakistan. Method We conducted a cross-sectional health facility survey in four districts of the province of Sindh in Pakistan using a modified version of WHO’s Guidelines for essential trauma care. 93 public health facilities (81 primary care facilities, nine secondary care hospitals, three tertiary hospitals) and 12 large private hospitals were surveyed. Interviews of healthcare providers and visual inspections of essential equipment and supplies as per guidelines were performed. A total of 141 physicians providing various levels of care were tested for their knowledge of basic emergency care using a validated instrument. Results Only 4 (44%) public secondary, 3 (25%) private secondary hospitals and all three tertiary care hospitals had designated emergency rooms. The majority of primary care health facilities had less than 60% of all essential equipments overall. Most of the secondary level public hospitals (78%) had less than 60% of essential equipments, and none had 80% or more. A fourth of private secondary care facilities and all tertiary care hospitals (n=3; 100%) had 80% or more essential equipments. The average percentage score on the physician knowledge test was 30%. None of the physicians scored above 60% correct responses. Conclusions The study findings demonstrated a gap in both essential equipment and provider knowledge necessary for effective emergency and trauma care. PMID:24157684

Management of Bile Duct Injury at Various Stages of Presentation: Experience from a Tertiary Care Centre.

PubMed

Ibrarullah, Md; Sankar, S; Sreenivasan, K; Gavini, S R K

2015-04-01

The clinical presentation, management and outcome of all patients with bile duct injury who presented to our tertiary care centre at various stages after cholecystectomy were analyzed. The patients were categorized into three groups: group A-patients in whom the injury was detected during cholecystectomy, group B-patients who presented within 2 weeks of cholecystectomy and group C-patients who presented after 2 weeks of cholecystectomy. Our team acted as rescue surgeons and performed 'on-table' repair for injuries occurring in another unit or in another hospital. Strasberg classification of bile duct injury was followed. In group A, partial and complete transections were managed by repair over T-tube and high hepaticojejunostomy, respectively. Patients in group B underwent endoscopic retrograde cholangiogram and/or magnetic resonance cholangiogram to evaluate the biliary tree. Those with intact common bile duct underwent endoscopic papillotomy and stenting in addition to drainage of intra-abdominal collection when present. For those with complete transection, early repair was considered if there was no sepsis. In presence of intra-abdominal sepsis an attempt was made to create controlled external biliary fistula. This was followed by hepatico jejunostomy at least after 3 months. Group C patients underwent hepaticojejunostomy at least 6 weeks after the injury. The outcome was graded into three categories: grade A-no clinical symptoms, normal LFT; grade B-no clinical symptoms, mild derangement of LFT or occasional episodes of pain or fever; grade C-pain, cholangitis and abnormal LFT; grade D-surgical revision or dilatation required. Fifty nine patients were included in the study and the distribution was group A-six patients, group B-33 patients and group C-20 patients. In group A, one patient with complete transection of the right hepatic duct (type C) and partial injury to left hepatic duct (LHD) underwent right hepaticojejunostomy and repair of the LHD over stent. Two patients with type D and three patients with type E 2 injury underwent repair over T-tube and hepaticojejunostomy, respectively. In group B, all except one of the 18 patients with type A injury underwent endoscopic papillotomy and stenting. The bile leak subsided at a mean interval of 8 days in all, except one patient who died of fulminant sepsis. Of the 15 patients with type E injury, five underwent hepaticojejunostomy after a minimum gap of 3 months. Early repair was considered in 10 patients. Twenty patients in group C underwent hepaticojejunostomy. In a mean follow-up of 40 months, the outcome was grade A in 54 patients, grade B in three patients (one from each of the three groups) and grade D in one patient (group C). The latter patient with a type E3 injury developed recurrent stricture and cholangitis necessitating percutaneous transhepatic dilatation. The high success rate of bile duct repair in the present study can be attributed to the appropriate timing, meticulous technique and the tertiary care experience.

Awareness and practices regarding bio-medical waste management among health care workers in a tertiary care hospital in Delhi.

PubMed

Bhagawati, G; Nandwani, S; Singhal, S

2015-01-01

Health care institutions are generating large amount of Bio-Medical Waste (BMW), which needs to be properly segregated and treated. With this concern, a questionnaire based cross-sectional study was done to determine the current status of awareness and practices regarding BMW Management (BMWM) and areas of deficit amongst the HCWs in a tertiary care teaching hospital in New Delhi, India. The correct responses were graded as satisfactory (more than 80%), intermediate (50-80%) and unsatisfactory (less than 50%). Some major areas of deficit found were about knowledge regarding number of BMW categories (17%), mercury waste disposal (37.56%) and definition of BMW (47%).

Complementary and alternative medicine (CAM) use in children with functional abdominal pain (FAP) and irritable bowel syndrome (IBS) differs in tertiary vs. primary care and is related to mother's view of child disability

USDA-ARS?s Scientific Manuscript database

We sought to determine if CAM use was greater in children in tertiary vs. primary care, and whether child or parent report of pain characteristics, and/or child and mother's psychological characteristics differed between those who did/did not use CAM. We identified children 7-10 years of age with FA...

[The heart failure patient: a case report].

PubMed

Alconero-Camarero, Ana Rosa; Arozamena-Pérez, Jorge; García-Garrido, Lluïsa

2014-01-01

Given its prevalence, high mortality rate, morbidity, chronicity and use of resources, heart failure (HF) is a priority issue from a social and health standpoint, due to the ageing population and to lack of adherence to and the complexity of treatment. For these reasons, an individualized care plan needs to be established to meet the real and potential needs of the patient diagnosed with HF. A clinical case is presented of a patient admitted to the Cardiology Critical Care (CCC) unit of a tertiary hospital. A patient care plan was prepared following the steps of the scientific method and relying on the NANDA taxonomy, and the NOC and NIC to design goals and nursing interventions, respectively. Copyright © 2013 Elsevier España, S.L. All rights reserved.

A case report of dexmedetomidine used to treat intractable pain and delirium in a tertiary palliative care unit.

PubMed

Hilliard, Neil; Brown, Stuart; Mitchinson, Steve

2015-03-01

This case report describes an end-stage cancer patient with intractable neuropathic pain and delirium who was successfully managed during the last 3 weeks of her life with a continuous subcutaneous infusion of dexmedetomidine. A 55-year-old woman with locally advanced cervical cancer and uncontrolled pelvic pain was admitted to a tertiary palliative care unit for pain management. As her disease progressed, the patient's pelvic pain intensified despite treatment with methadone, gabapentin, ketamine, and hydromorphone administered by continuous subcutaneous infusion plus frequent breakthrough doses of hydromorphone and sufentanil. A continuous subcutaneous infusion of dexmedetomidine was started and titrated to achieve pain relief. The patient's pain and delirium cleared. The treatment was successful in fulfilling the patient's goal of care: not to be deeply and continuously sedated, but to be rousable and of clear mind while still having good pain control. Dexmedetomidine is a potentially useful medication for the targeted treatment of intractable pain and delirium in the tertiary palliative care environment. Future research is required to compare dexmedetomidine infusion to standard treatment with midazolam infusion for treatment of intractable symptoms in the palliative care environment. © The Author(s) 2014.

A Qualitative Study of Psychosocial Problems among Parents of Children with Cerebral Palsy Attending Two Tertiary Care Hospitals in Western India

PubMed Central

Panchal, Dhara Antani

2014-01-01

Objective. To explore the psychosocial problems faced by the parents of children with cerebral palsy (CP) in rural and urban settings. Design. Qualitative research design using focus group discussions (FGDs) was used for the study. Setting. Two FGDs comprising one at a rural tertiary level care hospital and the other at an urban tertiary level care hospital were conducted. Participants. A total of thirteen parents participated in the two FGDs. Main Outcome Measured. Psychosocial problems experienced by the parents of children suffering from CP were measured. Results. The problems experienced by the mothers were associated with common themes such as disturbed social relationships, health problems, financial problems, moments of happiness, worries about future of the child, need for more support services, and lack of adequate number of trained physiotherapists. All the parents had children with problems since birth and most had approached various health care providers for a cure for their child. Conclusions. A wide range of psychosocial problems are experienced by the parents of children with CP. Studies like this can provide valuable information for designing a family centered care programme for children with CP. PMID:24967331

A third of patients treated at a tertiary-level surgical service could be treated at a secondary-level facility.

PubMed

Van Straten, S; Stannard, C; Bulabula, J; Boodhia, K; Paul, K; Leong, J; Klipin, M J

2017-08-25

South Africa (SA) has an overburdened public healthcare system. Some patients admitted to Charlotte Maxeke Johannesburg Academic Hospital (CMJAH), SA, may not require tertiary care, but the numbers and details are uncertain. Clinical research in SA is limited by scarce skills and limited access to data. To determine the proportion of and length of stay for secondary-, tertiary- and quaternary-level patients discharged from the Department of Surgery at CMJAH over 1 year. This is a retrospective analysis of electronic discharge (ED) summaries from the Department of Surgery at CMJAH between 1 April 2015 and 1 April 2016. An SQL query of the database generated a .csv file of all discharges with the following fields: database reference number, length of stay and level of care. The details of each record were verified by MBBCh V students, using a defined level-ofcare template and the full discharge summary. The data were reviewed by a senior clinician. There were 3 007 discharge summaries - 97 were not classifiable, two were test records and one was a duplicate. These 100 records were excluded. There were no primary-level records. Secondary-level patients represented 29% (854) of those discharged and 19% of total bed days. Tertiary- and quaternary-level patients together represented 71% of the total and 81% of bed days. The average length of stay was 4.31 days for secondary, 6.98 days for tertiary and 9.77 days for quaternary level-of-care allocation. Almost one-third (29%) of patients discharged from CMJAH's Department of Surgery were deemed suitable for secondarylevel care. These patients had a shorter length of stay and comprised 19% of total bed days. Students and electronic databases represent an important research resource.

Impact of a transfer center on interhospital referrals and transfers to a tertiary care center.

PubMed

Southard, Patricia A; Hedges, Jerris R; Hunter, John G; Ungerleider, Ross M

2005-07-01

The partnership of faculty physicians and senior clinical hospital administrators in the decision to accept interhospital transfers has not been fully studied. Transfers to academic medical centers on the basis of economics have been of particular concern. To evaluate the impact of joint decision making on transfer acceptance, and to evaluate the basis for decisions to transfer patients to an academic medical center. This was a database study of requested adult interhospital transfers, excluding psychiatric transfers, occurring between January 1, 2003, and December 31, 2003, by using data from a computerized patient-tracking system. Where possible, comparisons with the prior calendar year (i.e., prior to implementation of the administrative review process) were made. Incidence of refusal to accept requested transfers and payer mix of transfer patients were the main outcomes of interest. More than 90% of the adult patients were transferred for conditions that required tertiary care or met Emergency Medical Treatment and Labor Act (EMTALA) requirements. The patient conditions that did not meet tertiary care needs included obstetric patients who did not have prenatal care, patients who had hand and facial trauma, and patients who weighed more than 300 pounds. The payer mix of transfer patients remained stable when using the administrator and physician team to determine acceptance of transfers. During the evaluation period, approximately 91,500 patients statewide lost some level of Medicaid coverage. The value of an administrator and physician team as partners in the interhospital transfer process was demonstrated. Active management of interhospital transfers supports transfer of patients who require tertiary care or who meet EMTALA criteria, thus conserving limited bed capacity and ensuring financial equity, while caring for the uninsured and underinsured patients throughout the state.

Freestanding midwifery units: Maternal and neonatal outcomes following transfer.

PubMed

Monk, Amy R; Grigg, Celia P; Foureur, Maralyn; Tracy, Mark; Tracy, Sally K

2017-03-01

the viability of freestanding midwifery units in Australia is restricted, due to concerns over their safety, particularly for women and babies who, require transfer. to compare the maternal and neonatal birth outcomes of women who planned, to give birth at freestanding midwifery units and subsequently, transferred to a tertiary maternity unit to the maternal and neonatal, outcomes of a low-risk cohort of women who planned to give birth in, tertiary maternity unit. a descriptive study compared two groups of women with low-risk singleton, pregnancies who were less than 28 weeks pregnant at booking: women who, planned to give birth at a freestanding midwifery unit (n=494) who, transferred to a tertiary maternity unit during the antenatal, intrapartum or postnatal periods (n=260) and women who planned to give, birth at a tertiary maternity unit (n=3157). Primary outcomes were mode, of birth, Apgar score of less than 7 at 5minutes and admission to, special care nursery or neonatal intensive care. the proportion of women who experienced a caesarean section was lower, among the freestanding midwifery unit women who transferred during the, intrapartum/postnatal period compared to women in the tertiary maternity, unit group (16.1% versus 24.8% respectively). Other outcomes were, comparable between the cohorts. Rates of primary outcomes in relation to, stage of transfer varied when stratified by parity. these descriptive results support the provision of care in freestanding, midwifery units as an alternative to tertiary maternity units for women, with low risk pregnancies at the time of booking. A larger study, powered, to determine statistical significance of any differences in outcomes, is, required. Copyright © 2017 Elsevier Ltd. All rights reserved.

[Illness behavior in chronic pain].

PubMed

Lavielle, Pilar; Clark, Patricia; Martínez, Homero; Mercado, Francisco; Ryan, Gery

2008-01-01

To describe the illness behaviour in patients with chronic pain. We conducted semi-structured interviews to 53 patients during 2000, in a tertiary care center. We explored their initial interpretations, responses and subsequent practices to chronic pain, until they received a diagnosis that satisfied them. Illness behaviour was determined by pain intensity and disability; beliefs regarding pain causes, trust in social networks, and quality and satisfaction with the health care systems. In terms of the decision to seek care, the first option was to go to the popular sector, followed by consulting a general physician, and as last resort, to go to a tertiary care center ("with a specialist"). Illness behaviour should be conceptualized as a process, which combines the use of different health care sectors by the same subjects, as a result of care provided sequentially by each previous sector.

Pilot of integrated, colocated neurology in a primary care medical home.

PubMed

Young, Nathan P; Elrashidi, Muhamad Y; Crane, Sarah J; Ebbert, Jon O

2017-06-01

Novel health care delivery models are needed to reduce health care use while delivering effective and safe care. We developed a model of a neurologist integrated and colocated in primary care leveraging "curbside," electronic, and traditional consultations. Our objective was to examine the impact on health care resource use of diagnostic testing and referrals for face-to-face neurological consultation and adverse outcomes associated with electronic and curbside consultations. Consecutive patients from December 1, 2014, to March 13, 2015, were included in the analysis about whom contact was made between a primary care clinician and a colocated neurologist. Over 3.5 months of the pilot, 359 unique patients generated 429 consultations (179 curbsides, 68 electronic consultations, and 182 face-to-face visits). The integrated model resulted in avoidance of 78 face-to-face tertiary neurology consultations, 39 brain magnetic resonance imaging, 50 electromyograms, and 53 other advanced imaging studies. Earlier curbside consultation may have prevented unnecessary testing or face-to-face tertiary neurology consultations in 40 (22%) patients. Earlier face-to-face consultation may have avoided expensive testing in 31 (17%) patients. No cases met criteria for an adverse outcome. The number of referrals to tertiary neurology declined by 64%, and the total number of face-to-face visits per month declined by 25%. Colocated neurology in a primary care medical home offers a promising intervention to deliver high-value care. © 2016 John Wiley & Sons, Ltd.

Scrub typhus: audit of an outbreak.

PubMed

Krishna, Mani Ram; Vasuki, B; Nagaraju, K

2015-06-01

To document the epidemiological, clinical and laboratory profile of all children with scrub typhus at a tertiary care centre in Chennai between September 2010 and June 2011. The case records of all children admitted and diagnosed with scrub typhus between September 2010 and June 2011 were analysed to look for salient clinical and laboratory parameters. During the study period, 52 children were admitted with scrub typhus in the authors' hospital. The presenting complaints included fever in all cases. Other symptoms included swelling of legs (50 %) and vomiting (45 %). 13 % presented with CNS symptoms. The commonest physical findings included eschar (67 %), hepatomegaly (94 %), splenomegaly (73 %) and third spacing (67 %). Salient lab parameters included packed cell volume (PCV) <30 (48 %), leucocytosis (56 %), positive C-reactive protein (CRP) (92 %), hypoalbuminemia (79 %). Common complications included acute kidney injury (10 %) and peripheral gangrene (4 %). There was no mortality in the present case series. The clinical profile of children with scrub typhus in a tertiary care centre is reported. Eschar and hepatosplenomegaly with a high CRP value is helpful in diagnosis. All patients responded well to the treatment.

Undergraduate nurse students' perspectives of spiritual care education in an Australian context.

PubMed

Cooper, Katherine Louise; Chang, Esther

2016-09-01

The Australian Nursing and Midwifery Accreditation Council competency standards highlight the need to provide holistic care that is inclusive of spiritual care. Literature shows that internationally many nurses feel unsure of how to provide spiritual care which has been attributed to a lack of spiritual care education during undergraduate nursing programs. This study explores the impact of a spiritual care subject in an undergraduate nursing program in an Australian tertiary institution. Qualitative research design using in-depth semi-structured interviews. A tertiary institution with a Christian orientation in Sydney, Australia. Six undergraduate nursing students who had completed the spiritual care subject. Two themes emerged from the data: Seeing the person as a whole and Being with the person. The spiritual care subject had a positive impact on the perceptions of undergraduate nursing students. In particular students perceived themselves more prepared to provide holistic care that was inclusive of spiritual care. Copyright © 2016 Elsevier Ltd. All rights reserved.

Health care utilization patterns for young children in rural counties of the I-95 corridor of South Carolina.

PubMed

McElligott, James T; Summer, Andrea P

2013-01-01

The objective of this study was to assess health care utilization patterns for young children with Medicaid insurance in the rural counties of the I-95 corridor in South Carolina relative to other regions of the state. We hypothesize that young children received less well care and higher levels of tertiary care in the rural counties along the I-95 corridor (I-95) of South Carolina. A Medicaid cohort of children less than 3 years of age was used to compare Early, Periodic, Diagnosis, Screening and Treatment (EPSDT) visits; preventable emergency department (ED) visits; and inpatient visits between I-95, other rural and urban county groupings. The adjusted odds of a child having had 80% of the recommended EPSDT visits were reduced for I-95 compared to other rural counties. The odds of a preventable inpatient or ED visit were increased for all rural counties, with the highest rates in the other rural counties. Children accessed well care less in the I-95 corridor compared to other rural areas of South Carolina. Rural children accessed tertiary care more often than urban children, a finding most prominent outside the I-95 corridor, likely attributable to more available access of tertiary care in rural counties outside the I-95 corridor. © 2012 National Rural Health Association.

Horses for Courses: Moving India towards Universal Health Coverage through Targeted Policy Design.

PubMed

Maurya, Dayashankar; Virani, Altaf; Rajasulochana, S

2017-12-01

The debate on how India's health system should move towards universal health coverage was (meant to be) put to rest by the recent National Health Policy 2017. However, the new policy is silent about tackling bottlenecks mentioned in the said policy proposal. It aims to provide universal access to free primary care by strengthening the public system, and to secondary and tertiary care through strategic purchasing from the private sector, to overcome deficiencies in public provisioning in the short run. Yet, in doing so, it ignores critical factors needed to replicate successful models of public healthcare delivery from certain states that it hopes to emulate. The policy also overestimates the capacity of the public sector and downplays the challenges observed in purchasing secondary care. Drawing from literature in policy design, we emphasize that primary, secondary and tertiary care have distinct characteristics, and their provision requires separate approaches or policy tools depending on the context. Public provisioning, contract purchasing and insurance mechanisms are different policy tools that have to be matched with the context and characteristics of the policy arena. Given the current challenges of India's health system, we argue that tertiary care services are most suitable for insurance-based purchasing, while the public sector should concentrate on building the required capacities to dominate the provisioning of secondary care and fill gaps in primary care delivery, for India to achieve its universal coverage ambitions.

Treatment of chronic subdural hematomas with subdural evacuating port system placement in the intensive care unit: evolution of practice and comparison with bur hole evacuation in the operating room.

PubMed

Flint, Alexander C; Chan, Sheila L; Rao, Vivek A; Efron, Allen D; Kalani, Maziyar A; Sheridan, William F

2017-12-01

OBJECTIVE The aims of this study were to evaluate a multiyear experience with subdural evacuating port system (SEPS) placement for chronic subdural hematoma (cSDH) in the intensive care unit at a tertiary neurosurgical center and to compare SEPS placement with bur hole evacuation in the operating room. METHODS All cases of cSDH evacuation were captured over a 7-year period at a tertiary neurosurgical center within an integrated health care delivery system. The authors compared the performance characteristics of SEPS and bur hole placement with respect to recurrence rates, change in recurrence rates over time, complications, length of stay, discharge disposition, and mortality rates. RESULTS A total of 371 SEPS cases and 659 bur hole cases were performed (n = 1030). The use of bedside SEPS placement for cSDH treatment increased over the 7-year period, from 14% to 80% of cases. Reoperation within 6 months was higher for the SEPS (15.6%) than for bur hole drainage (9.1%) across the full 7-year period (p = 0.002). This observed overall difference was due to a higher rate of reoperation during the same hospitalization (7.0% for SEPS vs 3.2% for bur hole; p = 0.008). Over time, as the SEPS procedure became more common and modifications of the SEPS technique were introduced, the rate of in-hospital reoperation after SEPS decreased to 3.3% (p = 0.02 for trend), and the difference between SEPS and bur hole recurrence was no longer significant (p = 0.70). Complications were uncommon and were similar between the groups. CONCLUSIONS Overall performance characteristics of bedside SEPS and bur hole drainage in the operating room were similar. Modifications to the SEPS technique over time were associated with a reduced reoperation rate.

Disease patterns and clinical outcomes of patients admitted in intensive care units of tertiary referral hospitals of Tanzania.

PubMed

Sawe, Hendry R; Mfinanga, Juma A; Lidenge, Salum J; Mpondo, Boniventura C T; Msangi, Silas; Lugazia, Edwin; Mwafongo, Victor; Runyon, Michael S; Reynolds, Teri A

2014-09-23

In sub-Saharan Africa the availability of intensive care unit (ICU) services is limited by a variety of factors, including lack of financial resources, lack of available technology and well-trained staff. Tanzania has four main referral hospitals, located in zones so as to serve as tertiary level referral centers. All the referral hospitals have some ICU services, operating at varying levels of equipment and qualified staff. We analyzed and describe the disease patterns and clinical outcomes of patients admitted in ICUs of the tertiary referral hospitals of Tanzania. This was a retrospective analysis of ICU patient records, for three years (2009 to 2011) from all tertiary referral hospitals of Tanzania, namely Muhimbili National Hospital (MNH), Kilimanjaro Christian Medical Centre (KCMC), Mbeya Referral Hospital (MRH) and Bugando Medical Centre (BMC). MNH is the largest of the four referral hospitals with 1300 beds, and MRH is the smallest with 480 beds. The ratio of hospital beds to ICU beds is 217:1 at MNH, 54:1 at BMC, 39:1 at KCMC, and 80:1 at MRH. KCMC had no infusion pumps. None of the ICUs had a point-of-care (POC) arterial blood gas (ABG) analyzer. None of the ICUs had an Intensive Care specialist or a nutritionist. A masters-trained critical care nurse was available only at MNH. From 2009-2011, the total number of patients admitted to the four ICUs was 5627, male to female ratio 1.4:1, median age of 34 years. Overall, Trauma (22.2%) was the main disease category followed by infectious disease (19.7%). Intracranial injury (12.5%) was the leading diagnosis in all age groups, while pneumonia (11.7%) was the leading diagnosis in pediatric patients (<18 years). Patients with tetanus (2.4%) had the longest median length ICU stay: 8 (5,13) days. The overall in-ICU mortality rate was 41.4%. The ICUs in tertiary referral hospitals of Tanzania are severely limited in infrastructure, personnel, and resources, making it difficult or impossible to provide optimum care to critically ill patients and likely contributing to the dauntingly high mortality rates.

Clinical pathway across tertiary and community care after an interventional cardiology procedure.

PubMed

Doran, K; Sampson, B; Staus, R; Ahern, C; Schiro, D

1997-01-01

Many patients who receive medical interventional cardiology procedures at a tertiary hospital live outside the metropolitan area and may experience fragmentation in care, less emotional support by family members, inaccurate and delayed communication, and lack of educational follow-up on discharge from the hospital. A clinical pathway titled "Heart Health Care Patterns" was developed to link acute phase, recovery phase, rehabilitation phase, and enhancement/maintenance phase. The 12-month clinical pathway combines Gordon's Functional Health Patterns and the Omaha System developed by the Omaha Visiting Nurse Association. The rating scale for outcomes assesses the patient at different phases to provide objective data and information throughout the year.

Pediatric oncology clinical trial participation where the geography is vast: Development of a clinical research system for tertiary and satellite centers in Ontario, Canada.

PubMed

Alexander, Sarah; Greenberg, Mark; Malkin, David; Portwine, Carol; Johnston, Donna; Silva, Mariana; Zelcer, Shayna; Sonshine, Samantha; Manzo, Janet; Bennett, Carla; Brodeur-Robb, Kathy; Deveault, Catherine; Ramachandran, Nivetha; Gibson, Paul

2018-04-01

Opportunities for participation in clinical trials are a core component of the care of children with cancer. In Ontario, many pediatric patients live long distances from their cancer center. This paper describes the work that was done in order to allow patients participating in Children's Oncology Group trials to receive care, including research protocol related care, jointly between the tertiary pediatric cancer center and the closer-to-home satellite center. The system is a pragmatic risk-based model, supporting excellence in care while ensuring good conduct of the research in compliance with applicable regulations and guidelines, including ethics oversight. © 2017 Wiley Periodicals, Inc.

Frequency of color blindness in pre-employment screening in a tertiary health care center in Pakistan.

PubMed

Chhipa, Shaukat Ali; Hashmi, Farzeen K; Ali, Shehreen; Kamal, Mustafa; Ahmad, Khabir

2017-01-01

To describe the frequency of color vision deficiency among Pakistani adults presenting for pre-employment health screening in a tertiary care hospital. The cross-sectional study was carried out at the Aga Khan University Hospital, Karachi, and the data was collected for color vision deficiency, age, gender, and job applied for from pre-employment examination during 2013-2014. IBM SPSS 20 was used for statistical analysis. Three thousand four hundred and thirty seven persons underwent pre-employment screening during 2013 and 2014; 1837 (53.44%) were males and 1600 (46.65%) females. The mean age was 29.01 (±6.53) years. A total of 0.9% (32/3437) persons had color vision deficiency with male being 1.4% and female 0.4%. Color vision deficiency was observed in 0.9% of candidates screened for pre-employment health check up in a tertiary care hospital. The color vision deficiency was predominantly present in male individuals.

Practices and challenges of infectious waste management: A qualitative descriptive study from tertiary care hospitals in Pakistan

PubMed Central

Kumar, Ramesh; Shaikh, Babar Tasneem; Somrongthong, Ratana; Chapman, Robert S

2015-01-01

Background and Objective: Infectious waste management practices among health care workers in the tertiary care hospitals have been questionable. The study intended to identify issues that impede a proper infectious waste management. Methods: Besides direct observation, in-depths interviews were conducted with the hospital administrators and senior management involved in healthcare waste management during March 2014. We looked at the processes related to segregation, collection, storage and disposal of hospital waste, and identified variety of issues in all the steps. Results: Serious gaps and deficiencies were observed related to segregation, collection, storage and disposal of the hospital wastes, hence proving to be hazardous to the patients as well as the visitors. Poor safety, insufficient budget, lack of trainings, weak monitoring and supervision, and poor coordination has eventually resulted in improper waste management in the tertiary hospitals of Rawalpindi. Conclusion: Study has concluded that the poor resources and lack of healthcare worker’s training in infectious waste results in poor waste management at hospitals. PMID:26430405

Enabling student placement through strategic partnerships between a health-care organization and tertiary institutions.

PubMed

Henderson, Amanda; Heel, Alison; Twentyman, Michelle

2007-01-01

Nursing management needs to demonstrate its commitment to clinical education for undergraduate nursing students. The vision for the nursing leadership and management team at Princess Alexandra Hospital is to guide and support the development of hospital clinicians, at all levels in the organization, to effectively facilitate undergraduate students' learning during their clinical practical experiences. This paper examines the evolution of the meaning, commitment and practices that have been intrinsic to the development of strategic partnerships between the health-care organization and tertiary institutions to ensure that hospital staff who consistently facilitate student learning in the clinical context are well supported. The partnerships are based on open channels of communication between the health-care organization and the tertiary institutions whereby each party identifies its needs and priorities. This has resulted in increased hospital staff satisfaction through greater involvement by them in the placements of students, and enhanced understanding of clinicians of the student placement process that has contributed to improved satisfaction and outcomes for the students.

Integrating preventive care and nursing standardized terminologies in nursing education: a case study.

PubMed

Burkhart, Lisa; Sommer, Sheryl

2007-01-01

This study investigated the development of a community-focused curriculum integrating primary, secondary, and tertiary prevention and nursing standardized terminologies as an organizing infrastructure. This is a case study of the curriculum redesign of the Marcella Niehoff School of Nursing, Loyola University Chicago. Faculty developed a conceptual framework integrating core concepts into curriculum design, course content, and clinical applications. A coherent curriculum was designed using a community-focused approach; primary, secondary, and tertiary prevention strategies; and standardized terminologies as the organizing infrastructure to teach and apply nursing practice. The curriculum provides a meaningful correlation between the classroom and clinical experience. Students journey with their patients throughout the health care experience, applying nursing concepts using standardized terminologies. Clinical experiences provide students with the opportunity to transfer knowledge to the health experiences of patients in their care. Patient encounters, whether at the primary, secondary, or tertiary level of prevention, are used to assist students in developing critical thinking skills through the use of standardized nursing terminologies.

[Experience of the surgical management of the esophageal achalasia in a tertiary care hospital].

PubMed

Barajas-Fregoso, Elpidio Manuel; Romero-Hernández, Teodoro; Sánchez-Fernández, Patricio Rogelio; Fuentes-Orozco, Clotilde; González-Ojeda, Alejandro; Macías-Amezcua, Michel Dassaejv

2015-01-01

Achalasia is a primary esophageal motor disorder. The most common symptoms are: dysphagia, chest pain, reflux and weight loss. The esophageal manometry is the standard for diagnosis. The aim of this paper is to determine the effectiveness of the surgical management in patients with achalasia in a tertiary care hospital. A case series consisting of achalasia patients, treated surgically between January and December of 2011. Clinical charts were reviewed to obtain data and registries of the type of surgical procedure, morbidity and mortality. Fourteen patients were identified, with an average age of 49.1 years. The most common symptoms were: dysphagia, vomiting, weight loss and pyrosis. Eight open approaches were performed and six by laparoscopy, with an average length of cardiomyotomy of 9.4 cm. Eleven patients received an antireflux procedure. The effectiveness of procedures performed was 85.7 %. Surgical management offered at this tertiary care hospital does not differ from that reported in other case series, giving effectiveness and safety for patients with achalasia.

A Comprehensive Primary Health Care Delivery Model.

ERIC Educational Resources Information Center

Pullen, Carol; And Others

1994-01-01

This primary health care model is based on four assumptions: emphasis on collective, not individual, needs; coordination of preventive/episodic care with secondary/tertiary care; comprehensive, holistic approach; and partnership and equality among professional disciplines and community members. Stakeholders involved are medical, nursing, and…

Cost analysis of an outbreak of Clostridium difficile infection ribotype 027 in a Dutch tertiary care centre.

PubMed

van Beurden, Y H; Bomers, M K; van der Werff, S D; Pompe, E A P M; Spiering, S; Vandenbroucke-Grauls, C M J E; Mulder, C J J

2017-04-01

The economic impact of Clostridium difficile infection (CDI) on the healthcare system is significant. From May 2013 to May 2014, an outbreak of C. difficile ribotype 027 occurred in a Dutch tertiary care hospital, involving 72 patients. The primary aim of this study was to provide insight into the financial burden that this CDI outbreak brought upon this hospital. A retrospective analysis was performed to estimate the costs of a one-year-long C. difficile ribotype 027 outbreak. Medical charts were reviewed for patient data. In addition, all costs associated with the outbreak control measures were collected. The attributable costs of the whole outbreak were estimated to be €1,222,376. The main contributing factor was missed revenue due to increased length of stay of CDI patients and closure of beds to enable contact isolation of CDI patients (36%). A second important cost component was extra surveillance and activities of the Department of Medical Microbiology and Infection Control (25%). To the authors' knowledge, this is the first study to provide insight into the attributable costs of CDI in an outbreak setting, and to delineate the major cost items. It is clear that the economic consequences of CDI are significant. The high costs associated with a CDI outbreak should help to justify the use of additional resources for CDI prevention and control. Copyright © 2016 The Healthcare Infection Society. Published by Elsevier Ltd. All rights reserved.

Hepatitis B and C virus prevalence in couples attending an in vitro fertilization clinic in a tertiary care hospital in Saudi Arabia: comparison with ten years earlier.

PubMed

Albadran, Asma; Hibshi, Ali; Saeed, Bahjat; Coskun, Serdar; Awartani, Khalid Arab

2017-01-01

Viral hepatitis B (HBV) and C (HCV) are a major public health problem in Saudi Arabia. Recent data has indicated a major reduction in viral hepatitis prevalence in Saudi population. However, there is limited data for infertile Saudi couples. To determine the prevalence of HCV and HBV attending an in vitro fertilization (IVF) clinic in Saudi Arabia between 2012 and 2015 to compare with the prevalence 10 years earlier in the same center. Retrospective prevalence study. Tertiary care center in Riyadh. Data on the prevalence of HBV and HCV was collected on all couples seen at the IVF unit between 2002-2005 and 2012-2015. Prevalence of HBV and HCV. In 4442 patients during 2002-2005 and 5747 patients during 2012-2015, the prevalence of HBV was significantly less in 2012-2015 compared with 2002-2005 (1.67% [97 patients] vs 4.7% [210 patients], P < .0001), respectively, but HCV prevalence was similar for the two periods (0.7% for both periods) (P=.887). The hepatitis B seroprevalence rate was higher in males compared to females during 2002-2005 (6.3% vs 3.1%) (P < .0001) and 2012-2015 (2.4% vs 1.1% ) (P < .0001), respectively. The significant drop in HBV prevalence was most likely due to the introduction of the vaccination program in 1989, while reasons for HCV prevalence remaining unchanged are unclear. No data on confounding factors that may have affected the prevalence.

A Case Series of the Probability Density and Cumulative Distribution of Laryngeal Disease in a Tertiary Care Voice Center.

PubMed

de la Fuente, Jaime; Garrett, C Gaelyn; Ossoff, Robert; Vinson, Kim; Francis, David O; Gelbard, Alexander

2017-11-01

To examine the distribution of clinic and operative pathology in a tertiary care laryngology practice. Probability density and cumulative distribution analyses (Pareto analysis) was used to rank order laryngeal conditions seen in an outpatient tertiary care laryngology practice and those requiring surgical intervention during a 3-year period. Among 3783 new clinic consultations and 1380 operative procedures, voice disorders were the most common primary diagnostic category seen in clinic (n = 3223), followed by airway (n = 374) and swallowing (n = 186) disorders. Within the voice strata, the most common primary ICD-9 code used was dysphonia (41%), followed by unilateral vocal fold paralysis (UVFP) (9%) and cough (7%). Among new voice patients, 45% were found to have a structural abnormality. The most common surgical indications were laryngotracheal stenosis (37%), followed by recurrent respiratory papillomatosis (18%) and UVFP (17%). Nearly 55% of patients presenting to a tertiary referral laryngology practice did not have an identifiable structural abnormality in the larynx on direct or indirect examination. The distribution of ICD-9 codes requiring surgical intervention was disparate from that seen in clinic. Application of the Pareto principle may improve resource allocation in laryngology, but these initial results require confirmation across multiple institutions.

Remote biomonitoring of temperatures in mothers and newborns: design, development and testing of a wearable sensor device in a tertiary-care hospital in southern India.

PubMed

Mony, Prem K; Thankachan, Prashanth; Bhat, Swarnarekha; Rao, Suman; Washington, Maryann; Antony, Sumi; Thomas, Annamma; Nagarajarao, Sheela C; Rao, Hiteshwar; Amrutur, Bharadwaj

2018-04-01

Newer technologies such as wearables, sensors, mobile telephony and computing offer opportunities to monitor vital physiological parameters and tackle healthcare problems, thereby improving access and quality of care. We describe the design, development and testing of a wearable sensor device for remote biomonitoring of body temperatures in mothers and newborns in southern India. Based on client needs and technological requirements, a wearable sensor device was designed and developed using principles of 'social innovation' design. The device underwent multiple iterations in product design and engineering based on user feedback, and then following preclinical testing, a techno-feasibility study and clinical trial were undertaken in a tertiary-care teaching hospital in Bangalore, India. Clinical trial phases I and IIa for evaluation of safety and efficacy were undertaken in the following sequence: 7 healthy adult volunteers; 18 healthy mothers; 3 healthy babies; 10 stable babies in the neonatal care intensive unit and 1 baby with morbidities. Time-stamped skin temperature readings obtained at 5 min intervals over a 1-hour period from the device secured on upper arms of mothers and abdomen of neonates were compared against readings from thermometers used routinely in clinical practice. Devices were comfortably secured on to adults and neonates, and data were efficiently transmitted via the gateway device for secure storage and retrieval for analysis. The mean skin temperatures in mothers were lower than the axillary temperatures by 2°C; and in newborns, there was a precision of -0.5°C relative to axillary measurements. While occasional minimal adverse events were noted in healthy volunteers, no adverse events were noted in mothers or neonates. This proof-of-concept study shows that this device is promising in terms of feasibility, safety and accuracy (with appropriate calibration) with potential for further refinements in device accuracy and pursuit of further phases of clinical research for improved maternal and neonatal health.

Higher pain scores, similar opioid doses and side effects associated with antipyretic analgesics in specialised tertiary pain care.

PubMed

Lötsch, Jörn; Freynhagen, Rainer; von Hentig, Nils; Griessinger, Norbert; Zimmermann, Michael; Sittl, Reinhard; Geisslinger, Gerd

2010-11-01

To evaluate whether non-opioid antipyretic analgesics are associated with lower pain scores, opioid doses and side effects in pain patients in tertiary care. In a cross-sectional observational study, data from 519 Caucasians (197 men, 322 women; mean age 55.6 ± 15 years) who had undertaken pain therapy for various causes for 77.5 ± 90.8 months, obtained in three separate study centres, was analysed for actual 24-h pain scores, daily opioid doses and the occurrence of side effects. Of the 519 patients, 352 received opioids and 260 antipyretic analgesics, from whom 154 received both classes and 304 only either class. The administration of non-opioid antipyretic analgesics was associated with higher average pain scores (4.6 ± 2.5 vs 3.9 ± 2.6; P = 0.01), tendentially higher average oral morphine equivalent doses (121.8 ± 162.2 vs 146.7 ± 242.4 mg/d; P = 0.25) and a similar incidence of side effects (P = 0.21). These results were correspondingly seen when analysing the three study centres separately as independent cohorts. With the caution advised for cross-sectional data, the results dispute a clinical benefit of non-opioid antipyretic analgesics for most chronic pain patients in tertiary care and draw attention towards prospectively re-evaluating the utility of non-opioid antipyretic analgesics in tertiary pain care in a randomised placebo controlled trial.

Comparison of stress and burnout among anesthesia and surgical residents in a tertiary care teaching hospital in North India.

PubMed

Gandhi, K; Sahni, N; Padhy, S K; Mathew, P J

2017-10-23

The residents undergoing training at hospitals in our country face challenges in terms of infrastructure and high workload with undefined working hours. The aim of the study was to compare the stress and burnout levels in trainee doctors doing residency in surgical fields and anesthesia at a tertiary care academic center in North India. A comparative, observational study was conducted in a tertiary care teaching hospital in North India. After Ethics Committee approval, 200 residents (100 each from surgical branches and anesthesia) were required to fill a questionnaire with information about age, sex, year of residency, marital status, and the Perceived Stress Scale-10, and Burnout Clinical Subtype Questionnaire-12. Burnout and perceived stress were compared between residents of anesthesia and surgical specialties. Residents of both surgical and anesthesia branches scored high in perceived stress, namely 21 and 18, respectively. The score was significantly higher in surgical residents (P = 0.03) and increased progressively with the year of residency. The majority of residents (90% surgical, 80% anesthesia) felt that they were being overloaded with work. However, only 20%-30% of respondents felt that there was lack of development of individual skills and still fewer (<10%) reported giving up in view of difficulties. There is high level of stress and overload dimension of burnout among the residents of anesthesia and surgical branches at our tertiary care academic institution and the surgical residents score marginally higher than anesthesia residents.

Chicken pox outbreak in the Intensive Care Unit of a tertiary care hospital: Lessons learnt the hard way.

PubMed

Sarit, Sharma; Shruti, Sharma; Deepinder, Chhina; Chhina, R S

2015-12-01

Varicella-zoster virus (VZV) causes 2 clinically and epidemiologically distinct forms of diseases. Chickenpox (varicella) is the disease that results from primary infection with the VZV. Herpes zoster (HZ) results from the reactivation of VZV latently infecting the dorsal root ganglia. We are reporting an outbreak of varicella infection among the health care workers (HCWs) in the Intensive Care Unit (ICU) of a tertiary care hospital. We found transmission of varicella among eight HCWs of pulmonary ICU. They had a history of contact with a patient having HZ infection. Investigation of the outbreak was conducted as per guidelines. Better dissemination of information on disease transmission, isolation of infected patients inside the hospital, and adequate protection (including vaccination) for susceptible employees are important to prevent such outbreaks.

Improving care planning and coordination for service users with medical co-morbidity transitioning between tertiary medical and primary care services.

PubMed

Cranwell, K; Polacsek, M; McCann, T V

2017-08-01

WHAT IS KNOWN ON THE SUBJECT?: Mental health service users with medical co-morbidity frequently experience difficulties accessing and receiving appropriate treatment in emergency departments. Service users frequently experience fragmented care planning and coordinating between tertiary medical and primary care services. Little is known about mental health nurses' perspectives about how to address these problems. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Emergency department clinicians' poor communication and negative attitudes have adverse effects on service users and the quality of care they receive. The findings contribute to the international evidence about mental health nurses' perspectives of service users feeling confused and frustrated in this situation, and improving coordination and continuity of care, facilitating transitions and increasing family and caregiver participation. Intervention studies are needed to evaluate if adoption of these measures leads to sustainable improvements in care planning and coordination, and how service users with medical co-morbidity are treated in emergency departments in particular. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Effective planning and coordination of care are essential to enable smooth transitions between tertiary medical (emergency departments in particular) and primary care services for service users with medical co-morbidity. Ongoing professional development education and support is needed for emergency department clinicians. There is also a need to develop an organized and systemic approach to improving service users' experience in emergency departments. Introduction Mental health service users with medical co-morbidity frequently experience difficulties accessing appropriate treatment in medical hospitals, and often there is poor collaboration within and between services. Little is known about mental health nurses' perspectives on how to address these problems. Aim To explore mental health nurses' perspectives of the experience of service users with medical co-morbidity in tertiary medical services, and to identify how to improve care planning and coordination for service users transitioning between tertiary medical and primary care services. Method Embedded within an experience-based co-design study, focus group discussions were conducted with 17 emergency department nurses and other clinicians, in Melbourne, Australia. Results Three main themes were abstracted from the data: feeling confused and frustrated, enhancing service users' transition and experience and involving families and caregivers. Participants perceived the service user experience to be characterized by fear, confusion and a sense of not being listened to. They highlighted that service users' transition and experience could be enhanced by facilitating transitions and improving coordination and continuity of care. They also emphasized the need to increase family and caregiver participation. Conclusion Our findings contribute to knowledge about improving the way service users are treated in emergency departments and improving care planning and coordination; in particular, facilitating transitions, improving coordination and continuity of care and increasing family and caregiver participation. © 2016 The Authors. Journal of Psychiatric and Mental Health Nursing Published by John Wiley & Sons Ltd.

Delivering tertiary centre specialty care to ALS patients via telemedicine: a retrospective cohort analysis.

PubMed

Selkirk, Stephen M; Washington, Monique O; McClellan, Frances; Flynn, Broderick; Seton, Jacinta M; Strozewski, Richard

2017-08-01

This study was undertaken to determine if ALS patients evaluated via telemedicine received the same quality of care as patients evaluated by traditional face-to-face encounters. A retrospective cohort study design was used. Participants were patients diagnosed with ALS that received multidisciplinary care at the tertiary Cleveland VA ALS Centre between 1 March 2008- and 31 anuary 2015. Participants were not randomised, but chose telemedicine based on preference, disability level or distance from the clinic. Telemedicine in this study consisted of a video conferencing platform enabling remote rather than face-to-face encounters with participants. There was no significant association between receiving quality ALS care and the mode of care. There was a trend for telemedicine patients to utilise home health care less often than those that received clinic care (AOR 0.50; 95% CI 0.16-1.59). There was no significant difference in survival time between the two groups (log-rank test χ 2  = 3.62, df = 1, p = 0.05). Patients receiving telemedicine had a higher probability of remaining stable or having <30% decrease in ALSFRS-R over time (log-rank test χ 2  = 4.46, df = 1, p = 0.03). There was a significantly lower risk of disease progression for patients receiving telemedicine (HR = 0.39, 95% CI = 0.16-0.93). Patients managed by telemedicine received the same quality of care and had similar outcomes to those patients seen via traditional face-to-face encounters. Telemedicine is an effective platform for delivering high quality tertiary ALS care.

The effect of increasing the coinsurance rate on outpatient utilization of healthcare services in South Korea.

PubMed

Lee, Hyo Jung; Jang, Sung-In; Park, Eun-Cheol

2017-02-20

The Korean healthcare system is composed of costly and inefficient structures that fail to adequately divide the functions and roles of medical care organizations. To resolve this matter, the government reformed the cost-sharing policy in November of 2011 for the management of outpatients visiting general or tertiary hospitals with comparatively mild diseases. The purpose of the present study was to examine the impact of increasing the coinsurance rate of prescription drug costs for 52 mild diseases at general or tertiary hospitals on outpatient healthcare service utilization. The present study used health insurance claim data collected from 2010 to 2013. The study population consisted of 505,691 outpatients and was defined as those aged 20-64 years who had visited medical care organizations for the treatment of 52 diseases both before and after the program began. To examine the effect of the cost-sharing policy on outpatient healthcare service utilization (percentage of general or tertiary hospital utilization, number of outpatient visits, and outpatient medical costs), a segmented regression analysis was performed. After the policy to increase the coinsurance rate on prescription drug costs was implemented, the number of outpatient visits at general or tertiary hospitals decreased (β = -0.0114, p < 0.0001); however, the number increased at hospitals and clinics (β = 0.0580, p < 0.0001). Eventually, the number of outpatient visits to hospitals and clinics began to decrease after policy initiation (β = -0.0018, p < 0.0001). Outpatient medical costs decreased for both medical care organizations (general or tertiary hospitals: β = -2913.4, P < 0.0001; hospitals or clinics: β = -591.35, p < 0.0001), and this decreasing trend continued with time. It is not clear that decreased utilization of general or tertiary hospitals has transferred to that of clinics or hospitals due to the increased cost-sharing policy of prescription drug costs. This result indicates the cost-sharing policy, intended to change patient behaviors for healthcare service utilization, has had limited effects on rebuilding the healthcare system and the function of medical care organizations.

Increased carrier prevalence of deficient CYP2C9, CYP2C19 and CYP2D6 alleles in depressed patients referred to a tertiary psychiatric hospital.

PubMed

Ruaño, Gualberto; Villagra, David; Rahim, Umme Salma; Windemuth, Andreas; Kocherla, Mohan; Bower, Bruce; Szarek, Bonnie L; Goethe, John W

2008-11-01

This study compared the types and carrier prevalences of clinically significant DNA polymorphisms in the cytochrome P450 (CYP450) genes CYP2C9, CYP2C19 and CYP2D6 in major depressive disorder patients with a control group of nonpsychiatrically ill, medical outpatients. We conducted a case-control study using 73 psychiatric outpatients diagnosed with depression and referred to a tertiary center, The Institute of Living (Hartford, CT, USA), for treatment resistance or intolerable side-effects to psychotropic drugs. The controls were 120 cardiovascular patients from Hartford Hospital being treated for dyslipidemia but otherwise healthy and not psychiatrically ill. DNA typing to detect polymorphisms in the genes CYP2C9, CYP2C19 and CYP2D6 was accomplished with the Tag-It™ mutation detection assay and the Luminex xMAP ® system. The percentage of individuals in psychiatric versus control groups with two wild-type alleles for CYP2C9, CYP2C19 and CYP2D6 genes, were 50 versus 74% (p < 0.001), 71 versus 73% (not statistically significant) and 36 versus 43% (trend, p < 0.2), respectively. Within the psychiatric population, 57% of individuals were carriers of non-wild-type alleles for 2-3 genes, compared with 36% in the control population (p < 0.0001). The balance, 43% in the psychiatric population and 64% in the control, were carriers of non-wild-type alleles for none or one gene. These findings reveal that clinically relevant CYP2C9 polymorphisms occur more frequently in depressed psychiatric patients than in nonpsychiatric controls. The same trend was found for polymorphisms in the CYP2D6 gene. We found a significant cumulative metabolic deficiency in the psychiatric population for combinations of the CYP2C9, CYP2C19 and CYP2D6 genes. The significant enrichment of CYP2C9-deficient alleles in the psychiatric population validates a previously reported association of this gene with the risk for depression disorders. The high prevalence of carriers with deficient and null alleles suggests that CYP450 DNA typing may play a role in the management of psychiatric patients at tertiary care institutions.

Does gynecologic malignancy predict likelihood of a tertiary palliative care unit hospital admission? A comparison of local, provincial and national death rates.

PubMed

Pilkey, Jana; Demers, Chantale; Chochinov, Harvey; Venkatesan, Nithya

2012-12-01

The purpose of this study was to determine whether the presence of gynecologic malignancies predicts the likelihood of a tertiary palliative care unit hospital admission. In this study, patients admitted to a specialized tertiary palliative care unit (TPCU) with gynecologic malignancies were compared to national and provincial death rates to determine if gynecologic malignancy predicts admission, and subsequent death, in a TPCU. Eighty-two gynecologic cancer patients were admitted to our TPCU over the 5- year study period. Out of all cancer deaths in the TPCU, death from ovarian cancer was 3.7% compared with 2.4% (p = 0.0068) of all cancer deaths in Manitoba and 2.3% (p = 0.0043) of all cancer deaths in Canada. Cervical cancer accounted for 1.7% of all our patients deaths compared with 0.7% (p = 0.0001) provincially and 0.6% (p = 0.0001) nationally. Uterine cancer deaths were not significantly different from the provincial and national death rates, whereas vulvar and fallopian cancers were too rare to allow for statistical analysis. Gynecologic cancers may be predictive of admission to a palliative care unit.

Surveillance of musculoskeletal injuries and disorders in a diverse cohort of workers at a tertiary care medical center.

PubMed

Pompeii, Lisa A; Lipscomb, Hester J; Dement, John M

2008-05-01

The purpose of this study was to investigate the incidence of work-related musculoskeletal (MSK) injuries and disorders among a dynamic cohort of health care workers, including direct care providers and support services, employed at a tertiary care medical center. Human resources data were used to define the cohort and time at risk. Workers' compensation (WC) records (1997-2003) were utilized to identify work-related MSK claims. Poisson regression was used to generate gender specific rate ratios and 95% confidence intervals (CI) of MSK injuries among workgroups. MSK injuries resulted equally ( approximately 30% each) from lift/push/pull of equipment, patient handling, and slip/trip/falls. Injury rates and their mechanisms varied substantially by occupational group, gender, and race. Even with declining injury rates over time, black workers had rates 2.5 times higher than other workers and women had rates 1.8 times higher than men. Male and female nurses' aides, housekeepers, and radiology technicians had among the highest rates of injury, while lost workdays rates were highest for male and female nurses' aides, female housekeepers, and male patient transporters. Differential risk associated with work tasks in highly segregated work populations can contribute to disparities in health, and the patterns we observed partly reflect the high concentration of female and black workers in occupations with increased physical demands. While the greatest public health impact will be achieved by implementing prevention strategies among large workgroups with high injury rates, public health efforts must not ignore smaller, often segregated, workgroups identified in this study as high risk. (c) 2008 Wiley-Liss, Inc.

C-Window Peaks on CE-HPLC are Extremely Rare in Northern India, and Only Infrequently Represent HbC.

PubMed

Dass, Jasmita; Mittal, Suchi; Saraf, Amrita; Kotwal, Jyoti

2018-01-01

Hemoglobin C (HbC, HBB:c.19G > A) is a structural variant that has been reported rarely from India. This was a retrospective review of all high performance liquid chromatography (HPLCs) submitted over a 14 year period to a tertiary care center in North India with an aim of finding hemoglobins that elute in the C-window. Of the 32,364 HPLCs screened, 6 cases showed peaks in the C-window. Of these 6 cases, only two cases contained hemoglobin C. These was one case each of HbC/β thalassemia and compound heterozygosity for HbC and HbD. There were 4 cases which showed very similar red cell indices and chromatograms with multiple peaks eluting in D-window, C-window and an additional peak with a retention time of 4.74 min. These four cases were compound heterozygous for an α chain variant HbQ-India and a β-chain variant HbD.

Gas gangrene secondary to Clostridium perfringens in pediatric oncology patients.

PubMed

Temple, Ana-Maria M; Thomas, Neal J

2004-07-01

To report 2 cases of severe gas gangrene secondary to Clostridium perfringens in pediatric oncology patients. We describe 2 children with acute presentations of gas gangrene secondary to C. perfringens. Both children were initially seen and treated in a community hospital emergency department and subsequently were cared for in a pediatric intensive care unit in a tertiary care, university-based children's hospital. Both children demonstrated severe and unrelenting decompensation and required operative intervention within the first hospital day, which included amputation of the infected limb. One child survived and one child expired despite heroic measures. Gas gangrene secondary to C. perfringens is an uncommon but life-threatening and limb-threatening condition in pediatric cancer patients. A high index of suspicion in a immunocompromised child with cancer who presents with extremity pain in combination with neutropenia is the key to early diagnosis and may lead to improved survival. This disease requires prompt recognition and aggressive treatment to allow any hope of recovery. Emergency medicine physicians who treat these children should be aware of this severe and potentially fatal infectious process and should not delay treatment or prompt orthopedic surgery consultation.

Secondary and tertiary preventions of thyroid disease.

PubMed

Azizi, Fereidoun; Mehran, Ladan; Hosseinpanah, Farhad; Delshad, Hossein; Amouzegar, Atieh

2018-05-01

Secondary and tertiary preventions are concerned with the recognition of the disease process in a very early stage and delay in progression to complete disease and minimization of complications and the impact of illness. All articles related to secondary and tertiary prevention of thyroid diseases were reviewed. Using related key words, articles published between 2001 and 2015 were evaluated, categorized, and analyzed. In secondary prevention, congenital hypothyroidism and subclinical hypo and hyperthyroidism are equally important. Routine screening of patients with multinodular goiter by either ultrasonography or calcitonin is a controversial issue, while calcitonin assessments in medullary cancer and RET in family members are recommended. Screening of thyroid disease in pregnancy is limited to those with risk factors. Views regarding the importance of thyroid autoimmunity in secondary prevention are also presented. In tertiary prevention, prescribing excessive doses of levothyroxine, in the elderly in particular and appropriate care of all patients to avoid progression and complications are the key issues. Optimization of management of thyroid diseases requires timely screening, prevention of progression to more sever disease, optimal medical care, and avoidance of iatrogenic conditions.

A multicentre, randomised controlled, non-inferiority trial, comparing nasal high flow with nasal continuous positive airway pressure as primary support for newborn infants with early respiratory distress born in Australian non-tertiary special care nurseries (the HUNTER trial): study protocol

PubMed Central

Manley, Brett J; Roberts, Calum T; Arnolda, Gaston R B; Wright, Ian M R; Owen, Louise S; Dalziel, Kim M; Foster, Jann P; Davis, Peter G; Buckmaster, Adam G

2017-01-01

Introduction Nasal high-flow (nHF) therapy is a popular mode of respiratory support for newborn infants. Evidence for nHF use is predominantly from neonatal intensive care units (NICUs). There are no randomised trials of nHF use in non-tertiary special care nurseries (SCNs). We hypothesise that nHF is non-inferior to nasal continuous positive airway pressure (CPAP) as primary support for newborn infants with respiratory distress, in the population cared for in non-tertiary SCNs. Methods and analysis The HUNTER trial is an unblinded Australian multicentre, randomised, non-inferiority trial. Infants are eligible if born at a gestational age ≥31 weeks with birth weight ≥1200 g and admitted to a participating non-tertiary SCN, are <24 hours old at randomisation and require non-invasive respiratory support or supplemental oxygen for >1 hour. Infants are randomised to treatment with either nHF or CPAP. The primary outcome is treatment failure within 72 hours of randomisation, as determined by objective oxygenation, apnoea or blood gas criteria or by a clinical decision that urgent intubation and mechanical ventilation, or transfer to a tertiary NICU, is required. Secondary outcomes include incidence of pneumothorax requiring drainage, duration of respiratory support, supplemental oxygen and hospitalisation, costs associated with hospital care, cost-effectiveness, parental stress and satisfaction and nursing workload. Ethics and dissemination Multisite ethical approval for the study has been granted by The Royal Children’s Hospital, Melbourne, Australia (Trial Reference No. 34222), and by each participating site. The trial is currently recruiting in eight centres in Victoria and New South Wales, Australia, with one previous site no longer recruiting. The trial results will be published in a peer-reviewed journal and will be presented at national and international conferences. Trial registration number Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614001203640; pre-results. PMID:28645982

A multicentre, randomised controlled, non-inferiority trial, comparing nasal high flow with nasal continuous positive airway pressure as primary support for newborn infants with early respiratory distress born in Australian non-tertiary special care nurseries (the HUNTER trial): study protocol.

PubMed

Manley, Brett J; Roberts, Calum T; Arnolda, Gaston R B; Wright, Ian M R; Owen, Louise S; Dalziel, Kim M; Foster, Jann P; Davis, Peter G; Buckmaster, Adam G

2017-06-23

Nasal high-flow (nHF) therapy is a popular mode of respiratory support for newborn infants. Evidence for nHF use is predominantly from neonatal intensive care units (NICUs). There are no randomised trials of nHF use in non-tertiary special care nurseries (SCNs). We hypothesise that nHF is non-inferior to nasal continuous positive airway pressure (CPAP) as primary support for newborn infants with respiratory distress, in the population cared for in non-tertiary SCNs. The HUNTER trial is an unblinded Australian multicentre, randomised, non-inferiority trial. Infants are eligible if born at a gestational age ≥31 weeks with birth weight ≥1200 g and admitted to a participating non-tertiary SCN, are <24 hours old at randomisation and require non-invasive respiratory support or supplemental oxygen for >1 hour. Infants are randomised to treatment with either nHF or CPAP. The primary outcome is treatment failure within 72 hours of randomisation, as determined by objective oxygenation, apnoea or blood gas criteria or by a clinical decision that urgent intubation and mechanical ventilation, or transfer to a tertiary NICU, is required. Secondary outcomes include incidence of pneumothorax requiring drainage, duration of respiratory support, supplemental oxygen and hospitalisation, costs associated with hospital care, cost-effectiveness, parental stress and satisfaction and nursing workload. Multisite ethical approval for the study has been granted by The Royal Children's Hospital, Melbourne, Australia (Trial Reference No. 34222), and by each participating site. The trial is currently recruiting in eight centres in Victoria and New South Wales, Australia, with one previous site no longer recruiting. The trial results will be published in a peer-reviewed journal and will be presented at national and international conferences. Australian and New Zealand Clinical Trials Registry (ANZCTR): ACTRN12614001203640; pre-results. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Basic Risk Factors Awareness in Non-Communicable Diseases (BRAND) Study Among People Visiting Tertiary Care Centre in Mysuru, Karnataka.

PubMed

Thippeswamy, Thippeswamy; Chikkegowda, Prathima

2016-04-01

Non Communicable Diseases (NCDs) are the major causes of mortality and morbidity globally. Awareness about NCDs and their risk factors has an important role in prevention and management strategies of these NCDs. 1) To assess the awareness of risk factors contributing to NCDs among the patients visiting tertiary care hospital in Mysuru district; 2) To compare the difference in awareness of risk factors for NCDs among the urban and rural patients with/ without NCD visiting the tertiary care hospital. A cross- sectional study was conducted in a tertiary care centre- JSS Hospital, Mysuru, Karnataka from March 2013 - August 2013. The patients visiting Medicine OPD during the period were the study subjects. The subjects were allocated into 4 groups: Urban without any NCD, Urban with atleast one NCD, rural without NCD, rural with atleast one NCD. A pretested questionnaire regarding awareness of risk factors for NCDs was used in the study and frequency and proportions were used to analyse the data. A total of 400 subjects, 100 subjects in each group were included in the study. Out of these subjects about 65% of the urban group and 42% of the rural group subjects were aware of the NCDs and their risk factors. Least awareness was observed among the rural subjects without any NCDs (35%). The awareness of risk factors of NCDs and knowledge regarding prevention of NCDs was not satisfactory. The results highlighted the need and scope for health education and interventions to improve the awareness about NCDs and their risk factors.

Frequency and risk factors associated with dry eye in patients attending a tertiary care ophthalmology center in Mexico City.

PubMed

Martinez, Jaime D; Galor, Anat; Ramos-Betancourt, Nallely; Lisker-Cervantes, Andrés; Beltrán, Francisco; Ozorno-Zárate, Jorge; Sánchez-Huerta, Valeria; Torres-Vera, Marco-Antonio; Hernández-Quintela, Everardo

2016-01-01

The purpose of this study was to ascertain the frequency and risk factors of dry eye (DE) among patients attending a tertiary care ophthalmology center in Mexico. Approximately 338 consecutive new patients attending a tertiary care ophthalmology center in Mexico City underwent an ocular surface examination, which included tear film break-up time, fluorescein corneal staining, Schirmer's test, and evaluation of meibum quality. Symptoms of DE were evaluated by the Ocular Surface Disease Index and Dry Eye Questionnaire-5. Information on demographics, exposures, past medical and ocular history, and medications was also collected. The frequency of severe DE symptoms was found to be 43% based on the Ocular Surface Disease Index and 30% based on Dry Eye Questionnaire-5. Risk factors significantly associated with increased DE symptoms included dry mouth and gastrointestinal ulcer medications. With regard to signs, aqueous tear deficiency was a less-frequent finding (22%) in our population than evaporative deficiency (94%). Risk factors associated with aqueous tear deficiency were dry mouth and diuretic use. No risk factors were associated with evaporative deficiency. Risk factors associated with meibomian gland dysfunction included old age, male sex, arthritis, and use of an antihypertensive. The only risk factor associated with corneal staining was dry mouth. This is the first study to demonstrate the frequency of symptomatic and clinical DE in a tertiary care ophthalmology center in Mexico. The frequency of DE ranged from 30% using a symptomatic definition to 94% using objective measures. Different risk factors were found for different aspects of DE, suggesting differing underlying pathophysiologies behind different DE subtypes.

Pediatric emergency care in europe: a descriptive survey of 53 tertiary medical centers.

PubMed

Mintegi, Santiago; Shavit, Itai; Benito, Javier

2008-06-01

To examine determinants of quality of care provided by pediatric emergency departments (PEDs) in tertiary European centers. Analysis of questionnaires was sent to directors of PEDs. Questionnaires were sent through the pediatric research group of the European Society for Emergency Medicine. Three major descriptive categories were included in a 28-point questionnaire: institution's pediatric inpatient capabilities, scope of services, and medical staff education and structure. Sixty-five questionnaires were completed in full. Fifty-three tertiary medical centers from 14 countries were included in the study. In 86.8% of these institutions, the PED is separated from the adult emergency department; 91% have a pediatric intensive care unit, and 72% have an in-patient pediatric trauma service. Eighty-eight percent of the PEDs have incorporated triage protocols. Social service was not available in 17% of the departments. Sedation for painful procedures is provided by the staff in 77% of the PEDs. Only 24% of the PED medical directors have been formally trained in pediatric emergency medicine. In 17% of the departments, there is a 24-hour 7-day residents' coverage with no attending pediatrician or pediatric emergency medicine-trained physician. According to this pilot study, the basic services provided by tertiary PEDs in Europe appear to be appropriate. Physicians training level and staffing may not be adequate to achieve optimal patient outcome.

The association between improved quality diabetes indicators, health outcomes and costs: towards constructing a "business case" for quality of diabetes care--a time series study.

PubMed

Wilf-Miron, Rachel; Bolotin, Arkadi; Gordon, Nesia; Porath, Avi; Peled, Ronit

2014-12-01

In primary health care systems where member's turnover is relatively low, the question, whether investment in quality of care improvement can make a business case, or is cost effective, has not been fully answered.The objectives of this study were: (1) to investigate the relationship between improvement in selected measures of diabetes (type 2) care and patients' health outcomes; and (2) to estimate the association between improvement in performance and direct medical costs. A time series study with three quality indicators - Hemoglobin A1c (HbA1c) testing, HbA1C and LDL- cholesterol (LDL-C) control - which were analyzed in patients with diabetes, insured by a large health fund. Health outcomes measures used: hospitalization days, Emergency Department (ED) visits and mortality. Poisson, GEE and Cox regression models were employed. Covariates: age, gender and socio-economic rank. 96,553 adult (age >18) patients with diabetes were analyzed. The performance of the study indicators, significantly and steadily improved during the study period (2003-2009). Poor HbA1C (>9%) and inappropriate LDL-C control (>100 mg/dl) were significantly associated with number of hospitalization days. ED visits did not achieve statistical significance. Improvement in HbA1C control was associated with an annual average of 2% reduction in hospitalization days, leading to substantial reduction in tertiary costs. The Hazard ratio for mortality, associated with poor HbA1C and LDL-C, control was 1.78 and 1.17, respectively. Our study demonstrates the effect of continuous improvement in quality care indicators, on health outcomes and resource utilization, among patients with diabetes. These findings support the business case for quality, especially in healthcare systems with relatively low enrollee turnover, where providers, in the long term, could "harvest" their investments in improving quality.

Tertiary paediatric emergency department use in children and young people with cerebral palsy.

PubMed

Meehan, Elaine; Reid, Susan M; Williams, Katrina; Freed, Gary L; Babl, Franz E; Sewell, Jillian R; Rawicki, Barry; Reddihough, Dinah S

2015-10-01

The aim of this study was to describe the pattern of tertiary paediatric emergency department (ED) use in children and young people with cerebral palsy (CP). A retrospective analysis of ED data routinely collected at the two tertiary paediatric hospitals in Victoria, Australia, cross-matched with the Victorian Cerebral Palsy Register. Data pertaining to the ED presentations of 2183 registered individuals born 1993-2008 were obtained. Between 2008 and 2012, 37% (n = 814) of the CP cohort had 3631 tertiary paediatric ED presentations. Overall, 40% (n = 332) of presenters were residing in inner metropolitan Melbourne; 44% (n = 356) in outer Melbourne; and 13% (n = 108) in regional Victoria. Presenters were more likely than non-presenters to be younger, non-ambulant and have epilepsy. In total, 71% of presentations were triaged as Australasian Triage Scale 1-3 (urgent), and 44% resulted in a hospital admission. Disorders of the respiratory, neurological and gastrointestinal systems, and medical device problems were responsible for 72% of presentations. Many of the tertiary paediatric ED presentations in this group were appropriate based on the high admission rate and the large proportion triaged as urgent. However, there is evidence that some families are bypassing local services and travelling long distances to attend the tertiary paediatric ED, even for less urgent complaints that do not require hospital admission. Alternative pathways of care delivery, and strategies to promote the management of common problems experienced by children and young people with CP in non-paediatric EDs or primary care settings, may go some way towards reducing unnecessary tertiary paediatric ED use in this group. © 2015 The Authors. Journal of Paediatrics and Child Health © 2015 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Cardiac surgery for inmates in the Texas Department of Corrections.

PubMed

Bilfinger, T V; Conti, V R

1990-10-01

All Texas prison inmates requiring hospitalization since 1983 have been transferred to a separate prison hospital adjacent to a tertiary care university hospital. We reviewed and analyzed the data regarding one major tertiary care service, namely cardiac surgery, to describe the rate of utilization of this service and its results. From January 1, 1984, to June 30, 1988, 73 inmates underwent 74 cardiac operations, 50 of which were coronary revascularizations. The age-adjusted rates of utilization for coronary artery bypass grafting were substantially higher for inmates over age 45 than for that described for the general population, whereas the utilization rates for valve surgery were comparable. There were no perioperative or late deaths, and 86% of the inmate patients are currently employed within the Texas Department of Corrections system or were employed at the time of their release. The utilization rates and the results of this representative tertiary medical care service for the state's prison population are comparable to those achieved in the private sector, and may have a substantial beneficial effect on inmate rehabilitation.

Resistance patterns of multidrug resistant Acinetobacter baumannii in an ICU of a tertiary care hospital, Malaysia

PubMed Central

Janahiraman, Sivakami; Aziz, Muhammad Nazri; Hoo, Fan Kee; P’ng, Hon Shen; Boo, Yang Liang; Ramachandran, Vasudevan; Shamsuddin, Ahmad Fuad

2015-01-01

Backgrounds & Objective: Antimicrobial resistance is a major health problem worldwide in hospitals. The main contributing factors are exposures to broad-spectrum antimicrobials and cross-infections. Understanding the extent and type of antimicrobial use in tertiary care hospitals will aid in developing national antimicrobial stewardship priorities. Methods: In this study, we have analyzed the antimicrobial agents’ usage for acquisition of multidrug resistant using retrospective, cross-sectional, single-centre study in a multidisciplinary ICU at tertiary care hospital. Results: Acinetobacter baumannii (ACB) was isolated in various specimens from 662 patients. From these, 136 patients who were diagnosed with Ventilator-associated pneumonia (VAP) caused by ACB were included into the study. In our study, MDR strain accounts for 51% of all VAP cases caused by ACB. The development of ACB VAP were 10.5 + 6.4 days for MDR strains compared to susceptible organism (7.8 + 4.5 days) and had significantly longer ICU stay. Conclusion: The study concludes that prudent use of antimicrobial agents is important to reduce acquisition of MDR ACB. PMID:26870101

SynopSIS: integrating physician sign-out with the electronic medical record.

PubMed

Sarkar, Urmimala; Carter, Jonathan T; Omachi, Theodore A; Vidyarthi, Arpana R; Cucina, Russell; Bokser, Seth; van Eaton, Erik; Blum, Michael

2007-09-01

Safe delivery of care depends on effective communication among all health care providers, especially during transfers of care. The traditional medical chart does not adequately support such communication. We designed a patient-tracking tool that enhances provider communication and supports clinical decision making. To develop a problem-based patient-tracking tool, called Sign-out, Information Retrieval, and Summary (SynopSIS), in order to support patient tracking, transfers of care (ie, sign-outs), and daily rounds. Tertiary-care, university-based teaching hospital. SynopSIS compiles and organizes information from the electronic medical record to support hospital discharge and disposition decisions, daily provider decisions, and overnight or cross-coverage decisions. It reflects the provider's patient-care and daily work-flow needs. We plan to use Web-based surveys, audits of daily use, and interdisciplinary focus groups to evaluate SynopSIS's impact on communication between providers, quality of sign-out, patient continuity of care, and rounding efficiency. We expect SynopSIS to improve care by facilitating communication between care teams, standardizing sign-out, and automating daily review of clinical and laboratory trends. SynopSIS redesigns the clinical chart to better serve provider and patient needs. (c) 2007 Society of Hospital Medicine.

Evaluation of day care versus inpatient cataract surgery performed at a Jiangsu public Tertiary A hospital.

PubMed

Zhuang, Min; Cao, Juan; Cui, Minglan; Yuan, Songtao; Liu, Qinghuai; Fan, Wen

2018-06-05

High cataract incidence and low cataract surgical rate are serious public health problems in China, despite the fact that efficient day care cataract surgery has been implemented in some public Tertiary A hospitals in China. In this study, we compared not only clinical outcomes, hospitalization time and total costs but also payment manners between day care and inpatient procedures for cataract surgery in a Jiangsu public Tertiary A hospital to put forward several instructional suggestions for the improvement of government medical policies. In total, 4151 day care cases and 2509 inpatient cases underwent the same cataract surgery in the day care ward and ordinary ward respectively, and were defined as two groups. General information, complications, postoperative best corrected visual acuity (BCVA), hospitalization time, total costs and especially payment method were analyzed to compare day care versus inpatient. The general data display no significant differences (P > 0.05), and no significant difference between complications and postoperative BCVA were observed between the two groups (P > 0.05). The period of stay in hospital was significantly different (P < 0.001). The total costs were lower for day care than for inpatients (P < 0.001). To avoid sampling error, we analyzed the data of payment manner for each patient among this period. Day care patients tended to pay for the procedure using the Urban Employees Basic Medical Insurance (UEBMI) method, while inpatients tended to use the Out-of-Pocket Medical Treatment (OMT) payment method (P < 0.001). Day surgery of cataract is more cost-effective and efficient than inpatient surgery with equivalent clinical outcomes. As an efficient therapeutic regimen, day care surgery should be further promoted and supported by the government policies.

Successful clinical outcomes following decentralization of tertiary paediatric HIV care to a community-based paediatric antiretroviral treatment network, Chiangrai, Thailand, 2002 to 2008

PubMed Central

Hansudewechakul, Rawiwan; Naiwatanakul, Thananda; Katana, Abraham; Faikratok, Worawan; Lolekha, Rangsima; Thainuea, Vorapathu; McConnell, Michelle S

2012-01-01

Introduction Most paediatric antiretroviral treatments (ARTs) in Thailand are limited to tertiary care hospitals. To decentralize paediatric HIV treatment and care, Chiangrai Prachanukroh Hospital (CRH) strengthened a provincial paediatric HIV care network by training community hospital (CH) care teams to receive referrals of children for community follow-up. In this study, we assessed factors associated with death and clinical outcomes of HIV-infected children who received care at CRH and CHs after implementation of a community-based paediatric HIV care network. Methods Clinical records were abstracted for all children who initiated ART at CRH. Paired Wilcoxon signed rank tests were used to assess CD4% and virological change among all children. Cox proportional hazard models were used to assess factors associated with death. Treatment outcomes (CD4%, viral load (VL) and weight-for-age Z-score (WAZ)) were compared between CRH and CH children who met the criteria for analysis. Results Between February 2002 and April 2008, 423 HIV-infected children initiated ART and 410 included in the cohort analysis. Median follow-up for the cohort was 28 months (interquartile range (IQR)=12 to 42); 169 (41%) children were referred for follow-up at CH. As of 31 March 2008, 42 (10%) children had died. Baseline WAZ (<−2 (p=0.001)) and baseline CD4% (<5% (p=0.015)) were independently associated with death. At 48 months, 86% of ART-naïve children in follow-up had VL<400 copies/ml. For sub-group analysis, 133 children at CRH and 154 at CHs were included for comparison. Median baseline WAZ was lower in CH children than in CRH children (p=0.001); in both groups, WAZ, CD4% and VL improved after ART with no difference in rate of WAZ and CD4% gain (p=0.421 and 0.207, respectively). Conclusions Children at CHs had more severe immunological suppression and low WAZ at baseline. Community- and tertiary care-based paediatric ART follow-ups result in equally beneficial outcomes with the strengthening of a provincial referral network between tertiary and community care. Nutrition interventions may benefit children in community-based HIV treatment and care. PMID:23078768

Pilot-scale tertiary MBBR nitrification at 1°C: characterization of ammonia removal rate, solids settleability and biofilm characteristics.

PubMed

Young, Bradley; Delatolla, Robert; Ren, Baisha; Kennedy, Kevin; Laflamme, Edith; Stintzi, Alain

2016-08-01

Pilot-scale moving bed biofilm reactor (MBBR) is used to investigate the kinetics and biofilm response of municipal, tertiary nitrification at 1°C. The research demonstrates that significant rates of tertiary MBBR nitrification are attainable and stable for extended periods of operation at 1°C, with a maximum removal rate of 230 gN/m(3) d at 1°C. At conventional nitrogen loading rates, low ammonia effluent concentrations below 5 mg-N/L were achieved at 1°C. The biofilm thickness and dry weight biofilm mass (massdw) were shown to be stable, with thickness values showing a correlation to the protein/polysaccharide ratio of the biofilm extracellular polymeric substances. Lastly, tertiary MBBR nitrification is shown to increase the effluent suspended solids concentrations by approximately 3 mg total suspended solids /L, with 19-60% of effluent solids being removed after 30 min of settling. The settleability of the effluent solids was shown to be correlated to the nitrogen loading of the MBBR system.

Trajectory of cause of death among brought dead neonates in tertiary care public facilities of Pakistan: A multicenter study.

PubMed

Mustufa, Muhammad Ayaz; Sheikh, Munir Ahmed; Taseer, Ijaz-Ul-Haque; Raza, Syed Jamal; Arshad, Muhammad Sohail; Akhter, Tasleem; Arain, Ghazala Mohyuddin; Habibullah, Sultana; Safdar, Sohail; Firdous, Rukhsana; Adnan, Muhammad

2017-02-01

Considering the fact that Pakistan is amongst the countries with very high neonatal mortality rates, we conducted a research study to determine the possible causes and characteristics of neonates presenting dead to the emergency department of tertiary public health care facilities of Pakistan using verbal autopsies. A descriptive case series study was conducted in emergency department/pediatrics ward/neonatal ward/nursery unit of ten tertiary care public health facilities, situated in seven major cities of Pakistan from November, 2011 to June, 2013. Precoded verbal autopsy proforma was used to collect information regarding cause of death, family narratives and other associated risks accountable for pathway to mortality. We identified 431 neonates presenting dead to the emergency department (238 males and 193 females). Sepsis (26.7%), birth asphyxia (18.8%) and persistent pulmonary arrest (17.2%) were main primary causes of brought death. Around 72% brought dead neonates were referred from doctors/health care facilities and more than 28% caregivers mentioned that they were not informed about the diagnosis/ailment of their deceased newborn. Findings of our study suggest that infectious disease remains the main primary cause of neonatal mortality. Underweight in newborns (64%) was estimated as a leading associated risk. Delays in referrals to respective health care facility enlightened the concern of sub-standard prerequisites of neonatal care that could be one of the major contributing risk factor of high mortality rates.

Epidemiological and mycological characteristics of candidemia in patients with hematological malignancies attending a tertiary-care center in India.

PubMed

Dewan, Eshani; Biswas, Debasis; Kakati, Barnali; Verma, S K; Kotwal, Aarti; Oberoi, Aroma

2015-09-01

We undertook the present study to ascertain the contributing risk factors and explore the epidemiological and mycological characteristics of opportunistic candidemia among patients with hematological malignancies. Observational cross-sectional study in a tertiary care center. Consecutive patients with hematological malignancies reporting to the collaborating medical and pediatric units with a febrile episode were recruited and screened for candidemia by blood culture. Recovered Candida isolates were speciated and antifungal susceptibility testing was performed as per Clinical and Laboratory Standards Institute guideline (CLSI) guidelines M44-A. Further analysis was done for potential risk factors and compared between culture positive and negative patients. Of 150 patients recruited, the majority (n=27) were between 51 and 60 years and the male to female ratio was 1.63:1. Fifteen patients (10%) were culture positive. The culture positivity was significantly higher in acute lymphocytic leukemia (ALL) than in non-ALL patients (p=0.03). There was significant association of candidaemia with leucopenia, chemotherapeutic drugs, corticosteroids and presence of indwelling devices. Duration of disease (p=0.032) and duration of hospitalization (p=0.003) were significantly prolonged in culture positive patients. C. tropicalis was the commonest isolate (46.67%), with non- Candida albicans outnumbering C. albicans in all categories of hematological malignancies (2.75:1). All isolates of C. albicans were uniformly sensitive to all the azoles, but only 50% were sensitive to amphotericin B and none to nystatin and flucytosine. This observational study identifies ALL and chronic lymphocytic leukemia (CLL) as the forms of hematological malignancy predominantly associated with candidemia; specifies risk factors and chemotherapeutic agents predisposing patients towards its occurrence; reports a preponderance of C. tropicalis among the causative agents and finds voriconazole to be the most effective antifungal agent against the recovered isolates. This information could assist in tailoring prophylactic and therapeutic antifungal practices for this infection, according to local epidemiological and mycological characteristics. Copyright © 2015. Published by Elsevier B.V.

Factors contributing to nursing team work in an acute care tertiary hospital.

PubMed

Polis, Suzanne; Higgs, Megan; Manning, Vicki; Netto, Gayle; Fernandez, Ritin

Effective nursing teamwork is an essential component of quality health care and patient safety. Understanding which factors foster team work ensures teamwork qualities are cultivated and sustained. This study aims to investigate which factors are associated with team work in an Australian acute care tertiary hospital across all inpatient and outpatient settings. All nurses and midwives rostered to inpatient and outpatient wards in an acute care 600 bed hospital in Sydney Australia were invited to participate in a cross sectional survey between September to October 2013. Data were collected, collated, checked and analysed using Statistical Package for the Social Sciences (SPSS) Version 21. Factors reporting a significant correlation with where p < 0.05 were analysed in a multiple regression model. A total of 501 surveys were returned. Nursing teamwork scores ranged between 3.32 and 4.08. Teamwork subscale Shared Mental Model consistently rated the highest. Mean scores for overall communication between nurses and team leadership were 3.6 (S.D. 0.57) and 3.8 (SD 0.6) respectively. Leadership and communication between nurses were significant predictors of team work p < 0.001. Our findings describe factors predictive of teamwork in an acute care tertiary based hospital setting across inpatient and outpatient specialty units. Our findings are of particular relevance in identifying areas of nurse education and workforce planning to improve nursing team work.

Organizational Strategies for Building Capacity in Evidence-Based Oncology Nursing Practice: A Case Report of an Australian Tertiary Cancer Center.

PubMed

Chan, Raymond Javan; Bowers, Alison; Barton-Burke, Margaret

2017-03-01

The ever-increasing cancer care demand has posed a challenge for oncology nurses to deliver evidence-based, innovative care. Despite efforts to promote evidence-based practice, barriers remain and executives find it difficult to implement evidence-based practice efficiently. Using the successful experience of an Australian tertiary cancer center, this paper depicts 4 effective strategies for facilitating evidence-based practice at the organizational level-the Embedded Scholar: Enabler, Enactor, and Engagement (4 Es) Model-includes a 12-week evidence-based practice program that prioritizes relevant research proposed by clinical staff and endorses high-quality, evidence-based point-of-care resources. Crown Copyright © 2016. Published by Elsevier Inc. All rights reserved.

Healthcare associated infections in Paediatric Intensive Care Unit of a tertiary care hospital in India: Hospital stay & extra costs.

PubMed

Sodhi, Jitender; Satpathy, Sidhartha; Sharma, D K; Lodha, Rakesh; Kapil, Arti; Wadhwa, Nitya; Gupta, Shakti Kumar

2016-04-01

Healthcare associated infections (HAIs) increase the length of stay in the hospital and consequently costs as reported from studies done in developed countries. The current study was undertaken to evaluate the impact of HAIs on length of stay and costs of health care in children admitted to Paediatric Intensive Care Unit (PICU) of a tertiary care hospital in north India. This prospective study was done in the seven bedded PICU of a large multi-specialty tertiary care hospital in New Delhi, India. A total of 20 children with HAI (cases) and 35 children without HAI (controls), admitted to the PICU during the study period (January 2012 to June 2012), were matched for gender, age, and average severity of illness score. Each patient's length of stay was obtained prospectively. Costs of healthcare were estimated according to traditional and time driven activity based costing methods approach. The median extra length of PICU stay for children with HAI (cases), compared with children with no HAI (controls), was seven days (IQR 3-16). The mean total costs of patients with and without HAI were ' 2,04,787 (US$ 3,413) and ' 56,587 (US$ 943), respectively and the mean difference in the total cost between cases and controls was ' 1,48,200 (95% CI 55,716 to 2,40,685, p<0.01). This study highlights the effect of HAI on costs for PICU patients, especially costs due to prolongation of hospital stay, and suggests the need to develop effective strategies for prevention of HAI to reduce costs of health care.

Family practice obstetrics in a teaching hospital. Does a tertiary care environment make a difference?

PubMed Central

Jordan, J. M.; Gaspar, D.

1995-01-01

OBJECTIVE: To determine referral rates, to study the nature of consultations with obstetricians, and to examine how both patient and physician characteristics affect referrals. DESIGN: Case series. Retrospective review of hospital records. SETTING: Victoria Hospital, a tertiary care centre affiliated with the University of Western Ontario in London, Ont. PARTICIPANTS: Five hundred forty-two women admitted consecutively for delivery under the care of family physicians from October 1, 1990, to September 31, 1991. OUTCOME MEASURE: The number and types of obstetrical consultations obtained for the study population. RESULTS: Of the 50.7% of cases requiring consultation, half were delivered by obstetricians. The most common reasons for consultation were failure to progress in labour, induction of labour, posterior presentation, fetal distress, and pregnancy-induced hypertension. The most common reasons for obstetricians to attend delivery were to perform forceps rotations and cesarean sections. CONCLUSIONS: Parity and risk classification were the two most important factors for predicting whether consultation would occur. The high rate of consultation in this study might relate to ease of access to consultation in a tertiary care environment. More study is needed to examine the reasons for consultation because it seems that some of the situations for which obstetricians were consulted could have been safely managed by family physicians. PMID:7787491

Palliative care in the neonatal unit: neonatal nursing staff perceptions of facilitators and barriers in a regional tertiary nursery.

PubMed

Kilcullen, Meegan; Ireland, Susan

2017-05-11

Neonatology has made significant advances in the last 30 years. Despite the advances in treatments, not all neonates survive and a palliative care model is required within the neonatal context. Previous research has focused on the barriers of palliative care provision. A holistic approach to enhancing palliative care provision should include identifying both facilitators and barriers. A strengths-based approach would allow barriers to be addressed while also enhancing facilitators. The current study qualitatively explored perceptions of neonatal nurses about facilitators and barriers to delivery of palliative care and also the impact of the regional location of the unit. The study was conducted at the Townsville Hospital, which is the only regional tertiary neonatal unit in Australia. Semi-structured interviews were conducted with a purposive sample of eight neonatal nurses. Thematic analysis of the data was conducted within a phenomenological framework. Six themes emerged regarding family support and staff factors that were perceived to support the provision of palliative care of a high quality. Staff factors included leadership, clinical knowledge, and morals, values, and beliefs. Family support factors included emotional support, communication, and practices within the unit. Five themes emerged from the data that were perceived to be barriers to providing quality palliative care. Staff perceived education, lack of privacy, isolation, staff characteristics and systemic (policy, and procedure) factors to impact upon palliative care provision. The regional location of the unit also presented unique facilitators and barriers to care. This study identified and explored facilitators and barriers in the delivery of quality palliative care for neonates in a regional tertiary setting. Themes identified suggested that a strengths-approach, which engages and amplifies facilitating factors while identified barriers are addressed or minimized, would be successful in supporting quality palliative care provision in the neonatal care setting. Study findings will be used to inform clinical education and practice.

Consequences of Moral Distress in the Intensive Care Unit: A Qualitative Study.

PubMed

Henrich, Natalie J; Dodek, Peter M; Gladstone, Emilie; Alden, Lynn; Keenan, Sean P; Reynolds, Steven; Rodney, Patricia

2017-07-01

Moral distress is common among personnel in the intensive care unit, but the consequences of this distress are not well characterized. To examine the consequences of moral distress in personnel in community and tertiary intensive care units in Vancouver, Canada. Data for this study were obtained from focus groups and analysis of transcripts by themes and sub-themes in 2 tertiary care intensive care units and 1 community intensive care unit. According to input from 19 staff nurses (3 focus groups), 4 clinical nurse leaders (1 focus group), 13 physicians (3 focus groups), and 20 other health professionals (3 focus groups), the most commonly reported emotion associated with moral distress was frustration. Negative impact on patient care due to moral distress was reported 26 times, whereas positive impact on patient care was reported 11 times and no impact on patient care was reported 10 times. Having thoughts about quitting working in the ICU was reported 16 times, and having no thoughts about quitting was reported 14 times. In response to moral distress, health care providers experience negative emotional consequences, patient care is perceived to be negatively affected, and nurses and other health care professionals are prone to consider quitting working in the intensive care unit. ©2017 American Association of Critical-Care Nurses.

Frequency and risk factors associated with dry eye in patients attending a tertiary care ophthalmology center in Mexico City

PubMed Central

Martinez, Jaime D; Galor, Anat; Ramos-Betancourt, Nallely; Lisker-Cervantes, Andrés; Beltrán, Francisco; Ozorno-Zárate, Jorge; Sánchez-Huerta, Valeria; Torres-Vera, Marco-Antonio; Hernández-Quintela, Everardo

2016-01-01

Purpose The purpose of this study was to ascertain the frequency and risk factors of dry eye (DE) among patients attending a tertiary care ophthalmology center in Mexico. Methods Approximately 338 consecutive new patients attending a tertiary care ophthalmology center in Mexico City underwent an ocular surface examination, which included tear film break-up time, fluorescein corneal staining, Schirmer’s test, and evaluation of meibum quality. Symptoms of DE were evaluated by the Ocular Surface Disease Index and Dry Eye Questionnaire-5. Information on demographics, exposures, past medical and ocular history, and medications was also collected. Results The frequency of severe DE symptoms was found to be 43% based on the Ocular Surface Disease Index and 30% based on Dry Eye Questionnaire-5. Risk factors significantly associated with increased DE symptoms included dry mouth and gastrointestinal ulcer medications. With regard to signs, aqueous tear deficiency was a less-frequent finding (22%) in our population than evaporative deficiency (94%). Risk factors associated with aqueous tear deficiency were dry mouth and diuretic use. No risk factors were associated with evaporative deficiency. Risk factors associated with meibomian gland dysfunction included old age, male sex, arthritis, and use of an antihypertensive. The only risk factor associated with corneal staining was dry mouth. Conclusion This is the first study to demonstrate the frequency of symptomatic and clinical DE in a tertiary care ophthalmology center in Mexico. The frequency of DE ranged from 30% using a symptomatic definition to 94% using objective measures. Different risk factors were found for different aspects of DE, suggesting differing underlying pathophysiologies behind different DE subtypes. PMID:27499613

Awareness about basic life support and emergency medical services and its associated factors among students in a tertiary care hospital in South India.

PubMed

Aroor, Akshatha Rao; Saya, Rama Prakash; Attar, Nazir Rahim; Saya, Ganesh Kumar; Ravinanthanan, Manikandan

2014-07-01

The knowledge and skills about the basic life support (BLS) and the advanced life support are the most important determining factors of the cardiopulmonary resuscitation (CPR) success rates. To determine the level of awareness on BLS and skills among undergraduate and postgraduate students of medical and dental profession, as well as nursing students and interns in a tertiary care hospital. This descriptive cross-sectional study was conducted in a tertiary care hospital in South India. The awareness level on BLS and factors associated which include age, sex, level of training (undergraduate, internship, and postgraduate groups), course of study (nursing, dental, and medical groups), and previous exposure to BLS were assessed by using a structured questionnaire. The association of these variables with awareness level was assessed by independent t test, analysis of variance, and linear regression analysis. Among 520 study subjects, 229 were students, 171 were interns, and 120 were postgraduate students. The overall mean score of awareness was 4.16 ± 1.40 (score range: 0-10). Age, sex, level of training, course of study, and previous exposure to BLS were significantly associated with awareness level in univariate analysis (P < 0.05). Linear regression model also showed that all the above variables were significantly associated with awareness level (P < 0.05). About 322 (61.9%) subjects attributed lack of awareness about BLS to lack of available professional training. About 479 (92.1%) responded that BLS training should be a part of medical curriculum. Awareness level on BLS is below average indicating the importance of professional training at all levels in a tertiary care health institution.

Process and outcome measures of quality of care at the diabetes outpatient clinic, University College Hospital, Ibadan.

PubMed

Adeleye, J O; Kuti, M A

2017-02-01

The study aims to assess the quality of care provided at a diabetes outpatient clinic of a tertiary hospital in Nigeria using quality indicators approved by the National Diabetes Quality Improvement Alliance (NDQIA). The medical records of patients who had visited the clinic at least two times within a 12 months period preceding the index visit were reviewed during a 5 month period. Process measure indicators, approved by the NDQIA (evaluating the functioning of the clinic) and outcome measures, published by the American Diabetes Association, (evaluating the health status of the attending patients) were retrieved from the medical records. The 332 records reviewed showed that the most consistently performed process measures were blood pressure and weight measurement (>90%). Foot examination was done infrequently (10.5%). Less than 50% had at least an annual low-density lipoprotein cholesterol (LDL-C) and hemoglobin A1c testing done. The mean (standard deviation) HbA1C (%), LDL-C (mg/dL) systolic blood pressure (SBP) (mmHg), and diastolic blood pressure (DBP) (mmHg) were 7.6 (2.0), 107.3 (31.5), 134.3 (20.8), 79.5 (11.0), respectively. HbA1C >8.0%, LDL-C >130 mg/dL, SBP >130 mmHg, and DBP >90 mmHg) were observed in 34.8%, 21.1%, 40.4%, and 23.8%, respectively. Although the organization of the outpatient services allowed for good performance with regards to "free" services such as blood pressure and weight measurement, it performed suboptimally for foot examinations. Performance indicators that required payment were consistently underperformed. Regular assessment of the quality of care may help in the identification of opportunities for improvement in the organization and delivery of care.

Prognostic factors in patients with advanced cancer: use of the patient-generated subjective global assessment in survival prediction.

PubMed

Martin, Lisa; Watanabe, Sharon; Fainsinger, Robin; Lau, Francis; Ghosh, Sunita; Quan, Hue; Atkins, Marlis; Fassbender, Konrad; Downing, G Michael; Baracos, Vickie

2010-10-01

To determine whether elements of a standard nutritional screening assessment are independently prognostic of survival in patients with advanced cancer. A prospective nested cohort of patients with metastatic cancer were accrued from different units of a Regional Palliative Care Program. Patients completed a nutritional screen on admission. Data included age, sex, cancer site, height, weight history, dietary intake, 13 nutrition impact symptoms, and patient- and physician-reported performance status (PS). Univariate and multivariate survival analyses were conducted. Concordance statistics (c-statistics) were used to test the predictive accuracy of models based on training and validation sets; a c-statistic of 0.5 indicates the model predicts the outcome as well as chance; perfect prediction has a c-statistic of 1.0. A training set of patients in palliative home care (n = 1,164) was used to identify prognostic variables. Primary disease site, PS, short-term weight change (either gain or loss), dietary intake, and dysphagia predicted survival in multivariate analysis (P < .05). A model including only patients separated by disease site and PS with high c-statistics between predicted and observed responses for survival in the training set (0.90) and validation set (0.88; n = 603). The addition of weight change, dietary intake, and dysphagia did not further improve the c-statistic of the model. The c-statistic was also not altered by substituting physician-rated palliative PS for patient-reported PS. We demonstrate a high probability of concordance between predicted and observed survival for patients in distinct palliative care settings (home care, tertiary inpatient, ambulatory outpatient) based on patient-reported information.

Predicting loop–helix tertiary structural contacts in RNA pseudoknots

PubMed Central

Cao, Song; Giedroc, David P.; Chen, Shi-Jie

2010-01-01

Tertiary interactions between loops and helical stems play critical roles in the biological function of many RNA pseudoknots. However, quantitative predictions for RNA tertiary interactions remain elusive. Here we report a statistical mechanical model for the prediction of noncanonical loop–stem base-pairing interactions in RNA pseudoknots. Central to the model is the evaluation of the conformational entropy for the pseudoknotted folds with defined loop–stem tertiary structural contacts. We develop an RNA virtual bond-based conformational model (Vfold model), which permits a rigorous computation of the conformational entropy for a given fold that contains loop–stem tertiary contacts. With the entropy parameters predicted from the Vfold model and the energy parameters for the tertiary contacts as inserted parameters, we can then predict the RNA folding thermodynamics, from which we can extract the tertiary contact thermodynamic parameters from theory–experimental comparisons. These comparisons reveal a contact enthalpy (ΔH) of −14 kcal/mol and a contact entropy (ΔS) of −38 cal/mol/K for a protonated C+•(G–C) base triple at pH 7.0, and (ΔH = −7 kcal/mol, ΔS = −19 cal/mol/K) for an unprotonated base triple. Tests of the model for a series of pseudoknots show good theory–experiment agreement. Based on the extracted energy parameters for the tertiary structural contacts, the model enables predictions for the structure, stability, and folding pathways for RNA pseudoknots with known or postulated loop–stem tertiary contacts from the nucleotide sequence alone. PMID:20100813

Role of Retinopathy of Prematurity (ROP) Tertiary Centers of Excellence in Capacity-building.

PubMed

Rani, Padmaja Kumari; Balakrishnanan, D; Padhi, T R; Jalali, Subhadra

2016-11-07

Tertiary Centres of Excellence in India have been at the forefront of the efforts against Retinopathy of Prematurity (ROP) - associated blindness. The epidemic of blindness from ROP; however, has now spread rapidly into large parts of interiors of developing countries due to improved newborn care facilities. Due to their knowledge and experience of more than a decade, these centres of excellence, both from child care and Ophthalmology care, now need to come forward in substantial measures and need to be supported by funds and programs so that concerns of neonatal eye-health, training, screening, prevention and treatment can get integrated and embedded into newborn critical care and health programs. This will protect newborn preterm survivors from losing the potentially good vision that they are born with, reduce the rapidly rising blindness epidemic, and also protect staff from potential high-value litigations.

Experience of Emergency Peripartum Hysterectomies at a Tertiary Care Hospital in Quetta, Pakistan

PubMed Central

Fatima, Mahrukh; Kasi, Pashtoon Murtaza; Baloch, Shahnaz Naseer; Afghan, Abaseen Khan

2011-01-01

Emergency peripartum hysterectomy (EPH) is associated with significant morbidity and mortality worldwide. The purpose of our paper was to determine the incidence, morbidity, and mortality of EPH done at our institution; the largest tertiary care government hospital in the city of Quetta, Pakistan. During the study period there were 12,642 deliveries, out of which 46 women had undergone an EPH, translating into an incidence of ∼4 per 1,000 births. Disturbingly, 82.6% of these patients had received no antenatal care prior to their presentation. There were 4 (8.7%) maternal deaths and 31 (67.4%) perinatal deaths. The commonest indication noted was uterine rupture in 21 (45.7%) cases. Lack of antenatal care is indeed a modifiable factor that needs to be addressed to help reduce maternal and fetal morbidity/mortality not only from emergency hysterectomies but also from all other preventable causes. PMID:21977328

Tertiary work-up of apparent treatment-resistant hypertension.

PubMed

Heimark, Sondre; Eskås, Per Anders; Mariampillai, Julian Eek; Larstorp, Anne Cecilie K; Høieggen, Aud; Fadl Elmula, Fadl Elmula M

2016-10-01

Treatment-resistant hypertension (TRH) has regained attention with development of new methods for treatment. However, the prevalence of TRH varies considerably from primary to secondary and tertiary care. We aimed to assess the prevalence of true TRH in a population of patients with apparent TRH in a university hospital setting of tertiary work-up and also investigate reasons for poor BP control and evaluate how work-up can be performed in general practice and secondary care. In this cohort study, we characterize a study population from Oslo Renal Denervation (RDN) Study. Patients (n = 83) were referred for RDN from secondary care. All patients underwent thorough medical investigation and 24-h ambulatory blood pressure measurements (24ABPM) after directly observed therapy (DOT). We then assessed reasons for lack of BP control. Fifty-three of 83 patients did not have true TRH. Main reasons for non-TRH were poor drug adherence (32%), secondary hypertension (30%) and white coat hypertension (15%). Forty-seven percent achieved blood pressure control after DOT with subsequent 24ABPM. There were otherwise no statistically significant differences in patient characteristics between the true TRH and the non-TRH group. Despite being a highly selected cohort referred for tertiary work-up of apparent TRH, BP control was achieved or secondary causes were identified in almost two thirds of the patients. Thorough investigation according to guidelines and DOT with subsequent 24ABPM is needed in work-up of apparent TRH.

Evaluation of Health Literacy Status Among Patients in a Tertiary Care Hospital in Coastal Karnataka, India

PubMed Central

U.P, Rathnakar; Belman, Madhuri; Kamath, Ashwin; B, Unnikrishnan; Shenoy K, Ashok; A.L, Udupa

2013-01-01

Introduction: People with limited health literacy are more likely to make medication errors, and they have less health knowledge, worse health status, more hospitalizations, and higher healthcare costs than people with adequate literacy. The objective of this study is to assess the health literacy status among patients who are able to read and understand English attending a tertiary care hospital by using Rapid Estimate of Adult Literacy in Medicine [REALM] technique and to compare the health literacy levels to educational status and other baseline characteristics. Material and Methods: A widely used word recognition method [REALM] was used to assess the HL status of 200 patients attending a tertiary care hospital in Southern India. The number of correctly pronounced words was used to assign a grade-equivalent reading level. Scores 0 to 44 indicate reading skills at or below the 6th grade level, scores from 45 to 60 represent skills at the 7th or 8th grade level, and scores above 60 indicate skills at the high-school level or higher. Results: HL status was found below adequate level in more than 50% of the patients. Younger age group showed better HL scores compared to those aged more than 25 years. General education level or the medium of education does not truly reflect HL levels as brought out in the study. Even those with postgraduate qualification had poor HL skills. Conclusion: The study was carried out to find out the HL levels among patients attending a tertiary care hospital. It was assumed that the general education levels may not reflect true HL status. In view of the results of this study it can be concluded that patient’s HL skills should not be taken for granted and adequate attention should be paid in educating and briefing patients whenever patients are required to interpret and understand health care related documents. PMID:24392398

Evaluation of health literacy status among patients in a tertiary care hospital in coastal karnataka, India.

PubMed

U P, Rathnakar; Belman, Madhuri; Kamath, Ashwin; B, Unnikrishnan; Shenoy K, Ashok; A L, Udupa

2013-11-01

People with limited health literacy are more likely to make medication errors, and they have less health knowledge, worse health status, more hospitalizations, and higher healthcare costs than people with adequate literacy. The objective of this study is to assess the health literacy status among patients who are able to read and understand English attending a tertiary care hospital by using Rapid Estimate of Adult Literacy in Medicine [REALM] technique and to compare the health literacy levels to educational status and other baseline characteristics. A widely used word recognition method [REALM] was used to assess the HL status of 200 patients attending a tertiary care hospital in Southern India. The number of correctly pronounced words was used to assign a grade-equivalent reading level. Scores 0 to 44 indicate reading skills at or below the 6th grade level, scores from 45 to 60 represent skills at the 7th or 8th grade level, and scores above 60 indicate skills at the high-school level or higher. HL status was found below adequate level in more than 50% of the patients. Younger age group showed better HL scores compared to those aged more than 25 years. General education level or the medium of education does not truly reflect HL levels as brought out in the study. Even those with postgraduate qualification had poor HL skills. The study was carried out to find out the HL levels among patients attending a tertiary care hospital. It was assumed that the general education levels may not reflect true HL status. In view of the results of this study it can be concluded that patient's HL skills should not be taken for granted and adequate attention should be paid in educating and briefing patients whenever patients are required to interpret and understand health care related documents.

Nickel-Catalyzed Coupling Reactions of Alkyl Electrophiles, Including Unactivated Tertiary Halides, to Generate Carbon–Boron Bonds

PubMed Central

Dudnik, Alexander S.

2012-01-01

Through the use of a catalyst formed in situ from NiBr2•diglyme and a pybox ligand (both of which are commercially available), we have achieved our first examples of coupling reactions of unactivated tertiary alkyl electrophiles, as well as our first success with nickel-catalyzed couplings that generate bonds other than C–C bonds. Specifically, we have determined that this catalyst accomplishes Miyaura-type borylations of unactivated tertiary, secondary, and primary alkyl halides with diboron reagents to furnish alkylboronates, a family of compounds with substantial (and expanding) utility, under mild conditions; indeed, the umpolung borylation of a tertiary alkyl bromide can be achieved at a temperature as low as −10 °C. The method exhibits good functional-group compatibility and is regiospecific, both of which can be issues with traditional approaches to the synthesis of alkylboronates. In contrast to seemingly related nickel-catalyzed C–C bond-forming processes, tertiary halides are more reactive than secondary or primary halides in this nickel-catalyzed C–B bond-forming reaction; this divergence is particularly noteworthy in view of the likelihood that both transformations follow an inner-sphere electron-transfer pathway for oxidative addition. PMID:22668072

A feasibility study of brain-targeted treatment for people with painful knee osteoarthritis in tertiary care.

PubMed

Harms, Anton; Heredia-Rizo, Alberto M; Moseley, G Lorimer; Hau, Raphael; Stanton, Tasha R

2018-06-11

To assess the feasibility and clinical impact of brain-targeted treatment (BT; aiming to target sensorimotor processing) in knee osteoarthritis patients attending tertiary care. Randomized replicated case series. The study involved three phases, each of 2 weeks duration: (1) no-treatment phase; (2) BT phase (left/right judgments and touch discrimination training); and (3) usual care (education, strengthening, and stretching training). Primary outcomes were: timely recruitment; number of participants completing the interventions; treatment compliance and barriers; follow-up rates; and treatment impact on pain and function. Fear-avoidance beliefs and clinical measures of cortical body representation (tactile acuity and left/right judgment performance) were secondary outcomes. A total of 5% (19/355) of all assessed patients were eligible to participate and of these, 58% (11/19) agreed to participate. Ten patients completed the study, and 9 were successfully followed up, with treatment compliance varying between interventions. Compliance was poor for the touch discrimination component of BT. No significant effects were observed for pain relief or knee function after any treatment. A positive impact of treatment was found for fear-avoidance beliefs (usual care vs. washout, p = 0.007; BT vs. washout, p = 0.029) and left/right judgment accuracy (usual care vs. washout; p = 0.006). Clear barriers were identified to implementing BT in tertiary care for knee osteoarthritis. Access to all available services (especially the use of interpreters), and treatment options that do not require additional assistance to perform (e.g., touch discrimination training) represent the main lessons learned.

Profile of infective endocarditis at a tertiary-care hospital in Japan over a 14-year period: characteristics, outcome and predictors for in-hospital mortality.

PubMed

Hase, Ryota; Otsuka, Yoshihito; Yoshida, Kazuki; Hosokawa, Naoto

2015-04-01

The aims of this study were to describe the epidemiological features and clinical characteristics of infective endocarditis (IE) at a tertiary-care hospital in Japan and to identify the factors associated with in-hospital mortality. A retrospective observational study was conducted at a 925-bed tertiary-care teaching hospital in Japan. All adult patients diagnosed with definite IE between August 2000 and July 2014 according to the modified Duke criteria were included. A total of 180 patients (60.6% men; mean age, 69.1 years) with definite IE were included. The most common pathogen was Staphylococcus aureus (27.2%). Nine patients (5.0%) had culture-negative IE. Transthoracic and transoesophageal echocardiography were performed in 180 (100%) and 132 patients (73.3%), respectively, and vegetations were detected in 128 patients (71.1%). Surgical therapy was performed in 31 patients (17.2%). Overall, the in-hospital mortality rate was 26.1%. The independent predictors of in-hospital mortality were methicillin-resistant S. aureus (MRSA), vascular phenomena, health care-associated IE and heart failure. MRSA, vascular phenomena, health care-associated IE and heart failure were independent predictors of in-hospital mortality. The unique characteristics in our cohort were the very high mean age, low rate of culture-negative IE, high rate of definite IE without detected vegetations and predominance of S. aureus. Copyright © 2015 The Authors. Published by Elsevier Ltd.. All rights reserved.

Eclipsing Binaries with Possible Tertiary Components

NASA Astrophysics Data System (ADS)

Snyder, LeRoy F.

2013-05-01

Many eclipsing binary star systems (EBS) show long-term variations in their orbital periods which are evident in their O-C (observed minus calculated period) diagrams. This research carried out an analysis of 324 eclipsing binary systems taken from the systems analyzed in the Bob Nelson's O-C Files database. Of these 18 systems displayed evidence of periodic variations of the arrival times of the eclipses. These rates of period changes are sinusoidal variations. The sinusoidal character of these variations is suggestive of Keplerian motion caused by an orbiting companion. The reason for these changes is unknown, but mass loss, apsidal motion, magnetic activity and the presence of a third body have been proposed. This paper has assumed light time effect as the cause of the sinusoidal variations caused by the gravitational pull of a tertiary companion orbiting around the eclipsing binary systems. An observed minus calculated (O-C) diagram of the 324 systems was plotted using a quadratic ephemeris to determine if the system displayed a sinusoidal trend in theO-C residuals. After analysis of the 18 systems, seven systems, AW UMa, BB PEG, OO Aql, V508 Oph, VW Cep, WCrv and YY ERI met the benchmark of the criteria of a possible orbiting companion. The other 11 systems displayed a sinusoidal variation in the O-C residuals of the primary eclipses but these systems in the Bob Nelson's O-C Files did not contain times of minimum (Tmin) of the secondary eclipses and therefore not conclusive in determining the presents of the effects of a tertiary companion. An analysis of the residuals of the seven systems yields a light-time semi-amplitude, orbital period, eccentricity and mass of the tertiary companion as the amplitude of the variation is proportional to the mass, period and inclination of the 3rd orbiting body. Knowing the low mass of the tertiary body in the seven cases the possibility of five of these tertiary companions being brown dwarfs is discussed.

Prevalence of antibodies against Treponema pallidum among HIV-positive patients in a tertiary care hospital in Mexico.

PubMed

Mata-Marín, José Antonio; Sandoval-Sánchez, Juan Joel; Huerta-García, Gloria; Arroyo-Anduiza, Carla Ileana; Alcalá-Martínez, Enrique; Mata-Marín, Luis Alberto; Sandoval-Ramirez, Jorge Luis; Gaytán-Martínez, Jesús

2015-02-01

Our objective was to determine the seroprevalence of syphilis among HIV-infected patients in a tertiary care hospital in Mexico City. A cross-sectional study was developed, and 318 HIV-positive patients were evaluated from January to February 2013 at Hospital de Infectología, National Medical Center 'La Raza' (a tertiary care hospital specialising in infectious diseases in Mexico City). Laboratory data were screened for the detection of antibodies against Treponema pallidum. Patients completed a questionnaire relating to socio-demographic data and factors associated with syphilis. Of the 318 patients, 83% were men. The mean age ± SD was 36 ± 11 years; 52% were men who have sex with men and 47% had undertaken higher education. The overall seroprevalence of syphilis among these patients was 25% (95% confidence interval 21%, 30%). Men who have sex with men had a significantly higher seroprevalence (30% vs. 15%, p = 0.009). We conclude that, in Mexico, there is a high seroprevalence of syphilis antibodies in HIV-infected patients and that men who have sex with men are the group most affected. © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav.

Long-term Clinical and Cost Outcomes of a Pharmacist-managed Risk Factor Management Clinic in Singapore: An Observational Study.

PubMed

Tan, She Hui; Kng, Kwee Keng; Lim, Sze Mian; Chan, Alexandre; Loh, Jason Kwok Kong; Lee, Joyce Yu-Chia

2017-12-01

Few studies have determined the benefits of pharmacist-run clinics within a tertiary institution, and specifically on their capability to improve clinical outcomes as well as reduce the cost of illness. This study was designed to investigate the effectiveness of a pharmacist-managed risk factor management clinic (RFMP) in an acute care setting through the comparison of clinical (improvement in glycosylated hemoglobin level) and cost outcomes with patients receiving usual care. This single-center, observational study included patients aged ≥21 years old and diagnosed with type 2 diabetes mellitus (DM) who received care within the cardiology department of a tertiary institution between January 1, 2014, and December 31, 2015. The intervention group comprised patients who attended the RFMP for 3 to 6 months, and the usual-care group comprised patients who received standard cardiologist care. Univariate analysis and multiple linear regression were conducted to analyze the clinical and cost outcomes. A total of 142 patients with DM (71 patients in the intervention group and 71 patients in the usual-care group) with similar baseline characteristics were included. After adjusting for differences in baseline systolic blood pressure and triglyceride levels, the mean reduction in glycosylated hemoglobin level at 6 months from baseline in the intervention group was significantly lower by 0.78% compared with the usual-care group. Patients in the usual-care group had a significantly higher risk of hospital admissions within the 12 months from baseline compared with the intervention group (odds ratio, 3.84 [95% CI, 1.17-12.57]; P = 0.026). Significantly lower mean annual direct medical costs were also observed in the intervention group (US $8667.03 [$17,416.20] vs US $56,665.02 [$127,250.10]; P = 0.001). The pharmacist-managed RFMP exhibited improved clinical outcomes and reduced health care costs compared with usual care within a tertiary institute. Copyright © 2017 The Authors. Published by Elsevier Inc. All rights reserved.

Allied Health Professional Support in Pediatric Inflammatory Bowel Disease: A Survey from the Canadian Children Inflammatory Bowel Disease Network—A Joint Partnership of CIHR and the CH.I.L.D. Foundation

PubMed Central

Benchimol, Eric I.; Mack, David; Huynh, Hien Q.; Critch, Jeff; Otley, Anthony; Deslandres, Colette; Jacobson, Kevan; deBruyn, Jennifer; Carroll, Matthew W.; Van Limbergen, Johan; Sherlock, Mary; Bax, Kevin; Lawrence, Sally; Seidman, Ernest; Issenman, Robert; Church, Peter; Griffiths, Anne M.

2017-01-01

Objectives The current number of healthcare providers (HCP) caring for children with inflammatory bowel disease (IBD) across Canadian tertiary-care centres is underinvestigated. The aim of this survey was to assess the number of healthcare providers (HCP) in ambulatory pediatric IBD care across Canadian tertiary-care centres. Methods Using a self-administered questionnaire, we examined available resources in academic pediatric centres within the Canadian Children IBD Network. The survey evaluated the number of HCP providing ambulatory care for children with IBD. Results All 12 tertiary pediatric gastroenterology centres participating in the network responded. Median full-time equivalent (FTE) of allied health professionals providing IBD care at each site was 1.0 (interquartile range (IQR) 0.6–1.0) nurse, 0.5 (IQR 0.2–0.8) dietitian, 0.3 (IQR 0.2–0.8) social worker, and 0.1 (IQR 0.02–0.3) clinical psychologists. The ratio of IBD patients to IBD physicians was 114 : 1 (range 31 : 1–537 : 1), patients to nurses/physician assistants 324 : 1 (range 150 : 1–900 : 1), dieticians 670 : 1 (range 250 : 1–4500 : 1), social workers 1558 : 1 (range 250 : 1–16000 : 1), and clinical psychologists 2910 : 1 (range 626 : 1–3200 : 1). Conclusions There was a wide variation in HCP support among Canadian centres. Future work will examine variation in care including patients' outcomes and satisfaction across Canadian centres. PMID:28593172

Severe Traumatic Brain Injury at a Tertiary Referral Center in Tanzania: Epidemiology and Adherence to Brain Trauma Foundation Guidelines.

PubMed

Smart, Luke R; Mangat, Halinder S; Issarow, Benson; McClelland, Paul; Mayaya, Gerald; Kanumba, Emmanuel; Gerber, Linda M; Wu, Xian; Peck, Robert N; Ngayomela, Isidore; Fakhar, Malik; Stieg, Philip E; Härtl, Roger

2017-09-01

Severe traumatic brain injury (TBI) is a major cause of death and disability worldwide. Prospective TBI data from sub-Saharan Africa are sparse. This study examines epidemiology and explores management of patients with severe TBI and adherence to Brain Trauma Foundation Guidelines at a tertiary care referral hospital in Tanzania. Patients with severe TBI hospitalized at Bugando Medical Centre were recorded in a prospective registry including epidemiologic, clinical, treatment, and outcome data. Between September 2013 and October 2015, 371 patients with TBI were admitted; 33% (115/371) had severe TBI. Mean age was 32.0 years ± 20.1, and most patients were male (80.0%). Vehicular injuries were the most common cause of injury (65.2%). Approximately half of the patients (47.8%) were hospitalized on the day of injury. Computed tomography of the brain was performed in 49.6% of patients, and 58.3% were admitted to the intensive care unit. Continuous arterial blood pressure monitoring and intracranial pressure monitoring were not performed in any patient. Of patients with severe TBI, 38.3% received hyperosmolar therapy, and 35.7% underwent craniotomy. The 2-week mortality was 34.8%. Mortality of patients with severe TBI at Bugando Medical Centre, Tanzania, is approximately twice that in high-income countries. Intensive care unit care, computed tomography imaging, and continuous arterial blood pressure and intracranial pressure monitoring are underused or unavailable in the tertiary referral hospital setting. Improving outcomes after severe TBI will require concerted investment in prehospital care and improvement in availability of intensive care unit resources, computed tomography, and expertise in multidisciplinary care. Copyright © 2017 Elsevier Inc. All rights reserved.

Remote biomonitoring of temperatures in mothers and newborns: design, development and testing of a wearable sensor device in a tertiary-care hospital in southern India

PubMed Central

Mony, Prem K; Thankachan, Prashanth; Bhat, Swarnarekha; Rao, Suman; Washington, Maryann; Antony, Sumi; Thomas, Annamma; Nagarajarao, Sheela C; Rao, Hiteshwar; Amrutur, Bharadwaj

2018-01-01

Objective Newer technologies such as wearables, sensors, mobile telephony and computing offer opportunities to monitor vital physiological parameters and tackle healthcare problems, thereby improving access and quality of care. We describe the design, development and testing of a wearable sensor device for remote biomonitoring of body temperatures in mothers and newborns in southern India. Methods Based on client needs and technological requirements, a wearable sensor device was designed and developed using principles of ‘social innovation’ design. The device underwent multiple iterations in product design and engineering based on user feedback, and then following preclinical testing, a techno-feasibility study and clinical trial were undertaken in a tertiary-care teaching hospital in Bangalore, India. Clinical trial phases I and IIa for evaluation of safety and efficacy were undertaken in the following sequence: 7 healthy adult volunteers; 18 healthy mothers; 3 healthy babies; 10 stable babies in the neonatal care intensive unit and 1 baby with morbidities. Time-stamped skin temperature readings obtained at 5 min intervals over a 1-hour period from the device secured on upper arms of mothers and abdomen of neonates were compared against readings from thermometers used routinely in clinical practice. Results Devices were comfortably secured on to adults and neonates, and data were efficiently transmitted via the gateway device for secure storage and retrieval for analysis. The mean skin temperatures in mothers were lower than the axillary temperatures by 2°C; and in newborns, there was a precision of –0.5°C relative to axillary measurements. While occasional minimal adverse events were noted in healthy volunteers, no adverse events were noted in mothers or neonates. Conclusions This proof-of-concept study shows that this device is promising in terms of feasibility, safety and accuracy (with appropriate calibration) with potential for further refinements in device accuracy and pursuit of further phases of clinical research for improved maternal and neonatal health. PMID:29670758

Quality Improvement Initiative for Family-Centered Care in the Neonatal Intensive Care Unit of a Tertiary Hospital in South Africa.

PubMed

Maree, Carin; Kekana, Poppy; van der Walt, Christa; Yazbek, Mariatha; Leech, Ronell

The introduction of family-centered care in the neonatal intensive care unit was identified as a high priority to facilitate bonding and attachment with potential positive outcomes for the parents and infants. The aim of the study was, therefore, to develop and implement a quality improvement initiative to foster family-centered care in a tertiary neonatal intensive care unit from birth onward. A pretest posttest intervention design was used using mixed methods over 3 phases to determine the perceived level of family-centered care according to healthcare professionals and parents using self-administered questionnaires; to develop and implement a quality improvement initiative to enhance family-centered care in a neonatal intensive care unit using a nominal group technique, followed by the quality improvement process; and to evaluate the outcomes of the initiative by repeating the self-administered questionnaires to parents and staff. Various activities were introduced as part of the initiative such as early breastfeeding, early introduction of parents to their infant, open visitation policy, and involvement in caring activities. The perceived level of care according to staff and parents increased. It is expected to enhance bonding and attachment between the infants and their parents, with consequential long-term positive outcomes.

Photocatalytic oxidation mechanism of alkanes in contact with titanium dioxide

NASA Technical Reports Server (NTRS)

Formenti, M.; Juillet, F.; Teichner, S. J.

1977-01-01

Isobutane was photooxidized on titanium dioxide between -16 and +180 C in tertiary butanol and acetone. The formation of tertiary butanol preceded the formation of acetone. Above 20 C the latter compound became clearly predominant. The reaction kinetics obeyed a steady state model of oxygen chemisorption with the involvement of isobutane in the physisorbed phase.

Integration of Palliative Care Into Comprehensive Cancer Treatment at Moi Teaching and Referral Hospital in Western Kenya

PubMed Central

Kipsang, Susan; Gramelspacher, Gregory; Choi, Eunyoung; Brown, Colleen; Hill, Adam B.; Loehrer, Patrick J.; Busakhala, Naftali; Chite Asirwa, F.

2015-01-01

Purpose The prognosis for the majority of patients with cancer in Kenya is poor, with most patients presenting with advanced disease. In addition, many patients are unable to afford the optimal therapies required. Therefore, palliative care is an essential part of comprehensive cancer care. This study reviews the implementation of a palliative care service based at the Moi Teaching and Referral Hospital in Eldoret, Kenya, and describes the current scope and challenges of providing palliative care services in an East African tertiary public referral hospital. Methods This is a review of the palliative care clinical services at the only tertiary public referral hospital in western Kenya from January 2012 through September 2014. Palliative care team members documented each patient's encounter on standardized palliative care assessment forms; data were then entered into the Academic Model Providing Access to Health Care (AMPATH)-Oncology database. Interviews were also conducted to identify current challenges and opportunities for program improvement. Results This study documents the implementation of a palliative care service line in Eldoret, Kenya. Barriers to providing optimal palliative cancer care include distance to pharmacies that stock opioids, limited selection of opioid preparations, education of health care workers in palliative care, access to palliative chemoradiation, and limited availability of outpatient and inpatient hospice services. Conclusion Palliative care services in Eldoret, Kenya, have become a key component of its comprehensive cancer treatment program. PMID:28804768

Integration of Palliative Care Into Comprehensive Cancer Treatment at Moi Teaching and Referral Hospital in Western Kenya.

PubMed

Cornetta, Kenneth; Kipsang, Susan; Gramelspacher, Gregory; Choi, Eunyoung; Brown, Colleen; Hill, Adam B; Loehrer, Patrick J; Busakhala, Naftali; Chite Asirwa, F

2015-10-01

The prognosis for the majority of patients with cancer in Kenya is poor, with most patients presenting with advanced disease. In addition, many patients are unable to afford the optimal therapies required. Therefore, palliative care is an essential part of comprehensive cancer care. This study reviews the implementation of a palliative care service based at the Moi Teaching and Referral Hospital in Eldoret, Kenya, and describes the current scope and challenges of providing palliative care services in an East African tertiary public referral hospital. This is a review of the palliative care clinical services at the only tertiary public referral hospital in western Kenya from January 2012 through September 2014. Palliative care team members documented each patient's encounter on standardized palliative care assessment forms; data were then entered into the Academic Model Providing Access to Health Care (AMPATH)-Oncology database. Interviews were also conducted to identify current challenges and opportunities for program improvement. This study documents the implementation of a palliative care service line in Eldoret, Kenya. Barriers to providing optimal palliative cancer care include distance to pharmacies that stock opioids, limited selection of opioid preparations, education of health care workers in palliative care, access to palliative chemoradiation, and limited availability of outpatient and inpatient hospice services. Palliative care services in Eldoret, Kenya, have become a key component of its comprehensive cancer treatment program.

Paediatric surgery outreach: analysis of referrals to a tertiary paediatric surgery service to plan an outreach programme Kwa-Zulu Natal, South Africa.

PubMed

Manickchund, Yashoda; Hadley, G P

2017-10-01

Paediatric surgical disease is a neglected health problem. Patients travel great distances to tertiary level care for management. This study aimed at analysing referral patterns to design an outreach programme for paediatric surgery in KwaZulu Natal. Data forms of patients referred to the service between January and July 2016 were correlated with the clinical record. Delays in management were compared to morbidity and mortality. Out of 781, 158 referrals were accepted as emergencies. The majority (62%) were children aged < 1 year. Gastro-intestinal problems (38.4%) and congenital anomalies (26.9%) formed the majority. Patients who died had a significantly longer delay in transfer. Longer total delay was associated with statistically significant greater morbidity. In a setting where a large rural population is served by single-centre tertiary care, delays exist and contribute to morbidity. The authors advocate the establishment of an outreach programme to address these issues.

Symptom Prevalence of Patients with Cancer in a Tertiary Cancer Center in Jordan.

PubMed

Alawneh, Alia; Anshasi, Huda; Khirfan, Ghaleb; Yaseen, Hesham; Quran, Anood

2017-01-01

Prevalence of symptoms experienced by patients with cancer was studied in different parts of the world. In Jordan, to the best of our knowledge, there is no published data on the prevalence of symptoms among patients with cancer. The aim of this study is to estimate the prevalence of symptoms among patients with cancer in Jordan. This was a secondary analysis of crosssectional survey that evaluate the psychometric properties of the Arabic version of the European Organization for Research and Treatment of Cancer Quality of Life 15 items Questionnaire for Palliative Care (EORTC QLQ-C15-PAL) among patients admitted to a tertiary cancer center in Jordan. A total of 175 patients with cancer participated in the study; 51.4% were males, 48.6 % were females, mean age of patients was 50 years. Median number of symptoms per patient was 6, interquartile range was 5-7. The majority of patients (143; 81%) had more than 3 non-pain symptoms each. The most frequently reported symptom was tiredness (82%), whereas the least prevalent symptom was depression (55%). Pain was prevalent in 71% of patients, median severity score was 50%. Patients with cancer suffer from a large constellation of symptoms, frequent assessment with a designated tool can help early identification of these symptoms and subsequent management. This highlights the need for integrated palliative services along with other health care provision.

Implementation of subcutaneous insulin protocol for non-critically ill hospitalized patients in andalusian tertiary care hospitals.

PubMed

Martínez-Brocca, María Asunción; Morales, Cristóbal; Rodríguez-Ortega, Pilar; González-Aguilera, Beatriz; Montes, Cristina; Colomo, Natalia; Piédrola, Gonzalo; Méndez-Muros, Mariola; Serrano, Isabel; Ruiz de Adana, Maria Soledad; Moreno, Alberto; Fernández, Ignacio; Aguilar, Manuel; Acosta, Domingo; Palomares, Rafael

2015-02-01

In 2009, the Andalusian Society of Endocrinology and Nutrition designed a protocol for subcutaneous insulin treatment in hospitalized non-critically ill patients (HIP). To analyze implementation of HIP at tertiary care hospitals from the Andalusian Public Health System. A descriptive, multicenter study conducted in 8 tertiary care hospitals on a random sample of non-critically ill patients with diabetes/hyperglycemia (n=306) hospitalized for ≥48 hours in 5 non-surgical (SM) and 2 surgical (SQ) departments. Type 1 and other specific types of diabetes, pregnancy and nutritional support were exclusion criteria. 288 patients were included for analysis (62.5% males; 70.3±10.3 years; 71.5% SM, 28.5% SQ). A scheduled subcutaneous insulin regimen based on basal-bolus-correction protocol was started in 55.9% (95%CI: 50.5-61.2%) of patients, 63.1% SM vs. 37.8% SQ (P<.05). Alternatives to insulin regimen based on basal-bolus-correction included sliding scale insulin (43.7%), diet (31.3%), oral antidiabetic drugs (17.2%), premixed insulin (1.6%), and others (6.2%). For patients previously on oral antidiabetic drugs, in-hospital insulin dose was 0.32±0.1 IU/kg/day. In patients previously on insulin, in-hospital insulin dose was increased by 17% [-13-53], and in those on insulin plus oral antidiabetic drugs, in-hospital insulin dose was increased by 26.4% [-6-100]. Supplemental insulin doses used for<40 IU/day and 40-80 IU/day were 72.2% and 56.7% respectively. HbA1c was measured in 23.6% of patients (95CI%: 18.8-28.8); 27.7% SM vs. 13.3% SQ (P<.05). Strategies are needed to improve implementation of the inpatient subcutaneous insulin protocol, particularly in surgical departments. Sliding scale insulin is still the most common alternative to insulin regimen based on basal-bolus-correction scheduled insulin. Metabolic control assessment during hospitalization should be encouraged. Copyright © 2014 SEEN. Published by Elsevier España, S.L.U. All rights reserved.

Tertiary education and its association with mental health indicators and educational factors among Arctic young adults: the NAAHS cohort study.

PubMed

Bania, Elisabeth Valmyr; Kvernmo, Siv Eli

2016-01-01

Background Completed tertiary education is closely associated with employment and influences income, health and personal well-being. Objective The purpose of the study is to explore predictors for completed tertiary education among indigenous Sami and non-indigenous young people in relation to mental health indicators and educational factors in sociocultural rural and urban contexts across the Arctic part of Norway. Design The Norwegian Arctic Adolescent Health Study (NAAHS) is a cross-sectional, school-based survey that was conducted in 2003-2005. Of all 5,877 10th graders (aged 15-16 years) in north Norway, 83% from all 87 municipalities participated; 450 (9.2%) reported indigenous Sami ethnicity, and 304 (6.2%) reported Laestadian affiliation. Data from NAAHS were merged with registry data from the National Education Database and Norwegian Patient Register for 3,987 adolescents who gave their consent for follow-up studies. Results Completion of upper secondary school is the only common predictor of a completed tertiary education degree for both genders. Among females, conduct problems was a significant predictor of lower level education, typically vocational professions, while among males severe mental health problems requiring treatment by the specialist health care system reduced the opportunity to complete tertiary education at intermediate and higher level. Parental higher educational level was associated with less lower education among females and less higher education among males. Men residing in the northernmost and remote areas were less likely to complete education on higher level. Males' completion of higher level education was strongly but not significantly associated (p=0.057) with higher average marks in lower secondary school. Conclusions The gender differences found in this study emphasize the need for gender-specific interventions to encourage, support and empower young people to attend and complete tertiary education. Young females with conduct problems choose lower or intermediate education, and males in need of specialist mental health care have half the chance to complete intermediate tertiary education compared with males not in contact with the mental health service. Closer cooperation between low threshold social services, general practitioners, mental health services and higher study institutions can help young male adults complete tertiary education.

Induction of labour: a continuous quality improvement and peer review program to improve the quality of care

PubMed Central

Harris, Susan; Buchinski, Bev; Gryzbowski, Stefan; Janssen, Patti; Mitchell, G.W. Erle; Farquharson, Duncan

2000-01-01

This article describes a program developed to improve the process of planned induction of labour and to reduce the rates of inappropriate induction. The setting is a tertiary-care maternity hospital in urban Vancouver, BC, in which 7000 deliveries take place annually. Approximately 65% of these can be considered primary care; the remainder are secondary- or tertiary-level cases. Continuous quality improvement (CQI) methods were used by a multidisciplinary team, which included nursing staff, physicians, health records personnel and a CQI facilitator. Interventions included the development of a new induction-booking process, clear criteria for induction, feedback to caregivers about changes and a peer review system to oversee and maintain improvement. The overall induction rate for the institution decreased, and this change has been maintained. PMID:11079064

Laryngoscope Illuminance in a Tertiary Care Medical Center: Industry Standards and Implications for Quality Laryngoscopy.

PubMed

Murphy, Michael K; Volsky, Peter G; Darrow, David H

2015-11-01

To test the hypothesis that a substantial proportion of laryngoscopes exhibit substandard illuminance by comparing laryngoscope illuminance in a tertiary-level medical center to established standards and identifying features associated with poor illuminance. Cross-sectional observational study. Academic tertiary care medical center (level 1 trauma center, specialty cardiac hospital, and general hospital). Laryngoscopes from main, cardiac, and outpatient operating rooms; emergency department; and code carts were tested using a standard technique. Illuminance (lux) was chosen as the outcome measure. Benchmarks were derived from the International Standards Organization and medical literature. Light types included incandescent bulb, light-emitting diode, and xenon. Personnel were surveyed regarding maintenance practices. Across all hospitals, 691 laryngoscopes were tested. Mean (SD) illuminance was 810 (700) lux for incandescent bulb-on-blade designs (n = 237), 1860 (1220) lux for incandescent bulb in-handle designs (n = 79), 4730 (3210) lux for LED (n = 354), and 28,800 (34,500) lux for xenon (n = 21). Seven percent of units failed to turn on (n = 45). Using an established threshold of 867 lux, 28% of devices (47% of incandescent, 12% of LED, and 10% of xenon) were substandard. All laryngoscopes were cleaned according to standard protocols following use; no preventive maintenance was reported. Twenty-eight percent of laryngoscopes in a tertiary care hospital exhibit substandard illuminance; these results corroborate the findings of our inaugural study on this subject. Consequently, our hospital is instituting changes to reduce the likelihood of substandard performance by laryngoscopes in circulation. © American Academy of Otolaryngology—Head and Neck Surgery Foundation 2015.

Bacteremia caused by a rare pathogen - Chromobacterium violaceum: a case report from Nepal.

PubMed

Parajuli, Narayan Prasad; Bhetwal, Anjeela; Ghimire, Sumitra; Maharjan, Anjila; Shakya, Shreena; Satyal, Deepa; Pandit, Roshan; Khanal, Puspa Raj

2016-01-01

Chromobacterium violaceum is a gram negative saprophytic bacterium, prevalent in tropical and subtropical climates. Infections caused by C. violaceum are very uncommon, yet it can cause severe systemic infections with higher mortality when entered into the bloodstream through open wound. A case of symptomatic bacteremia in a woman caused by C. violaceum was identified recently at a tertiary care teaching hospital in Nepal. Timely diagnosis by microbiological methods and rapid administration of antimicrobials led to a successful treatment of this life-threatening infection in this case. From this experience, we suggest to include this bacterium in the differential diagnosis of sepsis, especially when abraded skin is exposed to soil or stagnant water in tropical areas. The precise antimicrobial selection and timely administration should be considered when this infection is suspected.

"Informed" Consent: An Audit of Informed Consent of Cesarean Section Evaluating Patient Education and Awareness.

PubMed

Kirane, Akhilesh G; Gaikwad, Nandkishor B; Bhingare, Prashant E; Mule, Vidya D

2015-12-01

Better diagnosis and early referral due to increased health care coverage have increased the cesarean deliveries at tertiary-care hospitals of India. Improvements in the health care system raise many concerns and need of cross-checking system in place to counter the problems pertaining to patient education and participation of patient. While most of the cesarean sections are done in good faith for the patient, it does not escape the purview of consumer awareness and protection. This cross-sectional study was undertaken at a tertiary level government institution to understand the level of awareness of 220 patients regarding the various aspects of cesarean delivery which are essential for women to know before giving an informed consent. 71 % of the women had knowledge about the indication and need to do cesarean delivery. Of these, only one-third (25 % of total women) were properly explained about procedure and complications. Other demographic and social characteristics were also evaluated. While the health care schemes have had their improved results, the onus lies upon the caregivers to improve and maintain the quality of health care in these tertiary-care government hospitals in proportion to the increase in patient load. The results of this study highlight the need for proper counseling of patients regarding complications of cesarean section. The fact that only 25 % of total cases were explained proper procedure and complication as opposed to 71 % of patients having proper knowledge about the indication of cesarean section points out the lack of information in seemingly "informed" consent. To bring about awareness about the risks and complications of cesarean section, there is a need that patients be counseled during the antenatal visits, specifically when patients visit near term for antenatal check up.

Interhospital transfer handoff practices among US tertiary care centers: A descriptive survey.

PubMed

Herrigel, Dana J; Carroll, Madeline; Fanning, Christine; Steinberg, Michael B; Parikh, Amay; Usher, Michael

2016-06-01

Interhospital transfer is an understudied area within transitions of care. The process by which hospitals accept and transfer patients is not well described. National trends and best practices are unclear. To describe the demographics of large transfer centers, to identify common handoff practices, and to describe challenges and notable innovations involving the interhospital transfer handoff process. A convenience sample of 32 tertiary care centers in the United States was studied. Respondents were typically transfer center directors surveyed by phone. Data regarding transfer center demographics, handoff communication practices, electronic infrastructure, and data sharing were obtained. The median number of patients transferred each month per receiving institution was 700 (range, 250-2500); on average, 28% of these patients were transferred to an intensive care unit. Transfer protocols and practices varied by institution. Transfer center coordinators typically had a medical background (78%), and critical care-trained registered nurse was the most prevalent (38%). Common practices included: mandatory recorded 3-way physician-to-physician conversation (84%) and mandatory clinical status updates prior to patient arrival (81%). However, the timeline of clinical status updates was variable. Less frequent transfer practices included: electronic medical record (EMR) cross-talk availability and utilization (23%), real-time transfer center documentation accessibility in the EMR (32%), and referring center clinical documentation available prior to transport (29%). A number of innovative strategies to address challenges involving interhospital handoffs are reported. Interhospital transfer practices vary widely amongst tertiary care centers. Practices that lead to improved patient handoffs and reduced medical errors need additional prospective evaluation. Journal of Hospital Medicine 2016;11:413-417. © 2016 Society of Hospital Medicine. © 2016 Society of Hospital Medicine.

Molecular characterization of Candida isolates from intensive care unit patients, Krakow, Poland.

PubMed

Małek, Marianna; Paluchowska, Paulina; Bogusz, Bożena; Budak, Alicja

Over the last decades, Candida species have emerged as important pathogens in immunocompromised patients. Nosocomial infections are mainly of endogenous origin. Nevertheless, some cases of exogenous candidiasis have also been reported. The aim of this study was to evaluate the genetic relatedness between Candida albicans, Candida glabrata, Candida tropicalis, Candida krusei and Candida kefyr isolates recovered from intensive care unit (ICU) patients. A total of 132 Candida clinical isolates (62 C. albicans, 40 C. glabrata, 13 C. tropicalis, 11 C. krusei, 6 C. kefyr), obtained from specimens of endotracheal aspirate, urine and blood taken from patients of a tertiary hospital in Poland, were included in the study. Species identification was performed by PCR method and genetic relatedness was assessed by randomly amplified polymorphic DNA assay (RAPD) with five primers. The RAPD analysis revealed high genetic diversity among the studied Candida isolates, indicating that most of the strains were from endogenous sources. Only two clonal strains of C. glabrata isolated from different patients were observed, suggesting a possible cross-transmission of these pathogens. Our study confirmed the high discriminatory power of the RAPD assay. This genotyping method can be applied to local epidemiological studies of Candida species. Copyright © 2016 Asociación Española de Micología. Publicado por Elsevier España, S.L.U. All rights reserved.

Building a taxonomy of integrated palliative care initiatives: results from a focus group

PubMed Central

Ewert, Benjamin; Hodiamont, Farina; van Wijngaarden, Jeroen; Payne, Sheila; Groot, Marieke; Hasselaar, Jeroen; Menten, Johann; Radbruch, Lukas

2016-01-01

Background Empirical evidence suggests that integrated palliative care (IPC) increases the quality of care for palliative patients and supports professional caregivers. Existing IPC initiatives in Europe vary in their design and are hardly comparable. InSuP-C, a European Union research project, aimed to build a taxonomy of IPC initiatives applicable across diseases, healthcare sectors and systems. Methods The taxonomy of IPC initiatives was developed in cooperation with an international and multidisciplinary focus group of 18 experts. Subsequently, a consensus meeting of 10 experts revised a preliminary taxonomy and adopted the final classification system. Results Consisting of eight categories, with two to four items each, the taxonomy covers the process and structure of IPC initiatives. If two items in at least one category apply to an initiative, a minimum level of integration is assumed to have been reached. Categories range from the type of initiative (items: pathway, model or guideline) to patients’ key contact (items: non-pc specialist, pc specialist, general practitioner). Experts recommended the inclusion of two new categories: level of care (items: primary, secondary or tertiary) indicating at which stage palliative care is integrated and primary focus of intervention describing IPC givers’ different roles (items: treating function, advising/consulting or training) in the care process. Conclusions Empirical studies are required to investigate how the taxonomy is used in practice and whether it covers the reality of patients in need of palliative care. The InSuP-C project will test this taxonomy empirically in selected initiatives using IPC. PMID:26647043

Evaluation of the performance of C. DIFF QUIK CHEK COMPLETE and its usefulness in a hospital setting with a high prevalence of Clostridium difficile infection.

PubMed

Chung, Hae-Sun; Lee, Miae

2017-01-01

Rapid and accurate diagnosis of Clostridium difficile infection (CDI) is crucial for patient care, infection control, and efficient surveillance. We evaluated C. DIFF QUIK CHEK COMPLETE (QCC; TechLab), which detects glutamate dehydrogenase (GDH) antigen (QCC-Ag) and toxin A/B (QCC-Tox) simultaneously, and compared it to the laboratory diagnostics for CDI currently in use in a tertiary hospital setting with a high prevalence of CDI. QCC, RIDASCREEN C. difficile toxin A/B assay (Toxin EIA; R-Biopharm AG), chromID C. difficile agar (bioMérieux) culture (ChromID culture), and Xpert C. difficile PCR assay (Xpert PCR; Cepheid) were performed according to the manufacturers' instructions. Performances of the assays were compared against that of Xpert PCR as a reference. Of the 231 loose stool specimens, 83 (35.9%) were positive by Xpert PCR. The sensitivity, specificity, and positive and negative predictive values were 97.6%, 93.9%, 90.0%, and 98.6%, respectively, for QCC-Ag and 55.4%, 100%, 100%, and 80.0%, respectively, for QCC-Tox. The median threshold cycle values of the QCC-Tox(+) specimens were lower than those of the QCC-Tox(-) specimens. Results of QCC as an initial screening test were confirmed in 81.0% (187/231) of samples; these specimens did not require further testing. QCC is a rapid, easy, and cost-effective method that would be a useful first-line screening assay for laboratory diagnosis of CDI in a tertiary hospital with a high prevalence of CDI. A two-step algorithm using QCC as an initial screening tool, followed by Xpert PCR as a confirmatory test, is a practical and cost-effective approach. Copyright © 2016 American Federation for Medical Research.

A Mixed-methods Study to Assess Interrater Reliability and Nurse Perception of the Braden Scale in a Tertiary Acute Care Setting.

PubMed

Ho, Chester H; Cheung, Amanda; Southern, Danielle; Ocampo, Wrechelle; Kaufman, Jaime; Hogan, David B; Baylis, Barry; Conly, John M; Stelfox, Henry T; Ghali, William A

2016-12-01

Research regarding the reliability of the Braden Scale and nurses' perspectives on the instrument for predicting pressure ulcer (PU) risk in acute care settings is limited. A mixed-methods study was conducted in a tertiary acute care facility to examine interrater reliability (IRR) of the Braden Scale and its subscales, and a qualitative survey using semi-structured interviews was conducted among nurses caring for patients in acute care units to gain nurse perspective regarding scale usability. Data were extracted from a previous retrospective, randomized, controlled trial involving adult patients with compromised mobility receiving care in a tertiary acute care hospital in Canada. One-way, intraclass correlation coefficients (ICCs) were calculated on item and total scores, and kappa statistics were used to determine reliability of categorizing patients on their risk. Interview results were categorized by common themes. Reliability was assessed on 64 patients, where nurses and research staff independently assessed enrolled participants at baseline and after 72 hours using the Braden Scale as it appeared on an electronic medical record. IRR for the total score was high (ICC = 0.807). The friction and shear item had the lowest reliability (ICC = 0.266). Reliability of categorizing patients' level of risk had moderate agreement (κ = 0.408). Three (3) major and 12 subthemes emerged from the 14 nurse interviews; nurses were aware of the scale's purpose but were uncertain of its effectiveness, some items were difficult to rate, and questions were raised as to whether using the scale enhanced patient care. Aspects identified by nurses to enhance usability included: 1) changes to the electronic version (incorporating the scale into daily assessment documents with readily available item descriptions), 2) additional training, and 3) easily available resource material to improve reliability and usability of scale. These findings need to be considered when using the Braden Scale in clinical practice. Further study of the value of the total Braden Scale and its subscales is warranted.

Rural-to-Urban Migrants' Experiences with Primary Care under Different Types of Medical Institutions in Guangzhou, China

PubMed Central

Zeng, Jiazhi; Shi, Leiyu; Zou, Xia; Chen, Wen; Ling, Li

2015-01-01

Objectives China is facing the unprecedented challenge of rapidly increasing rural-to-urban migration. Migrants are in a vulnerable state when they attempt to access to primary care services. This study was designed to explore rural-to-urban migrants’ experiences in primary care, comparing their quality of primary care experiences under different types of medical institutions in Guangzhou, China. Methods The study employed a cross-sectional survey of 736 rural-to-urban migrants in Guangzhou, China in 2014. A validated Chinese version of Primary Care Assessment Tool—Adult Short Version (PCAT-AS), representing 10 primary care domains was used to collect information on migrants’ quality of primary care experiences. These domains include first contact (utilization), first contact (accessibility), ongoing care, coordination (referrals), coordination (information systems), comprehensiveness (services available), comprehensiveness (services provided), family-centeredness, community orientation and culturally competent. These measures were used to assess the quality of primary care performance as reported from patients’ perspective. Analysis of covariance was conducted for comparison on PCAT scores among migrants accessing primary care in tertiary hospitals, municipal hospitals, community health centers/community health stations, and township health centers/rural health stations. Multiple linear regression models were used to explore factors associated with PCAT total scores. Results After adjustments were made, migrants accessing primary care in tertiary hospitals (25.49) reported the highest PCAT total scores, followed by municipal hospitals (25.02), community health centers/community health stations (24.24), and township health centers/rural health stations (24.18). Tertiary hospital users reported significantly better performance in first contact (utilization), first contact (accessibility), coordination (information system), comprehensiveness (service available), and cultural competence. Community health center/community health station users reported significantly better experience in the community orientation domain. Township health center/rural health station users expressed significantly better experience in the ongoing care domain. There were no statistically significant differences across settings in the ongoing care, comprehensiveness (services provided), and family-centeredness domains. Multiple linear regression models showed that factors positively associated with higher PCAT total scores also included insurance covering parts of healthcare payment (P<0.001). Conclusions This study highlights the need for improvement in primary care provided by primary care institutions for rural-to-urban migrants. Relevant policies related to medical insurance should be implemented for providing affordable healthcare services for migrants accessing primary care. PMID:26474161

No Variation in Patient Care Outcomes After Implementation of Resident Shift Work Duty Hour Limitations and a Hospitalist Model System.

PubMed

Hollier, John M; Wilson, Stephen D

This study examines whether implementing a resident shift work schedule (RSWS) alone or combined with a hospitalist-led model system (HMS/RSWS) affects patient care outcomes or costs at a pediatric tertiary care teaching hospital. A retrospective sample compared pre- and postintervention groups for the most common primary discharge diagnoses, including asthma and cellulitis (RSWS intervention) and inflammatory bowel disease and diabetic ketoacidosis (HMS/RSWS intervention). Outcome variables included length of stay, number of subspecialty consultations, and hospitalization charges. For the RSWS intervention, the preintervention (n = 107) and postintervention (n = 92) groups showed no difference in any of the outcome variables. For the HMS/RSWS intervention, the preintervention (n = 98) and postintervention (n = 69) groups did not differ in demographics or length of stay. However, subspecialty consultations increased significantly during postintervention from 0.83 to 1.52 consults/hospitalization ( P < .01) without significantly increasing hospitalization charges. Neither the RSWS nor HMS/RSWS intervention affected patient care outcomes at a pediatric tertiary care teaching hospital.

Characteristics of patients with diabetes screened for tuberculosis in a tertiary care hospital in South India

PubMed Central

Kumpatla, S.; Sekar, A.; Achanta, S.; Sharath, B. N.; Kumar, A. M. V.; Harries, A. D.

2013-01-01

Setting: Tertiary care hospital for diabetes mellitus (DM) in Tamil Nadu, South India. Objective: To compare the socio-demographic, clinical and biochemical characteristics in DM patients with and without tuberculosis (TB). Design: A descriptive study involving a review of routinely maintained records to capture the results of screening of DM patients for TB between March and December 2012. DM patients were first asked whether they already had TB, and if not they were screened for TB symptoms, followed by investigations for and possible diagnosis of TB. Results: Of 7083 DM patients, 38 already had TB. Of the remainder, 125 (1.8%) had TB symptoms; 71 were investigated and 12 were newly diagnosed with TB. Of the 50 TB patients, 64% had smear-positive pulmonary TB (PTB). DM-TB patients were older, and had lower education level and economic status, a higher frequency of alcohol use, lower body mass index, a longer duration of DM, a greater likelihood of receiving insulin and poorer glycaemic control. Conclusion: Screening of DM patients for TB was feasible in a tertiary care hospital. The yield of new TB cases was low and merits further investigation. Socio-demographic and clinical characteristics were different in patients with DM and TB compared to those with DM only. PMID:26393064

Customer satisfaction survey with clinical laboratory and phlebotomy services at a tertiary care unit level.

PubMed

Koh, Young Rae; Kim, Shine Young; Kim, In Suk; Chang, Chulhun L; Lee, Eun Yup; Son, Han Chul; Kim, Hyung Hoi

2014-09-01

We performed customer satisfaction surveys for physicians and nurses regarding clinical laboratory services, and for outpatients who used phlebotomy services at a tertiary care unit level to evaluate our clinical laboratory and phlebotomy services. Thus, we wish to share our experiences with the customer satisfaction survey for clinical laboratory and phlebotomy services. Board members of our laboratory designed a study procedure and study population, and developed two types of questionnaire. A satisfaction survey for clinical laboratory services was conducted with 370 physicians and 125 nurses by using an online or paper questionnaire. The satisfaction survey for phlebotomy services was performed with 347 outpatients who received phlebotomy services by using computer-aided interviews. Mean satisfaction scores of physicians and nurses was 58.1, while outpatients' satisfaction score was 70.5. We identified several dissatisfactions with our clinical laboratory and phlebotomy services. First, physicians and nurses were most dissatisfied with the specimen collection and delivery process. Second, physicians and nurses were dissatisfied with phlebotomy services. Third, molecular genetic and cytogenetic tests were found more expensive than other tests. This study is significant in that it describes the first reference survey that offers a survey procedure and questionnaire to assess customer satisfaction with clinical laboratory and phlebotomy services at a tertiary care unit level.

Customer Satisfaction Survey With Clinical Laboratory and Phlebotomy Services at a Tertiary Care Unit Level

PubMed Central

Koh, Young Rae; Kim, Shine Young; Kim, In Suk; Chang, Chulhun L.; Lee, Eun Yup; Son, Han Chul

2014-01-01

We performed customer satisfaction surveys for physicians and nurses regarding clinical laboratory services, and for outpatients who used phlebotomy services at a tertiary care unit level to evaluate our clinical laboratory and phlebotomy services. Thus, we wish to share our experiences with the customer satisfaction survey for clinical laboratory and phlebotomy services. Board members of our laboratory designed a study procedure and study population, and developed two types of questionnaire. A satisfaction survey for clinical laboratory services was conducted with 370 physicians and 125 nurses by using an online or paper questionnaire. The satisfaction survey for phlebotomy services was performed with 347 outpatients who received phlebotomy services by using computer-aided interviews. Mean satisfaction scores of physicians and nurses was 58.1, while outpatients' satisfaction score was 70.5. We identified several dissatisfactions with our clinical laboratory and phlebotomy services. First, physicians and nurses were most dissatisfied with the specimen collection and delivery process. Second, physicians and nurses were dissatisfied with phlebotomy services. Third, molecular genetic and cytogenetic tests were found more expensive than other tests. This study is significant in that it describes the first reference survey that offers a survey procedure and questionnaire to assess customer satisfaction with clinical laboratory and phlebotomy services at a tertiary care unit level. PMID:25187892

Awareness of cervical cancer and Pap smear among nursing staff at a rural tertiary care hospital in Central India.

PubMed

Jain, S M; Bagde, M N; Bagde, N D

2016-01-01

Cancer cervix is the leading cause of cancer deaths in females in developing countries and one in five women suffering from cervical cancer lives in India. The aim of this study is to determine the awareness about cervical cancer and Pap smear among nurses working in a tertiary care institute. Study Setting and Design: Cross-sectional survey in a tertiary care institute. Nurses working at our institute excluding those who have worked or working in the Obstetrics and Gynecology department were provided with a pre-designed questionnaire testing their knowledge about cervical cancer. Approximately, 86% were aware about cancer cervix and 69% were aware of a pre-cancerous stage. 42.3% were not aware of any risk factor and 27.6% were not aware of any symptom of cancer cervix. 86.2% were aware about Pap smear, but only 58.6% were aware that facilities of Pap smear were available at our hospital. Knowledge about cervical cancer and awareness of Pap smear as screening test was inadequate in nursing staff. Awareness programs about cervical cancer and screening are needed to increase awareness for this preventable condition. There is a need to arrange reorientation programs to sensitize nurses and establish cytology clinics to offer facilities for easily accessible and affordable screening.

Contemporary Parenteral Antiplatelet Bridging Strategies: A Single-Center Real-World Experience at a Tertiary Care Center.

PubMed

Stern, Gretchen; Rimsans, Jessica; Qamar, Arman; Vaduganathan, Muthiah; Bhatt, Deepak L

2018-03-13

Oral antiplatelet therapy may require interruption soon after percutaneous coronary intervention (PCI) or acute coronary syndrome. The optimal parenteral antiplatelet bridge strategy with glycoprotein IIb/IIIa inhibitors or cangrelor, a P2Y12 inhibitor, is unclear. We explore real-world use of cangrelor or eptifibatide for antiplatelet bridging at a large tertiary-care center. Thirty-one patients (9 eptifibatide, 20 cangrelor, and 2 both) received bridge therapy from October 2015 to June 2017. Primary bridge therapy indications included surgery (68%), limited enteral access/absorption (16%), and high-perceived bleed risk (16%). Median duration of bridge therapy was 61 (20-100) hours for cangrelor and 83 (19-98) hours for eptifibatide. Severe/life-threatening bleeding or stent thrombosis was not observed. GUSTO-defined bleeding occurred in 30% (cangrelor) and 27% (eptifibatide). Initial dosing errors occurred in 23% of patients. Death during hospitalization occurred in 16% of patients. Parenteral antiplatelet bridging was used for ~3 days in this single-center, tertiary care experience, commonly for unplanned surgery following PCI. Despite high-risk presentations with >15% in-hospital mortality, efficacy profiles were reassuring with no identified stent thrombosis, but bleeding and dosing errors were common. Antiplatelet bridging should only be used in well-selected patients at the appropriate dose for the minimal necessary duration.

Cometabolism of Methyl tertiary Butyl Ether and Gaseous n-Alkanes by Pseudomonas mendocina KR-1 Grown on C5 to C8 n-Alkanes

PubMed Central

Smith, Christy A.; O'Reilly, Kirk T.; Hyman, Michael R.

2003-01-01

Pseudomonas mendocina KR-1 grew well on toluene, n-alkanes (C5 to C8), and 1° alcohols (C2 to C8) but not on other aromatics, gaseous n-alkanes (C1 to C4), isoalkanes (C4 to C6), 2° alcohols (C3 to C8), methyl tertiary butyl ether (MTBE), or tertiary butyl alcohol (TBA). Cells grown under carbon-limited conditions on n-alkanes in the presence of MTBE (42 μmol) oxidized up to 94% of the added MTBE to TBA. Less than 3% of the added MTBE was oxidized to TBA when cells were grown on either 1° alcohols, toluene, or dextrose in the presence of MTBE. Concentrated n-pentane-grown cells oxidized MTBE to TBA without a lag phase and without generating tertiary butyl formate (TBF) as an intermediate. Neither TBF nor TBA was consumed by n-pentane-grown cells, while formaldehyde, the expected C1 product of MTBE dealkylation, was rapidly consumed. Similar Ks values for MTBE were observed for cells grown on C5 to C8 n-alkanes (12.95 ± 2.04 mM), suggesting that the same enzyme oxidizes MTBE in cells grown on each n-alkane. All growth-supporting n-alkanes (C5 to C8) inhibited MTBE oxidation by resting n-pentane-grown cells. Propane (Ki = 53 μM) and n-butane (Ki = 16 μM) also inhibited MTBE oxidation, and both gases were also consumed by cells during growth on n-pentane. Cultures grown on C5 to C8 n-alkanes also exhibited up to twofold-higher levels of growth in the presence of propane or n-butane, whereas no growth stimulation was observed with methane, ethane, MTBE, TBA, or formaldehyde. The results are discussed in terms of their impacts on our understanding of MTBE biodegradation and cometabolism. PMID:14660389

Attitudes and Awareness Regarding Hepatitis B and Hepatitis C Amongst Health-care Workers of a Tertiary Hospital in India.

PubMed

Setia, S; Gambhir, Rs; Kapoor, V; Jindal, G; Garg, S; Setia, S

2013-10-01

Hepatitis is an inflammatory disease of the liver. In sever cases, it may lead to permanent liver damage including liver cirrhosis or hepato-cellular carcinoma and may ultimately lead to death. Health-care workers (HCWs), due to their regular contact with patients are at a high-risk of acquiring this disease. The aim of this study was to assess the knowledge and attitude toward hepatitis B and C infection among the health-care interns and correlate the level of awareness to the attitude they behold toward the disease. A closed ended questionnaire consisting of questions to evaluate the knowledge regarding hepatitis B and C infection and attitude of the (HCWs/interns) was duly filled by 255 participants including, 100 dental, 100 medical, and 55 nursing interns. Statistical analysis was carried out using the Chi-square test, ANOVA test, post-hoc test and Pearson's correlation. Although most of the interns were aware of the existence of hepatitis B and C infection, the level of awareness regarding the modes of transmission and vaccination was found to be dissatisfactory. Awareness level regarding the infection among nursing interns was statistically significantly lower than the dental and medical interns. A direct positive correlation as found between awareness score and behavior score, which reveals that interns with better awareness level had better attitudes toward the infection and prevention of its transmission. There is an urgent need to increase the level and quality of training among HCWs to prevent the spread of hepatitis B virus and hepatitis C virus.

Nickel-Catalyzed Reductive Allylation of Tertiary Alkyl Halides with Allylic Carbonates.

PubMed

Chen, Haifeng; Jia, Xiao; Yu, Yingying; Qian, Qun; Gong, Hegui

2017-10-09

The construction of all C(sp 3 ) quaternary centers has been successfully achieved under Ni-catalyzed cross-electrophile coupling of allylic carbonates with unactivated tertiary alkyl halides. For allylic carbonates bearing C1 or C3 substituents, the reaction affords excellent regioselectivity through the addition of alkyl groups to the unsubstituted allylic carbon terminus. The allylic alkylation method also exhibits excellent functional-group compatibility, and delivers the products with high E selectivity. © 2017 Wiley-VCH Verlag GmbH & Co. KGaA, Weinheim.

Investigation of health care waste management in Binzhou District, China

DOE Office of Scientific and Technical Information (OSTI.GOV)

Ruoyan, Gai; Xu Lingzhong; Li Huijuan

In China, national regulations and standards for health care waste management were implemented in 2003. To investigate the current status of health care waste management at different levels of health care facilities (HCF) after the implementation of these regulations, one tertiary hospital, one secondary hospital, and four primary health care centers from Binzhou District were visited and 145 medical staff members and 24 cleaning personnel were interviewed. Generated medical waste totaled 1.22, 0.77, and 1.17 kg/bed/day in tertiary, secondary, and primary HCF, respectively. The amount of medical waste generated in primary health care centers was much higher than that inmore » secondary hospitals, which may be attributed to general waste being mixed with medical waste. This study found that the level of the HCF, responsibility for medical waste management in departments and wards, educational background and training experience can be factors that determine medical staff members' knowledge of health care waste management policy. Regular training programs and sufficient provision of protective measures are urgently needed to improve occupational safety for cleaning personnel. Financing and administrative monitoring by local authorities is needed to improve handling practices and the implementation of off-site centralized disposal in primary health care centers.« less

Family caregivers in public tertiary care hospitals in Bangladesh: Risks and opportunities for infection control

PubMed Central

Islam, M. Saiful; Luby, Stephen P.; Sultana, Rebeca; Rimi, Nadia Ali; Zaman, Rashid Uz; Uddin, Main; Nahar, Nazmun; Rahman, Mahmudur; Hossain, M. Jahangir; Gurley, Emily S.

2015-01-01

Background Family caregivers are integral to patient care in Bangladeshi public hospitals. This study explored family caregivers’ activities and their perceptions and practices related to disease transmission and prevention in public hospitals. Methods Trained qualitative researchers conducted a total of 48 hours of observation in 3 public tertiary care hospitals and 12 in-depth interviews with family caregivers. Results Family caregivers provided care 24 hours a day, including bedside nursing, cleaning care, and psychologic support. During observations, family members provided 2,065 episodes of care giving, 75% (1,544) of which involved close contact with patients. We observed family caregivers washing their hands with soap on only 4 occasions. The majority of respondents said diseases are transmitted through physical contact with surfaces and objects that have been contaminated with patient secretions and excretions, and avoiding contact with these contaminated objects would help prevent disease. Conclusion Family caregivers are at risk for hospital-acquired infection from their repeated exposure to infectious agents combined with their inadequate hand hygiene and knowledge about disease transmission. Future research should explore potential strategies to improve family caregivers’ knowledge about disease transmission and reduce family caregiver exposures, which may be accomplished by improving care provided by health care workers. PMID:24406254

Family caregivers in public tertiary care hospitals in Bangladesh: risks and opportunities for infection control.

PubMed

Islam, M Saiful; Luby, Stephen P; Sultana, Rebeca; Rimi, Nadia Ali; Zaman, Rashid Uz; Uddin, Main; Nahar, Nazmun; Rahman, Mahmudur; Hossain, M Jahangir; Gurley, Emily S

2014-03-01

Family caregivers are integral to patient care in Bangladeshi public hospitals. This study explored family caregivers' activities and their perceptions and practices related to disease transmission and prevention in public hospitals. Trained qualitative researchers conducted a total of 48 hours of observation in 3 public tertiary care hospitals and 12 in-depth interviews with family caregivers. Family caregivers provided care 24 hours a day, including bedside nursing, cleaning care, and psychologic support. During observations, family members provided 2,065 episodes of care giving, 75% (1,544) of which involved close contact with patients. We observed family caregivers washing their hands with soap on only 4 occasions. The majority of respondents said diseases are transmitted through physical contact with surfaces and objects that have been contaminated with patient secretions and excretions, and avoiding contact with these contaminated objects would help prevent disease. Family caregivers are at risk for hospital-acquired infection from their repeated exposure to infectious agents combined with their inadequate hand hygiene and knowledge about disease transmission. Future research should explore potential strategies to improve family caregivers' knowledge about disease transmission and reduce family caregiver exposures, which may be accomplished by improving care provided by health care workers. Copyright © 2014 Association for Professionals in Infection Control and Epidemiology, Inc. All rights reserved.

Implementation of Robert's Coping with Labor Algorithm© in a large tertiary care facility.

PubMed

Fairchild, Esther; Roberts, Leissa; Zelman, Karen; Michelli, Shelley; Hastings-Tolsma, Marie

2017-07-01

to implement use of Roberts' Coping with Labor Algorithm © (CWLA) with laboring women in a large tertiary care facility. this was a quality improvement project to implement an alternate approach to pain assessment during labor. It included system assessment for change readiness, implementation of the algorithm across a 6-week period, evaluation of usefulness by nursing staff, and determination of sustained change at one month. Stakeholder Theory (Friedman and Miles, 2002) and Deming's (1982) Plan-Do-Check-Act Cycle, as adapted by Roberts et al (2010), provided the framework for project implementation. the project was undertaken on a labor and delivery (L&D) unit of a large tertiary care facility in a southwestern state in the USA. The unit had 19 suites with close to 6000 laboring patients each year. full, part-time, and per diem Registered Nurse (RN) staff (N=80), including a subset (n=18) who served as the pilot group and champions for implementing the change. a majority of RNs held a positive attitude toward use of the CWLA to assess laboring women's coping with the pain of labor as compared to a Numeric Rating Scale (NRS). RNs reported usefulness in using the CWLA with patients from a wide variety of ethnicities. A pre-existing well-developed team which advocated for evidence-based practice on the unit proved to be a significant strength which promoted rapid change in practice. this work provides important knowledge supporting use of the CWLA in a large tertiary care facility and an approach for effectively implementing that change. Strengths identified in this project contributed to rapid implementation and could be emulated in other facilities. Participant reports support usefulness of the CWLA with patients of varied ethnicity. Assessment of change sustainability at 1 and 6 months demonstrated widespread use of the algorithm though long-term determination is yet needed. Copyright © 2017 Elsevier Ltd. All rights reserved.

Theory of perceived access to breast health care in African American women.

PubMed

Garmon, Sandra C

2012-01-01

The theory presented in this article proposes an alternative view of access to care on the basis of an African American woman's perception of the necessity, availability, and appropriateness of breast health care. The theory of perceived access to breast health care in African American women may also be useful in framing future research studies exploring the relationship between access to care and utilization of primary, secondary, and tertiary clinical preventive services related to breast health care.

Burnout and quality of life in nurses of a tertiary care hospital in Pakistan.

PubMed

Naz, Shahana; Hashmi, Ali Madeeh; Asif, Aftab

2016-05-01

To determine the relationship of burnout and quality of life among nurses of different departments at a tertiary care hospital. The observational, cross-sectional study was conducted at Mayo Hospital, Lahore, from November 2013 to May2014, and comprised nurses recruited by convenience sampling. Maslach Burnout Inventory was used to assess burnout and World Health Organisation Quality of life instrument's BREF version was used to assess quality of life of the subjects. Data was analysed using SPSS 16. Of the 106 nurses with a mean age of 35.5±7 years, 83(79%) were experiencing severe burnout and a low quality of life. Nurses of Surgery and Obstetrics/Gynaecology departments who worked longer hours on the night shift scored higher on burnout and lower on quality of life. Burnout in nurses was very common because of increasing workload and can negatively affect their quality of life leading to compromised patient care.

Leading up to saying "yes": A qualitative study on the experience of patients with refractory epilepsy regarding presurgical investigation for resective surgery.

PubMed

Shih, Patti; Nikpour, Armin; Bleasel, Andrew; Herkes, Geoffrey; Mitchell, Rebecca; Seah, Rebecca; Mumford, Virginia; Braithwaite, Jeffrey; Vagholkar, Sanjyot; Rapport, Frances

2018-06-01

Adult patients with refractory epilepsy who are potential candidates for resective surgery undergo a period of presurgical investigation in tertiary epilepsy centers (TECs), where they engage extensively with healthcare professionals and receive a range of treatment-related information. This qualitative study aimed to examine the experiences of adult patients with refractory epilepsy leading up to and during presurgical investigation and how their perceptions of resective surgery are shaped. In-depth interviews with 12 patients and six epilepsy specialist clinicians and 12 observations of routine patient-clinician consultations took place at two TECs in Sydney, Australia. Data were thematically analyzed via group work. Patients reflected on prior experiences of poor seizure control and inadequate antiepileptic drug management and a lack of clarity about their condition before referral to tertiary care. Poor continuity of care and disrupted care transitions affected patients from regional locations. Tertiary referral increased engagement with personalized information about refractory epilepsy, which intensified during presurgical assessments with additional hospital visits and consultations. Experiential information, such as testimonials of other patients, influenced perceptions of surgery and fostered more trust and confidence towards healthcare professionals. Qualitative inquiry detailed multifaceted effects of information on patients' overall treatment trajectory and experience of healthcare. Earlier patient identification for surgical assessments should be accompanied by access to good quality information at primary and community care levels and strengthened referral processes. Copyright © 2018 The Authors. Published by Elsevier Inc. All rights reserved.

Improving Access to Further and Higher Education for Young People in Public Care: European Policy and Practice

ERIC Educational Resources Information Center

Jackson, Sonia; Cameron, Claire

2014-01-01

Across Europe young people in public care are around five times less likely to attend tertiary education than those who have not been in care. This book provides a comprehensive account of why this shocking discrepancy exists and outlines ways to address the imbalance. Drawing extensively on new original research, the book examines the…

Young children with functional abdominal pain (FAP) and irritable bowel syndrome (IBS) followed in pediatric gastroenterology (PED-GI) vs primary pediatric care (PED): Differences in outcomes

USDA-ARS?s Scientific Manuscript database

The American Academy of Pediatrics suggests that children with recurrent abdominal pain without alarm signs be managed in pediatric rather than specialty care. However, many of these children are seen in tertiary care. In a longitudinal examination of physical and psychological symptoms, we hypothes...

Reverse transport of children from a tertiary pediatric hospital.

PubMed

McPherson, Mona L; Jefferson, Larry S; Smith, E O'Brian; Sitler, Garry C; Graf, Jeanine M

2007-01-01

The purpose of this study was to determine the epidemiology and resources used and to study the potential savings of pediatric reverse transport patients. A case control study was performed with patients undergoing a reverse or outbound transport from a large, pediatric hospital. Twenty-five children undergoing reverse transport were compared with matched controls. Lengths of stay and costs were compared between the reverse transport and matched control patients. Fifty-two percent of the reverse transport patients returned home, whereas 32% went home for end-of-life care and 16% went to other facilities. The average reverse transport was more than 400 miles and cost $6,064. The reverse transport of these patients did not save pediatric intensive care unit (PICU) days but did result in a shorter hospital stay compared with the matched controls (10 vs. 19 days, P = .03). Decreased utilization of bed days came from less use of intermediate care unit resources. Pediatric patients undergo reverse transports for a variety of reasons, often for end-of-life care. The ability to reverse transport pediatric patients may not save PICU bed days but may offer pediatric tertiary care hospitals a means to provide more intermediate care bed availability.

Disruptive innovation in academic medical centers: balancing accountable and academic care.

PubMed

Stein, Daniel; Chen, Christopher; Ackerly, D Clay

2015-05-01

Numerous academic medicine leaders have argued that academic referral centers must prepare for the growing importance of accountability-driven payment models by adopting population health initiatives. Although this shift has merit, execution of this strategy will prove significantly more problematic than most observers have appreciated. The authors describe how successful implementation of an accountable care health strategy within a referral academic medical center (AMC) requires navigating a critical tension: The academic referral business model, driven by tertiary-level care, is fundamentally in conflict with population health. Referral AMCs that create successful value-driven population health systems within their organizations will in effect disrupt their own existing tertiary care businesses. The theory of disruptive innovation suggests that balancing the push and pull of academic and accountable care within a single organization is achievable. However, it will require significant shifts in resource allocation and changes in management structure to enable AMCs to make the inherent difficult choices and trade-offs that will ensue. On the basis of the theories of disruptive innovation, the authors present recommendations for how academic health systems can successfully navigate these issues as they transition toward accountability-driven care.

The clinical, operational, and financial worlds of neonatal palliative care: A focused ethnography.

PubMed

Williams-Reade, Jackie; Lamson, Angela L; Knight, Sharon M; White, Mark B; Ballard, Sharon M; Desai, Priti P

2015-04-01

Due to multiple issues, integrated interdisciplinary palliative care teams in a neonatal intensive care unit (NICU) may be difficult to access, sometimes fail to be implemented, or provide inconsistent or poorly coordinated care. When implementing an effective institution-specific neonatal palliative care program, it is critical to include stakeholders from the clinical, operational, and financial worlds of healthcare. In this study, researchers sought to gain a multidisciplinary perspective into issues that may impact the implementation of a formal neonatal palliative care program at a tertiary regional academic medical center. In this focused ethnography, the primary researcher conducted semistructured interviews that explored the perspectives of healthcare administrators, finance officers, and clinicians about neonatal palliative care. The perspectives of 39 study participants informed the identification of institutional, financial, and clinical issues that impact the implementation of neonatal palliative care services at the medical center and the planning process for a formal palliative care program on behalf of neonates and their families. Healthcare professionals described experiences that influenced their views on neonatal palliative care. Key themes included: (a) uniqueness of neonatal palliative care, (b) communication and conflict among providers, (c) policy and protocol discrepancies, and (d) lack of administrative support. The present study highlighted several areas that are challenging in the provision of neonatal palliative care. Our findings underscored the importance of recognizing and procuring resources needed simultaneously from the clinical, operational, and financial worlds in order to implement and sustain a successful neonatal palliative care program.

Treatment of a critically ill child with disseminated Candida glabrata with a recombinant human antibody specific for fungal heat shock protein 90 and liposomal amphotericin B, caspofungin, and voriconazole.

PubMed

Sutherland, Adam; Ellis, David

2008-07-01

To report a case of fungal sepsis treated prospectively with liposomal amphotericin, caspofungin, and a novel monoclonal antibody specific for candidal heat shock protein 90 (Mycograb, Neutec Pharma, Manchester, UK). Case report. Pediatric intensive care unit in a tertiary care children's hospital. A 7-yr-old male with a history of global developmental delay, epilepsy, and gastroesophageal reflux, who presented to the emergency department with a transdiaphragmatic herniation of bowel and subsequent Candida glabrata infection. Efungumab 1 mg/kg twice daily for 5 days. C-reactive protein fell from 225 mg/L to 99 mg/L, and physiological monitoring parameters improved when Mycograb was used in conjunction with high-dose antifungals. Mycograb therapy was well tolerated, but further experience with this therapy in children is needed.

Successful affiliations: principles and practices.

PubMed

Rice, Ann Madden

2011-01-01

An affiliation can help a healthcare provider prepare for the challenges of healthcare reform, the rapidly changing landscapes of the commercial insurance industry, and the public's expectations about service and quality. UC Davis Medical Center, a 645-bed tertiary hospital in Sacramento, California, with many hospital-based clinics and a community-based group of primary care clinics, has developed a number of principles for affiliation. These principles are based on its experience in legal and financial affiliations with an academic practice group, with individual and small groups of primary care physicians, and with community hospitals around oncology services linked with U.C. Davis' National Cancer Institute-designated cancer center. This article offers a process for evaluating the appropriateness of an affiliation. The chances for a successful affiliation improve if each party has indicated the value it hopes to derive and how to measure that value, has communicated with all affected constituents, and has an agreed-upon method for resolving disputes.

Facilitating LGBT Medical, Health and Social Care Content in Higher Education Teaching

ERIC Educational Resources Information Center

Davy, Zowie; Amsler, Sarah; Duncombe, Karen

2015-01-01

Increasingly, Lesbian, Gay, Bisexual, and Transgender (LGBT) health care is becoming an important quality assurance feature of primary, secondary and tertiary healthcare in Britain. While acknowledging these very positive developments, teaching LGBT curricula content is contingent upon having educators understand the complexity of LGBT lives. The…

Effect of Mass Flow on Stack Eductor Performance.

DTIC Science & Technology

1984-06-01

absolute viscosity, lbf-sec/ft2 - density, Ibm/ft 3 "function of" ENGLISH LETTER SYMBOLS 2 A - area, in , ft B - atmospheric pressure, in Hg c - sonic... absolute temperature ratio T* - tertiary flow to primary flow absolute temperature t ratio - secondary -o primary mass flow rate ratio W* - tertiary to...secondary to primary absolute Tp temperature ratio TiL tertiary to primary absolute -TE temperature ratio secondary to primary flow density ratio

Increased ICU resource needs for an academic emergency general surgery service*.

PubMed

Lissauer, Matthew E; Galvagno, Samuel M; Rock, Peter; Narayan, Mayur; Shah, Paulesh; Spencer, Heather; Hong, Caron; Diaz, Jose J

2014-04-01

ICU needs of nontrauma emergency general surgery patients are poorly described. This study was designed to compare ICU utilization of emergency general surgery patients admitted to an acute care emergency surgery service with other general surgery patients. Our hypothesis is that tertiary care emergency general surgery patients utilize more ICU resources than other general surgical patients. Retrospective database review. Academic, tertiary care, nontrauma surgical ICU. All patients admitted to the surgical ICU over age 18 between March 2004 and June 2012. None. Six thousand ninety-eight patients were evaluated: 1,053 acute care emergency surgery, 1,964 general surgery, 1,491 transplant surgery, 995 facial surgery/otolaryngology, and 595 neurosurgery. Acute care emergency surgery patients had statistically significantly longer ICU lengths of stay than other groups: acute care emergency surgery (13.5 ± 17.4 d) versus general surgery (8.7 ± 12.9), transplant (7.8 ± 11.6), oral-maxillofacial surgery (5.5 ± 4.2), and neurosurgery (4.47 ± 9.8) (all p< 0.01). Ventilator usage, defined by percentage of total ICU days patients required mechanical ventilation, was significantly higher for acute care emergency surgery patients: acute care emergency surgery 73.4% versus general surgery 64.9%, transplant 63.3%, oral-maxillofacial surgery 58.4%, and neurosurgery 53.1% (all p < 0.01). Continuous renal replacement therapy usage, defined as percent of patients requiring this service, was significantly higher in acute care emergency surgery patients: acute care emergency surgery 10.8% versus general surgery 4.3%, transplant 6.6%, oral-maxillofacial surgery 0%, and neurosurgery 0.5% (all p < 0.01). Acute care emergency surgery patients were more likely interhospital transfers for tertiary care services than general surgery or transplant (24.5% vs 15.5% and 8.3% respectively, p < 0.001 for each) and more likely required emergent surgery (13.7% vs 6.7% and 3.5%, all p < 0.001). Chronic comorbidities were similar between acute care emergency surgery and general surgery, whereas transplant had fewer. Emergency general surgery patients have increased ICU needs in terms of length of stay, ventilator usage, and continuous renal replacement therapy usage compared with other services, perhaps due to the higher percentage of transfers and emergent surgery required. These patients represent a distinct population. Understanding their resource needs will allow for better deployment of hospital resources.

Consumer satisfaction with tertiary healthcare in China: findings from the 2015 China National Patient Survey.

PubMed

Sun, Jing; Hu, Guangyu; Ma, Jing; Chen, Yin; Wu, Laiyang; Liu, Qiannan; Hu, Jia; Livoti, Christine; Jiang, Yu; Liu, Yuanli

2017-04-01

This study aims to develop understanding of Chinese patient satisfaction with tertiary hospitals. The study draws on data collected from the 2015 China National Patient Survey. A Likert five-point scale was used to formulate the questionnaires. Descriptive analysis and logistic regression analysis were conducted. A structured questionnaire was used by 1432 interviewers to interview 27 475 outpatients and 19 938 inpatients in 136 tertiary hospitals from 31 provinces. Outpatients in the dispensing area and inpatients in the discharging area were randomly interviewed. Key domains of the questionnaire include the layout of service functions, environment maintenance, process management, quality of care, humane care and the patient-doctor relationship. Within each domain, several indicators were set, and each indicator was given a statement. The overall satisfaction scores are 4.42 ± 0.68 and 4.67 ± 0.62 for outpatient and inpatient, respectively. The domains with highest satisfaction are 'diagnosis and treatment' for outpatient and 'nursing care' for inpatient. Outpatients were least satisfied with long waiting time, while inpatients were least satisfied with the food. The strongest predictor of overall satisfaction appears to be 'patient-doctor relationship' for both outpatients (OR = 3.53, 95% CI: 3.17-3.92) and inpatients (OR = 7.34, 95% CI: 5.55-9.70). Chinese hospitals need to pay more attention to offering more humane care to patients, hospital environment and process management improvement, reducing waiting times for seeing doctors and outpatient testing, and improving amenity services such as better food in the wards. © The Author 2017. Published by Oxford University Press in association with the International Society for Quality in Health Care. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

Cost-Effective Recruitment need for 24x7 Paediatricians in the State General Hospitals in Relation to the Reduction of Infant Mortality.

PubMed

Chatterjee, Ranjana; Chatterjee, Sukanta

2016-10-01

According to World Health Organisation (WHO), improvement of hospital based care can have an impact of upto 30% in reducing Infant Mortality Rate (IMR), whereas, strengthening universal outreach and family-community based care is known to have a greater impact. The study intends to assess how far gaps in the public health facilities contribute towards infant mortality, as 2/3 rd of infant mortality is due to suboptimum care seeking and weak health system. To identify cost-effectiveness of employment of additional paediatric manpower to provide round the clock skilled service to reduce IMR in the present state health facilities at the district general hospitals. A cross-sectional observational study was conducted in a tertiary teaching hospital and district hospitals of 2 districts (Hooghly and Howrah in West Bengal). Factors affecting infant mortality and shift wise analysis of proportion of infant deaths were analysed in both tertiary and district level hospitals. Information was gathered in a predesigned proforma for one year period by verifying hospital records and by personal interview with service personnel in the health establishment. SPSS software version 17 (Chicago, IL) was used. The p-value was calculated by Fischer exact t-test. Available hospital beds per 1000 population were 1.1. Percentage of paediatric beds available in comparison to total hospital bed was disproportionately lower (10%). Dearth of skilled medical care provider at odd hours in district hospitals resulted in significantly greater infant death (p < 0.0001), but was not seen in tertiary hospital. The investment for appointing four additional paediatricians for round the clock stay duty was found to be cost-effective. Provision of round the clock availability of skilled medical care may reduce hospital based infant mortality and it is cost-effective.

Tertiary education and its association with mental health indicators and educational factors among Arctic young adults: the NAAHS cohort study

PubMed Central

Bania, Elisabeth Valmyr; Kvernmo, Siv Eli

2016-01-01

Background Completed tertiary education is closely associated with employment and influences income, health and personal well-being. Objective The purpose of the study is to explore predictors for completed tertiary education among indigenous Sami and non-indigenous young people in relation to mental health indicators and educational factors in sociocultural rural and urban contexts across the Arctic part of Norway. Design The Norwegian Arctic Adolescent Health Study (NAAHS) is a cross-sectional, school-based survey that was conducted in 2003–2005. Of all 5,877 10th graders (aged 15–16 years) in north Norway, 83% from all 87 municipalities participated; 450 (9.2%) reported indigenous Sami ethnicity, and 304 (6.2%) reported Laestadian affiliation. Data from NAAHS were merged with registry data from the National Education Database and Norwegian Patient Register for 3,987 adolescents who gave their consent for follow-up studies. Results Completion of upper secondary school is the only common predictor of a completed tertiary education degree for both genders. Among females, conduct problems was a significant predictor of lower level education, typically vocational professions, while among males severe mental health problems requiring treatment by the specialist health care system reduced the opportunity to complete tertiary education at intermediate and higher level. Parental higher educational level was associated with less lower education among females and less higher education among males. Men residing in the northernmost and remote areas were less likely to complete education on higher level. Males’ completion of higher level education was strongly but not significantly associated (p=0.057) with higher average marks in lower secondary school. Conclusions The gender differences found in this study emphasize the need for gender-specific interventions to encourage, support and empower young people to attend and complete tertiary education. Young females with conduct problems choose lower or intermediate education, and males in need of specialist mental health care have half the chance to complete intermediate tertiary education compared with males not in contact with the mental health service. Closer cooperation between low threshold social services, general practitioners, mental health services and higher study institutions can help young male adults complete tertiary education. PMID:28156413

Comparative Evaluation of Accuracy of Pulse Oximeters and Factors Affecting Their Performance in a Tertiary Intensive Care Unit

PubMed Central

Sahi, Malvinder Singh; Mahawar, Bablesh; Rajpurohit, Sajjan

2017-01-01

Introduction Pulse oximetry is a widely used tool, unfortunately there is a paucity of data investigating its accuracy in Intensive Care Units (ICU) and if they are able to meet mandated FDA criteria as claimed by them in critically ill patients. Aim To assess bias, precision and accuracy of pulse oximeters used in ICU and factors affecting them. Materials and Methods A prospective cohort study, including 129 patients admitted to the ICU of a tertiary referral centre. Pulse oximetry and blood gas were done simultaneously. Pulse oximetry was done using two pulse oximetres: Nonin and Philips. All physiological variables like haemoglobin, lactate, use of vasopressors and blood pressure were recorded. Bland Altman curves were constructed to determine bias and limits of agreement. Effect of physiological variables on bias and difference between performance characteristics of bias was determined using SPSS. Results Pulse oximetry overestimated arterial oxygen saturation (SaO2) by 1.44%. There was negative correlation between bias and SaO2 (r=-0.32) and positive correlation with lactate (r=0.16). The Philips pulse oximeter had significant higher bias and variability than Nonin pulse oximeter. (2.49±2.99 versus 0.46±1.68, mean difference = 1.98, 95% C.I. = 1.53 – 2.43, p-value <0.001). Conclusion Pulse oximetry overestimates SaO2. Bias tends to increase with rising lactate and hypoxia. There is heterogeneity in performance of various pulse oximetry devices in ICU. PMID:28764215

Comparative Evaluation of Accuracy of Pulse Oximeters and Factors Affecting Their Performance in a Tertiary Intensive Care Unit.

PubMed

Singh, Anupam Kumar; Sahi, Malvinder Singh; Mahawar, Bablesh; Rajpurohit, Sajjan

2017-06-01

Pulse oximetry is a widely used tool, unfortunately there is a paucity of data investigating its accuracy in Intensive Care Units (ICU) and if they are able to meet mandated FDA criteria as claimed by them in critically ill patients. To assess bias, precision and accuracy of pulse oximeters used in ICU and factors affecting them. A prospective cohort study, including 129 patients admitted to the ICU of a tertiary referral centre. Pulse oximetry and blood gas were done simultaneously. Pulse oximetry was done using two pulse oximetres: Nonin and Philips. All physiological variables like haemoglobin, lactate, use of vasopressors and blood pressure were recorded. Bland Altman curves were constructed to determine bias and limits of agreement. Effect of physiological variables on bias and difference between performance characteristics of bias was determined using SPSS. Pulse oximetry overestimated arterial oxygen saturation (SaO 2 ) by 1.44%. There was negative correlation between bias and SaO 2 (r=-0.32) and positive correlation with lactate (r=0.16). The Philips pulse oximeter had significant higher bias and variability than Nonin pulse oximeter. (2.49±2.99 versus 0.46±1.68, mean difference = 1.98, 95% C.I. = 1.53 - 2.43, p-value <0.001). Pulse oximetry overestimates SaO 2 . Bias tends to increase with rising lactate and hypoxia. There is heterogeneity in performance of various pulse oximetry devices in ICU.

Evolving paradigm of illnesses presented to medical Intensive Care Unit in body builders: Cases from tertiary care center.

PubMed

Garg, Sunil Kumar

2015-04-01

Bodybuilding is the use of progressive resistance exercise to control and develop one's musculature. With the rise in number of persons adopting this activity, there is evolving paradigm of illnesses presented to intensive care in this population subset. Strict adherence to details of bodybuilding and avoidance of unsupervised medications are essential to prevent untoward effects.

Evolving paradigm of illnesses presented to medical Intensive Care Unit in body builders: Cases from tertiary care center

PubMed Central

Garg, Sunil Kumar

2015-01-01

Bodybuilding is the use of progressive resistance exercise to control and develop one's musculature. With the rise in number of persons adopting this activity, there is evolving paradigm of illnesses presented to intensive care in this population subset. Strict adherence to details of bodybuilding and avoidance of unsupervised medications are essential to prevent untoward effects. PMID:25878431

Usability Evaluation at the Point-of-Care: A Method to Identify User Information Needs in CPOE Applications

PubMed Central

Washburn, Jeff; Fiol, Guilherme Del; Rocha, Roberto A.

2006-01-01

Point of care usability evaluation may help identify information needs that occur during the process of providing care. We describe the process of using usability-specific recording software to record Computerized Physician Order Entry (CPOE) ordering sessions on admitted adult and pediatric patients at two urban tertiary hospitals in the Intermountain Healthcare system of hospitals. PMID:17238756

Tertiary-amine-containing thermo- and pH-sensitive hydrophilic ABA triblock copolymers: effect of different tertiary amines on thermally induced sol-gel transitions.

PubMed

Henn, Daniel M; Wright, Roger A E; Woodcock, Jeremiah W; Hu, Bin; Zhao, Bin

2014-03-11

This Article reports on the synthesis of a series of well-defined, tertiary-amine-containing ABA triblock copolymers, composed of a poly(ethylene oxide) (PEO) central block and thermo- and pH-sensitive outer blocks, and the study of the effect of different tertiary amines on thermally induced sol-gel transition temperatures (T(sol-gel)) of their 10 wt % aqueous solutions. The doubly responsive ABA triblock copolymers were prepared from a difunctional PEO macroinitiator by atom transfer radical polymerization of methoxydi(ethylene glycol) methacrylate and ethoxydi(ethylene glycol) methacrylate at a feed molar ratio of 30:70 with ∼5 mol % of either N,N-diethylaminoethyl methacrylate (DEAEMA), N,N-diisopropylaminoethyl methacrylate, or N,N-di(n-butyl)aminoethyl methacrylate. The chain lengths of thermosensitive outer blocks and the molar contents of tertiary amines were very similar for all copolymers. Using rheological measurements, we determined the pH dependences of T(sol-gel) of 10 wt % aqueous solutions of these copolymers in a phosphate buffer. The T(sol-gel) versus pH curves of all polymers exhibited a sigmoidal shape. The T(sol-gel) increased with decreasing pH; the changes were small on both high and low pH sides. At a specific pH, the T(sol-gel) decreased with increasing the hydrophobicity of the tertiary amine, and upon decreasing pH the onset pH value for the T(sol-gel) to begin to increase noticeably was lower for the more hydrophobic tertiary amine-containing copolymer. In addition, we studied the effect of different tertiary amines on the release behavior of FITC-dextran from 10 wt % micellar gels in an acidic medium at 37 and 27 °C. The release profiles for three studied hydrogels at 37 °C were essentially the same, suggesting that the release was dominated by the diffusion of FITC-dextran. At 27 °C, the release was significantly faster for the DEAEMA-containing copolymer, indicating that both diffusion and gel dissolution contributed to the release at this temperature.

Parental Satisfaction with Pediatric Day-Care Surgery and its Determinants in a Tertiary Care Hospital

PubMed Central

Sam, Cenita James; Arunachalam, Pavai A.; Manivasagan, Sivamani; Surya, T.

2017-01-01

Objective: The objective is to assess the level of parental satisfaction of pediatric day-care surgery and its different determinants. Materials and Methods: This is a descriptive study performed in a tertiary care hospital in India among parents of pediatric day-care surgery patients from June 2013 to March 2015. The core questionnaire for the assessment of patient satisfaction for general day care (COPS-D) was used. Variables related to surgery, overall satisfaction, one open-ended question, and socio-demographic data were also collected. Calculated sample size was 121. Results: The mean and standard deviation of parental satisfaction were estimated in eight domains of day care (COPS-D) using Likert scale 1–5. Preadmission visit had a mean of 4.63 (0.52), day of surgery 4.65 (0.58), operating room 4.76 (0.51), nursing care 4.46 (0.79), medical care 4.89 (0.48), information 4.51 (0.68), autonomy 4.64 (0.56), and discharge 4.50 (0.72). In elder children, there was less satisfaction on the information and discharge domains. Overall satisfaction was good in 88% of patients and was less than satisfactory when they had significant pain. Conclusion: Perception of quality of pediatric day-care surgery was assessed with a questionnaire and was found to be good. Variables related to surgery such as pain may be included in the questionnaire for assessing satisfaction in the day-care surgery. PMID:28974875

Building a taxonomy of integrated palliative care initiatives: results from a focus group.

PubMed

Ewert, Benjamin; Hodiamont, Farina; van Wijngaarden, Jeroen; Payne, Sheila; Groot, Marieke; Hasselaar, Jeroen; Menten, Johann; Radbruch, Lukas

2016-03-01

Empirical evidence suggests that integrated palliative care (IPC) increases the quality of care for palliative patients and supports professional caregivers. Existing IPC initiatives in Europe vary in their design and are hardly comparable. InSuP-C, a European Union research project, aimed to build a taxonomy of IPC initiatives applicable across diseases, healthcare sectors and systems. The taxonomy of IPC initiatives was developed in cooperation with an international and multidisciplinary focus group of 18 experts. Subsequently, a consensus meeting of 10 experts revised a preliminary taxonomy and adopted the final classification system. Consisting of eight categories, with two to four items each, the taxonomy covers the process and structure of IPC initiatives. If two items in at least one category apply to an initiative, a minimum level of integration is assumed to have been reached. Categories range from the type of initiative (items: pathway, model or guideline) to patients' key contact (items: non-pc specialist, pc specialist, general practitioner). Experts recommended the inclusion of two new categories: level of care (items: primary, secondary or tertiary) indicating at which stage palliative care is integrated and primary focus of intervention describing IPC givers' different roles (items: treating function, advising/consulting or training) in the care process. Empirical studies are required to investigate how the taxonomy is used in practice and whether it covers the reality of patients in need of palliative care. The InSuP-C project will test this taxonomy empirically in selected initiatives using IPC. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

Ambulatory care pavilion takes its place out front by solving multiple needs.

PubMed

Saukaitis, C A

1994-09-01

In sum, this structure exemplifies the fact that high-tech tertiary care medical centers can be user-friendly to the ambulatory health care consumer by serving their routine needs conveniently and efficiently. Says Gerald Miller, president of Crozer-Chester: "The ambulatory care pavilion has enabled Crozer to successfully and efficiently merge physicians' offices with institutional-based services and inpatient services. We are pleased with how the pavilion positions our medical center for the next century.

Association between education and quality of diabetes care in Switzerland.

PubMed

Flatz, Aline; Casillas, Alejandra; Stringhini, Silvia; Zuercher, Emilie; Burnand, Bernard; Peytremann-Bridevaux, Isabelle

2015-01-01

Low socioeconomic status is associated with higher prevalence of diabetes, worse outcomes, and worse quality of care. We explored the relationship between education, as a measure of socioeconomic status, and quality of care in the Swiss context. Data were drawn from a population-based survey of 519 adults with diabetes during fall 2011 and summer 2012 in a canton of Switzerland. We assessed patients and diabetes characteristics. Eleven indicators of quality of care were considered (six of process and five of outcomes of care). After bivariate analyses, regression analyses adjusted for age, sex, and diabetic complications were performed to assess the relationship between education and quality of care. Of 11 quality-of-care indicators, three were significantly associated with education: funduscopy (patients with tertiary versus primary education were more likely to get the exam: odds ratio, 1.8; 95% confidence interval [CI], 1.004-3.3) and two indicators of health-related quality of life (patients with tertiary versus primary education reported better health-related quality of life: Audit of Diabetes-Dependent Quality of Life: β=0.6 [95% CI, 0.2-0.97]; SF-12 mean physical component summary score: β=3.6 [95% CI, 0.9-6.4]). Our results suggest the presence of educational inequalities in quality of diabetes care. These findings may help health professionals focus on individuals with increased needs to decrease health inequalities.

A novel primary-specialist care collaborative demonstration project to improve the access and health care of medically complex patients.

PubMed

Siu, Henry Yu-Hin; Steward, Nicole; Peter, Jessica; Cooke, Laurel; Arnold, Donald M; Price, David

2017-09-01

Objective Medically complex patients experience fragmented health care compounded by long wait times. The MedREACH program was developed to improve access and overall system experience for medically complex patients. Program description MedREACH is a novel primary-tertiary care collaborative demonstration program that features community nursing outreach, community specialist outreach, and a multi-specialty consultation clinic. Methods All 179 patients, referring primary care clinicians, and specialists involved were eligible to participate. Patient and clinician feedback were elicited by feedback surveys. Process measures were evaluated by participant retrospective chart reviews. Community nursing outreach patients completed the Goal Attainment Scale. Results Forty-eight patients and 22 clinicians consented to the feedback survey. About 75% of patients were seen within 2 weeks of referral. Patients spent an average of 3, 1.63, and 1.2 visits with the nursing outreach, multi-specialty clinic, and specialist outreach, respectively. Patients indicated a better medical experience, health enablement, and goals attainment. Family physicians felt more supported in the community management of medically complex patients and, overall, physicians felt MedREACH could improve collaborative care for medically complex patients. Qualitative analysis of clinician responses identified the need for increased mental health services. Discussion MedREACH demonstrates a patient-centered link between primary and tertiary care that could improve health care access and overall experience.

Hospital discharge summary scorecard: a quality improvement tool used in a tertiary hospital general medicine service.

PubMed

Singh, G; Harvey, R; Dyne, A; Said, A; Scott, I

2015-12-01

We assessed the impact of completion and feedback of discharge summary scorecards on the quality of discharge summaries written by interns in a general medicine service of a tertiary hospital. The scorecards significantly improved summary quality in the first three rotations of the intern year and could be readily adopted by other units as a quality improvement intervention for optimizing clinical handover to primary care providers. © 2015 Royal Australasian College of Physicians.

Cardiorespiratory dynamics measured from continuous ECG monitoring improves detection of deterioration in acute care patients: A retrospective cohort study

PubMed Central

Clark, Matthew T.; Calland, James Forrest; Enfield, Kyle B.; Voss, John D.; Lake, Douglas E.; Moorman, J. Randall

2017-01-01

Background Charted vital signs and laboratory results represent intermittent samples of a patient’s dynamic physiologic state and have been used to calculate early warning scores to identify patients at risk of clinical deterioration. We hypothesized that the addition of cardiorespiratory dynamics measured from continuous electrocardiography (ECG) monitoring to intermittently sampled data improves the predictive validity of models trained to detect clinical deterioration prior to intensive care unit (ICU) transfer or unanticipated death. Methods and findings We analyzed 63 patient-years of ECG data from 8,105 acute care patient admissions at a tertiary care academic medical center. We developed models to predict deterioration resulting in ICU transfer or unanticipated death within the next 24 hours using either vital signs, laboratory results, or cardiorespiratory dynamics from continuous ECG monitoring and also evaluated models using all available data sources. We calculated the predictive validity (C-statistic), the net reclassification improvement, and the probability of achieving the difference in likelihood ratio χ2 for the additional degrees of freedom. The primary outcome occurred 755 times in 586 admissions (7%). We analyzed 395 clinical deteriorations with continuous ECG data in the 24 hours prior to an event. Using only continuous ECG measures resulted in a C-statistic of 0.65, similar to models using only laboratory results and vital signs (0.63 and 0.69 respectively). Addition of continuous ECG measures to models using conventional measurements improved the C-statistic by 0.01 and 0.07; a model integrating all data sources had a C-statistic of 0.73 with categorical net reclassification improvement of 0.09 for a change of 1 decile in risk. The difference in likelihood ratio χ2 between integrated models with and without cardiorespiratory dynamics was 2158 (p value: <0.001). Conclusions Cardiorespiratory dynamics from continuous ECG monitoring detect clinical deterioration in acute care patients and improve performance of conventional models that use only laboratory results and vital signs. PMID:28771487

Cardiorespiratory dynamics measured from continuous ECG monitoring improves detection of deterioration in acute care patients: A retrospective cohort study.

PubMed

Moss, Travis J; Clark, Matthew T; Calland, James Forrest; Enfield, Kyle B; Voss, John D; Lake, Douglas E; Moorman, J Randall

2017-01-01

Charted vital signs and laboratory results represent intermittent samples of a patient's dynamic physiologic state and have been used to calculate early warning scores to identify patients at risk of clinical deterioration. We hypothesized that the addition of cardiorespiratory dynamics measured from continuous electrocardiography (ECG) monitoring to intermittently sampled data improves the predictive validity of models trained to detect clinical deterioration prior to intensive care unit (ICU) transfer or unanticipated death. We analyzed 63 patient-years of ECG data from 8,105 acute care patient admissions at a tertiary care academic medical center. We developed models to predict deterioration resulting in ICU transfer or unanticipated death within the next 24 hours using either vital signs, laboratory results, or cardiorespiratory dynamics from continuous ECG monitoring and also evaluated models using all available data sources. We calculated the predictive validity (C-statistic), the net reclassification improvement, and the probability of achieving the difference in likelihood ratio χ2 for the additional degrees of freedom. The primary outcome occurred 755 times in 586 admissions (7%). We analyzed 395 clinical deteriorations with continuous ECG data in the 24 hours prior to an event. Using only continuous ECG measures resulted in a C-statistic of 0.65, similar to models using only laboratory results and vital signs (0.63 and 0.69 respectively). Addition of continuous ECG measures to models using conventional measurements improved the C-statistic by 0.01 and 0.07; a model integrating all data sources had a C-statistic of 0.73 with categorical net reclassification improvement of 0.09 for a change of 1 decile in risk. The difference in likelihood ratio χ2 between integrated models with and without cardiorespiratory dynamics was 2158 (p value: <0.001). Cardiorespiratory dynamics from continuous ECG monitoring detect clinical deterioration in acute care patients and improve performance of conventional models that use only laboratory results and vital signs.

Reenacted Case Scenarios for Undergraduate Healthcare Students to Illustrate Person-Centered Care in Dementia

ERIC Educational Resources Information Center

Bradley, Sandra L.; De Bellis, Anita; Guerin, Pauline; Walters, Bonnie; Wotherspoon, Alison; Cecchin, Maggie; Paterson, Jan

2010-01-01

Healthcare practitioners have suggested that interpreting person-centered care for people who have dementia to undergraduate students requires guidance in practical application. This article describes the production of a written and digital interdisciplinary educational resource for tertiary students. It uses real-life case scenarios provided by…

Challenges in reusing transactional data for daily documentation in neonatal intensive care.

PubMed

Kim, G R; Lawson, E E; Lehmann, C U

2008-11-06

The reuse of transactional data for clinical documentation requires navigation of computational, institutional and adaptive barriers. We describe organizational and technical issues in developing and deploying a daily progress note tool in a tertiary neonatal intensive care unit that reuses and aggregates data from a commercial integrated clinical information system.

Publications - GMC 53C | Alaska Division of Geological & Geophysical

Science.gov Websites

Alaska's Mineral Industry Reports AKGeology.info Rare Earth Elements WebGeochem Engineering Geology Alaska Paleozoic through Tertiary sandstones, North Slope, Alaska Authors: Alaska Research Associates Publication through Tertiary sandstones, North Slope, Alaska: Alaska Division of Geological & Geophysical Surveys

Treatment of Pancreatic and Periampullary Cancers at a Community Hospital: Successful Application of Tertiary Care Treatment Standards

PubMed Central

Moesinger, Robert C.; Davis, Jan W.; Hill, Britani; Johnston, W. Cory; Gray, Carl; Johnson, Harold; Ingersoll, Leslye; Whipple, Gary; Reilly, Mark; Harris, Robert; Hansen, Vincent

2011-01-01

Background. The treatment of pancreatic cancer and other periampullary neoplasms is complex and challenging. Major high-volume cancer centers can provide excellent multidisciplinary care of these patients but almost two-thirds of pancreatic cancer patients are treated at low volume centers. There is very little published data from low volume community cancer programs in regards to the treatment of periampullary cancer. In this study, a review of comprehensive periampullary cancer care at two low volume hospitals with comparison to national standards is presented. Methods. This is a retrospective review of 70 consecutive patients with periampullary neoplasms who underwent surgery over a 5-year period (2006–2010) at two community hospitals. Results. There were 51 successful resections of 70 explorations (73%) including 34 Whipple procedures. Mortality rate was 2.9%. Comparison of these patients to national standards was made in terms of operative mortality, resectability rate, administration of adjuvant therapy, clinical trial participation and overall survival. The results in these patients were comparable to national standards. Conclusions. With adequate commitment of resources and experienced surgical and oncologic practitioners, community cancer centers can meet national tertiary care standards in terms of pancreatic and periampullary cancer care. PMID:22312532

Intermittent Demand Forecasting in a Tertiary Pediatric Intensive Care Unit.

PubMed

Cheng, Chen-Yang; Chiang, Kuo-Liang; Chen, Meng-Yin

2016-10-01

Forecasts of the demand for medical supplies both directly and indirectly affect the operating costs and the quality of the care provided by health care institutions. Specifically, overestimating demand induces an inventory surplus, whereas underestimating demand possibly compromises patient safety. Uncertainty in forecasting the consumption of medical supplies generates intermittent demand events. The intermittent demand patterns for medical supplies are generally classified as lumpy, erratic, smooth, and slow-moving demand. This study was conducted with the purpose of advancing a tertiary pediatric intensive care unit's efforts to achieve a high level of accuracy in its forecasting of the demand for medical supplies. On this point, several demand forecasting methods were compared in terms of the forecast accuracy of each. The results confirm that applying Croston's method combined with a single exponential smoothing method yields the most accurate results for forecasting lumpy, erratic, and slow-moving demand, whereas the Simple Moving Average (SMA) method is the most suitable for forecasting smooth demand. In addition, when the classification of demand consumption patterns were combined with the demand forecasting models, the forecasting errors were minimized, indicating that this classification framework can play a role in improving patient safety and reducing inventory management costs in health care institutions.

Effect of Intensive Education and Training of Nurses on Ventilator-associated Pneumonia and Central Line-associated Bloodstream Infection Incidence in Intensive Care Unit at a Tertiary Care Center in North India.

PubMed

Sahni, Neeru; Biswal, Manisha; Gandhi, Komal; Kaur, Kulbeer; Saini, Vikas; Yaddanapudi, Lakshminarayana N

2017-11-01

The aim was to analyze the impact of education and training of nurses on the incidence of ventilator-associated pneumonia (VAP) and central line-associated bloodstream infection (CLABSI). A prospective observational study at a tertiary care hospital included adult patients with Intensive Care Unit stay >48 h. The study was done in three phases: in Phase 1, baseline VAP and CLABSI incidence was calculated; in Phase 2, education and training of nurses; and in Phase 3, data were recollected for the incidence of VAP and CLABSI. The baseline incidence of VAP in Phase 1 was 28.86/1000 ventilator days and that of CLABSI was 7.89/1000 central-line days. In Phase 3, the incidence of VAP increased to 35.06 and that of CLABSI decreased significantly, 1.73. Intensive education and training sessions with feedback from nurses over a period of 6 months led to significant reduction in the incidence of CLABSI; however, the incidence of VAP increased.

Building the Nonuniversity, Tertiary Care Center Hepatobiliary and Pancreatic Surgery Practice: Structural and Financial Considerations.

PubMed

Baker, Erin H; Siddiqui, Imran; Vrochides, Dionisios; Iannitti, David A; Martinie, John B; Rorabaugh, Lauren; Jeyarajah, D Rohan; Swan, Ryan Z

2016-12-01

Early in their careers, many new surgeons lack the background and experience to understand essential components needed to build a surgical practice. Surgical resident education is often devoid of specific instruction on the business of medicine and practice management. In particular, hepatobiliary and pancreatic (HPB) surgeons require many key components to build a successful practice secondary to significant interdisciplinary coordination and a scope of complex surgery, which spans challenging benign and malignant disease processes. In the following, we describe the required clinical and financial components for developing a successful HPB surgery practice in the nonuniversity tertiary care center. We discuss significant financial considerations for understanding community need and hospital investment, contract establishment, billing, and coding. We summarize the structural elements and key personnel necessary for establishing an effectual HPB surgical team. This article provides useful, essential information for a new HPB surgeon looking to establish a surgical practice. It also provides insight for health-care administrators as to the value an HPB surgeon can bring to a hospital or health-care system.

Referral Patterns of Emergent Pediatric Hand Injury Transfers to a Tertiary Care Center.

PubMed

Gornitzky, Alex L; Milby, Andrew H; Gunderson, Melissa A; Chang, Benjamin; Carrigan, Robert B

2016-01-01

Several studies have identified the inappropriate use of emergent interfacility transfer as an opportunity to improve health care use. The authors sought to identify common characteristics among children who were transferred from a community hospital to a pediatric tertiary care center for definitive treatment of hand/wrist injuries. All patients undergoing emergent transfer to a pediatric Level I trauma center and academic tertiary referral center for evaluation and management of injuries to the hand/wrist during the 2-year study period were retrospectively identified. Demographic and transfer data were abstracted from the medical record. Referring hospitals were subcategorized by the presence or absence of hand surgical emergency department coverage and the capability to admit/operate on children. Overall, 169 patients were identified who transferred to the authors' institution for hand injuries. There were no differences in the day or time of transfer. Of those transferred, 59 (35%) were admitted for definitive care, of whom 51 (86%) required a surgical intervention within 24 hours. Of the remaining 110 (65%) patients discharged from the emergency department, 27 (25%) underwent elective surgical intervention within 2 weeks. There were a greater number of transfers from institutions without the ability to admit children, regardless of hand surgical emergency department coverage status. Understanding pediatric referral patterns may improve use of emergency department facilities because most patients who were transferred were discharged the same day. Educational outreach and improved interfacility communication may result in enhanced resource use for evaluation and management of pediatric hand injuries. Copyright 2016, SLACK Incorporated.

Clinical presentation and treatment outcome of molar pregnancy: Ten years experience at a Tertiary Care Hospital in Dammam, Saudi Arabia.

PubMed

Al-Talib, Ayman A

2016-01-01

To study the clinical presentation and treatment outcome of molar pregnancy at a Tertiary Care Hospital in Dammam, Saudi Arabia. Reviewed medical records of all molar pregnancy cases among all the deliveries at a tertiary care hospital in Dammam from 2005 to 2014, after approval by institutional ethical review committee. Data abstracted included patient's age, parity, presenting symptoms, gestational age at diagnosis, uterine size, ultrasonographic findings, BhCG level at the time of diagnosis and at follow-up after evacuation, and blood loss during evacuation. Data was entered and analyzed using Excel; frequency distribution for categorical variables and descriptive statistics for continuous variables were computed. Of a total of 25,000 deliveries in ten years, 22 cases of complete molar pregnancy were encountered: 0.9 cases of molar pregnancy per 1000 pregnancies. Majority of patients (63.7%) were older than 35 years, and were nulliparous (45.5%). The commonest symptom was vaginal bleeding (86.4%) followed by hyperemesis gravidarum (41.0%); Hyperthyroidism was seen in 1 patient (4.5%). Ovarian enlargement by theca-lutin cyst was seen in 3 patients (13.6%). The majority of patients (63.6%) had normal BhCG within 9 weeks (63 days) after suction curettage. The majority of the cases followed a benign course. Aged older than 35 years seems a risk factor and vaginal bleeding is the commonest presenting symptom. Early booking of pregnant women to antenatal care clinics and routine first trimester ultrasound made diagnosis easier and earlier before complications appear.

Relationship between prenatal care and maternal complications in women with preeclampsia: implications for continuity and discontinuity of prenatal care.

PubMed

Liu, Ching-Ming; Chang, Shuenn-Dyh; Cheng, Po-Jen

2012-12-01

Prenatal care is associated with better pregnancy outcome and may be a patient safety issue. However, no studies have investigated the types and quality of prenatal care provided in northern Taiwan. This retrospective study assessed whether the hospital-based continuous prenatal care model at tertiary hospitals reduced the risk of perinatal morbidity and maternal complications in pre-eclampsia patients. Of 385 pre-eclampsia patients recruited from among 23,665 deliveries, 198 were classified as patients with little or no prenatal care who received traditional, individualized, and physician-based discontinuous prenatal care (community-based model), and 187 were classified as control patients who received tertiary hospital-based continuous prenatal care. The effects on perinatal outcome were significantly different between the two groups. The cases in the hospital-based care group were less likely to be associated with preterm delivery, low birth weight, very low birth weight, and intrauterine growth restriction. After adjustment of confounding factors, the factors associated with pregnant women who received little or no prenatal care by individualized physician groups were diastolic blood pressure ≥ 105 mmHg, serum aspartate transaminase level ≥ 150 IU/L, and low-birth-weight deliveries. This study also demonstrated the dose-response effect of inadequate, intermediate, adequate, and intensive prenatal care status on fetal birth weight and gestational periods (weeks to delivery). The types of prenatal care may be associated with different pregnancy outcomes and neonatal morbidity. Factors associated with inadequate prenatal care may be predictors of pregnancy outcome in pregnant women with pre-eclampsia. Copyright © 2012. Published by Elsevier B.V.

Interactional aspects of care during hospitalization: perspectives of family caregivers of psychiatrically ill in a tertiary care setting in India.

PubMed

Dinakaran, P; Mehrotra, Seema; Bharath, Srikala

2014-12-01

There are very few studies on user-perspectives about mental health care services that explore perspectives of family caregivers in India. An exploratory study was undertaken to understand the perceived importance of various aspects of interactions with mental health service providers during hospitalization, from the perspectives of family caregivers. In addition, it also aimed at documenting their actual experience of interactional aspects of care during the hospitalization of their relatives. The study was conducted on fifty family caregivers of patients with varied psychiatric diagnoses hospitalized in a tertiary psychiatric care setting in South India. Measures of Interactional aspects of care were developed to assess perceived importance of six different interactional domains of care and the actual experience of care in these domains. Provision of informational inputs and addressing of concerns raised emerged as the domains of care given highest importance. The item pertaining to 'sharing with the caregiver about different alternatives for treatment' received negative ratings in terms of actual experience by maximum number of participants (18%). Significant differences on perceived importance of four domains of interactional aspects of care (dignity, confidentiality and fairness, addressing concerns raised, informational inputs and prompt attention and consistent care) emerged between caregiver subgroups based on educational level of the caregiver, socio-economic status, hospitalization history and broad diagnostic categories. In addition, the care givers of patients with psychoses assigned significantly more positive ratings on actual experience for all the domains of interactional aspects of care. The findings have implications for further research and practice. Copyright © 2014 Elsevier B.V. All rights reserved.

Adolescent Presents With Altered Mental Status and Elevated Anion Gap After Suicide Attempt by Ethylene Glycol Ingestion.

PubMed

Schoen, Jessica C; Cain, Meghan R; Robinson, Jeffrey A; Schiltz, Brenda M; Mannenbach, Mark S

2016-10-01

We report the case of a 16-year-old healthy adolescent male who presented to the local emergency department with altered mental status. En route to a tertiary care facility, he began to decompensate and was found to be markedly acidotic. Further investigation revealed an elevated anion gap, and physical examination showed only abdominal pain and decreased level of consciousness. A broad differential diagnosis was considered at the time of the patient's presentation at the tertiary care center including ingestion of a volatile alcohol, sepsis, and an abdominal catastrophe. Although fomepizole and emergent dialysis were being initiated, laboratory tests confirmed ethylene glycol poisoning. This case demonstrates the importance of early recognition of potential ingestions in patients with altered mental status and supportive laboratory findings.

Getting the first birth right: A retrospective study of outcomes for low-risk primiparous women receiving standard care versus midwifery model of care in the same tertiary hospital.

PubMed

Wong, Nola; Browne, Jenny; Ferguson, Sally; Taylor, Jan; Davis, Deborah

2015-12-01

There is national and international concern for increasing obstetric intervention in childbirth and rising caesarean section rates. Repeat caesarean section is a major contributing factor, making primiparous women an important target for strategies to reduce unnecessary intervention and surgeries in childbirth. The aim was to compare outcomes for a cohort of low risk primiparous women who accessed a midwifery continuity model of care with those who received standard public care in the same tertiary hospital. A retrospective comparative cohort study design was implemented drawing on data from two databases held by a tertiary hospital for the period 1 January 2010 to 31 December 2011. Categorical data were analysed using the chi-squared statistic and Fisher's exact test. Continuous data were analysed using Student's t-test. Comparisons are presented using unadjusted and adjusted odds ratios, with 95% confidence intervals (CIs) and p-values with significance set at 0.05. Data for 426 women experiencing continuity of midwifery care and 1220 experiencing standard public care were compared. The study found increased rates of normal vaginal birth (57.7% vs. 48.9% p=0.002) and spontaneous vaginal birth (38% vs. 22.4% p=<0.001) and decreased rates of instrumental birth (23.5% vs. 28.5% p=0.050) and caesarean sections (18.8% vs. 22.5% p=0.115) in the midwifery continuity cohort. There were also fewer interventions in this group. No differences were found in neonatal outcomes. Strategies for reducing caesarean section rates and interventions in childbirth should focus on primiparous women as a priority. This study demonstrates the effectiveness of continuity midwifery models, suggesting that this is an important strategy for improving outcomes in this population. Copyright © 2015 Australian College of Midwives. Published by Elsevier Ltd. All rights reserved.

Extended-Spectrum β-lactam Resistance in the Enteric Flora of Patients at a Tertiary Care Medical Centre.

PubMed

Landers, T F; Mollenkopf, D F; Faubel, R L; Dent, A; Pancholi, P; Daniels, J B; Wittum, T E

2017-03-01

The dissemination of Enterobacteriaceae expressing resistance to extended-spectrum cephalosporins, which are therapeutically used in both human and veterinary medicine, is of critical concern. The normal commensal flora of food animals may serve as an important reservoir for the zoonotic food-borne transmission of Enterobacteriaceae harbouring β-lactam resistance. We hypothesized that the predominant AmpC and ESBL genes reported in US livestock and fresh retail meat products, bla CMY -2 and bla CTX -M , would also be predominant in human enteric flora. We recovered enteric flora from a convenience sample of patients included in a large tertiary medical centre's Clostridium difficile surveillance programme to screen for and estimate the frequency of carriage of AmpC and ESBL resistance genes. In- and outpatient diarrhoeic submissions (n = 692) received for C. difficile testing at the medical centre's clinical diagnostic laboratory from July to December, 2013, were included. Aliquoted to a transport swab, each submission was inoculated to MacConkey broth with cefotaxime, incubated at 37°C and then inoculated to MacConkey agars supplemented with cefoxitin and cefepime to select for the AmpC and ESBL phenotypes, with bla CMY and bla CTX -M genotypes confirmed by PCR and sequencing. From the 692 diarrhoeic submissions, our selective culture yielded 184 isolates (26.6%) with reduced susceptibility to cefotaxime. Of these, 46 (6.7%) samples harboured commensal isolates carrying the AmpC bla CMY . Another 21 (3.0%) samples produced isolates harbouring the ESBL bla CTX -M : 19 carrying CTX-M-15 and 2 with CTX-M-27. Our results indicate that β-lactam resistance genes likely acquired through zoonotic food-borne transmission are present in the enteric flora of this hospital-associated population at lower levels than reported in livestock and fresh food products. © 2016 Blackwell Verlag GmbH.

Cryptosporidium and Giardia removal by secondary and tertiary wastewater treatment.

PubMed

Taran-Benshoshan, Marina; Ofer, Naomi; Dalit, Vaizel-Ohayon; Aharoni, Avi; Revhun, Menahem; Nitzan, Yeshayahu; Nasser, Abidelfatah M

2015-01-01

Wastewater disposal may be a source of environmental contamination by Cryptosporidium and Giardia. This study was conducted to evaluate the prevalence of Cryptosporidium oocysts and Giardia cysts in raw and treated wastewater effluents. A prevalence of 100% was demonstrated for Giardia cysts in raw wastewater, at a concentration range of 10 to 12,225 cysts L(-1), whereas the concentration of Cryptosporidium oocysts in raw wastewater was 4 to 125 oocysts L(-1). The removal of Giardia cysts by secondary and tertiary treatment processes was greater than those observed for Cryptosporidium oocysts and turbidity. Cryptosporidium and Giardia were present in 68.5% and 76% of the tertiary effluent samples, respectively, at an average concentration of 0.93 cysts L(-1) and 9.94 oocysts L(-1). A higher detection limit of Cryptosporidium oocysts in wastewater was observed for nested PCR as compared to immune fluorescent assay (IFA). C. hominis was found to be the dominant genotype in wastewater effluents followed by C. parvum and C. andersoni or C. muris. Giardia was more prevalent than Cryptosporidium in the studied community and treatment processes were more efficient for the removal of Giardia than Cryptosporidium. Zoonotic genotypes of Cryptosporidium were also present in the human community. To assess the public health significance of Cryptosporidium oocysts present in tertiary effluent, viability (infectivity) needs to be assessed.

Identifying areas of need relative to liver disease: geographic clustering within a health service district.

PubMed

El-Atem, Nathan; Irvine, Katharine M; Valery, Patricia C; Wojcik, Kyle; Horsfall, Leigh; Johnson, Tracey; Janda, Monika; McPhail, Steven M; Powell, Elizabeth E

2017-08-01

Background Many people with chronic liver disease (CLD) are not detected until they present to hospital with advanced disease, when opportunities for intervention are reduced and morbidity is high. In order to build capacity and liver expertise in the community, it is important to focus liver healthcare resources in high-prevalence disease areas and specific populations with an identified need. The aim of the present study was to examine the geographic location of people seen in a tertiary hospital hepatology clinic, as well as ethnic and sociodemographic characteristics of these geographic areas. Methods The geographic locations of hepatology out-patients were identified via the out-patient scheduling database and grouped into statistical area (SA) regions for demographic analysis using data compiled by the Australian Bureau of Statistics. Results During the 3-month study period, 943 individuals from 71 SA Level 3 regions attended clinic. Nine SA Level 3 regions accounted for 55% of the entire patient cohort. Geographic clustering was seen especially for people living with chronic hepatitis B virus. There was a wide spectrum of socioeconomic advantage and disadvantage in areas with high liver disease prevalence. Conclusions The geographic area from which people living with CLD travel to access liver health care is extensive. However, the greatest demand for tertiary liver disease speciality care is clustered within specific geographic areas. Outreach programs targeted to these areas may enhance liver disease-specific health service resourcing. What is known about the topic? The demand for tertiary hospital clinical services in CLD is rising. However, there is limited knowledge about the geographic areas from which people living with CLD travel to access liver services, or the ethnic, socioeconomic and education characteristics of these areas. What does this paper add? The present study demonstrates that a substantial proportion of people living with CLD and accessing tertiary hospital liver services are clustered within specific geographic areas. The most striking geographic clustering was seen for people living with chronic hepatitis B, in regions with a relatively high proportion of people born in Vietnam and China. In addition to ethnicity, the data show an apparent ecological association between liver disease and both socioeconomic and educational and/or occupational disadvantage. What are the implications for practitioners? Identifying where demand for clinical services arises is an important step for service planning and preparing for potential outreach programs to optimise community-based care. It is likely that outreach programs to engage and enhance primary care services in geographic areas from which the greatest demand for tertiary liver disease speciality care arises would yield greater relative return on investment than non-targeted outreach programs.

Employee designation and health care worker support of an influenza vaccine mandate at a large pediatric tertiary care hospital.

PubMed

Feemster, Kristen A; Prasad, Priya; Smith, Michael J; Feudtner, Chris; Caplan, Arthur; Offit, Paul; Coffin, Susan E

2011-02-17

Determine predictors of support of a mandatory seasonal influenza vaccine program among health care workers (HCWs). Cross-sectional anonymous survey of 2443 (out of 8093) randomly selected clinical and non-clinical HCWs at a large pediatric network after implementation of a mandatory vaccination program in 2009-10. 1388 HCWs (58.2%) completed the survey and 75.2% of respondents reported agreeing with the new mandatory policy. Most respondents (72%) believed that the policy was coercive but >90% agreed that the policy was important for protecting patients and staff and was part of professional ethical responsibility. When we adjusted for attitudes and beliefs regarding influenza and the mandate, there was no significant difference between clinical and nonclinical staff in their support of the mandate (OR 1.08, 95% C.I. 0.94, 1.26). Attitudes and beliefs regarding influenza and the mandate may transcend professional role. Targeted outreach activities can capitalize on beliefs regarding patient protection and ethical responsibility. Copyright © 2011 Elsevier Ltd. All rights reserved.

Pediatric Admissions After Dental Care Under General Anesthesia: A Retrospective Study at a Tertiary Care Center.

PubMed

Lucy, Anna L; Gandhi, Roopa P; Gross, Lilyana; McNair, Bryan

2017-05-15

The purpose of this study was to identify factors associated with planned and unplanned pediatric hospital admissions following dental treatment under general anesthesia (DGA) in a tertiary care center. Dental and medical records of 100 subjects one to 20 years of age, with a known history of admission after DGA, were reviewed retrospectively for patient-, procedure-, and anesthesia-related factors as well as adverse events following DGA. During the review period (December 3, 2011 to June 30, 2015), 10,371 subjects underwent DGA, of which 100 subjects (less than one percent) required admission. A significant association was found between postoperative (PO) recovery time and unplanned admissions following DGA (P<0.001). Adverse post-operative events significantly associated with unplanned admissions included emesis (P=0.01) and hypoxia (P<0.001). Patients who were classified as having American Anesthesiology Association (ASA) III status were more frequently admitted following DGA. Adverse events such as emesis and hypoxia were significantly associated with patients with an unplanned admission.

Drug poisoning in the community among children: a nine years' experience from a tertiary care center in south India.

PubMed

Winston A, Blessed; Das Adhikari, Debasis; Das, Saibal; Vazhudhi, Kaysina; Kumar, Aniket; Shanthi Fx, Margaret; Agarwal, Indira

2017-02-01

This study was performed to determine the incidence, demographic distribution, types and outcomes across various drug poisonings among children from south India. This retrospective study included children less than 16 years who presented to the Pediatric Emergency Department with drug poisoning from the 1st of October 2004 to the 30th of September 2013. Out of the total 997 poisoning cases, 366 (36.71%) were contributed by drugs; mainly antiepileptics, central nervous system depressants, psychotropics, analgesic-antipyretics and natural drugs. Males and children of < 5 years were mostly affected. Although many children developed complications and required intensive care unit admissions, the total mortality rate was less than 1%. The incidence of drug poisoning showed a decreasing trend over the last 4 years. This study for the first time gives an elaborative insight into pediatric drug poisoning over a nine-year period from a Pediatric Emergency Department tertiary care center in south India.

Ponseti treatment in the management of clubfoot deformity - a continuing role for paediatric orthopaedic services in secondary care centres.

PubMed

Docker, Charles E J; Lewthwaite, Simon; Kiely, Nigel T

2007-07-01

The Ponseti technique is a well-proven way of managing paediatric clubfoot deformity. We describe a management set-up which spreads the care between secondary and tertiary care with no loss of quality. In our audit of the first 2 years of Ponseti casting in the treatment of idiopathic congenital talipes equinovarus (CTEV, clubfoot) deformity, we identified 77 feet having been treated in 50 patients. Forty-nine feet were treated primarily in Oswestry, a tertiary referral centre for paediatric orthopaedic conditions, and 13 feet were treated in conjunction with the physiotherapy department at one of the region's district general hospitals (Leighton Hospital, Crewe, Cheshire). Similar good results and low requirement for surgical interventions other than Achilles tenotomy, which forms part of the Ponseti regimen, were found in both cohorts. This 'hub-and-spoke' approach would appear to be efficient in terms of resource utilisation. Additional benefits for patients and their carers include ease of access to services and reduced financial and transport burdens.

Delays in diagnosis and treatment of extrapulmonary tuberculosis in Guatemala.

PubMed

Shah, Pooja Ajay; Coj, Merida; Rohloff, Peter

2017-10-09

A 23-year-old indigenous Guatemalan man presented in 2016 to our clinic in Sololá, Guatemala, with 10 months of recurrent neck swelling, fevers, night sweats and weight loss. Previously, he had sought care in three different medical settings, including a private physician-run clinic, a tertiary private cancer treatment centre and, finally, a rural government health post. With assistance from our institution's accompaniment staff, the patient was admitted to a public tertiary care hospital for work-up. Rifampin-susceptible tuberculosis was diagnosed, and appropriate treatment was begun. The case illustrates how low tuberculosis recognition among community health workers and health system segmentation creates obstacles to appropriate care, especially for patients with limited means. As a result, significant diagnostic and treatment delays can occur, increasing the public health burden of tuberculosis. © BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Prevalence, virulence factors and antifungal susceptibility of Candida spp. isolated from bloodstream infections in a tertiary care hospital in Brazil.

PubMed

Canela, Heliara Maria Spina; Cardoso, Bárbara; Vitali, Lucia Helena; Coelho, Harnoldo Colares; Martinez, Roberto; Ferreira, Márcia Eliana da Silva

2018-01-01

Candida spp. are responsible for 80% of all systemic fungal infections and are associated with high mortality rates. This study characterised 79 bloodstream isolates of C. albicans, C. glabrata, C. orthopsilosis, C. parapsilosis and C. tropicalis from patients in a Brazilian hospital. The susceptibility to amphotericin B, caspofungin, fluconazole and voriconazole was determined; virulence factor production was assessed based on haemolysin, phospholipase and proteinase activities, and the patients' clinical characteristics were analysed. C. albicans was the predominant species (44%), followed by C. glabrata (19%), C. tropicalis (19%), C. parapsilosis (14%) and C. orthopsilosis (4%). The candidemia incidence was 1.52 per 1000 admissions, and the crude mortality rate was 52%. One C. albicans isolate was resistant to fluconazole and voriconazole. Moreover, 20.2%, 2.5% and 3.8% of the isolates exhibited dose-dependent susceptibility to fluconazole, voriconazole and caspofungin, respectively. In conclusion, although the C. glabrata incidence was higher than that usually described in Brazil, its increase was previously observed in studies conducted worldwide. Furthermore, the azole resistance of the C. albicans isolate could be due to previous exposure to these antifungals. These results highlight the importance of epidemiological studies and will facilitate an improved understanding of candidemia in the studied hospital. © 2017 Blackwell Verlag GmbH.

Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project

PubMed Central

Centofanti, J; Swinton, M; Dionne, J; Barefah, A; Boyle, A; Woods, A; Shears, M; Heels-Ansdell, D; Cook, D

2016-01-01

Objective The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project. Design We enrolled dying patients, their families and 1–3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach. Setting 21-bed medical surgical ICU in a tertiary care, university-affiliated hospital. Results 33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1–3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection. Conclusions For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings. PMID:27033962

Barriers to home-based exercise program adherence with chronic low back pain: Patient expectations regarding new technologies.

PubMed

Palazzo, Clémence; Klinger, Evelyne; Dorner, Véronique; Kadri, Abdelmajid; Thierry, Olivier; Boumenir, Yasmine; Martin, William; Poiraudeau, Serge; Ville, Isabelle

2016-04-01

To assess views of patients with chronic low back pain (cLBP) concerning barriers to home-based exercise program adherence and to record expectations regarding new technologies. Qualitative study based on semi-structured interviews. A heterogeneous sample of 29 patients who performed a home-based exercise program for cLBP learned during supervised physiotherapy sessions in a tertiary care hospital. Patients were interviewed at home by the same trained interviewer. Interviews combined a funnel-shaped structure and an itinerary method. Barriers to adherence related to the exercise program (number, effectiveness, complexity and burden of exercises), the healthcare journey (breakdown between supervised sessions and home exercise, lack of follow-up and difficulties in contacting care providers), patient representations (illness and exercise perception, despondency, depression and lack of motivation), and the environment (attitudes of others, difficulties in planning exercise practice). Adherence could be enhanced by increasing the attractiveness of exercise programs, improving patient performance (following a model or providing feedback), and the feeling of being supported by care providers and other patients. Regarding new technologies, relatively younger patients favored visual and dynamic support that provided an enjoyable and challenging environment and feedback on their performance. Relatively older patients favored the possibility of being guided when doing exercises. Whatever the tool proposed, patients expected its use to be learned during a supervised session and performance regularly checked by care providers; they expected adherence to be discussed with care providers. For patients with cLBP, adherence to home-based exercise programs could be facilitated by increasing the attractiveness of the programs, improving patient performance and favoring a feeling of being supported. New technologies meet these challenges and seem attractive to patients but are not a substitute for the human relationship between patients and care providers. Copyright © 2016 Elsevier Masson SAS. All rights reserved.

Intensity of interprofessional collaboration among intensive care nurses at a tertiary hospital.

PubMed

Serrano-Gemes, G; Rich-Ruiz, M

To measure the intensity of interprofessional collaboration (IPC) in nurses of an intensive care unit (ICU) at a tertiary hospital, to check differences between the dimensions of the Intensity of Interprofessional Collaboration Questionnaire, and to identify the influence of personal variables. A cross-sectional descriptive study was conducted with 63 intensive care nurses selected by simple random sampling. Explanatory variables: age, sex, years of experience in nursing, years of experience in critical care, workday type and work shift type; variable of outcome: IPC. The IPC was measured by: Intensity of Interprofessional Collaboration Questionnaire. Descriptive and bivariate statistical analysis (IPC and its dimensions with explanatory variables). 73.8% were women, with a mean age of 46.54 (±6.076) years. The average years experience in nursing and critical care was 23.03 (±6.24) and 14.25 (±8.532), respectively. 77% had a full time and 95.1% had a rotating shift. 62.3% obtained average IPC values. Statistically significant differences were found (P<.05) between IPC (overall score) and overall assessment with years of experience in critical care. This study shows average levels of IPC; the nurses with less experience in critical care obtained higher IPC and overall assessment scores. Copyright © 2016 Sociedad Española de Enfermería Intensiva y Unidades Coronarias (SEEIUC). Publicado por Elsevier España, S.L.U. All rights reserved.

Hospitalist time usage and cyclicality: opportunities to improve efficiency.

PubMed

Kim, Christopher S; Lovejoy, William; Paulsen, Michael; Chang, Robert; Flanders, Scott A

2010-01-01

Academic medical centers (AMCs) have a constrained resident work force. Many AMCs have increased the use of nonresident service hospitalists to manage continued growth in clinical volume. To optimize their time in the hospital, it is important to understand hospitalists' work flow. We performed a time-motion study of hospitalists carrying the admission pager throughout the 3 types of shifts we have at our hospital (day shift, swing shift, and night shift). Tertiary academic medical center in the Midwest. Hospitalists spend about 15% of their time on direct patient care, and two-thirds of their time on indirect patient care. Of the indirect activities, communication and documentation dominate. Travel demands make up over 7% of a hospitalists' time. There are spikes in indirect patient care, followed closely by spikes in direct patient care, at shift changes. At our AMC, indirect patient care activities accounted for the majority of the admitting hospitalists' time spent in the hospital, with documentation and communication dominating this time. Travel takes a significant fraction of hospitalists' time. There is also a cyclical nature to activities performed throughout the day, which can cause patient delays and impose variability on support services. There is a need for both service-specific and systemic improvements for AMCs to efficiently manage further growth in their inpatient volume. (c) 2010 Society of Hospital Medicine.

The impact of stillbirth on bereaved parents: A qualitative study.

PubMed

Nuzum, Daniel; Meaney, Sarah; O'Donoghue, Keelin

2018-01-01

To explore the lived experiences and personal impact of stillbirth on bereaved parents. Semi-structured in-depth interviews analysed by Interpretative Phenomenological Analysis (IPA) on a purposive sample of parents of twelve babies born following fetal death at a tertiary university maternity hospital in Ireland with a birth rate of c8,500 per annum and a stillbirth rate of 4.6/1000. Stillbirth had a profound and enduring impact on bereaved parents. Four superordinate themes relating to the human impact of stillbirth emerged from the data: maintaining hope, importance of the personhood of the baby, protective care and relationships (personal and professional). Bereaved parents recalled in vivid detail their experiences of care following diagnosis of stillbirth and their subsequent care. The time between diagnosis of a life-limiting anomaly or stillbirth and delivery is highlighted as important for parents as they find meaning in their loss. The impact of stillbirth on bereaved parents is immense and how parents are cared for is recalled in precise detail as they revisit their experience. Building on existing literature, these data bring to light the depth of personal experience and impact of stillbirth for parents and provides medical professionals with valuable insights to inform their care of bereaved parents and the importance of clear and sensitive communication.

A needs-based workforce model to deliver tertiary-level community mental health care for distressed infants, children, and adolescents in South Australia: a mixed-methods study.

PubMed

Segal, Leonie; Guy, Sophie; Leach, Matthew; Groves, Aaron; Turnbull, Catherine; Furber, Gareth

2018-06-01

High-quality mental health services for infants, children, adolescents, and their families can improve outcomes for children exposed to early trauma. We sought to estimate the workforce needed to deliver tertiary-level community mental health care to all infants, children, adolescents, and their families in need using a generalisable model, applied to South Australia (SA). Workforce estimates were determined using a workforce planning model. Clinical need was established using data from the Longitudinal Study of Australian Children and the Young Minds Matter survey. Care requirements were derived by workshopping clinical pathways with multiprofessional panels, testing derived estimates through an online survey of clinicians. Prevalence of tertiary-level need, defined by severity and exposure to childhood adversities, was estimated at 5-8% across infancy and childhood, and 16% in mid-adolescence. The derived care pathway entailed reception, triage, and follow-up (mean 3 h per patient), core clinical management (mean 27 h per patient per year), psychiatric oversight (mean 4 h per patient per year), specialised clinical role (mean 12 h per patient per year), and socioeconomic support (mean 12 h per patient per year). The modelled clinical full-time equivalent was 947 people and budget was AU$126 million, more than five times the current service level. Our novel needs-based workforce model produced actionable estimates of the community workforce needed to address tertiary-level mental health needs in infants, children, adolescents, and their families in SA. A considerable expansion in the skilled workforce is needed to support young people facing current distress and associated family-based adversities. Because mental illness is implicated in so many burgeoning social ills, addressing this shortfall could have wide-ranging benefits. National Health and Medical Research Council (Australia), Department of Health SA. Copyright © 2018 The Authors. Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 license. Published by Elsevier Ltd.. All rights reserved.

Examining inequalities in uptake of maternal health care and choice of provider in underserved urban areas of Mumbai, India: a mixed methods study.

PubMed

Alcock, Glyn; Das, Sushmita; Shah More, Neena; Hate, Ketaki; More, Sharda; Pantvaidya, Shanti; Osrin, David; Houweling, Tanja A J

2015-09-28

Discussions of maternity care in developing countries tend to emphasise service uptake and overlook choice of provider. Understanding how families choose among health providers is essential to addressing inequitable access to care. Our objectives were to quantify the determinants and choice of maternity care provider in Mumbai's informal urban settlements, and to explore the reasons underlying their choices. The study was conducted in informal urban communities in eastern Mumbai. We developed regression models using data from a census of married women aged 15-49 to test for associations between maternal characteristics and uptake of care and choice of provider. We then conducted seven focus group discussions and 16 in-depth interviews with purposively selected participants, and used grounded theory methods to examine the reasons for their choices. Three thousand eight hundred forty-eight women who had given birth in the preceding 2 years were interviewed in the census. The odds of institutional prenatal and delivery care increased with education, economic status, and duration of residence in Mumbai, and decreased with parity. Tertiary public hospitals were the commonest site of care, but there was a preference for private hospitals with increasing socio-economic status. Women were more likely to use tertiary public hospitals for delivery if they had fewer children and were Hindu. The odds of delivery in the private sector increased with maternal education, wealth, age, recent arrival in Mumbai, and Muslim faith. Four processes were identified in choosing a health care provider: exploring the options, defining a sphere of access, negotiating autonomy, and protective reasoning. Women seeking a positive health experience and outcome adopted strategies to select the best or most suitable, accessible provider. In Mumbai's informal settlements, institutional maternity care is the norm, except among recent migrants. Poor perceptions of primary public health facilities often cause residents to bypass them in favour of tertiary hospitals or private sector facilities. Families follow a complex selection process, mediated by their ability to mobilise economic and social resources, and a concern for positive experiences of health care and outcomes. Health managers must ensure quality services, a functioning regulatory mechanism, and monitoring of provider behaviour.

Young Children with Functional Abdominal Pain (FAP) and Irritable Bowel Syndrome (IBS) Followed in Tertiary vs. Primary Care: Differences in Outcomes

USDA-ARS?s Scientific Manuscript database

Despite the fact that the American Academy of Pediatrics suggests that general pediatricians (PED) manage children with FAP/IBS without alarm signs many children are cared for by pediatric gastroenterologists (GI). In a longitudinal examination of physical symptoms, healthcare use, quality of life (...

Tangible resources for preparing patients for antiviral therapy for chronic hepatitis C.

PubMed

Bonner, Jason E; Barritt, A Sidney; Fried, Michael W; Evon, Donna M

2012-06-01

Chronic hepatitis C (HCV) infected patients with coexisting mental health and/or substance abuse issues face significant barriers to treatment and are often deferred. This paper sought to highlight critical pre-treatment strategies and provide tangible resources for HCV clinicians to facilitate preparation and successful treatment of these patients. Guided by the clinical experience of our liver center, a large, tertiary academic medical center, and informed by the extant literature, we summarize pre-treatment strategies and specific resources and recommendations for HCV providers. Four key pre-treatment strategies include: 1) screening for mental health/substance abuse issues using brief, reliable and validated instruments; 2) locating and establishing collaborative care with mental health and substance abuse specialists; 3) using a motivational interviewing communication style; and 4) addressing adherence-related issues. HCV clinicians are in a unique position to prepare patients with coexisting mental health and/or substance abuse issues for antiviral therapy.

Transportability of tertiary qualifications and CPD: a continuing challenge for the global health workforce.

PubMed

Saltman, Deborah C; Kidd, Michael R; Jackson, Debra; Cleary, Michelle

2012-07-09

In workforces that are traditionally mobile and have long lead times for new supply, such as health, effective global indicators of tertiary education are increasingly essential. Difficulties with transportability of qualifications and cross-accreditation are now recognised as key barriers to meeting the rapidly shifting international demands for health care providers. The plethora of mixed education and service arrangements poses challenges for employers and regulators, let alone patients; in determining equivalence of training and competency between individuals, institutions and geographical locations. This paper outlines the shortfall of the current indicators in assisting the process of global certification and competency recognition in the health care workforce. Using Organisation for Economic Cooperation and Development (OECD) data we highlight how International standardisation in the tertiary education sector is problematic for the global health workforce. Through a series of case studies, we then describe a model which enables institutions to compare themselves internally and with others internationally using bespoke or prioritised parameters rather than standards. The mobility of the global health workforce means that transportability of qualifications is an increasing area of concern. Valid qualifications based on workplace learning and assessment requires at least some variables to be benchmarked in order to judge performance.

The Comfort Measures Order Set at a Tertiary Care Academic Hospital: Is There a Comparable Difference in End-of-Life Care Between Patients Dying in Acute Care When CMOS Is Utilized?

PubMed

Lau, Christine; Stilos, Kalli; Nowell, Allyson; Lau, Fanchea; Moore, Jennifer; Wynnychuk, Lesia

2018-04-01

Standardized protocols have been previously shown to be helpful in managing end-of-life (EOL) care in hospital. The comfort measures order set (CMOS), a standardized framework for assessing imminently dying patients' symptoms and needs, was implemented at a tertiary academic hospital. We assessed whether there were comparable differences in the care of a dying patient when the CMOS was utilized and when it was not. A retrospective chart review was completed on patients admitted under oncology and general internal medicine, who were referred to the inpatient palliative care team for "EOL care" between February 2015 and March 2016. Of 83 patients, 56 (67%) received intiation of the CMOS and 27 (33%) did not for EOL care. There was significant involvement of spiritual care with the CMOS (66%), as compared to the group without CMOS (19%), P < .05. The use of CMOS resulted in 1.7 adjustments to symptom management per patient by palliative care, which was significantly less than the number of symptom management adjustments per patient when CMOS was not used (3.3), P < .05. However, initiating CMOS did not result in a signficant difference in patient distress around the time of death ( P = .11). Dyspnea was the most frequently identified symptom causing distress in actively dying patients. Implementation of the CMOS is helpful in providing a foundation to a comfort approach in imminently dying patients. However, more education on its utility as a framework for EOL care and assessment across the organization is still required.

Continuing professional development for volunteers working in palliative care in a tertiary care cancer institute in India: a cross-sectional observational study of educational needs.

PubMed

Deodhar, Jayita Kedar; Muckaden, Mary Ann

2015-01-01

Training programs for volunteers prior to their working in palliative care are well-established in India. However, few studies report on continuing professional development programs for this group. To conduct a preliminary assessment of educational needs of volunteers working in palliative care for developing a structured formal continuing professional development program for this group. Cross-sectional observational study conducted in the Department of Palliative Medicine of a tertiary care cancer institute in India. Participant volunteers completed a questionnaire, noting previous training, years of experience, and a comprehensive list of topics for inclusion in this program, rated in order of importance according to them. Descriptive statistics for overall data and Chi-square tests for categorical variables for group comparisons were applied using Statistical Package for Social Sciences version 18. Fourteen out of 17 volunteers completed the questionnaire, seven having 5-10-years experience in working in palliative care. A need for continuing professional development program was felt by all participants. Communication skills, more for children and elderly specific issues were given highest priority. Spiritual-existential aspects and self-care were rated lower in importance than psychological, physical, and social aspects in palliative care. More experienced volunteers (>5 years of experience) felt the need for self-care as a topic in the program than those with less (<5-years experience) (P < 0.05). Understanding palliative care volunteers' educational needs is essential for developing a structured formal continuing professional development program and should include self-care as a significant component.

Hot mill process parameters impacting on hot mill tertiary scale formation

NASA Astrophysics Data System (ADS)

Kennedy, Jonathan Ian

For high end steel applications surface quality is paramount to deliver a suitable product. A major cause of surface quality issues is from the formation of tertiary scale. The scale formation depends on numerous factors such as thermo-mechanical processing routes, chemical composition, thickness and rolls used. This thesis utilises a collection of data mining techniques to better understand the influence of Hot Mill process parameters on scale formation at Port Talbot Hot Strip Mill in South Wales. The dataset to which these data mining techniques were applied was carefully chosen to reduce process variation. There are several main factors that were considered to minimise this variability including time period, grade and gauge investigated. The following data mining techniques were chosen to investigate this dataset: Partial Least Squares (PLS); Logit Analysis; Principle Component Analysis (PCA); Multinomial Logistical Regression (MLR); Adaptive Neuro Inference Fuzzy Systems (ANFIS). The analysis indicated that the most significant variable for scale formation is the temperature entering the finishing mill. If the temperature is controlled on entering the finishing mill scale will not be formed. Values greater than 1070 °C for the average Roughing Mill and above 1050 °C for the average Crop Shear temperature are considered high, with values greater than this increasing the chance of scale formation. As the temperature increases more scale suppression measures are required to limit scale formation, with high temperatures more likely to generate a greater amount of scale even with fully functional scale suppression systems in place. Chemistry is also a significant factor in scale formation, with Phosphorus being the most significant of the chemistry variables. It is recommended that the chemistry specification for Phosphorus be limited to a maximum value of 0.015 % rather than 0.020 % to limit scale formation. Slabs with higher values should be treated with particular care when being processed through the Hot Mill to limit scale formation.

Why do Patients undergoing Chronic Obstructive Pulmonary Disease Treatment Turn Defaulters? A Follow up Study in a Tertiary Care Hospital in Jamnagar, India.

PubMed

Sarkar, Amrita; Javia, Abhay; Pithadia, Pradeep; Parmar, Dipesh

2017-07-01

Chronic Obstructive Pulmonary Disease (COPD), a progressive respiratory illness requiring long-term treatment, is a significant cause of morbidity, mortality and economic burden on the family as well as the country. In the tertiary health care facility where the study was carried out, it was observed that many COPD patients did not come for regular follow up. In these patients, treatment interruption may lead to increased morbidity and mortality. This study aimed to find out the reasons for defaulting follow up and treatment in COPD patients. All patients of COPD, attending TB Chest outpatient department during the study period (September 2012 to February 2013), were classified into Group A, B, C, and D according to latest Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Data was collected on patient's sociodemographic profile, severity of disease and reasons for defaulting follow up and treatment using pre-tested semi-structured questionnaires, patient history and clinical examination. Data obtained were entered in Microsoft Office Excel 2007 and analysed using Chi-square test. The mean age of the 200 patients recruited was 59.3 years. A total of 87% patients were male. Patients belonging to Group A, B, C and D were 11%, 25.5%, 41.5% and 22% respectively. Overall, 32% patients were defaulters. Three main reasons for default were non-affordability for treatment expenses (39.07%), resolution of symptoms (26.56%), and too ill to come (18.75%). The associations between default rate and demographic variables like age and gender were found statistically significant. Default rate among COPD patients is significantly associated with GOLD Group A and D, patient's income and patient literacy level. Main reasons for default were non-affordability of treatment expenses, too ill to come and resolution of symptoms.

Characteristics and pre-travel preparation of travelers at a Canadian pediatric tertiary care travel clinic: A retrospective analysis.

PubMed

Ma, Xiao Wei; Pell, Lisa G; Akseer, Nadia; Khan, Sarah; Lam, Ray E; Louch, Debra; Science, Michelle; Morris, Shaun K

2016-01-01

International travelers are susceptible to a wide spectrum of travel related morbidities. Despite rising number of international travelers in Canada, the demographics, risk profiles, and preventative strategies of high-risk traveler groups, including pediatric travelers visiting friends and relatives (VFRs) are not well described. A descriptive analysis was conducted on pre-travel consultations completed between January 2013 and August 2014 at a large pediatric tertiary care center in Toronto, Canada. Data on demographics, travel characteristics, and pre-travel interventions were extracted from 370 pre-travel consultations. Results were compared between all VFR and non-VFR travelers, as well as between children traveling to visit friends and relatives, for vacation, and for education and/or volunteer purposes. Forty-eight percent of consultations were for children <18 years of age (n = 177), of which 31% were for young children (<5 years of age). Young children were more likely to travel to visit friends and/or relatives than for other purposes (29% vs 9%, p < 0.0001). Children VFRs (cVFRs) were more likely to travel for >28 days than children traveling for vacation (43% vs 1%, p < 0.0001), and children traveling for education/volunteer purposes (43% vs 21%, p = 0.03). Around half of cVFRs traveled to destinations in Asia (51%). The majority stayed with locals, friends and/or relatives (85%), and nearly all traveled to urban destinations (98%). The most prescribed interventions for children were azithromycin (84%), Dukoral (66%), and the hepatitis A vaccine (60%). Atovaquone/proguanil was the most commonly prescribed antimalarial for children. Children that travel to visit friends and relatives represent a unique travel group and may require specific considerations during pre-travel preparations. Our findings can help develop targeted pre-travel strategies for children VFRs. Copyright © 2015 Elsevier Ltd. All rights reserved.

On the tertiary instability formalism of zonal flows in magnetized plasmas

NASA Astrophysics Data System (ADS)

Rath, F.; Peeters, A. G.; Buchholz, R.; Grosshauser, S. R.; Seiferling, F.; Weikl, A.

2018-05-01

This paper investigates the so-called tertiary instabilities driven by the zonal flow in gyro-kinetic tokamak core turbulence. The Kelvin Helmholtz instability is first considered within a 2D fluid model and a threshold in the zonal flow wave vector kZF>kZF,c for instability is found. This critical scale is related to the breaking of the rotational symmetry by flux-surfaces, which is incorporated into the modified adiabatic electron response. The stability of undamped Rosenbluth-Hinton zonal flows is then investigated in gyro-kinetic simulations. Absolute instability, in the sense that the threshold zonal flow amplitude tends towards zero, is found above a zonal flow wave vector kZF,cρi≈1.3 ( ρi is the ion thermal Larmor radius), which is comparable to the 2D fluid results. Large scale zonal flows with kZF

Hepatitis C Virus: Unnoticed and on the Rise in Blood Donor Screening? A 5 Years Cross-sectional Study on Seroprevalence in Voluntary Blood Donors from Central India.

PubMed

Saini, Purti Agrawal; Chakrabarti, Preeti Rihal; Varma, Amit V; Gambhir, Shankhini; Tignath, Gargi; Gupta, Priyanka

2017-01-01

The ultimate goal of a blood transfusion service is the provision of safe and adequate supply free from transfusion-transmitted infections (TTIs). TTIs not only threaten the recipient's safety, but they also increase disease burden. Seroprevalence of TTIs in healthy blood donors indirectly reflects the prevalence of these infections in the general healthy population. To study the seroprevalence of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) in healthy donors at a tertiary care hospital-based blood bank. To know the yearly and age-group prevalence of these TTIs as compared with other studies across India. This is 5 years observational cross-section study conducted in a tertiary hospital-based teaching institute of Central India (Malwa region). The results of serological testing of TTIs and donor variables were analyzed during 2011-2015. Chi-square test and Chi-square for trend analysis on TTIs prevalence. A total of 58,998 donors were screened for TTIs with dominance of male donation (99.7%). The overall cumulative seroprevalence was 1.14% in our study. The seroprevalence of HIV, HBV, and HCV was 0.09%, 0.98%, and 0.07%, respectively. We found a statistically significant increasing trend for HCV seropositivity during the study. Our study reflects an increasing trend of HCV seroprevalence over time. Thus, efforts are needed to increase the awareness and to educate the population in reducing risk factors for HCV infection.

Ab initio/GIAO-CCSD(T) (13)C NMR study of the rearrangement and dynamic aspects of rapidly equilibrating tertiary carbocations, C6H13(+) and C7H15(+).

PubMed

Olah, George A; Prakash, G K Surya; Rasul, Golam

2016-01-05

The rearrangement pathways of the equilibrating tertiary carbocations, 2,3-dimethyl-2-butyl cation (C6H13(+), 1), 2,3,3-trimethyl-2-butyl cation (C7H15(+), 5) and 2,3-dimethyl-2-pentyl cation (C7H15(+), 8 and 9) were investigated using the ab initio/GIAO-CCSD(T) (13)C NMR method. Comparing the calculated and experimental (13)C NMR chemical shifts of a series of carbocations indicates that excellent prediction of δ(13)C could be achieved through scaling. In the case of symmetrical equilibrating cations (1 and 5) the Wagner-Meerwein 1,2-hydride and 1,2-methide shifts, respectively, produce the same structure. This indicates that the overall (13)C NMR chemical shifts are conserved and independent of temperature. However, in the case of unsymmetrical equilibrating cations (8 and 9) the Wagner-Meerwein shift produces different tertiary structures, which have slightly different thermodynamic stabilities and, thus, different spectra. At the MP4(SDTQ)/cc-pVTZ//MP2/cc-pVTZ + ZPE level structure 8 is only 90 calories/mol more stable than structure 9. Based on computed (13)C NMR chemical shift calculations, mole fractions of these isomers were determined by assuming the observed chemical shifts are due to the weighted average of the chemical shifts of the static ions. © 2015 Wiley Periodicals, Inc.

Direct and indirect cost of myasthenia gravis: A prospective study from a tertiary care teaching hospital in India.

PubMed

Sonkar, Kamlesh Kumar; Bhoi, Sanjeev Kumar; Dubey, Deepanshu; Kalita, Jayantee; Misra, Usha Kant

2017-04-01

Myasthenia gravis (MG) requires lifelong treatment. The cost of management MG is very high in developed countries but there is no information on the cost of management of MG in the developing countries. This study reports the direct and indirect cost and predictors of cost of MG in a tertiary care teaching hospital in India. In a prospective hospital based study, from a tertiary hospital in India 66 consecutive patient during 2014-2015 were included. The age of the patients ranged between 6 and 75years. The severity of MG was assessed by myasthenia gravis foundation association (MGFA) class (MGFA) I-V. The patient data was collected s and their direct cost was calculated from the computerized Hospital information system. The indirect cost was calculated from patient's memory, checking the bills of transportation and wages loss by the patient or the care giver. Total annual cost of MG ranged between INR (4560-532227) with median INR 61390.5 (US$911.64). The median cost of outpatient department (OPD) consultation of 16 patients was INR 20439.9 (US$303.53), of 50 admitted patients was INR 44311.8 (US$658.03) and 21 intensive care unit (ICU) patients was INR 59574.3 (US$ 884.6) and the direct cost of thymectomy was INR 45000 (US$ 668.25). Direct cost was related to indirect cost (r=0.55; p=0.0001). Predictors of patient outcome were severity of MG, ICU admission, and thymectomy. The total median cost for management of myasthenia gravis was INR 61390.5 (4560-532227, US$911.64) per year, and the cost was mainly determined by the severity of MG. Copyright © 2016 Elsevier Ltd. All rights reserved.

The contribution of multiple pregnancies from overseas fertility treatment to obstetric services in a Western Australian tertiary obstetric hospital.

PubMed

Waller, Kylie Anne; Dickinson, Jan E; Hart, Roger J

2017-08-01

Increasingly couples are travelling overseas to access assisted reproductive technology, known as cross border reproductive care, although the incidence, pregnancy outcomes and healthcare costs are unknown. To determine obstetric and neonatal outcomes for multiple pregnancies conceived through fertility treatment overseas, and estimate cost of these pregnancies to the health system. Retrospective study of women receiving care for a multiple gestation between July 2013 and June 2015 at Western Australia's sole tertiary obstetric hospital, where conception was by overseas fertility treatment. Obstetric and neonatal outcomes were recorded and cost estimates calculated. Of 11 710 births, 422 were multiple pregnancies. Thirty-seven pregnancies were conceived with fertility treatment, with 11 (29.7%) conceived overseas. Median antenatal clinic attendances, ultrasound examinations, and fetal assessments for the overseas fertility cases were six, 10, and nine, respectively. The gestational age at delivery ranged from 30 to 38 weeks (median 34 + 1). Median neonatal admission duration was 18 days (range 0-47). Cost for obstetric care was estimated between $170 000 and $216 000, and cost of neonatal care was estimated as $810 000, giving a combined total cost of between $980 000 and $1 026 000. At the sole tertiary obstetric centre in WA, approximately one-third of all multiple pregnancies conceived with fertility treatment resulted from treatment overseas. The Australian healthcare cost for these 11 women and their infants exceeded $1 000 000. This study suggests that overseas fertility treatment has a significant health-related cost to the mother and infant, and the local healthcare system. © 2017 The Royal Australian and New Zealand College of Obstetricians and Gynaecologists.

Factors predicting quality of work life among nurses in tertiary-level hospitals, Bangladesh.

PubMed

Akter, N; Akkadechanunt, T; Chontawan, R; Klunklin, A

2018-06-01

This study examined the level of quality of work life and predictability of years of education, monthly income, years of experience, job stress, organizational commitment and work environment on quality of work life among nurses in tertiary-level hospitals in the People's Republic of Bangladesh. There is an acute shortage of nurses worldwide including Bangladesh. Quality of work life is important for quality of patient care and nurse retention. Nurses in Bangladesh are fighting to provide quality care for emerging health problems for the achievement of sustainable development goals. We collected data from 288 randomly selected registered nurses, from six tertiary-level hospitals. All nurses were requested to fill questionnaire consisted of Demographic Data Sheet, Quality of Nursing Work Life Survey, Expanded Nursing Stress Scale, Questionnaire of Organizational Commitment and Practice Environment Scale of the Nursing Work Index. Data were analysed by descriptive statistics and multiple regression. The quality of work life as perceived by nurses in Bangladesh was at moderate level. Monthly income was found as the best predictor followed by work environment, organizational commitment and job stress. A higher monthly income helps nurses to fulfil their personal needs; positive work environment helps to provide quality care to the patients. Quality of work life and predictors measured by self-report only may not reflect the original picture of the quality of work life among nurses. Findings provide information for nursing and health policymakers to develop policies to improve quality of work life among nurses that can contribute to quality of nursing care. This includes the working environment, commitment to the organization and measures to reduce job stress. © 2017 International Council of Nurses.

Analysis of orbital malignancies presenting in a tertiary care hospital in Pakistan

PubMed Central

Khan, Asad Aslam; Sarwar, Suhail; Sadiq, Mohammad Ali A; Ahmad, Imran; Tariq, Nayab; Sibghat-ul-Noor

2017-01-01

Objective: To determine the frequencies of various orbital malignancies amongst orbital lesions in patients presenting in a tertiary care hospital in Pakistan. Methods: A retrospective analysis of 666 orbital cases with an established histopathological diagnosis of malignant tumors treated in Mayo Hospital Lahore from 1996 to 2015 (20 years). Results: About 66% of the malignant tumors were primary, 25% secondary, 8% haematopoietic and 1% metastatic. Almost 50% of the cases were children. Retinoblastoma is the commonest tumor (43% overall and 87% among children). Squamous cell carcinoma is the second commonest (15.6% overall and 31% among adults). These are then followed by Adenoid cystic carcinoma of Lacrimal Gland (9%), Lymphoma/Leukaemia (8%) and Rhabdomyosarcoma (6.3%). Conclusion: Frequencies of various orbital malignancies show geographical variation in both paediatric and adult population. PMID:28367175

Gastrointestinal tract and liver graft-versus-host disease in pediatric patients with hematopoietic progenitor cell transplantation at a tertiary care center in Mexico.

PubMed

Jaramillo-Esparza, C M; Consuelo-Sánchez, A; Acosta-Rodríguez-Bueno, C P; Ramón-García, G; Sadowinski-Pine, S W; Escobar-Sánchez, M A; Castorena-Villa, I; Gaytán-Morales, F; Vázquez-Frias, R

2018-02-24

Graft-versus-host disease (GVHD) is a common multisystemic complication of allogeneic hematopoietic cell transplantation. The most frequent presentations of graft-versus-host disease involve the skin, the gastrointestinal tract, and the liver. The aim of the present study was to know the frequency of gastrointestinal tract and liver GVHD and the characteristics of disease presentation in pediatric patients that underwent hematopoietic stem cell transplantation (HSCT) at a tertiary care hospital center in Mexico City. A retrospective study was carried out, utilizing the case records of patients that underwent HSCT in 2015, to determine the frequency of GVHD in pediatric patients at a Mexican tertiary care hospital center. In 2015, 16 HSCT were performed, 11 of which were carried out in males (68%). Only 3 patients developed graft-versus-host disease (18.7%). One patient presented with skin and liver GVHD and 2 patients presented with gastrointestinal tract and liver GVHD, which was the most frequent type. HSCT is still an uncommon procedure in Mexico and there is a lower frequency of gastrointestinal tract and liver GVHD than that reported in other studies. Most certainly, there will be an increase in this type of patient and risk factors in the Mexican population must still be determined to help predict the onset of GVHD. Copyright © 2018 Asociación Mexicana de Gastroenterología. Publicado por Masson Doyma México S.A. All rights reserved.

Medication Administration Errors in an Adult Emergency Department of a Tertiary Health Care Facility in Ghana.

PubMed

Acheampong, Franklin; Tetteh, Ashalley Raymond; Anto, Berko Panyin

2016-12-01

This study determined the incidence, types, clinical significance, and potential causes of medication administration errors (MAEs) at the emergency department (ED) of a tertiary health care facility in Ghana. This study used a cross-sectional nonparticipant observational technique. Study participants (nurses) were observed preparing and administering medication at the ED of a 2000-bed tertiary care hospital in Accra, Ghana. The observations were then compared with patients' medication charts, and identified errors were clarified with staff for possible causes. Of the 1332 observations made, involving 338 patients and 49 nurses, 362 had errors, representing 27.2%. However, the error rate excluding "lack of drug availability" fell to 12.8%. Without wrong time error, the error rate was 22.8%. The 2 most frequent error types were omission (n = 281, 77.6%) and wrong time (n = 58, 16%) errors. Omission error was mainly due to unavailability of medicine, 48.9% (n = 177). Although only one of the errors was potentially fatal, 26.7% were definitely clinically severe. The common themes that dominated the probable causes of MAEs were unavailability, staff factors, patient factors, prescription, and communication problems. This study gives credence to similar studies in different settings that MAEs occur frequently in the ED of hospitals. Most of the errors identified were not potentially fatal; however, preventive strategies need to be used to make life-saving processes such as drug administration in such specialized units error-free.

Cost effectiveness of screening of all newly recruited employees for diabetes at a tertiary care hospital.

PubMed

Ali, Niloufer Sultan; Khuwaja, Ali Khan

2007-01-01

Diabetes Mellitus is a disease which remains asymptomatic for long duration of time and usually diagnosed either when gets complicated or by routine or opportunistic screening. The practice of universal screening is not recommended, particularly in constraint resources. However, we embarked with a study to assess the yield of recommended screening for Type 2 diabetes in all the newly recruited employees at a tertiary care hospital in Karachi. All the information required for this study was collected from medical records of all newly recruited employees of nursing services department of a tertiary care hospital of Karachi, Pakistan, over a period of 5 months (August 2004 to December 2004). Out of 360 subjects, 326, whose information was found to be complete, were included for final analysis. Mean age of the study subjects was 25.3 +/- 4.7 years and their mean casual plasma glucose level was 99.1 +/- 16.3 mg/dl. 315 (96.6%) study subjects had casual plasma glucose level of 139 mg/dl or less. Only 10 (3.1%) study subjects had casual plasma glucose levels between 140 to 199 mg/dl. Just one employee, 41 years old, was found to have casual plasma glucose level of 213 mg/dl. In this study, screening of all individuals for diabetes had a very low yield. Recommendation of universal screening for diabetes does not represent a good use of resources and perhaps not cost-effective. However, periodic screening of high risk individuals should be warranted.

Occupational Exposure to Infection: A study on Healthcare Waste Handlers of a Tertiary Care Hospital in South India.

PubMed

Shivalli, Siddharudha; Sowmyashree, H

2015-11-01

Occupational exposure to infection is an important public health concern. Such accidents are associated with a few, but pose significant risk to worker's health, family and the community. 1) To assess the knowledge and attitude of waste handlers regarding healthcare waste management in tertiary care hospital of Mangalore. 2) To assess the occupational risk of exposure to infection in their work setting. A cross-sectional study was conducted among healthcare waste handlers (involved in collection, storage and safe disposal) in a tertiary care hospital of Mangalore, India. A semi-structured and pre-tested proforma was used to assess respondents' knowledge and percentage score was calculated based on a scoring system. Chi square and independent sample t tests were applied to judge the association of study variables with knowledge and occupational risk of infection. A total of 43 healthcare waste handlers participated in the study and all were females. Almost half of them had poor knowledge (< 50% score) about healthcare waste management. As much as 41.8% of them had exposure to healthcare waste and 'needle stick injury' was the most common type. Age, literacy and experience did not significantly (p>0.05) influence the knowledge and occupational risk of infection. Respondents' knowledge regarding healthcare waste management was unsatisfactory. They were at high risk of occupational exposure to infection. It emphasizes the need of refresher training and reinforcement of personal protection measures in their work setting. © Journal of the Association of Physicians of India 2011.

High prevalence of undiagnosed diabetes among tuberculosis patients in peripheral health facilities in Kerala

PubMed Central

Kumari, A. K.; Subramonianpillai, J.; Shabna, D. S.; Kumar, S. M.; Balakrishnan, S.; Naik, B.; Kumar, A. M. V.; Isaakidis, P.; Satyanarayana, S.

2013-01-01

Setting: Two tertiary care hospitals and 12 peripheral health institutions (PHIs) in Trivandrum, Kerala, India. Objective: To determine factors associated with the prevalence of diabetes mellitus (DM) among tuberculosis (TB) patients and examine differences in the proportion of new DM cases among TB patients diagnosed at tertiary care centres and PHIs. Design: A descriptive study: TB patients diagnosed during March–September 2012 were screened for known DM. Those with unknown DM status were tested for random blood glucose and fasting blood glucose (FBG); FBG ≥ 126 mg/dl was diagnosed as new DM. Results: Of 920 TB patients, 689 (72%) were male and the mean (standard deviation) age was 47.6 (16.4) years. Of these, 298 (32.4%) were diabetic: 235 (26%) had previously known DM and 63 (7%) were newly diagnosed. During the screening at PHIs and tertiary care hospitals, respectively 30/183 (16.4%) and 33/737 (4.5%) were newly diagnosed with DM (OR 3.71; 95%CI 2.17–6.32). Overall, age >50 years and pulmonary tuberculosis were independently associated with a higher prevalence of diabetes. Conclusion: As nearly one in three TB patients had DM, we recommend that TB patients should be routinely screened for DM in Kerala. As the proportion of new DM was higher among TB patients diagnosed at PHIs, we would recommend that specific attention and investment be directed to PHIs. PMID:26393068

Implosion symmetry and ρR measurements on the National Ignition Facility from nascent 27-31 MeV tertiary protons (invited) (abstract)

NASA Astrophysics Data System (ADS)

Petrasso, Richard D.

1997-01-01

Tertiary protons with birth energies from ˜27 to 30.8 MeV result from the implosion of ignition-scale inertial confinement fusion targets, such as those planned for the National Ignition Facility (NIF). Measurement of the tertiaries' slowing can provide a determination of the imploded areal density of the fuel capsule, as well as implosion asymmetry that results from anisotropy of the areal density and plasma temperature. In order to determine the utility of tertiaries for all phases of the NIF, we analyze three representative cases: a gas capsule (0.7 kJ yield); a cryogenic fuel capsule that fails to ignite (15 kJ); and a cryogenic fuel capsule that ignites and burns (13 000 kJ). In each case, tertiaries escape from the capsule and convey critical information about implosion dynamics. In addition, we show that for some gas-capsule implosions anticipated on OMEGA, tertiaries may be the only species of energetic charged particles that can determine the fuel areal density. Presently, we are building a charge-coupled device (CCD)-based charged particle spectrometer for OMEGA and for NOVA. In addition to the tertiaries, the spectrometers are sensitive to a variety of the energetic charged particles, such as knock-on protons, deuterons, and tritons, and 3He-burnup protons. In fact the latter set of charged particles will usually be the dominant signal. We will describe the basic features of the spectrometers and the measured response of the CCDs to 1-5 MeV protons, 1-5 MeV alphas, and 14 MeV neutrons (and associated gammas), the latter constitute the principal source of noise. This work is done in collaboration with C. K. Li, D. Hicks, and F. Seguin of MIT; with B. Burke of LL/MIT; with M. Cable, S. Pollaine, S. Haan, T. Bernat, T. Phillips, and J. Kilkenny of LLNL; with J, Knauer, S. Cremer, C. Verdon, and B. Kremens of University of Rochester; and with C. Ruiz and R. Leeper of SNL. This work is supported in part by LLNL Subcontract B313875 and University of Rochester Subcontract 410025-G.

[Environmental noise levels in 2 intensive care units in a tertiary care centre].

PubMed

Ornelas-Aguirre, José Manuel; Zárate-Coronado, Olivia; Gaxiola-González, Fabiola; Neyoy-Sombra, Venigna

2017-04-03

The World Health Organisation (WHO) has established a maximum noise level of 40 decibels (dB) for an intensive care unit. The aim of this study was to compare the noise levels in 2 different intensive care units at a tertiary care centre. Using a cross-sectional design study, an analysis was made of the maximum noise level was within the intensive coronary care unit and intensive care unit using a digital meter. A measurement was made in 4 different points of each room, with 5minute intervals, for a period of 60minutes 7:30, 14:30, and 20:30. The means of the observations were compared with descriptive statistics and Mann-Whitney U. An analysis with Kruskal-Wallis test was performed to the mean noise level. The noise observed in the intensive care unit had a mean of 64.77±3.33dB (P=.08), which was similar to that in the intensive coronary care unit, with a mean of 60.20±1.58dB (P=.129). Around 25% or more of the measurements exceeded the level recommended by the WHO by up to 20 points. Noise levels measured in intensive care wards exceed the maximum recommended level for a hospital. It is necessary to design and implement actions for greater participation of health personnel in the reduction of environmental noise. Copyright © 2017 Instituto Nacional de Cardiología Ignacio Chávez. Publicado por Masson Doyma México S.A. All rights reserved.

Geometry at the aliphatic tertiary carbon atom: computational and experimental test of the Walsh rule.

PubMed

Böhm, Stanislav; Exner, Otto

2004-02-01

The geometrical parameters of molecules of 2-substituted 2-methylpropanes and 1-substituted bicyclo[2.2.2]octanes were calculated at the B3LYP/6-311+G(d,p) level. They agreed reasonably well with the mean crystallographic values retrieved from the Cambridge Structural Database for a set of diverse non-cyclic structures with a tertiary C atom. The angle deformations at this C atom produced by the immediately bonded substituent are also closely related to those observed previously in benzene mono derivatives (either as calculated or as derived from crystallographic data). The calculated geometrical parameters were used to test the classical Walsh rule: It is evidently true that an electron-attracting substituent increases the proportion of C-atom p-electrons in the bond to the substituent and leaves more s-electrons to the remaining bonds; as a consequence the C-C-C angles at a tertiary carbon are widened and the C-C bonds shortened. However, this rule describes only part of the reality since the bond angles and lengths are controlled by other factors as well, for instance by steric crowding. Another imperfection of the Walsh rule is that the sequence of substituents does not correspond to their electronegativities, as measured by any known scale; more probably it is connected with the inductive effect, but then only very roughly.

Compliance with guidelines for disease management in diabetes: results from the SwissDiab Registry.

PubMed

Schimke, Katrin E; Renström, Frida; Meier, Sandro; Stettler, Christoph; Brändle, Michael

2018-01-01

Tight glycemic control and aggressive treatment of additional cardiovascular risk factors can substantially reduce risk of diabetes-related complications. In 2013, the Swiss Society of Endocrinology and Diabetology (SSED) established national criteria on good disease management in diabetes, but little is known about compliance in clinical care. Here we assessed to what extent patients from two tertiary care centers in the German-speaking part of Switzerland enrolled in the Swiss Diabetes (SwissDiab) Registry adhere to the SSED criteria. SwissDiab is a prospective observational cohort study of patients regularly treated at Swiss tertiary diabetes centers. Data were collected through standardized annual health examinations. Baseline participant descriptive statistics, stratified by diabetes mellitus type 1 (DM1) and type 2 (DM2), were compared with SSED targets for glycemic control, blood pressure, blood lipids, weight maintenance, and ophthalmic examination. By the end of 2016, 604 participants with DM1 (40%) and DM2 (60%) had data available for analyses, 36% and 29% women, respectively. At baseline, all the SSED targets were met with two exceptions: a glycated hemoglobin A1c value <7% was measured in 32% of participants with DM1 (SSED target: ≥40%) and 47% and 56% of overweight or obese participants with DM1 and DM2, respectively, received nutritional counseling in the previous year (SSED target: ≥80%). The SSED targets for good disease management in diabetes were achieved in the majority of participants at the time of enrollment, but results also highlight areas where disease management can be improved, particularly the role of nutrition counseling.

Pediatric retinal detachment in the Eastern Province of Saudi Arabia: experience of a tertiary care hospital.

PubMed

Cheema, Rizwan A; Al-Khars, Wajeeha; Al-Askar, Essam; Amin, Yasir M

2009-01-01

Because no previous studies have addressed the issue, we describe clinical characteristics and surgical outcome of patients with rhegmatogenous retinal detachment (RRD) in a pediatric population of the Eastern province of Saudi Arabia. We conducted a retrospective review of all consecutive cases of pediatric RRD (0-18 years) patients presenting at Dhahran Eye Specialist Hospital, a tertiary care hospital, in the Eastern Province of Saudi Arabia over a period of 3 years. Twenty patients were included in the study, accounting for 9.4% of all retinal detachment surgery cases performed over a period of 3 years (January 2006 to December 2008). The median age was 11.0 years, (range, birth to 18 years). Trauma, (45%) myopia/vitreoretinal degeneration (10%) and prior ocular surgery (25%) were significant risk factors for RRD. Proliferative vitreoretinopathy (PVR) more than grade C was present in 14/20 (70%) of cases. Most patients (15/20, 75%) were treated with pars plana vitrectomy and placement of an encircling buckle, while silicone oil or gas was used as tamponade in 13/20 (65%) patients. Surgery was successful in 17/20 (85%) cases in achieving retinal re-attachment. Visual acuity improved significantly following surgery (Mean preop 2.146 LogMAR, Mean postop 1.497 LogMAR) ( P= .014). Longer duration of RRD ( P =.007) and macular involvement ( P =.05) were associated with worse anatomical outcomes following surgery. Pediatric RRD in the Eastern province is often associated with predisposing pathology. Surgery is successful in achieving anatomical reattachment of the retina in a majority of cases with improvement of visual acuity.

Prevalence and molecular diversity of invasive Streptococcus dysgalactiae and Streptococcus pyogenes in a German tertiary care medical centre.

PubMed

Rößler, S; Berner, R; Jacobs, E; Toepfner, N

2018-05-03

Prevalence of invasive ß-haemolytic streptococci (BHS) at a tertiary care hospital and molecular diversity of S. pyogenes and S. dysgalactiae was studied. Between 2012 and 2016, all blood culture sets (n = 55,839), CSF (n = 8413) and soft tissue (n = 20,926) samples were analysed for BHS positivity using HYBASE software. Molecular profiles of 99 S. pyogenes and S. dysgalactiae were identified by sequencing of M protein genes (emm types) and multiplex PCR typing of 20 other virulence determinants. Streptococci contributed to 6.2% of blood, 10.7% of CSF and 14.5% of soft tissue isolates, being among the most common invasive isolates. The overall rates of invasive S. pyogenes, S. agalactiae, S. dysgalactiae and S. pneumoniae were 2.4, 4.4, 2.1, and 5.3%. Whereas S. pneumoniae was 1.5% more common in CSF samples, BHS isolates were 2-fold and 11-fold higher in bacteraemia and invasive soft tissue infections. Genetic BHS typing revealed wide molecular diversity of invasive and noninvasive group A and group G BHS, whereas one emm-type (stG62647.0) and no other virulence determinants except scpA were detected in invasive group C BHS. BHS were important invasive pathogens, outpacing S. pneumoniae in bacteraemia and invasive soft tissue infections. The incidence of S. dysgalactiae infections was comparable to that of S. pyogenes even with less diversity of molecular virulence. The results of this study emphasise the need for awareness of BHS invasiveness in humans and the need to develop BHS prevention strategies.

Rheumatic heart disease: infectious disease origin, chronic care approach.

PubMed

Katzenellenbogen, Judith M; Ralph, Anna P; Wyber, Rosemary; Carapetis, Jonathan R

2017-11-29

Rheumatic heart disease (RHD) is a chronic cardiac condition with an infectious aetiology, causing high disease burden in low-income settings. Affected individuals are young and associated morbidity is high. However, RHD is relatively neglected due to the populations involved and its lower incidence relative to other heart diseases. In this narrative review, we describe how RHD care can be informed by and integrated with models of care developed for priority non-communicable diseases (coronary heart disease), and high-burden communicable diseases (tuberculosis). Examining the four-level prevention model (primordial through tertiary prevention) suggests primordial and primary prevention of RHD can leverage off existing tuberculosis control efforts, given shared risk factors. Successes in coronary heart disease control provide inspiration for similarly bold initiatives for RHD. Further, we illustrate how the Chronic Care Model (CCM), developed for use in non-communicable diseases, offers a relevant framework to approach RHD care. Systems strengthening through greater integration of services can improve RHD programs. Strengthening of systems through integration/linkages with other well-performing and resourced services in conjunction with policies to adopt the CCM framework for the secondary and tertiary prevention of RHD in settings with limited resources, has the potential to significantly reduce the burden of RHD globally. More research is required to provide evidence-based recommendations for policy and service design.

Assessment of delirium using the PRE-DELIRIC model in an intensive care unit in Argentina

PubMed Central

Sosa, Fernando Ariel; Roberti, Javier; Franco, Margarita Tovar; Kleinert, María Mercedes; Patrón, Agustina Risso; Osatnik, Javier

2018-01-01

Objective To describe the incidence of and risk factors for delirium in the intensive care unit of a tertiary care teaching hospital in Argentina and to conduct the first non-European study exploring the performance of the PREdiction of DELIRium in ICu patients (PRE-DELIRIC) model. Methods Prospective observational study in a 20-bed intensive care unit of a tertiary care teaching hospital in Buenos Aires, Argentina. The PRE-DELIRIC model was applied to 178 consecutive patients within 24 hours of admission to the intensive care unit; delirium was assessed with the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU). Results The mean age was 64.3 ± 17.9 years. The median time of stay in the intensive care unit was 6 (range, 2 - 56) days. Of the total number of patients, 49/178 (27.5%) developed delirium, defined as a positive CAM-ICU assessment, during their stay in the intensive care unit. Patients in the delirium group were significantly older and had a significantly higher Acute Physiological and Chronic Health Evaluation II (APACHE II) score. The mortality rate in the intensive care unit was 14.6%; no significant difference was observed between the two groups. Predictive factors for the development of delirium were increased age, prolonged intensive care unit stay, and opioid use. The area under the curve for the PRE-DELIRIC model was 0.83 (95%CI; 0.77 - 0.90). Conclusions The observed incidence of delirium highlights the importance of this problem in the intensive care unit setting. In this first study conducted outside Europe, PRE-DELIRIC accurately predicted the development of delirium. PMID:29742219

In-Hospital Mortality among Rural Medicare Patients with Acute Myocardial Infarction: The Influence of Demographics, Transfer, and Health Factors

ERIC Educational Resources Information Center

Muus, Kyle J.; Knudson, Alana D.; Klug, Marilyn G.; Wynne, Joshua

2011-01-01

Context/Purpose: Most rural hospitals can provide medical care to acute myocardial infarction (AMI) patients, but a need for advanced cardiac care requires timely transfer to a tertiary hospital. There is little information on AMI in-hospital mortality predictors among rural transfer patients. Methods: Cross-sectional retrospective analyses on…

Construction of 1-Heteroaryl-3-azabicyclo[3.1.0]hexanes by sp3-sp2 Suzuki-Miyaura and Chan-Evans-Lam Coupling Reactions of Tertiary Trifluoroborates.

PubMed

Harris, Michael R; Li, Qifang; Lian, Yajing; Xiao, Jun; Londregan, Allyn T

2017-05-05

Compounds that contain the 1-heteroaryl-3-azabicyclo[3.1.0]hexane architecture are of particular interest to the pharmaceutical industry yet remain a challenge to synthesize. We report herein an expedient and modular approach to the synthesis of 1-heteroaryl-3-azabicyclo[3.1.0]hexanes by Suzuki-Miyaura and Chan-Evans-Lam coupling reactions of tertiary trifluoroborate salts. Our Suzuki-Miyaura cross-coupling protocol is compatible with a broad range of aryl and heteroaryl bromides and chlorides. The unprecedented Chan-Evans-Lam coupling of tertiary trifluoroborates allows the facile construction of 1-heteroaryl-3-azabicyclo[3.1.0]hexanes containing C-tertiary arylamines at the ring juncture.

Optimizing perioperative Crohn's disease management: role of coordinated medical and surgical care.

PubMed

Bennett, Jennifer L; Ha, Christina Y; Efron, Jonathan E; Gearhart, Susan L; Lazarev, Mark G; Wick, Elizabeth C

2015-01-28

To investigate rates of re-establishing gastroenterology care, colonoscopy, and/or initiating medical therapy after Crohn's disease (CD) surgery at a tertiary care referral center. CD patients having small bowel or ileocolonic resections with a primary anastomosis between 2009-2012 were identified from a tertiary academic referral center. CD-specific features, medications, and surgical outcomes were abstracted from the medical record. The primary outcome measure was compliance rates with medical follow-up within 4 wk of hospital discharge and surveillance colonoscopy within 12 mo of surgery. Eighty-eight patients met study inclusion criteria with 92% (n=81) of patients returning for surgical follow-up compared to only 41% (n=36) of patients with documented gastroenterology follow-up within four-weeks of hospital discharge, P<0.05. Factors associated with more timely postoperative medical follow-up included younger age, longer length of hospitalization, postoperative biologic use and academic center patients. In the study cohort, 75.0% of patients resumed medical therapy within 12 mo, whereas only 53.4% of patients underwent a colonoscopy within 12 mo of surgery. Our study highlights the need for coordinated CD multidisciplinary clinics and structured handoffs among providers to improve of quality of care in the postoperative setting.

Pakistan’s Recommendations for Optimal Management of diabetes from Primary to Tertiary care level (PROMPT)

PubMed Central

Shera, A. Samad; Basit, Abdul; Team, PROMPT

2017-01-01

Pakistan is a developing country with limited resources and diverse socio-economic standards. Pakistan has high prevalence of diabetes and its complications, which is a great challenge to the existing health care system. National action plans for control of diabetes have been developed and initiatives have been taken but not at an ideal pace. First National Practice Guidelines for Pakistan were published in 1999. It was very helpful in standardizing the management of Type-2 diabetes. In view of important developments in the field of diabetes during the recent years, it was felt that 1999 National Clinical Practice Guidelines edited, should be revised. Also with rapidly increasing number of diabetic patients and the escalating burden on health economy, it is essential to develop a primary to secondary / tertiary care referral system. These guidelines are developed after an extensive research and cover many aspects of diabetes management. This special communication is an extract of a PROMPT document that has already been published as a Supplement in Pakistan Journal of Medical Sciences in 2017. We hope that these guidelines will help in improving the diabetes care in Pakistan. PMID:29142579

Marked variation in newborn resuscitation practice: A national survey in the UK☆

PubMed Central

Mann, Chantelle; Ward, Carole; Grubb, Mark; Hayes-Gill, Barrie; Crowe, John; Marlow, Neil; Sharkey, Don

2012-01-01

Background Although international newborn resuscitation guidance has been in force for some time, there are no UK data on current newborn resuscitation practices. Objective Establish delivery room (DR) resuscitation practices in the UK, and identify any differences between neonatal intensive care units (NICU), and other local neonatal services. Methods We conducted a structured two-stage survey of DR management, among UK neonatal units during 2009–2010 (n = 192). Differences between NICU services (tertiary level) and other local neonatal services (non-tertiary) were analysed using Fisher's exact and Student's t-tests. Results There was an 89% response rate (n = 171). More tertiary NICUs institute DR CPAP than non-tertiary units (43% vs. 16%, P = 0.0001) though there was no significant difference in frequency of elective intubation and surfactant administration for preterm babies. More tertiary units commence DR resuscitation in air (62% vs. 29%, P < 0.0001) and fewer in 100% oxygen (11% vs. 41%, P < 0.0001). Resuscitation of preterm babies in particular, commences with air in 56% of tertiary units. Significantly more tertiary units use DR pulse oximeters (58% vs. 29%, P < 0.01) and titrate oxygen based on saturations. Almost all services use occlusive wrapping to maintain temperature for preterm infants. Conclusions In the UK, there are many areas of good evidence based DR practice. However, there is marked variation in management, including between units of different designation, suggesting a need to review practice to fulfil new resuscitation guidance, which will have training and resource implications. PMID:22245743

The Department of Defense and Veteran Affairs Health Care Joint Venture at Tripler Army Medical Center Needs More Management Oversight

DTIC Science & Technology

2013-09-18

Affairs Pacific Island Health Care System TAMC, home of the Pacific Regional Medical Command (PRMC), is the only Federal tertiary care hospital in... Clinical Activities, National Level Interagency Agreements, TRICARE/VA Contractor Relationships, Joint Ventures, and Health Systems Studies. As of FY...reasons: because the date of service falls outside the validity period for the authorization or because the clinic that provided treatment was not

Implementing advanced nurse practitioner roles in acute care: an evaluation of organizational change.

PubMed

Cummings, Greta G; Fraser, Kim; Tarlier, Denise S

2003-03-01

Medical shortages are seen as the driving force behind the recent implementation of the advanced nurse practitioner (ANP) role in some Canadian hospitals. The authors analyzed the implementation of the ANP role in one tertiary care teaching hospital from the organizational change perspective. Despite successful implementation, issues of role definition, scope of practice boundaries, and staff reactions remain unresolved. Recommendations are discussed for implementing ANP roles in other acute care facilities.

The tertiary lake-basin at Florissant, Colorado, between South and Hayden Parks

USGS Publications Warehouse

Scudder, Samuel H.

1883-01-01

The following remarks are based upon collections and notes made during a visit to Florissant, in the summer of 1877, in company with Messrs. Arthur Lakes, of Golden, Colo., and F. C. Bowditch, of Boston, Mass. As five days only were spent in the place, most of the time was given up to the collection and care of specimens, so that only a general survey of the locality was possible. Mr. Lakes especially gave himself to the study of the geology of the district, and as he was previously familiar with the structure of the surrounding country, and placed his notes at my disposal, the first part of this paper should be considered our joint production.

Amputation and Diabetes: How to Protect Your Feet

MedlinePlus

... size. Your doctor may recommend specially designed shoes (orthopedic shoes) that fit the exact shape of your ... of a tertiary diabetes foot care service. Diabetes Research and Clinical Practice. 2016;114:69. Diabetes and ...

Initial Experience with "Honoring Choices Wisconsin": Implementation of an Advance Care Planning Pilot in a Tertiary Care Setting.

PubMed

Peltier, Wendy L; Gani, Faiz; Blissitt, Jennifer; Walczak, Katherine; Opper, Kristi; Derse, Arthur R; Johnston, Fabian M

2017-09-01

Although previous research on advance care planning (ACP) has associated ACP with improved quality of care at the end of life, the appropriate use of ACP remains limited. To evaluate the impact of a pilot program using the "Honoring Choices Wisconsin" (HCW) model for ACP in a tertiary care setting, and to understand barriers to system-wide implementation. Retrospective review of prospectively collected data. Patients who received medical or surgical oncology care at Froedtert and the Medical College of Wisconsin. Patient demographics, disease characteristics, patient satisfaction, and clinical outcomes. Data from 69 patients who died following the implementation of the HCW program were reviewed; 24 patients were enrolled in the HCW program while 45 were not. Patients enrolled in HCW were proportionally less likely to be admitted to the ICU (12.5% vs. 17.8%) and were more likely to be "do not resuscitate" (87.5% vs. 80.0%), as well as have a completed ACP (83.3% vs. 79.1%). Furthermore, admission to a hospice was also higher among patients who were enrolled in the HCW program (79.2% vs. 25.6%), with patients enrolled in HCW more likely to die in hospice (70.8% vs. 53.3%). The HCW program was favorably viewed by patients, patient caregivers, and healthcare providers. Implementation of a facilitator-based ACP care model was associated with fewer ICU admissions, and a higher use of hospice care. System-level changes are required to overcome barriers to ACP that limit patients from receiving end-of-life care in accordance with their preferences.

Minimal acceptable care as a vital component to Missouri's trauma system.

PubMed

Helling, Thomas S

2002-07-01

Immediate attention to life-threatening injuries and expeditious transfer of major and complex wounds to tertiary care trauma centers are the cornerstones of any trauma system. Rapid assessment and "minimalization" of care should be the buzz-word of rural (Level III) and suburban (Level II) trauma centers in order to provide quickest treatment of injuries by timely referral of patients for definitive attention. This concept is called minimal acceptable care and may serve to improve patient outcome by reducing the interval to ultimate treatment and avoidance of duplication of services.

Stable isotope evidence for gradual environmental changes and species survivorship across the Cretaceous/Tertiary Boundary

NASA Astrophysics Data System (ADS)

Barrera, Enriqueta; Keller, Gerta

1990-12-01

High-resolution δ13C and δ18O records have been generated from analyses of the planktonic foraminiferal species Heterohelix globulosa and the benthonic foraminiferal taxon Lenticulina spp from 3 m of a cored section spanning the Cretaceous/Tertiary (K/T) boundary at Brazos River, Texas. These are the first stable isotope records across the K/T boundary based on monospecific and monogeneric foraminiferal samples. They show a gradual decrease in δ13C values of about 2.5 permil beginning at the K/T boundary, as defined by the first appearance of Tertiary planktonic foraminifera, and continuing 17-20 cm above the boundary, approximately 40,000 years later. Gradual 13C depletion contrasts with the sudden δ13C drop at the K/T boundary observed in many deep-sea sections. The surface-to-bottom δ13C gradient decreased to less than zero approximately 25,000-30,000 years after the K/T boundary and remained negative for at least the next 140,000 years. Concomitant with change in δ13C values is a gradual decrease of about 2.5 permil in δ18C values which has not been observed at other localities. This 18O depletion suggests changes in temperature and/or salinity in the earliest Paleocene Gulf of Mexico. No extinction of foraminiferal species is associated with the K/T boundary or the onset of 18O and 13C depletions. Instead, two phases of Cretaceous species extinctions occur. One extinction phase is below the K/T boundary and below the tsunami bed of Bourgeois et al. [1988] and may be linked to sea level regression and environmental perturbations. The second extinction phase coincides with the minimum in δ13C and δ18O values in the Early Danian (Zone P0/Pla) and appears directly related to environmental changes reflected in the isotopic record. H. globulosa, which is commonly present in Maastrichtian and Danian sediments, exhibits significantly lower 18O/16O and 13C/12C ratios in Tertiary sediments relative to specimens from Maastrichtian sediments, demonstrating the survival of this important Cretaceous taxon after the K/T boundary event.

Explaining the de-prioritization of primary prevention: Physicians' perceptions of their role in the delivery of primary care

PubMed Central

Mirand, Amy L; Beehler, Gregory P; Kuo, Christina L; Mahoney, Martin C

2003-01-01

Background While physicians are key to primary preventive care, their delivery rate is sub-optimal. Assessment of physician beliefs is integral to understanding current behavior and the conceptualization of strategies to increase delivery. Methods A focus group with regional primary care physician (PCP) Opinion Leaders was conducted as a formative step towards regional assessment of attitudes and barriers regarding preventive care delivery in primary care. Following the PRECEDE-PROCEED model, the focus group aim was to identify conceptual themes that characterize PCP beliefs and practices regarding preventive care. Seven male and five female PCPs (family medicine, internal medicine) participated in the audiotaped discussion of their perceptions and behaviors in delivery of primary preventive care. The transcribed audiotape was qualitatively analyzed using grounded theory methodology. Results The PCPs' own perceived role in daily practice was a significant barrier to primary preventive care. The prevailing PCP model was the "one-stop-shop" physician who could provide anything from primary to tertiary care, but whose provision was dominated by the delivery of immediate diagnoses and treatments, namely secondary care. Conclusions The secondary-tertiary prevention PCP model sustained the expectation of immediacy of corrective action, cure, and satisfaction sought by patients and physicians alike, and, thereby, de-prioritized primary prevention in practice. Multiple barriers beyond the immediate control of PCP must be surmounted for the full integration of primary prevention in primary care practice. However, independent of other barriers, physician cognitive value of primary prevention in practice, a base mediator of physician behavior, will need to be increased to frame the likelihood of such integration. PMID:12729463

Evaluation of Viewpoints of Health Care Professionals on the Role of Ethics Committees and Hospitals in the Resolution of Clinical Ethical Dilemmas Based on Practice Environment.

PubMed

Marcus, Brian S; Carlson, Jestin N; Hegde, Gajanan G; Shang, Jennifer; Venkat, Arvind

2016-03-01

We sought to evaluate whether health care professionals' viewpoints differed on the role of ethics committees and hospitals in the resolution of clinical ethical dilemmas based on practice location. We conducted a survey study from December 21, 2013 to March 15, 2014 of health care professionals at six hospitals (one tertiary care academic medical center, three large community hospitals and two small community hospitals). The survey consisted of eight clinical ethics cases followed by statements on whether there was a role for the ethics committee or hospital in their resolution, what that role might be and case specific queries. Respondents used a 5-point Likert scale to express their degree of agreement with the premises posed. We used the ANOVA test to evaluate whether respondent views significantly varied based on practice location. 240 health care professionals (108-tertiary care center, 92-large community hospitals, 40-small community hospitals) completed the survey (response rate: 63.6 %). Only three individual queries of 32 showed any significant response variations across practice locations. Overall, viewpoints did not vary across practice locations within question categories on whether the ethics committee or hospital had a role in case resolution, what that role might be and case specific queries. In this multicenter survey study, the viewpoints of health care professionals on the role of ethics committees or hospitals in the resolution of clinical ethics cases varied little based on practice location.

The cost of postabortion care and legal abortion in Colombia.

PubMed

Prada, Elena; Maddow-Zimet, Isaac; Juarez, Fatima

2013-09-01

Although Colombia partially liberalized its abortion law in 2006, many abortions continue to occur outside the law and result in complications. Assessing the costs to the health care system of safe, legal abortions and of treating complications of unsafe, illegal abortions has important policy implications. The Post-Abortion Care Costing Methodology was used to produce estimates of direct and indirect costs of postabortion care and direct costs of legal abortions in Colombia. Data on estimated costs were obtained through structured interviews with key informants at a randomly selected sample of facilities that provide abortion-related care, including 25 public and private secondary and tertiary facilities and five primary-level private facilities that provide specialized reproductive health services. The median direct cost of treating a woman with abortion complications ranged from $44 to $141 (in U.S. dollars), representing an annual direct cost to the health system of about $14 million per year. A legal abortion at a secondary or tertiary facility was costly (medians, $213 and $189, respectively), in part because of the use of dilation and curettage, as well as because of administrative barriers. At specialized facilities, where manual vacuum aspiration and medication abortion are used, the median cost of provision was much lower ($45). Provision of postabortion care and legal abortion services at higher-level facilities results in unnecessarily high health care costs. These costs can be reduced significantly by providing services in a timely fashion at primary-level facilities and by using safe, noninvasive and less costly abortion methods.

Travel time and cancer care: an example of the inverse care law?

PubMed

Baird, G; Flynn, R; Baxter, G; Donnelly, M; Lawrence, J

2008-01-01

There is growing evidence that in rural areas cancer mortality is higher and referral occurs later, indicating different patterns of care. In Scotland services to rural areas have been organized through 'managed clinical networks'. In some cases, these organizational networks have been structured so that the referral hospital is not the one nearest to the patient's home. This study set out to discover if access to cancer specialist care in mainland Scotland altered with distance to tertiary care facilities. The aim was to explore the relationship between hospital admission rates, type of hospital and travel time. Retrospective analysis of all registered cancers in Scotland over the three-year period 2000-2002, examining incidence rates and accessibility of care over 3 years, measured by hospital discharge rates (equivalent to admission rates) and mean bed days for cancer patients. The type of hospital to which a cancer patient was admitted and the duration of admission varied with travel distance from a patient's home. All patients travelling more than one hour had lower admission rates to a specialist cancer centre. Those travelling more than 3 hours were not always admitted to the facility nearest their home address and were admitted for significantly fewer days than all other groups. Differences in tertiary cancer care obtained may explain some of the reasons behind late presentation and higher mortality rates. This study provides evidence that the recognized increased cancer mortality in rural patients is indeed compounded by an increased travel burden.

Perception on Informed Consent Regarding Nursing Care Practices in a Tertiary Care Center.

PubMed

Paudel, B; Shrestha, G K

Background Consent for care procedures is mandatory after receipt of adequate information. It maintains patient's rights and autonomy to make thoughtful decisions. Poor communication often leads to poor health quality. Objective To assess hospitalized patients' perception on informed consent regarding nursing care practices in a tertiary care center. Method This is a descriptive cross-sectional study among 113 admitted patients conducted in February 2012 at Dhulikhel Hospital, Nepal. Patients of various wards were selected using purposive non-probability sampling with at least 3 days of hospitalization. Close ended structured questionnaire was used to assess patients' perception on three different areas of informed consent (information giving, opportunity to make decision and taking prior consent). Result Among the participants 71.6% perceived positively regarding informed consent towards nursing care practices with a mean score of 3.32 ± 1.28. Patients' perception on various areas of informed consent viz. information giving, opportunities to make specific decision and taking prior consent were all positive with mean values of 3.43±1.12, 2.88±1.23, 3.65±1.49 respectively. Comparison of mean perception of informed consent with various variables revealed insignificant correlation (p-value >0.05) for age, educational level and previous hospitalization while it was significant (p-value < 0.05) for communication skills of nurses. Conclusion Majority of patients have positive perception on informed consent towards nursing care practices. Communication skills of nurses affect the perception of patients' regardless of age, education level and past experiences.

Care for post-stroke patients at Malaysian public health centres: self-reported practices of family medicine specialists.

PubMed

Abdul Aziz, Aznida F; Mohd Nordin, Nor Azlin; Abd Aziz, Noor; Abdullah, Suhazeli; Sulong, Saperi; Aljunid, Syed M

2014-03-02

Provision of post stroke care in developing countries is hampered by discoordination of services and limited access to specialised care. Albeit shortcomings, primary care continues to provide post-stroke services in less than favourable circumstances. This paper aimed to review provision of post-stroke care and related problems among Family Medicine Specialists managing public primary health care services. A semi-structured questionnaire was distributed to 121 Family Physicians servicing public funded health centres in a pilot survey focused on improving post stroke care provision at community level. The questionnaire assessed respondents background and practice details i.e. estimated stroke care burden, current service provision and opinion on service improvement. Means and frequencies described quantitative data. For qualitative data, constant comparison method was used until saturation of themes was reached. Response rate of 48.8% was obtained. For every 100 patients seen at public healthcentres each month, 2 patients have stroke. Median number of stroke patients seen per month is 5 (IQR 2-10). 57.6% of respondents estimated total stroke patients treated per year at each centre was less than 40 patients. 72.4% lacked a standard care plan although 96.6% agreed one was needed. Patients seen were: discharged from tertiary care (88.1%), shared care plan with specialists (67.8%) and patients who developed stroke during follow up at primary care (64.4%). Follow-ups were done at 8-12 weekly intervals (60.3%) with 3.4% on 'as needed' basis. Referrals ranked in order of frequency were to physiotherapy services, dietitian and speech and language pathologists in public facilities. The FMS' perceived 4 important 'needs' in managing stroke patients at primary care level; access to rehabilitation services, coordinated care between tertiary centres and primary care using multidisciplinary care approach, a standardized guideline and family and caregiver support. Post discharge stroke care guidelines and access to rehabilitation services at primary care is needed for post stroke patients residing at home in the community.

[Telemetric monitoring reduces visits to the emergency room and cost of care in patients with chronic heart failure].

PubMed

Pérez-Rodríguez, Gilberto; Brito-Zurita, Olga Rosa; Sistos-Navarro, Enrique; Benítez-Aréchiga, Zaria Margarita; Sarmiento-Salazar, Gloria Leticia; Vargas-Lizárraga, José Feliciano

2015-01-01

Tele-cardiology is the use of information technologies that help prolong survival, improve quality of life and reduce costs in health care. Heart failure is a chronic disease that leads to high care costs. To determine the effectiveness of telemetric monitoring for controlling clinical variables, reduced emergency room visits, and cost of care in a group of patients with heart failure compared to traditional medical consultation. A randomized, controlled and open clinical trial was conducted on 40 patients with Heart failure in a tertiary care centre in north-western Mexico. The patients were divided randomly into 2 groups of 20 patients each (telemetric monitoring, traditional medical consultation). In each participant was evaluated for: blood pressure, heart rate and body weight. The telemetric monitoring group was monitored remotely and traditional medical consultation group came to the hospital on scheduled dates. All patients could come to the emergency room if necessary. The telemetric monitoring group decreased their weight and improved control of the disease (P=.01). Systolic blood pressure and cost of care decreased (51%) significantly compared traditional medical consultation group (P>.05). Admission to the emergency room was avoided in 100% of patients in the telemetric monitoring group. In patients with heart failure, the telemetric monitoring was effective in reducing emergency room visits and saved significant resources in care during follow-up. Copyright © 2015 Academia Mexicana de Cirugía A.C. Published by Masson Doyma México S.A. All rights reserved.

First report of Candida auris in America: Clinical and microbiological aspects of 18 episodes of candidemia.

PubMed

Calvo, Belinda; Melo, Analy S A; Perozo-Mena, Armindo; Hernandez, Martin; Francisco, Elaine Cristina; Hagen, Ferry; Meis, Jacques F; Colombo, Arnaldo Lopes

2016-10-01

Characterization of a hospital outbreak of Candida auris candidemia that involved 18 critically ill patients in Venezuela. Bloodstream isolates of C. auris obtained from 18 patients admitted at a medical center in Maracaibo, between March, 2012 and July, 2013 were included. Species identification was confirmed by ITS rDNA sequencing. Isolates were subsequently typed by amplified fragment length polymorphism fingerprinting (AFLP). Susceptibility testing was performed according to CLSI. Clinical data were collected from all cases by using a standard clinical form. A total of 13 critically ill pediatric and 5 adult patients, with a median age of 26 days, were included. All were previously exposed to antibiotics and multiple invasive medical procedures. Clinical management included prompt catheter removal and antifungal therapy. Thirteen patients (72%) survived up to 30 days after onset of candidemia. AFLP fingerprinting of all C. auris isolates suggested a clonal outbreak. The isolates were considered resistant to azoles, but susceptible to anidulafungin and 50% of isolates exhibited amphotericin B MIC values of >1 μg/ml. The study demonstrated that C. auris is a multiresistant yeast pathogen that can be a source of health-care associated infections in tertiary care hospitals with a high potential for nosocomial horizontal transmission. Copyright © 2016 The British Infection Association. Published by Elsevier Ltd. All rights reserved.

Burnout in Otolaryngology-Head and Neck Surgery: A Single Academic Center Experience.

PubMed

Geelan-Hansen, Katie; Anne, Samantha; Benninger, Michael S

2018-05-01

Burnout in modern medicine is becoming more recognized and researched. The objective in this study is to evaluate burnout in a tertiary care academic institution and compare results among faculty, trainees, and advanced practice practitioners (APPs) in a cross-sectional survey using the Maslach Burnout Inventory. Fifty-two surveys were distributed; 44 participants completed the survey (85%): 25 staff physicians (57%), 14 resident physicians (32%), and 5 nurse practitioners (11%). Staff physicians had low emotional exhaustion, moderate depersonalization, and low result for reduced personal accomplishments; trainees reported low emotional exhaustion, high depersonalization, and moderate reduced personal accomplishment; and nurse practitioners reported moderate on all 3 dimensions. There is overall low burnout in this tertiary care academic center of otolaryngologist providers and no difference in rates among the different groups (trainees, APPs, staff). Measures addressing specific deficiencies among dimensions of burnout would be helpful to prevent disintegration of physician satisfaction into burnout.

Parent perspectives on attrition from tertiary care pediatric weight management programs.

PubMed

Hampl, Sarah; Demeule, Michelle; Eneli, Ihuoma; Frank, Maura; Hawkins, Mary Jane; Kirk, Shelley; Morris, Patricia; Sallinen, Bethany J; Santos, Melissa; Ward, Wendy L; Rhodes, Erinn

2013-06-01

To describe parent/caregiver reasons for attrition from tertiary care weight management clinics/programs. A telephone survey was administered to 147 parents from weight management clinics/programs in the National Association of Children's Hospitals and Related Institutions' (now Children's Hospital Association's) FOCUS on a Fitter Future II collaborative. Scheduling, barriers to recommendation implementation, and transportation issues were endorsed by more than half of parents as having a moderate to high influence on their decision not to return. Family motivation and mismatched expectations between families and clinic/program staff were mentioned as influential by more than one-third. Only mismatched expectations correlated with patient demographics and program characteristics. [corrected]. Although limited by small sample size, the study found that parents who left geographically diverse weight management clinics/programs reported similar reasons for attrition. Future efforts should include offering alternative visit times, more treatment options, and financial and transportation assistance and exploring family expectations.

Towards a rational antimicrobial testing policy in the laboratory.

PubMed

Banaji, N; Oommen, S

2011-01-01

Antimicrobial policy for prophylactic and therapeutic use of antimicrobials in a tertiary care setting has gained importance. A hospital's antimicrobial policy as laid down by its hospital infection control team needs to include inputs from the microbiology laboratory, besides the pharmacy and therapeutic committee. Therefore, it is of utmost importance that clinical microbiologists across India follow international guidelines and also take into account local settings, especially detection and presence of resistance enzymes. This article draws a framework for rational antimicrobial testing in our laboratories in tertiary care centers, from the Clinical and Laboratory Standards Institute guidelines. It does not address testing methodologies but suggests ways and means by which antimicrobial susceptibility reporting can be rendered meaningful not only to the treating physician but also to the resistance monitoring epidemiologist. It hopes to initiate some standardization in rational choice of antimicrobial testing in laboratories in the country pertaining to nonfastidious bacteria.

Metabolic Abnormalities and Clinical Lipodystrophy in Children With Human Immunodeficiency Virus Infection: A Report From a Tertiary Care Center in India.

PubMed

Kumar, Prasanna; Suri, Deepti; Vignesh, Pandiarajan; Verma Attri, Savita; Kumar Bhalla, Anil; Singh, Surjit

2017-12-01

A cross-sectional study from a tertiary care center in India was undertaken to assess and compare the prevalence of blood glucose and lipid profile aberrations in children who received first-line antiretroviral therapy (ART; n = 63) and in children who were naïve to ART (n = 46). Impaired fasting blood glucose values were found in 7 children in ART-experienced group but none in ART-naïve group (P = 0.02). Low concentrations of high-density lipoprotein cholesterol were more prevalent in the ART-naïve group compared with ART-experienced group (54.3% vs. 22.2%; P = 0.001). Hypertriglyceridemia was noted in a significant proportion of both ART-naïve (43.5%) and ART-experienced children (39.7%). Incidence of clinical lipodystrophy was 47.7%, and there was no significant association noted between lipid profile abnormalities and lipodystrophy.

Risk factors and costs of oral cancer in a tertiary care hospital in Delhi.

PubMed

Goyal, Sandeep; Tiwari, Vijay Kumar; Nair, Kesavan Sreekantan; Raj, Sherin

2014-01-01

The present study conducted with 100 oral cancer patients at a private tertiary care hospital in Delhi demonstrated that stage III cancer was associated with longer use of tobacco and poor oral hygiene. There was also statistically significant association (p<.05) between consumption of tobacco and alcohol. More than 60% treatment expenditure was on surgery followed by accommodation (9%) and investigations (8%). The effect of tobacco was well known among patients as 76% of the patients knew that common cancer in tobacco chewer is 'oral cancer', 22% of the patients however responded that they did not know which cancer is common in tobacco chewers. 58% said that they learnt about ill effects of tobacco from media while 24% said they learnt from family and friends. Out of 78 tobacco users, 60 (77%) said that they never received help to quit tobacco while 18(23%) have received help to quit.

Co-isolation of Vahlkampfia and acanthamoeba in acanthamoeba-like keratitis in a Spanish population.

PubMed

Arnalich-Montiel, Francisco; Lorenzo-Morales, Jacob; Irigoyen, Cristina; Morcillo-Laiz, Rafael; López-Vélez, Rogelio; Muñoz-Negrete, Francisco; Piñero, Jose E; Valladares, Basilio

2013-05-01

To report the co-isolation incidence of Acanthamoeba and Vahlkampfia in amoebic keratitis from a tertiary care institution in Madrid, Spain. In this retrospective case series, 7 eyes of 7 consecutive patients with culture-proven or polymerase chain reaction-positive Acanthamoeba keratitis were seen at a tertiary care institution from January 2010 to April 2011, and their charts were reviewed. Two of 7 patients showed mixed Acanthamoeba and Vahlkampfia keratitis. Good clinical response to the treatment was strongly correlated with early diagnosis, whereas delayed diagnosis resulted in poor response to the treatment in single or mixed infection. Co-isolation of Vahlkampfia and Acanthamoeba in Acanthamoeba-like keratitis has recently been detected in our population. This finding should raise awareness of the existence of other amoeba different from Acanthamoeba causing keratitis. There are not enough cases yet to determine the impact of mixed amoebic keratitis in the prognosis of this disease.

Utilization of arterial blood gas measurements in a large tertiary care hospital.

PubMed

Melanson, Stacy E F; Szymanski, Trevor; Rogers, Selwyn O; Jarolim, Petr; Frendl, Gyorgy; Rawn, James D; Cooper, Zara; Ferrigno, Massimo

2007-04-01

We describe the patterns of utilization of arterial blood gas (ABG) tests in a large tertiary care hospital. To our knowledge, no hospital-wide analysis of ABG test utilization has been published. We analyzed 491 ABG tests performed during 24 two-hour intervals, representative of different staff shifts throughout the 7-day week. The clinician ordering each ABG test was asked to fill out a utilization survey. The most common reasons for requesting an ABG test were changes in ventilator settings (27.6%), respiratory events (26.4%), and routine (25.7%). Of the results, approximately 79% were expected, and a change in patient management (eg, a change in ventilator settings) occurred in 42% of cases. Many ABG tests were ordered as part of a clinical routine or to monitor parameters that can be assessed clinically or through less invasive testing. Implementation of practice guidelines may prove useful in controlling test utilization and in decreasing costs.

Utility of video-EEG monitoring in a tertiary care epilepsy center.

PubMed

Kumar-Pelayo, M; Oller-Cramsie, M; Mihu, N; Harden, C

2013-09-01

Our video-EEG monitoring (VEEG) unit is part of a typical metropolitan tertiary care center that services a diverse patient population. We aimed to determine if the specific clinical reason for inpatient VEEG was actually resolved. Our method was to retrospectively determine the stated goal of inpatient VEEG and to analyze the outcome of one hundred consecutive adult patients admitted for VEEG. The reason for admission fit into one of four categories: 1) to characterize paroxysmal events as either epileptic or nonepileptic, 2) to localize epileptic foci, 3) to characterize the epilepsy syndrome, and 4) to attempt safe antiepileptic drug adjustment. We found that VEEG was successful in accomplishing the goal of admission in 77% of cases. The remaining 23% failed primarily due to lack of typical events during monitoring. Furthermore, of the overall study cohort, VEEG outcomes altered medical management in 53% and surgery was pursued in 5%. © 2013.

Radiology Consultation in the Era of Precision Oncology: A Review of Consultation Models and Services in the Tertiary Setting.

PubMed

DiPiro, Pamela J; Krajewski, Katherine M; Giardino, Angela A; Braschi-Amirfarzan, Marta; Ramaiya, Nikhil H

2017-01-01

The purpose of the article is to describe the various radiology consultation models in the Era of Precision Medicine. Since the inception of our specialty, radiologists have served as consultants to physicians of various disciplines. A variety of radiology consultation services have been described in the literature, including clinical decision support, patient-centric, subspecialty interpretation, and/or some combination of these. In oncology care in particular, case complexity often merits open dialogue with clinical providers. To explore the utility and impact of radiology consultation services in the academic setting, this article will further describe existing consultation models and the circumstances that precipitated their development. The hybrid model successful at our tertiary cancer center is discussed. In addition, the contributions of a consultant radiologist in breast cancer care are reviewed as the archetype of radiology consultation services provided to oncology practitioners.

Antibiotic Susceptibility Patterns of Bacterial Isolates from Pus Samples in a Tertiary Care Hospital of Punjab, India

PubMed Central

Trojan, Rugira; Razdan, Lovely

2016-01-01

We determined the prevalence and antibiotic susceptibilities patterns of bacterial isolates from pus samples collected from patients in a tertiary care hospital of Punjab, India. E. coli was the most prevalent pathogen (51.2%) followed by Staphylococcus aureus (21%), Klebsiella pneumoniae (11.6%), Pseudomonas aeruginosa (5.8%), Citrobacter spp. (3.5%), Acinetobacter baumannii (2.3%), Proteus mirabilis (2.3%), and Streptococcus spp. (2.3%). E. coli, K. pneumoniae, A. baumannii, and Citrobacter isolates were resistant to multiple antibiotics including higher generation cephalosporins. S. aureus and Streptococcus isolates were sensitive to cloxacillin and vancomycin. However, P. aeruginosa, P. mirabilis, and Streptococcus isolates were found to be less resistant to the spectrum of antibiotics tested. Overall, our findings indicate the prevalence of resistance to different classes of antibiotics in bacterial isolates from pus infections and hence highlight the need for effective surveillance, regulator reporting, and antibiogram-guided antibiotic prescription. PMID:27872643

Antibiotic Susceptibility Patterns of Bacterial Isolates from Pus Samples in a Tertiary Care Hospital of Punjab, India.

PubMed

Trojan, Rugira; Razdan, Lovely; Singh, Nasib

2016-01-01

We determined the prevalence and antibiotic susceptibilities patterns of bacterial isolates from pus samples collected from patients in a tertiary care hospital of Punjab, India. E. coli was the most prevalent pathogen (51.2%) followed by Staphylococcus aureus (21%), Klebsiella pneumoniae (11.6%), Pseudomonas aeruginosa (5.8%), Citrobacte r spp. (3.5%), Acinetobacter baumannii (2.3%), Proteus mirabilis (2.3%), and Streptococcus spp. (2.3%). E. coli , K. pneumoniae , A. baumannii , and Citrobacter isolates were resistant to multiple antibiotics including higher generation cephalosporins. S. aureus and Streptococcus isolates were sensitive to cloxacillin and vancomycin. However, P. aeruginosa , P. mirabilis , and Streptococcus isolates were found to be less resistant to the spectrum of antibiotics tested. Overall, our findings indicate the prevalence of resistance to different classes of antibiotics in bacterial isolates from pus infections and hence highlight the need for effective surveillance, regulator reporting, and antibiogram-guided antibiotic prescription.

Six Sigma process utilization in reducing door-to-balloon time at a single academic tertiary care center.

PubMed

Kelly, Elizabeth W; Kelly, Jonathan D; Hiestand, Brian; Wells-Kiser, Kathy; Starling, Stephanie; Hoekstra, James W

2010-01-01

Rapid reperfusion in patients with ST-elevation myocardial infarction (STEMI) is associated with lower mortality. Reduction in door-to-balloon (D2B) time for percutaneous coronary intervention requires multidisciplinary cooperation, process analysis, and quality improvement methodology. Six Sigma methodology was used to reduce D2B times in STEMI patients presenting to a tertiary care center. Specific steps in STEMI care were determined, time goals were established, and processes were changed to reduce each step's duration. Outcomes were tracked, and timely feedback was given to providers. After process analysis and implementation of improvements, mean D2B times decreased from 128 to 90 minutes. Improvement has been sustained; as of June 2010, the mean D2B was 56 minutes, with 100% of patients meeting the 90-minute window for the year. Six Sigma methodology and immediate provider feedback result in significant reductions in D2B times. The lessons learned may be extrapolated to other primary percutaneous coronary intervention centers. Copyright © 2010 Elsevier Inc. All rights reserved.

Ponseti Treatment in the Management of Clubfoot Deformity – A Continuing Role for Paediatric Orthopaedic Services in Secondary Care Centres

PubMed Central

Docker, Charles EJ; Lewthwaite, Simon; Kiely, Nigel T

2007-01-01

INTRODUCTION The Ponseti technique is a well-proven way of managing paediatric clubfoot deformity. We describe a management set-up which spreads the care between secondary and tertiary care with no loss of quality. PATIENTS AND METHODS In our audit of the first 2 years of Ponseti casting in the treatment of idiopathic congenital talipes equinovarus (CTEV, clubfoot) deformity, we identified 77 feet having been treated in 50 patients. Forty-nine feet were treated primarily in Oswestry, a tertiary referral centre for paediatric orthopaedic conditions, and 13 feet were treated in conjunction with the physiotherapy department at one of the region's district general hospitals (Leighton Hospital, Crewe, Cheshire). RESULTS Similar good results and low requirement for surgical interventions other than Achilles tenotomy, which forms part of the Ponseti regimen, were found in both cohorts. CONCLUSIONS This ‘hub-and-spoke’ approach would appear to be efficient in terms of resource utilisation. Additional benefits atients and their carers include ease of access to services and reduced financial and transport burdens. PMID:17688726

Choosing wisely and the use of antibiotics in ophthalmic surgery: There is more than meets the eye.

PubMed

Grosso, Andrea; Ceruti, Piero; Scarpa, Giuseppe; Giardini, Franco; Marchini, Giorgio; Aragona, Emanuela; Bert, Fabrizio; Bandello, Francesco; Siliquini, Roberta

2018-02-01

One of the directions of modern ophthalmology is toward an odontoiatric model, and new settings of eye care are becoming the standard of care: one day surgery and also office-based therapies. Retrospective analysis of three tertiary-care centers in Italy and analysis of the literature. We provide readers with state-of-the-art measures of prophylaxis in ophthalmic surgery. Role of antibiotics is criticized in the light of stewardship antimicrobial paradigm.

Long-term healthcare cost reduction with Intensive Short-term Dynamic Psychotherapy in a tertiary psychiatric service.

PubMed

Abbass, Allan; Kisely, Steve; Rasic, Daniel; Town, Joel M; Johansson, Robert

2015-05-01

To evaluate whether a mixed population of patients treated with Intensive Short-term Dynamic Psychotherapy (ISTDP) would exhibit reduced healthcare costs in long-term follow-up. A quasi-experimental design was employed in which data on pre- and post-treatment healthcare cost were compared for all ISTDP cases treated in a tertiary care service over a nine year period. Observed cost changes were compared with those of a control group of patients referred but never treated. Physician and hospital costs were compared to treatment cost estimates and normal population cost figures. 1082 patients were included; 890 treated cases for a broad range of somatic and psychiatric disorders and 192 controls. The treatment averaged 7.3 sessions and measures of symptoms and interpersonal problems significantly improved. The average cost reduction per treated case was $12,628 over 3 follow-up years: this compared favorably with the estimated treatment cost of $708 per patient. Significant differences were seen between groups for follow-up hospital costs. ISTDP in this setting appears to facilitate reductions in healthcare costs, supporting the notion that brief dynamic psychotherapy provided in a tertiary setting can be beneficial to health care systems overall. CLINICALTRIALS. NCT01924715. Copyright © 2015 Elsevier Ltd. All rights reserved.

Factors affecting utilization of university health services in a tertiary institution in South-West Nigeria.

PubMed

Obiechina, G O; Ekenedo, G O

2013-01-01

Most university health services have extensive health infrastructures, for the provision of effective and efficient health services to the students. In this study, we have tried to determine student's perception of factors affecting their utilization. To determine students' perception of health care services provided in a tertiary institution and assess students' attitude towards utilization. Simple random sampling technique was used to select 540 respondents, comprising of 390 males and 150 females. A structured and self-administered questionnaire was the instrument used to collect data for the study, while data collected was analyzed using descriptive statistics of frequency count and percentage. High cost of drugs (72.0%), non availability of essential drugs (54.8%), time spent waiting for treatment (67.2%), inadequate referral services (81.7%), and satisfaction with services (60.6%) were considered by the respondents as factors affecting the utilization of university health services. Students-medical staff relationship and accessibility to health facility (77.6% and 74.3% respectively) were, however, not considered as factors that affect utilization of university health services. It is recommended that to improve utilization and cost of care, government should make necessary efforts to incorporate tertiary institution into National Health Insurance scheme so that students above the age of 18 years can benefit from free treatment.

Environment surveillance of filamentous fungi in two tertiary care hospitals in China.

PubMed

Hao, Zhen-feng; Ao, Jun-hong; Hao, Fei; Yang, Rong-ya; Zhu, He; Zhang, Jie

2011-07-05

Invasive fungal infections have constituted an increasingly important cause of morbidity and mortality in immunocompromised patients. In this study, a surveillance project was conducted in three different intensive care units of two large tertiary hospitals in China. A one-year surveillance project was conducted in two tertiary hospitals which located in northern China and southwest China respectively. Air, surfaces and tap water were sampled twice a month in a central intensive care unit, a bone marrow transplant unit, a neurosurgery intensive care unit and a live transplant department. Environmental conditions such as humidity, temperature and events taking place, for example the present of the visitors, healthcare staff and cleaning crew were also recorded at the time of sampling. The air fungal load was 91.94 cfu/m(3) and 71.02 cfu/m(3) in the southwest China hospital and the northern China hospital respectively. The five most prevalent fungi collected from air and surfaces were Penicillium spp., Cladospcrium spp., Alternaria spp., Aspergillus spp. and Saccharomyces spp. in the southwest China hospital, meanwhile Penicillium spp., Fusarium spp., Aspergillus spp., Alternaria spp. and Cladospcrium spp. in the northern China hospital. The least contaminated department was intensive care units, and the heaviest contaminated department was neurosurgery intensive care unit. Seventy-three percent of all surfaces examined in the northern China hospital and eighty-six percent in the southwest China hospital yielded fungi. Fifty-four percent of water samples from the northern China hospital and forty-nine percent from the southwest China hospital yielded fungi. These findings suggested that the fungus exist in the environment of the hospital including air, surface and water. Air and surface fungal load fluctuated over the year. Air fungal load was lower in winter and higher in summer and autumn, but seldom exceeded acceptable level. The higher values were created during May to August in the northern China hospital and May to June and September to October in the southwest China hospital. A correlation between air fungal load and humidity, as well as personnel was observed.

Women's experience of intrapartum transfer from a Western Australian birth centre co-located to a tertiary maternity hospital.

PubMed

Kuliukas, Lesley; Duggan, Ravani; Lewis, Lucy; Hauck, Yvonne

2016-02-08

The aim of this Western Australian study was to describe the overall labour and birth experience of women who were transferred during the first and second stages of labour from a low risk woman-centred, midwifery-led birth centre to a co-located tertiary maternity referral hospital. Using a descriptive phenomenological design, fifteen women were interviewed up to 8 weeks post birth (July to October, 2013) to explore their experience of the intrapartum transfer. Giorgi's method of analysis was used. The following themes and subthemes emerged: 1) The midwife's voice with subthemes, a) The calming effect and b) Speaking up on my behalf; 2) In the zone with subthemes, a) Hanging in there and b) Post birth rationalizing; 3) Best of both worlds with subthemes a) The feeling of relief on transfer to tertiary birth suite and b) Returning back to the comfort and familiarity of the birth centre; 4) Lost sense of self; and 5) Lost birth dream with subthemes a) Narrowing of options and b) Feeling of panic. Women found the midwife's voice guided them through the transfer experience and were appreciative of continuity of care. There was a sense of disruption to expectations and disappointment in not achieving the labour and birth they had anticipated. There was however appreciation that the referral facility was nearby and experts were close at hand. The focus of care altered from woman to fetus, making women feel diminished. Women were glad to return to the familiar birth centre after the birth with the opportunity to talk through and fully understand their labour journey which helped them contextualise the transfer as one part of the whole experience. Findings can inform midwives of the value of a continuity of care model within a birth centre, allowing women both familiarity and peace of mind. Maternity care providers should ensure that the woman remains the focus of care after transfer and understand the significance of effective communication to ensure women are included in all care discussions.

Procalcitonin and C-reactive protein as markers of bacterial infection in critically ill children at onset of systemic inflammatory response syndrome.

PubMed

Simon, Liliana; Saint-Louis, Patrick; Amre, Devendra K; Lacroix, Jacques; Gauvin, France

2008-07-01

To compare the accuracy of procalcitonin and C-reactive protein as diagnostic markers of bacterial infection in critically ill children at the onset of systemic inflammatory response syndrome (SIRS). Prospective cohort study. Tertiary care, university-affiliated pediatric intensive care unit (PICU). Consecutive patients with SIRS. From June to December 2002, all PICU patients were screened daily to include cases of SIRS. At inclusion (onset of SIRS), procalcitonin and C-reactive protein levels as well as an array of cultures were obtained. Diagnosis of bacterial infection was made a posteriori by an adjudicating process (consensus of experts unaware of the results of procalcitonin and C-reactive protein). Baseline and daily data on severity of illness, organ dysfunction, and outcome were collected. Sixty-four patients were included in the study and were a posteriori divided into the following groups: bacterial SIRS (n = 25) and nonbacterial SIRS (n = 39). Procalcitonin levels were significantly higher in patients with bacterial infection compared with patients without bacterial infection (p = .01). The area under the receiver operating characteristic curve for procalcitonin was greater than that for C-reactive protein (0.71 vs. 0.65, respectively). A positive procalcitonin level (>or=2.5 ng/mL), when added to bedside clinical judgment, increased the likelihood of bacterial infection from 39% to 92%, while a negative C-reactive protein level (<40 mg/L) decreased the probability of bacterial infection from 39% to 2%. Procalcitonin is better than C-reactive protein for differentiating bacterial from nonbacterial SIRS in critically ill children, although the accuracy of both tests is moderate. Diagnostic accuracy could be enhanced by combining these tests with bedside clinical judgment.

Diabetes Care in Malaysia: Problems, New Models, and Solutions.

PubMed

Hussein, Zanariah; Taher, Sri Wahyu; Gilcharan Singh, Harvinder Kaur; Chee Siew Swee, Winnie

2015-01-01

Diabetes is a major public health concern in Malaysia, and the prevalence of type 2 diabetes (T2D) has escalated to 20.8% in adults above the age of 30, affecting 2.8 million individuals. The burden of managing diabetes falls on primary and tertiary health care providers operating in various settings. This review focuses on the current status of diabetes in Malaysia, including epidemiology, complications, lifestyle, and pharmacologic treatments, as well as the use of technologies in its management and the adoption of the World Health Organization chronic care model in primary care clinics. A narrative review based on local available health care data, publications, and observations from clinic experience. The prevalence of diabetes varies among the major ethnic groups in Malaysia, with Asian Indians having the highest prevalence of T2D, followed by Malays and Chinese. The increase prevalence of overweight and obesity has accompanied the rise in T2D. Multidisciplinary care is available in tertiary and primary care settings with integration of pharmacotherapy, diet, and lifestyle changes. Poor dietary adherence, high consumption of carbohydrates, and sedentary lifestyle are prevalent in patients with T2D. The latest medication options are available with increasing use of intensive insulin regimens, insulin pumps, and continuous glucose monitoring systems for managing glycemic control. A stepwise approach is proposed to expand the chronic care model into an Innovative Care for Chronic Conditions framework to facilitate implementation and realize better outcomes in primary care settings. A comprehensive strategy and approach has been established by the Malaysian government to improve prevention, treatment, and control of diabetes as an urgent response to this growing chronic disease. Copyright © 2015 The Authors. Published by Elsevier Inc. All rights reserved.

A qualitative study of health care providers' perceptions and experiences of working together to care for children with medical complexity (CMC).

PubMed

Altman, Lisa; Zurynski, Yvonne; Breen, Christie; Hoffmann, Tim; Woolfenden, Susan

2018-01-31

Children with medical complexity (CMC) have a wide range of long term health problems and disabilities that have an adverse impact on their quality of life. They have high levels of family identified health care needs and health care utilisation. There is no Australian literature on the experiences of health care providers working in the Australian tertiary, secondary and primary health care system, whilst managing CMC. This information is essential to inform the design of integrated health care systems for these children. We address this knowledge gap by exploring the perceptions and experiences of health care providers on the provision of health care for CMC aged 0 to 18 years. A qualitative research study was undertaken. Stakeholder forums, group and individual in depth interviews were undertaken using a semi-structured interview guide. The stakeholder forums were audio recorded and transcribed verbatim. Field notes of the stakeholder forums, group and individual interviews were taken. Inductive thematic analysis was undertaken to identify key themes. One hundred and three providers took part in the stakeholder forums and interviews across 3 local health districts, a tertiary paediatric hospital network, and primary health care organisations. Providers expressed concern regarding family capacity to negotiate the system, which was impacted by the medical complexity of the children and psychosocial complexity of their families. Lack of health care provider capacity in terms of their skills, time and availability to manage CMC was also a key problem. These issues occurred within a health system that had impaired capacity in terms of fragmentation of care and limited communication among health care providers. When designing integrated care models for CMC, it is essential to understand and address the challenges experienced by their health care providers. This requires adequate training of providers, additional resources and time for coordination of care, improved systems of communication among services, with timely access to key information for parents and providers.

Enantiospecific sp2-sp3 coupling of secondary and tertiary boronic esters

NASA Astrophysics Data System (ADS)

Bonet, Amadeu; Odachowski, Marcin; Leonori, Daniele; Essafi, Stephanie; Aggarwal, Varinder K.

2014-07-01

The cross-coupling of boronic acids and related derivatives with sp2 electrophiles (the Suzuki-Miyaura reaction) is one of the most powerful C-C bond formation reactions in synthesis, with applications that span pharmaceuticals, agrochemicals and high-tech materials. Despite the breadth of its utility, the scope of this Nobel prize-winning reaction is rather limited when applied to aliphatic boronic esters. Primary organoboron reagents work well, but secondary and tertiary boronic esters do not (apart from a few specific and isolated examples). Through an alternative strategy, which does not involve using transition metals, we have discovered that enantioenriched secondary and tertiary boronic esters can be coupled to electron-rich aromatics with essentially complete enantiospecificity. As the enantioenriched boronic esters are easily accessible, this reaction should find considerable application, particularly in the pharmaceutical industry where there is growing awareness of the importance of, and greater clinical success in, creating biomolecules with three-dimensional architectures.

Clinical profile of dermatological emergencies and intensive care unit admissions in a tertiary care center - an Indian perspective.

PubMed

Samudrala, Suvarna; Dandakeri, Sukumar; Bhat, Ramesh M

2018-05-01

Although dermatology is largely considered as an outpatient specialty, dermatological conditions comprise 5-8% of cases presenting to the emergency department. The need for a dermatological intensive care unit is widely acknowledged due to the increasing incidence of acute skin failure. Very few studies have been done to characterize the common conditions seen in the emergency department and intensive care units. We undertook this study to analyze the spectrum of dermatological conditions presenting to the emergency department and the clinical profile of patients admitted to the intensive care unit. A prospective study was conducted for 9 months. Patients requiring primary dermatological consultation in the emergency department and patients admitted in the dermatology intensive care unit were examined, and their clinical variables were statistically analyzed. A total of 248 cases were seen in the emergency department, out of which 72 (29.1%) cases were admitted and 176 (70.9%) were treated in the emergency department on an outpatient basis. The most common condition seen in non-admitted patients was acute urticaria (28.9%). The most common cause for admission in patients presenting to the emergency department was erythroderma (23.6%). Sixty-two patients were admitted to the intensive care unit, the most common diagnosis being erythroderma (40.3%). This prospective study aimed to provide an insight into the types of cases evaluated in the emergency department by dermatologists in a large tertiary care hospital in coastal Karnataka in South India. © 2018 The International Society of Dermatology.

Physician Satisfaction With Integrated Behavioral Health in Pediatric Primary Care.

PubMed

Hine, Jeffrey F; Grennan, Allison Q; Menousek, Kathryn M; Robertson, Gail; Valleley, Rachel J; Evans, Joseph H

2017-04-01

As the benefits of integrated behavioral health care services are becoming more widely recognized, this study investigated physician satisfaction with ongoing integrated psychology services in pediatric primary care clinics. Data were collected across 5 urban and 6 rural clinics and demonstrated the specific factors that physicians view as assets to having efficient access to a pediatric behavioral health practitioner. Results indicated significant satisfaction related to quality and continuity of care and improved access to services. Such models of care may increase access to care and reduce other service barriers encountered by individuals and their families with behavioral health concerns (ie, those who otherwise would seek services through referrals to traditional tertiary care facilities).

Managed care and the scale efficiency of US hospitals.

PubMed

Brown, H Shelton; Pagán, José A

2006-12-01

Managed care penetration has been partly responsible for slowing down increases in health care costs in recent years. This study uses a 1992-1996 Health Care Utilization Project sample of hospitals to analyze the relationship between managed care penetration in local insurance markets and hospital scale efficiency. After controlling for hospital and market area variables, we find that managed care insurance, particularly the preferred provider type, is associated with increases in hospital scale efficiency in tertiary cases. The results presented here are consistent with the view that managed care can lead to reductions in health cost inflation by controlling the diffusion of technology via improvements in the scale efficiency of hospitals.

Pediatric medical complexity algorithm: a new method to stratify children by medical complexity.

PubMed

Simon, Tamara D; Cawthon, Mary Lawrence; Stanford, Susan; Popalisky, Jean; Lyons, Dorothy; Woodcox, Peter; Hood, Margaret; Chen, Alex Y; Mangione-Smith, Rita

2014-06-01

The goal of this study was to develop an algorithm based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes for classifying children with chronic disease (CD) according to level of medical complexity and to assess the algorithm's sensitivity and specificity. A retrospective observational study was conducted among 700 children insured by Washington State Medicaid with ≥1 Seattle Children's Hospital emergency department and/or inpatient encounter in 2010. The gold standard population included 350 children with complex chronic disease (C-CD), 100 with noncomplex chronic disease (NC-CD), and 250 without CD. An existing ICD-9-CM-based algorithm called the Chronic Disability Payment System was modified to develop a new algorithm called the Pediatric Medical Complexity Algorithm (PMCA). The sensitivity and specificity of PMCA were assessed. Using hospital discharge data, PMCA's sensitivity for correctly classifying children was 84% for C-CD, 41% for NC-CD, and 96% for those without CD. Using Medicaid claims data, PMCA's sensitivity was 89% for C-CD, 45% for NC-CD, and 80% for those without CD. Specificity was 90% to 92% in hospital discharge data and 85% to 91% in Medicaid claims data for all 3 groups. PMCA identified children with C-CD (who have accessed tertiary hospital care) with good sensitivity and good to excellent specificity when applied to hospital discharge or Medicaid claims data. PMCA may be useful for targeting resources such as care coordination to children with C-CD. Copyright © 2014 by the American Academy of Pediatrics.

Pediatric Medical Complexity Algorithm: A New Method to Stratify Children by Medical Complexity

PubMed Central

Cawthon, Mary Lawrence; Stanford, Susan; Popalisky, Jean; Lyons, Dorothy; Woodcox, Peter; Hood, Margaret; Chen, Alex Y.; Mangione-Smith, Rita

2014-01-01

OBJECTIVES: The goal of this study was to develop an algorithm based on International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM), codes for classifying children with chronic disease (CD) according to level of medical complexity and to assess the algorithm’s sensitivity and specificity. METHODS: A retrospective observational study was conducted among 700 children insured by Washington State Medicaid with ≥1 Seattle Children’s Hospital emergency department and/or inpatient encounter in 2010. The gold standard population included 350 children with complex chronic disease (C-CD), 100 with noncomplex chronic disease (NC-CD), and 250 without CD. An existing ICD-9-CM–based algorithm called the Chronic Disability Payment System was modified to develop a new algorithm called the Pediatric Medical Complexity Algorithm (PMCA). The sensitivity and specificity of PMCA were assessed. RESULTS: Using hospital discharge data, PMCA’s sensitivity for correctly classifying children was 84% for C-CD, 41% for NC-CD, and 96% for those without CD. Using Medicaid claims data, PMCA’s sensitivity was 89% for C-CD, 45% for NC-CD, and 80% for those without CD. Specificity was 90% to 92% in hospital discharge data and 85% to 91% in Medicaid claims data for all 3 groups. CONCLUSIONS: PMCA identified children with C-CD (who have accessed tertiary hospital care) with good sensitivity and good to excellent specificity when applied to hospital discharge or Medicaid claims data. PMCA may be useful for targeting resources such as care coordination to children with C-CD. PMID:24819580

A successful strategy for increasing the influenza vaccination rate of healthcare workers without a mandatory policy outside of the United States: a multifaceted intervention in a Japanese tertiary care center.

PubMed

Honda, Hitoshi; Sato, Yumiko; Yamazaki, Akinori; Padival, Simi; Kumagai, Akira; Babcock, Hilary

2013-11-01

Although mandatory vaccination programs have been effective in improving the vaccination rate among healthcare workers, implementing this type of program can be challenging because of varied reasons for vaccine refusal. The purpose of our study is to measure improvement in the influenza vaccination rate from a multifaceted intervention at a Japanese tertiary care center where implementing a mandatory vaccination program is difficult. Before-and-after trial. Healthcare workers at a 550-bed, tertiary care, academic medical center in Sapporo, Japan. We performed a multifaceted intervention including (1) use of a declination form, (2) free vaccination, (3) hospital-wide announcements during the vaccination period, (4) prospective audit and real-time telephone interview for healthcare workers who did not receive the vaccine, (5) medical interview with the hospital executive for noncompliant (no vaccine, no declination form) healthcare workers during the vaccination period, and (6) mandatory submission of a vaccination document if vaccinated outside of the study institution. With the new multifaceted intervention, the vaccination rate in the 2012-2013 season increased substantially, up to 97%. This rate is similar to that reported in studies with a mandatory vaccination program. Improved vaccination acceptance, particularly among physicians, likely contributed to the overall increase in the vaccination rate reported in the study. Implementation of comprehensive strategies with strong leadership can lead to substantial improvements in vaccine uptake among healthcare workers even without a mandatory vaccination policy. The concept is especially important for institutions where implementing mandatory vaccination programs is challenging.

Listeriosis at a tertiary care hospital in beijing, china: high prevalence of nonclustered healthcare-associated cases among adult patients.

PubMed

Wang, Huan-Ling; Ghanem, Khalil G; Wang, Peng; Yang, Shuang; Li, Tai-Sheng

2013-03-01

Listeriosis is an emerging infectious disease associated with high mortality. There are few published reports from East Asia and developing countries. Our goal was to describe the clinical characteristics and outcomes of patients diagnosed with Listeria monocytogenes at a tertiary care hospital in Beijing, China. Peking Union Medical College Hospital (PUMCH), an 1800-bed hospital, consists of 2 campuses that house different medical departments. We retrospectively reviewed all culture-proven cases of listeriosis occurring at PUMCH between 1999 and 2011. Point estimates and 95% confidence intervals are presented. There were 38 patients with listeriosis: 5 neonatal, 8 maternal, and 25 nonmaternal. The median age of the adult nonmaternal patients was 47 (range, 18-79) years with a female predominance (72%). Forty percent (n = 10) had an underlying rheumatic disease. Forty-four percent of cases (n = 11) were healthcare-associated infections occurring a median of 20 (range, 3-44) days after hospital admission. Only 2 of the 11 healthcare-associated cases clustered in space and time. One healthcare-associated case occurred in a patient receiving KHI-272 therapy, an oral, irreversible dual EGFR/HER2 inhibitor. The neonatal and maternal listeriosis cases were similar to those reported in the literature. Nonclustered healthcare-associated cases of L. monocytogenes occurred at a large tertiary care hospital in Beijing, China. The source of these infections is unclear. Although rare, in the setting of immunosuppression, Listeria should be considered in the differential diagnosis of healthcare-associated infections, even in the absence of a point-source outbreak.

Does rural or urban residence make a difference to neonatal outcome in premature birth? A regional study in Australia.

PubMed

Abdel-Latif, M E; Bajuk, B; Oei, J; Vincent, T; Sutton, L; Lui, K

2006-07-01

Patients living in rural areas may be at a disadvantage in accessing tertiary health care. To test the hypothesis that very premature infants born to mothers residing in rural areas have poorer outcomes than those residing in urban areas in the state of New South Wales (NSW) and the Australian Capital Territory (ACT) despite a coordinated referral and transport system. "Rural" or "urban" status was based on the location of maternal residence. Perinatal characteristics, major morbidity and case mix adjusted mortality were compared between 1879 rural and 6775 urban infants <32 weeks gestational age, born in 1992-2002 and admitted to all 10 neonatal intensive care units in NSW and ACT. Rural mothers were more likely to be teenaged, indigenous, and to have had a previous premature birth, prolonged ruptured membrane, and antenatal corticosteroid. Urban mothers were more likely to have had assisted conception and a caesarean section. More urban (93% v 83%) infants were born in a tertiary obstetric hospital. Infants of rural residence had a higher mortality (adjusted odds ratio (OR) 1.26, 95% confidence interval (CI) 1.07 to 1.48, p = 0.005). This trend was consistently seen in all subgroups and significantly for the tertiary hospital born population and the 30-31 weeks gestation subgroup. Regional birth data in this gestational age range also showed a higher stillbirth rate among rural infants (OR 1.20, 95% CI 1.09 to 1.32, p<0.001). Premature births from rural mothers have a higher risk of stillbirth and mortality in neonatal intensive care than urban infants.

Self esteem and organizational commitment among health information management staff in tertiary care hospitals in Tehran.

PubMed

Sadoughi, Farahnaz; Ebrahimi, Kamal

2014-12-12

Self esteem (SE) and organizational commitment (OC)? have significant impact on the quality of work life. This study aims to gain a better understanding of the relationships between SE and OC among health information management staff in tertiary care hospitals in Tehran (Iran). This was a descriptive correlational and cross sectional study conducted on the health information management staff of tertiary care hospitals in Tehran, Iran. A total of 155 participants were randomly selected from 400 staff. Data were collected by two standard questionnaires. The SE and OC was measured using Eysenck SE scale and Meyer and Allen's three component model, respectively. The collected data were analyzed with the SPSS (version 16) using statistical tests of of independent T-test, Pearson Correlation coefficient, one way ANOVA and F tests. The OC and SE of the employees' were 67.8?, out of 120 (weak) and 21.0 out of 30 (moderate), respectively. The values for affective commitment, normative commitment, and continuance commitment were respectively 21.3 out of 40 (moderate), 23.9 out of 40 (moderate), and 22.7 out of 40 (moderate). The Pearson correlation coefficient test showed a significant OC and SE was statistically significant (P<0.05). The one way ANOVA test (P<0.05) did not show any significant difference between educational degree and work experience with SE and OC. This research showed that SE and OC ?are moderate. SE and OC have strong correlation with turnover, critical thinking, job satisfaction, and individual and organizational improvement. Therefore, applying appropriate human resource policies is crucial to reinforce these measures.

Prevalence and Risk Factors for Peripheral Neuropathy among Type 2 Diabetes Mellitus Patients at a Tertiary Care Hospital in Coastal Karnataka.

PubMed

Gogia, Sonalika; Rao, Chythra R

2017-01-01

In view of the growing burden of type 2 diabetes mellitus (T2DM) globally and associated microvascular and macrovascular complications, the study was done to assess the prevalence and risk factors for diabetic neuropathy among T2DM patients attending a tertiary care hospital. T2DM patients' ≥30 years of both gender, presenting to the Medicine Department at a tertiary care hospital were included in the study. Diabetic Neuropathy Symptom (DNS) questionnaire to assess symptoms and Diabetic Neuropathy Examination (DNE) scoring to assess clinical signs were used. A total of 273 patients were included. The mean age was 57.8 ± 11.5 years. The male to female distribution was 75% (202) and 25% (71), respectively. According to DNS instrument, 41.4% patients scored positive for the presence of neuropathy while only 24.5% had neuropathy according to DNE score. The proportion of males affected by neuropathy was more than females. 43.1% males had a positive DNS score while only 27.2% of them had a positive DNE score. Duration of the disease was positively correlated with neuropathy. Neuropathy was more prevalent among people who had higher systolic and diastolic blood pressure as per DNS and DNE instruments. The present study identified a higher proportion of males to be affected by neuropathy. Hence, more detailed evaluation must be accorded to elderly male diabetic patients with longer duration of the disease. Lifestyle modifications and watchful screening need to be incorporated as part of routine patient health education during follow-up clinic visits.

Long-term outcome of vertigo and dizziness associated disorders following treatment in specialized tertiary care: the Dizziness and Vertigo Registry (DiVeR) Study.

PubMed

Obermann, Mark; Bock, Eva; Sabev, Nikolay; Lehmann, Nils; Weber, Ralph; Gerwig, Marcus; Frings, Markus; Arweiler-Harbeck, Diana; Lang, Stephan; Diener, Hans-Christoph

2015-09-01

To investigate the long-term outcome of interdisciplinary treatment in a tertiary care neuro-otology institution after 2 years as part of the Dizziness and Vertigo Registry study. Risk factors associated with unfavourable outcome were assessed. 3113 consecutive patients with disorders of vertigo and dizziness were recruited prospectively between March 2010 and February 2012. Patients were clinically assessed and treated according to their diagnosis. Standardized instruments were used at baseline and at 2-year follow-up [Dizziness Handicap Inventory (DHI), Quality of Life Questionnaire, General Depression Scale, Stait-Trait Anxiety Index], as well as a custom health-related questionnaire. The primary outcome variable of this observational study was the change in DHI after 2 years. Patients suffered from phobic postural vertigo (23%), benign peripheral paroxysmal vertigo (14.4%), unilateral vestibulopathy (10.5%), central vestibular disorders (8%), Menière's disease (9.8%), vestibular migraine (6.9%), bilateral vestibulopathy (5.5%), and vestibular paroxysmia (3.1%). Mean disease duration was 4.6 ± 6.3 years. 1272 patients were available for follow-up, 1159 completed the DHI score. 72.1% of patients improved in DHI score from baseline to 2 years follow-up. Mean reduction in DHI score was 14 points (p = 0.02). Long-term outcome following diagnosis and treatment in a specialized tertiary care centre is good and persistent after 2 years. Risk factors for an unfavourable outcome were advanced age, severe disability, constant vertigo or dizziness, and concomitant back pain, while depression and anxiety did not contribute to this risk considerably.

Enhanced diisobutene production in the presence of methyl tertiary butyl ether

DOEpatents

Smith, Jr., Lawrence A.

1983-01-01

In the liquid phase reaction of isobutene in the presence of resin cation exchange resins with itself in a C.sub.4 hydrocarbon stream to form dimers, the formation of higher polymers, oligomers, and co-dimer by-products is suppressed by the presence of 0.0001 to 1 mole per mole of isobutene of methyl tertiary butyl ether.

Enhanced diisobutene production in the presence of methyl tertiary butyl ether

DOEpatents

Smith, L.A. Jr.

1983-03-01

In the liquid phase reaction of isobutene in the presence of resin cation exchange resins with itself in a C[sub 4] hydrocarbon stream to form dimers, the formation of higher polymers, oligomers, and co-dimer by-products is suppressed by the presence of 0.0001 to 1 mole per mole of isobutene of methyl tertiary butyl ether. 1 fig.

Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598

PubMed Central

Nassar, N; Roberts, CL; Raynes-Greenow, CH; Barratt, A; Peat, B

2007-01-01

Objectives To evaluate the effectiveness of a decision aid for women with a breech presentation compared with usual care. Design Randomised controlled trial. Setting Tertiary obstetric hospitals offering external cephalic version (ECV). Population Women with a singleton pregnancy were diagnosed antenatally with a breech presentation at term, and were clinically eligible for ECV. Methods Women were randomised to either receive a decision aid about the management options for breech presentation in addition to usual care or to receive usual care only with standard counselling from their usual pregnancy care provider. The decision aid comprised a 24-page booklet supplemented by a 30-minute audio-CD and worksheet that was designed for women to take home and review with a partner. Main outcome measures Decisional conflict (uncertainty), knowledge, anxiety and satisfaction with decision making, and were assessed using self-administered questionnaires. Results Compared with usual care, women reviewing the decision aid experienced significantly lower decisional conflict (mean difference −8.92; 95% CI −13.18, −4.66) and increased knowledge (mean difference 8.40; 95% CI 3.10, 13.71), were more likely to feel that they had enough information to make a decision (RR 1.30; 95% CI 1.14, 1.47), had no increase in anxiety and reported greater satisfaction with decision making and overall experience of pregnancy and childbirth. In contrast, 19% of women in the usual care group reported they would have made a different decision about their care. Conclusions A decision aid is an effective and acceptable tool for pregnant women that provides an important adjunct to standard counselling for the management of breech presentation. Please cite this paper as: Nassar N, Roberts C, Raynes-Greenow C, Barratt A, Peat B, on behalf of the Decision Aid for Breech Presentation Trial Collaborators. Evaluation of a decision aid for women with breech presentation at term: a randomised controlled trial [ISRCTN14570598]. BJOG 2007;114:325–333. PMID:17217360

Microstructural Characterization of Alloy 617 Crept into the Tertiary Regime

DOE Office of Scientific and Technical Information (OSTI.GOV)

Lillo, Thomas Martin; Wright, Richard Neil

2015-07-01

The microstructure of Alloy 617 was characterized following creep tests interrupted at total creep strains ranging from 2-20%. A range of creep temperatures (750-1000oC) and initial creep stresses (10-145 MPa) produced creep test durations ranging from 1 to 5800 hours. Image analysis of optical photomicrographs on longitudinal sections of the gage length was used to document the fraction of creep porosity as a function of creep parameters. Creep porosity was negligible below tertiary creep strains of 10% and increased with tertiary creep strain, thereafter. For a given temperature and total creep strain, creep porosity increased with decreasing creep stress. Creepmore » porosity increased linearly with duration of the creep experiment. TEM performed on the gage sections did not reveal significant creep cavity formation on grain boundaries at the sub-micron level. It was concluded that the onset of tertiary creep did not result from creep cavitation and more likely arose due to the formation of low energy dislocation substructures with increasing tertiary strain.« less

Robotic liver surgery is the optimal approach as bridge to transplantation.

PubMed

Magistri, Paolo; Tarantino, Giuseppe; Ballarin, Roberto; Coratti, Andrea; Di Benedetto, Fabrizio

2017-02-08

The role of minimally invasive liver surgery as a bridge to transplantation is very promising but still underestimated. However, it should be noted that surgical approach for hepatocellular carcinomas (HCC) is not merely a technical or technological issue. Nowadays, the epidemiology of HCC is evolving due to the increasing role of non-alcoholic fatty-liver-disease, and the emerging concerns on direct-acting antivirals against hepatitis C virus in terms of HCC incidence. Therefore, a fully multidisciplinary study of the cirrhotic patient is currently more important than ever before, and the management of those patients should be reserved to tertiary referral hepatobiliary centers. In particular, minimally invasive approach to the liver showed several advantages compared to the classical open procedure, in terms of: (1) the small impact on abdominal wall; (2) the gentle manipulation on the liver; (3) the limited surgical trauma; and (4) the respect of venous shunts. Therefore, more direct indications should be outlined also in the Barcelona Clinic Liver Cancer model. We believe that treatment of HCC in cirrhotic patients should be reserved to tertiary referral hepatobiliary centers, that should offer patient-tailored approaches to the liver disease, in order to provide the best care for each case, according to the individual comorbidities, risk factors, and personal quality of life expectations.

Discrete-choice experiment to measure patient preferences for the surgical management of colorectal cancer.

PubMed

Salkeld, G; Solomon, M; Butow, P; Short, L

2005-06-01

Establishing trust between a patient and his or her surgeon is of paramount importance. The aim of this study was to assess the relative importance of the 'attributes of trust' between surgeon and patient with colorectal cancer. A discrete-choice questionnaire was conducted with 60 men and 43 women who had completed primary treatment for colorectal cancer in two teaching hospitals in Sydney, Australia. Forty-seven of the 103 patients based their choice of surgical management on a single attribute and the remainder were willing to trade between different attributes. In order of importance, patients based their choice of surgical management on specialty training (beta coefficient = 0.83), surgeon's communication (beta = 0.82), type of hospital (beta = 0.72) and who decides treatment (beta = 0.01). Patients who were vigilant in their decision-making style and those who did not have tertiary education were more likely to change their preferences in the repeat interview. Clinicians may have a better chance of meeting a patient's expectations about the process of care if they assess the patient's desire for knowledge and give those who do not have tertiary education more time to assimilate information about their treatment. Copyright (c) 2005 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Evaluation of How Integrative Oncology Services Are Valued between Hematology/Oncology Patients and Hematologists/Oncologists at a Tertiary Care Center.

PubMed

Hansra, D M; McIntyre, K; Ramdial, J; Sacks, S; Patrick, C S; Cutler, J; McIntyre, B; Feister, K; Miller, M; Taylor, A K; Farooq, F; de Mayolo, J Antunez; Ahn, E

2018-01-01

Evidence regarding opinions on integrative modalities by patients and physicians is lacking. Methods . A survey study was conducted assessing how integrative modalities were valued among hematology/oncology patients and hematologists and oncologists at a major tertiary medical center. Results. 1008 patients and 55 physicians were surveyed. With the exception of support groups, patients valued nutrition services, exercise therapy, spiritual/religious counseling, supplement/herbal advice, support groups, music therapy, and other complimentary medicine services significantly more than physicians ( P ≤ 0.05). Conclusion . With the exception of support groups, patients value integrative modalities more than physicians. Perhaps with increasing education, awareness, and acceptance by providers and traditional institutions, integrative modalities could be equally valued between patients and providers. It is possible that increased availability and utilization of integrative oncology modalities at tertiary hospital sites could improve patient satisfaction, quality of life, and other clinical endpoints.

Factors associated with long diagnostic delay in celiac disease.

PubMed

Fuchs, Valma; Kurppa, Kalle; Huhtala, Heini; Collin, Pekka; Mäki, Markku; Kaukinen, Katri

2014-11-01

Here, we investigated the factors associated with long diagnostic delay in celiac disease and the impact of the national Current Care Guidelines in reducing the delay. This population-based study involved 825 adult celiac disease patients. The diagnosis was considered delayed when the interval between first symptoms and diagnosis was >10 years. The patients were asked about the duration and type of symptoms before diagnosis, time and site (tertiary, secondary, or primary care) of the diagnosis, family history of the disease, and presence of significant comorbidities. Analysis was performed by binary logistic regression. Altogether, 261 (32%) out of 825 participants reported a diagnostic delay of >10 years. Female gender, neurological or musculoskeletal disorders and presence of diarrhea, abdominal pain, and malabsorption were associated with prolonged delay. Male gender, diagnosis after the introduction of the first Current Care Guidelines in 1997, and being detected by serological screening, and family history of celiac disease were associated with a lower risk of delayed diagnosis. Factors not associated with the delay were site of diagnosis, age, and presence of dermatitis herpetiformis, type 1 diabetes, or thyroidal disease. The number of long diagnostic delays in celiac disease has decreased over the past decades. The shift of diagnostics from secondary and tertiary care to primary care has not been detrimental. National guidelines together with increased awareness and active screening in at-risk groups of celiac disease are important in these circumstances.

Severe maternal morbidity and near misses in tertiary hospitals, Kelantan, Malaysia: a cross-sectional study.

PubMed

Norhayati, Mohd Noor; Nik Hazlina, Nik Hussain; Sulaiman, Zaharah; Azman, Mohd Yacob

2016-03-05

Severe maternal conditions have increasingly been used as alternative measurements of the quality of maternal care and as alternative strategies to reduce maternal mortality. We aimed to study severe maternal morbidity and maternal near miss among women in two tertiary hospitals in Kota Bharu, Kelantan, Malaysia. A cross-sectional study with record review was conducted in 2014. Severe maternal morbidity and maternal near miss were classified using the new World Health Organization criteria. Health indicators for obstetric care were calculated and descriptive analyses were performed using SPSS version 22.0. In total, 21,579 live births, 395 women with severe maternal morbidity, 47 women with maternal near miss and two maternal deaths were analysed. The severe maternal morbidity incidence ratio was 18.3 per 1000 live births and the maternal near miss incidence ratio was 2.2 per 1000 live births. The maternal near miss mortality ratio was 23.5 and the mortality index was 4.1 %. The process indicators for essential interventions were almost 100.0 %. Haemorrhagic disorders were the most common event for severe maternal morbidity (68.6 %) and maternal near miss (80.9 %) and management-based criteria accounted for 85.1 %. Comprehensive emergency care and intensive care as well as overall improvements in the quality of maternal health care need to be achieved to substantial reduce maternal death.

Endocrine surgery as a model for value-based health care delivery.

PubMed

Abdulla, Amer G; Ituarte, Philip H G; Wiggins, Randi; Teisberg, Elizabeth O; Harari, Avital; Yeh, Michael W

2012-01-01

Experts advocate restructuring health care in the United States into a value-based system that maximizes positive health outcomes achieved per dollar spent. We describe how a value-based system implemented by the University of California, Los Angeles UCLA Section of Endocrine Surgery (SES) has optimized both quality and costs while increasing patient volume. Two SES clinical pathways were studied, one allocating patients to the most appropriate surgical care setting based on clinical complexity, and another standardizing initial management of papillary thyroid carcinoma (PTC). The mean cost per endocrine case performed from 2005 to 2010 was determined at each of three care settings: A tertiary care inpatient facility, a community inpatient facility, and an ambulatory facility. Blood tumor marker levels (thyroglobulin, Tg) and reoperation rates were compared between PTC patients who underwent routine central neck dissection (CND) and those who did not. Surgical patient volume and regional market share were analyzed over time. The cost of care was substantially lower in both the community inpatient facility (14% cost savings) and the ambulatory facility (58% cost savings) in comparison with the tertiary care inpatient facility. Patients who underwent CND had lower Tg levels (6.6 vs 15.0 ng/mL; P = 0.024) and a reduced need for re-operation (1.5 vs 6.1%; P = 0.004) compared with those who did not undergo CND. UCLA maintained its position as the market leader in endocrine procedures while expanding its market share by 151% from 4.9% in 2003 to 7.4% in 2010. A value-driven health care delivery system can deliver improved clinical outcomes while reducing costs within a subspecialty surgical service. Broader application of these principles may contribute to resolving current dilemmas in the provision of care nationally.

Demonstrating a Conceptual Framework to Provide Efficient Wound Management Service for a Wound Care Center in a Tertiary Hospital.

PubMed

Chen, Yu-Tsung; Chang, Chang-Cheng; Shen, Jen-Hsiang; Lin, Wei-Nung; Chen, Mei-Yen

2015-11-01

Although the benefits of wound care services and multidisciplinary team care have been well elaborated on in the literature, there is a gap in the actual practice of wound care and the establishment of an efficient referral system. The conceptual framework for establishing efficient wound management services requires elucidation.A wound care center was established in a tertiary hospital in 2010, staffed by an integrated multidisciplinary team including plastic surgeons, a full-time coordinator, a physical therapist, occupational therapists, and other physician specialists. Referral patients were efficiently managed following a conceptual framework for wound care. This efficient wound management service consists of 3 steps: patient entry and onsite immediate wound debridement, wound re-evaluation, and individual wound bed preparation plan. Wound conditions were documented annually over 4 consecutive years.From January 2011 to December 2014, 1103 patients were recruited from outpatient clinics or inpatient consultations for the 3-step wound management service. Of these, 62% of patients achieved healing or improvement in wounds, 13% of patients experienced no change, and 25% of patients failed to follow-up. The outcome of wound treatment varied by wound type. Sixty-nine percent of diabetic foot ulcer patients were significantly healed or improved. In contrast, pressure ulcers were the most poorly healed wound type, with only 55% of patients achieving significantly healed or improved wounds.The 3-step wound management service in the wound care center efficiently provided onsite screening, timely debridement, and multidisciplinary team care. Patients could schedule appointments instead of waiting indefinitely for care. Further wound condition follow-up, education, and prevention were also continually provided.

PROPOSAL OF A CLINICAL CARE PATHWAY FOR THE MANAGEMENT OF ACUTE UPPER GASTROINTESTINAL BLEEDING.

PubMed

Franco, Matheus Cavalcante; Nakao, Frank Shigueo; Rodrigues, Rodrigo; Maluf-Filho, Fauze; Paulo, Gustavo Andrade de; Libera, Ermelindo Della

2015-12-01

Upper gastrointestinal bleeding implies significant clinical and economic repercussions. The correct establishment of the latest therapies for the upper gastrointestinal bleeding is associated with reduced in-hospital mortality. The use of clinical pathways for the upper gastrointestinal bleeding is associated with shorter hospital stay and lower hospital costs. The primary objective is the development of a clinical care pathway for the management of patients with upper gastrointestinal bleeding, to be used in tertiary hospital. It was conducted an extensive literature review on the management of upper gastrointestinal bleeding, contained in the primary and secondary information sources. The result is a clinical care pathway for the upper gastrointestinal bleeding in patients with evidence of recent bleeding, diagnosed by melena or hematemesis in the last 12 hours, who are admitted in the emergency rooms and intensive care units of tertiary hospitals. In this compact and understandable pathway, it is well demonstrated the management since the admission, with definition of the inclusion and exclusion criteria, passing through the initial clinical treatment, posterior guidance for endoscopic therapy, and referral to rescue therapies in cases of persistent or rebleeding. It was also included the care that must be taken before hospital discharge for all patients who recover from an episode of bleeding. The introduction of a clinical care pathway for patients with upper gastrointestinal bleeding may contribute to standardization of medical practices, decrease in waiting time for medications and services, length of hospital stay and costs.

Improving Pediatric Asthma Care and Outcomes Across Multiple Hospitals.

PubMed

Nkoy, Flory; Fassl, Bernhard; Stone, Bryan; Uchida, Derek A; Johnson, Joseph; Reynolds, Carolyn; Valentine, Karen; Koopmeiners, Karmella; Kim, Eun Hea; Savitz, Lucy; Maloney, Christopher G

2015-12-01

Gaps exist in inpatient asthma care. Our aims were to assess the impact of an evidence-based care process model (EB-CPM) 5 years after implementation at Primary Children's Hospital (PCH), a tertiary care facility, and after its dissemination to 7 community hospitals. Participants included asthmatics 2 to 17 years admitted at 8 hospitals between 2003 and 2013. The EB-CPM was implemented at PCH between January 2008 and March 2009, then disseminated to 7 community hospitals between January and June 2011. We measured compliance using a composite score (CS) for 8 quality measures. Outcomes were compared between preimplementation and postimplementation periods. Confounding was addressed through multivariable regression analyses. At PCH, the CS increased and remained at >90% for 5 years after implementation. We observed sustained reductions in asthma readmissions (P = .026) and length of stay (P < .001), a trend toward reduced costs (P = .094), and no change in hospital resource use, ICU transfers, or deaths. The CS also increased at the 7 community hospitals, reaching 80% to 90% and persisting >2 years after dissemination, with a slight but not significant readmission reduction (P = .119), a significant reduction in length of stay (P < .001) and cost (P = .053), a slight increase in hospital resource use (P = .032), and no change in ICU transfers or deaths. Our intervention resulted in sustained, long-term improvement in asthma care and outcomes at the tertiary care hospital and successful dissemination to community hospitals. Copyright © 2015 by the American Academy of Pediatrics.

DOE Office of Scientific and Technical Information (OSTI.GOV)

Weydert, M.; Brennan, J.G.; Andersen, R.A.

Reaction of (MeC{sub 5}H{sub 4}){sub 3}UX (X = Cl, MeC{sub 5}H{sub 4}) with t-BuLi affords the tertiary alkyl complex (MeC{sub 5}H{sub 4}){sub 3}U(t-Bu). Despite uranium(IV) generally being the preferred oxidation state in organometallic systems, (MeC{sub 5}H{sub 4}){sub 3}U(t-Bu) reacts with Lewis bases (L = PMe{sub 3}, THF, RCN, RNC) to yield the reduced uranium(III) base adducts (MeC{sub 5}H{sub 4}){sub 3}U(L). Carbon monoxide undergoes migratory insertion into the metal tertiary alkyl bond. The resulting acyl derivative decomposes at 90{degree}C to yield insoluble uranium-containing products and a mixture of tert-butyltoluenes by ring expansion of a methylcyclopentadienyl ligand. Ethylene also undergoes migratory insertionmore » into the metal tertiary alkyl bond. No subsequent insertion of ethylene into the metal carbon bond takes place after the first equivalent has inserted. In marked contrast, reaction of various (MeC{sub 5}H{sub 4}){sub 3}ThX (X = Cl, I, MeC{sub 5}H{sub 4}, O-2,6-Me{sub 2}C{sub 6}H{sub 3}, OTs) compounds with t-BuLi gave intractable materials. However, reaction of the cationic species [(RC{sub 5}H{sub 4}){sub 3}Th](BPh{sub 4}) (R = Me{sub 3}Si, t-Bu) with t-BuLi yields the new thorium hydrides (RC{sub 5}H{sub 4}){sub 3}ThH. 40 refs., 2 figs.« less

Multicenter COMPACT study of COMplications in patients with sickle cell disease and utilization of iron chelation therapy.

PubMed

Jordan, Lanetta; Adams-Graves, Patricia; Kanter-Washko, Julie; Oneal, Patricia A; Sasane, Medha; Vekeman, Francis; Bieri, Christine; Magestro, Matthew; Marcellari, Andrea; Duh, Mei Sheng

2015-03-01

Over the past few decades, lifespans of sickle cell disease (SCD) patients have increased; hence, they encounter multiple complications. Early detection, appropriate comprehensive care, and treatment may prevent or delay onset of complications. We collected longitudinal data on sickle cell disease (SCD) complication rates and associated resource utilization relative to blood transfusion patterns and iron chelation therapy (ICT) use in patients aged ≥16 years to address a gap in the literature. Medical records of 254 SCD patients ≥16 years were retrospectively reviewed at three US tertiary care centers. We classified patients into cohorts based on cumulative units of blood transfused and ICT history: <15 units, no ICT (Cohort 1 [C1]), ≥15 units, no ICT (Cohort 2 [C2]), and ≥15 units with ICT (Cohort 3 [C3]). We report SCD complication rates per patient per year; cohort comparisons use rate ratios (RRs). Cohorts had 69 (C1), 91 (C2), and 94 (C3) patients. Pain led to most hospitalizations (76%) and emergency department (ED) (82%) visits. Among transfused patients (C2+C3), those receiving ICT were less likely to experience SCD complications than those who did not (RR [95% CI] C2 vs. C3: 1.33 [1.25-1.42]). Similar trends (RR [95% CI]) were observed in ED visits and hospitalizations associated with SCD complications (C2 vs. C3, ED: 1.94 [1.70-2.21]; hospitalizations: 1.61 [1.45-1.78]), but not in outpatient visits. Although the most commonly reported SCD complication among all patients was pain, patients who received ICT were less likely to experience pain and other complications than those who did not. These results highlight the need for increased patient and provider education on the importance of comprehensive disease management.

Bladder and bowel dysfunctions in 1748 children referred to pelvic physiotherapy: clinical characteristics and locomotor problems in primary, secondary, and tertiary healthcare settings.

PubMed

van Engelenburg-van Lonkhuyzen, Marieke L; Bols, Esther M J; Benninga, Marc A; Verwijs, Wim A; de Bie, Rob A

2017-02-01

The aims of this study are to evaluate in a pragmatic cross-sectional study, the clinical characteristics of childhood bladder and/or bowel dysfunctions (CBBD) and locomotor problems in the primary through tertiary health care setting. It was hypothesized that problems would increase, going from primary to tertiary healthcare. Data were retrieved from patient-records of children (1-16 years) presenting with CBBD and visiting pelvic physiotherapists. Prevalence's of dysfunctions were compared between healthcare settings and gender using ANOVA and chi-square test. Agreement between physicians' diagnoses and parent-reported symptoms was evaluated (Cohen's Kappa). One thousand seventy hundred forty-eight children (mean age 7.7 years [SD 2.9], 48.9% boys) were included. Daytime urinary incontinence (P = 0.039) and enuresis (P < 0.001) were more diagnosed in primary healthcare, whereas constipation (P < 0.001) and abdominal pain (P = 0.009) increased from primary to tertiary healthcare. All parent-reported symptoms occurred more frequently than indicated by the physicians. Poor agreement between physicians' diagnoses and parent-reported symptoms was found (k = 0.16). Locomotor problems prevailed in all healthcare settings, motor skills (P = 0.041) and core stability (P = 0.015) significantly more in tertiary healthcare. Constipation and abdominal pain (physicians' diagnoses) and the parent-reported symptoms hard stools and bloating increased from primary to tertiary healthcare. Discrepancies exist between the prevalence's of physicians' diagnoses and parent-reported symptoms. Locomotor problems predominate in all healthcare settings. What is Known: • Childhood bladder and/or bowel dysfunctions (CCBD) are common. • Particularly tertiary healthcare characteristics of CBBD are available What is New: • Characteristics of CBBD referred to pelvic physiotherapy are comparable in primary, secondary, and tertiary healthcare settings. • Concomitant CBBD appeared to be more prevalent than earlier reported. • Discrepancies exist between referring physicians' diagnoses and parent-reported symptoms.

Patients without borders: the emergence of medical tourism.

PubMed

Ramírez de Arellano, Annette B

2007-01-01

A growing number of patients from the United States and other developed countries are traveling abroad with the express purpose of obtaining health care, including elective surgery and long-term care. This trend is not innocuous. It can lead developing countries to emphasize technology-intensive tertiary care for foreigners at the expense of basic health care for their citizens. Moreover, it can exacerbate the brain drain from the public to the private sector. The examples of Thailand and India suggest the distorting effects of this trend and raise questions of social equity in the distribution of scarce resources.

Causes of prolonged hospitalization among general internal medicine patients of a tertiary care center.

PubMed

Ruangkriengsin, Darat; Phisalprapa, Pochamana

2014-03-01

Unnecessary days of prolonged hospitalization may lead to the increase in hospital-related complications and costs, especially in tertiary care center Currently, there have not been many studies about the causes of prolonged hospitalization. Some identified causes could, however, be prevented and improved. To identify the prevalence, causes, predictive factors, prognosis, and economic burden of prolonged hospitalization in patients who had been in general internal medicine wards of the tertiary care center for 7 days or more. Retrospective chart review study was conducted among all patients who were admitted for 7 days or more in general internal medicine wards of Siriraj Hospital, the largest tertiary care center in Thailand. The period of this study was from 1 August 2012 to 30 September 2012. Demographic data, principle diagnosis, comorbid diseases, complications, discharge status, total costs of admission and percentage of reimbursement were collected. The causes of prolonged hospitalization at day 7, 14, 30, and 90 were assessed. Five hundred and sixty-two charts were reviewed. The average length of stay was 25.9 days. The two most common causes of prolonged admission at day 7 were treatment of main diagnosed disease with stable condition (27.6%) and waiting for completion of intravenous antibiotics administration with stable condition (19.5%). The causes of prolonged hospitalization at day 14 were unstable condition from complications (22.6%) and those waiting for completion of intravenous antibiotics administration with stable condition (15.8%). The causes of prolonged admission at day 30 were unstable conditions from complications (25.6%), difficulty weaning or ventilator dependence (17.6%), and caregiver problems (15.2%). The causes of prolonged hospitalization at day 90 were unstable condition from complications (30.0%), caregiver problems (30.0%), and palliative care (25.0%). Poor outcomes were shown in the patients admitted more than 90 days. Percentage of death, being bedridden, and re-admission were 55, 40, and 22, respectively. The goal of treatment was only palliative care in 80 percent of this patient group. Respiratory failure among the hospitalized was the strongest predictive factors of death (Odds ratio = 7.5, p < 0.001). The average costs of admission per patient was 163,870 THB and the percentage of reimbursement was only 72%. For total costs of admission in these two months, Siriraj Hospital lost a large amount of money (about 26 million THB) for patients admitted for 7 days or more and almost 50% of this was spent on the patients admitted for 90 days or more. The average cost of admission per patient in the latter group was 1,073,004 THB. Prolonged hospitalization had adverse outcomes for the patients and the hospital, such as high complications, poor outcomes, high costs of treatment and low reimbursement ratio that created an enormous economic burden for the hospital. Therefore possible preventable causes of prolonged admission must be identified, prevented and managed by improving quality of multidisciplinary health care system and ancillary services.

Streptococcus pneumoniae serotype prevalence and antibiotic resistance among young children with invasive pneumococcal disease: experience from a tertiary care center in South India.

PubMed

Nagaraj, Savitha; Kalal, Bhuvanesh Sukhlal; Manoharan, Anand; Shet, Anita

2017-06-01

We performed a study to describe the clinical profile, antimicrobial susceptibility and prevalent serotypes of pneumococcal isolates from children with suspected invasive pneumococcal disease (IPD) admitted to a tertiary care hospital in South India. Hospitalized children, ≤ 5 years with fever (>38 °C); increased respiratory rate or neurological symptoms were recruited, (as part of the Alliance for Surveillance of Invasive Pneumococci - ASIP - project) from January 2011 to March 2013. Identification of pneumococcal isolates from blood or cerebrospinal fluid samples was done by routine culture methods. Isolates were analyzed for antimicrobial susceptibility, and confirmed by serotyping (using Quellung's test) and multiplex PCR. Out of the 171 samples received in the lab, 17 grew pneumococci identified by standard methods. Fourteen of them were confirmed by multiplex PCR. Maximum recruitment was observed during the months of January and February (36.4%, 28.6%). The average age of affected subjects was 21 months. The common clinical presentation was pneumonia (42.8%). Two isolates belonging to the 19F and 19B serotypes were resistant to penicillin (on Etest). The observed serotype distribution was 6B and 19F (2 each), and 1, 2, 6A, 9V, 10A, 14, 15A, 19B, 21, 35F (1 each). The overall fatality rate was 14.3% (n=2); the S. pneumoniae isolates from these two patients belonged to the non-vaccine serotype 19B and vaccine serotype 19F and demonstrated in vitro resistance to penicillin and erythromycin. Our study demonstrates the presence of invasive pneumococcal disease among under-5-year-old children in India caused by serotypes that are in large part covered by available pneumococcal vaccines.

Streptococcus pneumoniae serotype prevalence and antibiotic resistance among young children with invasive pneumococcal disease: experience from a tertiary care center in South India

PubMed Central

Nagaraj, Savitha; Kalal, Bhuvanesh Sukhlal; Manoharan, Anand; Shet, Anita

2017-01-01

Introduction We performed a study to describe the clinical profile, antimicrobial susceptibility and prevalent serotypes of pneumococcal isolates from children with suspected invasive pneumococcal disease (IPD) admitted to a tertiary care hospital in South India. Methods Hospitalized children, ≤ 5 years with fever (>38 °C); increased respiratory rate or neurological symptoms were recruited, (as part of the Alliance for Surveillance of Invasive Pneumococci – ASIP – project) from January 2011 to March 2013. Identification of pneumococcal isolates from blood or cerebrospinal fluid samples was done by routine culture methods. Isolates were analyzed for antimicrobial susceptibility, and confirmed by serotyping (using Quellung’s test) and multiplex PCR. Results Out of the 171 samples received in the lab, 17 grew pneumococci identified by standard methods. Fourteen of them were confirmed by multiplex PCR. Maximum recruitment was observed during the months of January and February (36.4%, 28.6%). The average age of affected subjects was 21 months. The common clinical presentation was pneumonia (42.8%). Two isolates belonging to the 19F and 19B serotypes were resistant to penicillin (on Etest). The observed serotype distribution was 6B and 19F (2 each), and 1, 2, 6A, 9V, 10A, 14, 15A, 19B, 21, 35F (1 each). The overall fatality rate was 14.3% (n=2); the S. pneumoniae isolates from these two patients belonged to the non-vaccine serotype 19B and vaccine serotype 19F and demonstrated in vitro resistance to penicillin and erythromycin. Conclusion Our study demonstrates the presence of invasive pneumococcal disease among under-5-year-old children in India caused by serotypes that are in large part covered by available pneumococcal vaccines. PMID:28626738

Compliance with guidelines for disease management in diabetes: results from the SwissDiab Registry

PubMed Central

Schimke, Katrin E; Meier, Sandro; Stettler, Christoph; Brändle, Michael

2018-01-01

Objective Tight glycemic control and aggressive treatment of additional cardiovascular risk factors can substantially reduce risk of diabetes-related complications. In 2013, the Swiss Society of Endocrinology and Diabetology (SSED) established national criteria on good disease management in diabetes, but little is known about compliance in clinical care. Here we assessed to what extent patients from two tertiary care centers in the German-speaking part of Switzerland enrolled in the Swiss Diabetes (SwissDiab) Registry adhere to the SSED criteria. Research design and methods SwissDiab is a prospective observational cohort study of patients regularly treated at Swiss tertiary diabetes centers. Data were collected through standardized annual health examinations. Baseline participant descriptive statistics, stratified by diabetes mellitus type 1 (DM1) and type 2 (DM2), were compared with SSED targets for glycemic control, blood pressure, blood lipids, weight maintenance, and ophthalmic examination. Results By the end of 2016, 604 participants with DM1 (40%) and DM2 (60%) had data available for analyses, 36% and 29% women, respectively. At baseline, all the SSED targets were met with two exceptions: a glycated hemoglobin A1c value <7% was measured in 32% of participants with DM1 (SSED target: ≥40%) and 47% and 56% of overweight or obese participants with DM1 and DM2, respectively, received nutritional counseling in the previous year (SSED target: ≥80%). Conclusions The SSED targets for good disease management in diabetes were achieved in the majority of participants at the time of enrollment, but results also highlight areas where disease management can be improved, particularly the role of nutrition counseling. PMID:29527307

Prevalence of psychiatric co-morbidity among patients attending dental OPD and the role of consultation-liaison psychiatry in dental practice in a tertiary care general hospital.

PubMed

Ray, Pradip K; Ray Bhattacharya, Sampa; Makhal, Manabendra; Majumder, Uttam; De, Shantanu; Ghosh, Subhankar

2015-01-01

Psychiatric co-morbidities are frequent among patients attending dental OPD, some of which go unrecognized and hence untreated. The present study has been carried out to detect the psychiatric co-morbidities among dental patients and determine the scope of consultation-liaison (C-L) psychiatry in a rural teaching hospital regarding comprehensive management of the patients. This cross-sectional, descriptive type study was conducted in a multi-speciality tertiary care teaching hospital in the northern part of West Bengal, India. One hundred patients attending the dental OPD were randomly included in the study and every patient was consecutively referred to psychiatry department for assessment, during the period from 1(st) November 2013 to 30(th) April 2014. All referred patients were clinically examined and psychiatric co-morbidity was assessed by the help of General Health Questionnaire (GHQ)-28 and Mental Status Examination. The data were subjected to statistical package for social sciences (SPSS), version 16, and statistically analyzed using Cross tab and Chi test. P <0.05 was considered to be statistically significant. The commonest dental illness was dental caries (22%). More than two-third of the patients had psychiatric co-morbidity according to GHQ-28 total score. Sixty-eight patients were diagnosed to have mental disorder on mental status examination. Somatoform disorder (25%) was the commonest type of mental disorder, followed by mixed anxiety and depression (14%). This study has pointed the need for psychological examination of patients visiting dental specialty with unexplained physical symptoms. Such patients can be identified and treated, provided a psychiatric consultation service exists.

Analysis of Drug Resistance Determinants in Klebsiella pneumoniae Isolates from a Tertiary-Care Hospital in Beijing, China

PubMed Central

Wang, Qi; Woo, Patrick C. Y.; Tan, Lin; Jing, Hua; Gao, George F.; Liu, Cui Hua

2012-01-01

Background The rates of multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) isolates among Enterobacteriaceae isolates, particularly Klebsiella pneumoniae, have risen substantially worldwide. Methodology/Principal Findings To better understand the molecular mechanisms of drug resistance in K. pneumoniae, we analyzed the drug resistance determinants for K. pneumoniae isolates collected from the 306 Hospital, a tertiary-care hospital in Beijing, China, for the period of September 1, 2010-October 31, 2011. Drug susceptibility testing, PCR amplification and sequencing of the drug resistance determinants were performed. Conjugation experiments were conducted to examine the natural ability of drug resistance to disseminate among Enterobacteriaceae strains using a sodium azide-resistant Escherichia coli J53 strain as a recipient. Among the 223 consecutive non-repetitive K. pneumoniae isolates included in this study, 101 (45.3%) were extended-spectrum beta-lactamases (ESBLs) positive. The rates of MDR, XDR, and PDR isolates were 61.4% (n = 137), 22.0% (n = 49), and 1.8% (n = 4), respectively. Among the tested drug resistance-associated genes, the following ones were detected at relatively high rates bla CTX-M-10 (80, 35.9%), aacC2 (73, 32.7%), dhfr (62, 27.8%), qnrS (58, 26.0%), aacA4 (57, 25.6%), aadA1 (56, 25.1%). Results from conjugation experiments indicate that many of the drug resistance genes were transmissible. Conclusions/Significance Our data give a “snapshot” of the complex genetic background responsible for drug resistance in K. pneumoniae in China and demonstrate that a high degree of awareness and monitoring of those drug resistance determinants are urgently needed in order to better control the emergence and transmission of drug-resistant K. pneumoniae isolates in hospital settings. PMID:22860106

Reduction of nutrients, microbes, and personal care products in domestic wastewater by a benchtop electrocoagulation unit

PubMed Central

Symonds, E. M.; Cook, M. M.; McQuaig, S. M.; Ulrich, R. M.; Schenck, R. O.; Lukasik, J. O.; Van Vleet, E. S.; Breitbart, M.

2015-01-01

To preserve environmental and human health, improved treatment processes are needed to reduce nutrients, microbes, and emerging chemical contaminants from domestic wastewater prior to discharge into the environment. Electrocoagulation (EC) treatment is increasingly used to treat industrial wastewater; however, this technology has not yet been thoroughly assessed for its potential to reduce concentrations of nutrients, a variety of microbial surrogates, and personal care products found in domestic wastewater. This investigation's objective was to determine the efficiency of a benchtop EC unit with aluminum sacrificial electrodes to reduce concentrations of the aforementioned biological and chemical pollutants from raw and tertiary-treated domestic wastewater. EC treatment resulted in significant reductions (p < 0.05, α = 0.05) in phosphate, all microbial surrogates, and several personal care products from raw and tertiary-treated domestic wastewater. When wastewater was augmented with microbial surrogates representing bacterial, viral, and protozoan pathogens to measure the extent of reduction, EC treatment resulted in up to 7-log10 reduction of microbial surrogates. Future pilot and full-scale investigations are needed to optimize EC treatment for the following: reducing nitrogen species, personal care products, and energy consumption; elucidating the mechanisms behind microbial reductions; and performing life cycle analyses to determine the appropriateness of implementation. PMID:25797885

Utilization of implantable defibrillators in Africa.

PubMed

Millar, R N Scott; Mayosi, B M

2003-01-01

Sub-Saharan Africa is dominated by diseases of poverty. HIV/AIDS affects 28.5 out of a total of 600 million in the region. South Africa is the only country in sub-Saharan Africa in which implantable cardiovertor defibrillators (ICDs) are implanted (0.8/million in 2001). Only 3 of the 35 new ICDs were implanted in state-funded public hospitals. The pacemaker implantation rate for South Africa was 41/million in 2001. Approximately 20% of the population consume 56% of the health care expenditure, mainly funded by Medical Insurance. A tax-funded state health care system serves the rest of the population, but is concentrated on improving sanitation and primary health care. Diversion of funds from academic tertiary hospitals has reduced specialised services, particularly cardiology and cardiac surgery, and has resulted in an exodus of skilled personnel to the private sector. In the rest of sub-Saharan Africa, tertiary health care is mainly privately funded. Cardiology and cardiac surgery is not widely available. Many countries are crippled by debt and chronic local conflicts. Only one state hospital (Groote Schuur, Cape Town) provides an electrophysiology (EP) service including catheter ablation and ICD implantation, and training in EP, by two electrophysiologists. EP services are available privately in 3 centres. No EP service exists in the rest of sub-Saharan Africa.

Reduction of nutrients, microbes, and personal care products in domestic wastewater by a benchtop electrocoagulation unit.

PubMed

Symonds, E M; Cook, M M; McQuaig, S M; Ulrich, R M; Schenck, R O; Lukasik, J O; Van Vleet, E S; Breitbart, M

2015-03-23

To preserve environmental and human health, improved treatment processes are needed to reduce nutrients, microbes, and emerging chemical contaminants from domestic wastewater prior to discharge into the environment. Electrocoagulation (EC) treatment is increasingly used to treat industrial wastewater; however, this technology has not yet been thoroughly assessed for its potential to reduce concentrations of nutrients, a variety of microbial surrogates, and personal care products found in domestic wastewater. This investigation's objective was to determine the efficiency of a benchtop EC unit with aluminum sacrificial electrodes to reduce concentrations of the aforementioned biological and chemical pollutants from raw and tertiary-treated domestic wastewater. EC treatment resulted in significant reductions (p < 0.05, α = 0.05) in phosphate, all microbial surrogates, and several personal care products from raw and tertiary-treated domestic wastewater. When wastewater was augmented with microbial surrogates representing bacterial, viral, and protozoan pathogens to measure the extent of reduction, EC treatment resulted in up to 7-log10 reduction of microbial surrogates. Future pilot and full-scale investigations are needed to optimize EC treatment for the following: reducing nitrogen species, personal care products, and energy consumption; elucidating the mechanisms behind microbial reductions; and performing life cycle analyses to determine the appropriateness of implementation.

Reduction of nutrients, microbes, and personal care products in domestic wastewater by a benchtop electrocoagulation unit

NASA Astrophysics Data System (ADS)

Symonds, E. M.; Cook, M. M.; McQuaig, S. M.; Ulrich, R. M.; Schenck, R. O.; Lukasik, J. O.; van Vleet, E. S.; Breitbart, M.

2015-03-01

To preserve environmental and human health, improved treatment processes are needed to reduce nutrients, microbes, and emerging chemical contaminants from domestic wastewater prior to discharge into the environment. Electrocoagulation (EC) treatment is increasingly used to treat industrial wastewater; however, this technology has not yet been thoroughly assessed for its potential to reduce concentrations of nutrients, a variety of microbial surrogates, and personal care products found in domestic wastewater. This investigation's objective was to determine the efficiency of a benchtop EC unit with aluminum sacrificial electrodes to reduce concentrations of the aforementioned biological and chemical pollutants from raw and tertiary-treated domestic wastewater. EC treatment resulted in significant reductions (p < 0.05, α = 0.05) in phosphate, all microbial surrogates, and several personal care products from raw and tertiary-treated domestic wastewater. When wastewater was augmented with microbial surrogates representing bacterial, viral, and protozoan pathogens to measure the extent of reduction, EC treatment resulted in up to 7-log10 reduction of microbial surrogates. Future pilot and full-scale investigations are needed to optimize EC treatment for the following: reducing nitrogen species, personal care products, and energy consumption; elucidating the mechanisms behind microbial reductions; and performing life cycle analyses to determine the appropriateness of implementation.

Dissemination of genetically related IMP-6-producing multidrug-resistant Pseudomonas aeruginosa ST235 in South Korea.

PubMed

Yoo, Jung Sik; Yang, Ji Woo; Kim, Hye Mee; Byeon, Jeongheum; Kim, Hwa Su; Yoo, Jae Il; Chung, Gyung Tae; Lee, Yeong Seon

2012-04-01

The present study aimed to describe the prevalence and molecular epidemiology of metallo-β-lactamase (MBL)-producing Pseudomonas aeruginosa isolates obtained from non-tertiary care hospitals and geriatric hospitals in South Korea. Of the 644 isolates, 224 were carbapenem-resistant, amongst which 41 (18.3%) were MBL-producers and the major MBL type was IMP-6 (35 isolates). IMP-6-producing isolates were multidrug-resistant and showed higher minimum inhibitory concentrations for meropenem than imipenem. All of the IMP-6-producing isolates had class 1 integrons with amplification sizes of 4.5 kb/5.5 kb (34 isolates) or 3.0 kb (1 isolate); 4.5 kb/5.5 kb integrons had bla(IMP-6)-qac-aacA4-bla(OXA-1)-aadA1 (5.5 kb) and aadB-cmlA-bla(OXA-10)-aadA1 (4.5 kb). Pulsed-field gel electrophoresis (PFGE) analysis indicated that all IMP-6-producing P. aeruginosa from various geographic areas had nearly identical patterns with >85% similarity. All IMP-6-producing isolates showed high genetic similarity to those obtained from tertiary care hospitals and had the same integron type, indicating the spread of these strains to the three types of hospitals nationwide. These data show the wide spreading of clonally related IMP-6-producing P. aeruginosa (sequence type 235) through tertiary, non-tertiary and geriatric hospitals in South Korea. Continuous monitoring and thorough infection control should be performed in all types of hospitals to prevent further spreading of MBL-producing P. aeruginosa. Copyright © 2012 Elsevier B.V. and the International Society of Chemotherapy. All rights reserved.

Management of fever and neutropenia in children with cancer.

PubMed

Vedi, A; Pennington, V; O'Meara, M; Stark, K; Senner, A; Hunstead, P; Adnum, K; Londall, W; Maurice, L; Wakefield, Claire; Cohn, R J

2015-07-01

Febrile neutropenia remains a common, life-threatening complication of chemotherapy in paediatric oncology. Delays in institution of empiric antibiotics have been identified at tertiary and regional centres caring for these patients and associated with decreased survival. Our objective was to reduce the time to administration of empiric antibiotics to less than 60 min from the time of presentation to hospital. A retrospective study of the records of oncology patients presenting to the emergency department of a tertiary hospital over a 3-month period was performed and time to first antibiotic administration recorded. Potential causes of delay in commencement of antibiotics were identified and an algorithm-based approach to the management of fever in immunocompromised children developed and implemented. Follow-up evaluation data were collected at 12 and 60 months post-intervention. Causes of delay in commencement of antibiotics at regional hospitals that share care with the tertiary hospital were identified through questionnaires, interviews and focus groups, involving patients and medical and nursing staff. The impact of the introduction of the algorithm at one peripheral hospital was evaluated. The mean time to empiric antibiotics was reduced from 148 min (95% confidence interval (CI) 81-216) at baseline to 76 min (95% CI 50-101) at 12 months post-intervention and sustained at 65 min (95% CI 52-77) 5 years after the intervention. At the peripheral hospital, mean time to antibiotic delivery was reduced from 221 min (95% CI 114-328) to 65 min (95% CI 42-87) at 12 months after the intervention. The introduction of the guideline, with teaching and support for staff and parents, resulted in an improvement in practice, meeting international guidelines and achieving sustained results at 5 years after introduction at a tertiary hospital. The guideline has been shown to be feasible and effective at a regional hospital.

Morphine clearance in children: does race or genetics matter?

PubMed

Sadhasivam, Senthilkumar; Krekels, Elke H J; Chidambaran, Vidya; Esslinger, Hope R; Ngamprasertwong, Pornswan; Zhang, Kejian; Fukuda, Tsuyoshi; Vinks, Alexander A

2012-01-01

Interindividual variability in analgesic response and adverse effects of opioids because of narrow therapeutic indices are major clinical problems. Morphine is an opioid commonly used in children to manage perioperative pain. Al-though size and age often are considered primary covariates for morphine pharmacokinetic models, the impact of other factors important in personalizing care such as race and genetic variations on morphine disposition is not well documented. Genotype blinded clinical observational pharmacokinetic study. One hundred forty-six African American and Caucasian children scheduled for elective outpatient adenotonsillectomy were enrolled in our prospective genotype blinded observational study with standard perioperative clinical care. Tertiary care pediatric institution. Morphine bolus for intraoperative analgesia in children and pharmacokinetic analyses in different races. Pharmacokinetics and pharmacogenetics of intravenous morphine in a homogeneous pediatric outpatient surgical pain population were evaluated. The authors observed that African American children have higher morphine clearance than Caucasian children. The increased clearance is directed toward the formation of morphine-3-glucuronide formation, rather than the formation of morphine-6-glucuronide. Common uridine diphosphate glucuronosyl transferase (UGT) 2B7 genetic variations (2161C>T and 802C>T) were not associated with observed racial differences in morphine's clearance although the wild type of the UGT2B7 isozyme is more prevalent in the African Americans. Race of the child is an important factor in perioperative intravenous morphine's clearance and its potential role in personalizing analgesia with morphine needs further investigation.

Traditional birth attendants issue: a menace in developing countries.

PubMed

Buowari, O Y

2012-01-01

A significant proportion of births in Nigeria still occur at homes of traditional birth attendant. Traditional birth attendants are popular in developing and low resource countries. They lack no formal education or medical training and their clients end up with obstetric complications which lead to severe morbidity and mortality. Two cases of pregnant women that engaged the services of traditional birth attendants (TBA) before presenting at a health facility are presented. They ended up with severe morbidity and mortalities. A 29 year old gravida 3 + para 2+0 woman with two previous caesarean section(C/S) was counselled for elective c/s but declined. She presented at the home of a TBA, had spontaneous vagina deliver, collapsed one hour after delivery and was dead by the time she was brought to the hospital. A 30 year old gravida 10 para 7 + 3 presented in hospital after being in labour at the home of a TBA for three days. On presentation in hospital there was absent foetal heart sound. At surgery there was ruptured uterus and subtotal hysterectomy was done. To improve the situation better access to optimal antenatal care and intrapartum care together with early referral of high-risk patients must be facilitated. Increased community awareness, promotion of appropriate technology for effective health care planning strategy from the grassroots level to tertiary centres is important in the reduction of obstructed labour. One of the most effective means of reducing maternal mortality is the provision of caesarean section for all women who need it.

Reporting an outbreak of Candida pelliculosa fungemia in a neonatal intensive care unit.

PubMed

Lin, Hsiao-Chuan; Lin, Hsiang-Yu; Su, Bai-Hong; Ho, Mao-Wang; Ho, Cheng-Mao; Lee, Ching-Yi; Lin, Ming-Hsia; Hsieh, Hsin-Yang; Lin, Hung-Chih; Li, Tsai-Chung; Hwang, Kao-Pin; Lu, Jang-Jih

2013-12-01

Fungemia in preterm infants is associated with high mortality and morbidity. This study reports an outbreak of unusual fungemia in a tertiary neonatal intensive care unit (NICU). Ten Candida pelliculosa bloodstream isolates were identified from six infants hospitalized in the NICU from February to March 2009. Environmental study was performed, and genetic relatedness among the 10 clinical isolates of C pelliculosa and six control C pelliculosa strains was characterized by randomly amplified polymorphic DNA assay. In vitro susceptibility of isolates to six antifungal agents was analyzed by broth microdilution method. Amphotericin B was given to infected infants and prophylactic fluconazole was prescribed to the other noninfected extremely low birth weight infants during the outbreak. Thrombocytopenia (platelet counts <100×10(9)/L) was the early laboratory finding in four infants. One of six patients died, making overall mortality 17%. Fluconazole, voriconazole, amphotericin B, and micafungin provided good antifungal activity. Cultures from the environment and hands of caregivers were all negative. Molecular studies indicated the outbreak as caused by a single strain. The outbreak was controlled by strict hand washing, cohort infected patients, confined physicians and nurses to take care of patients, prophylactic fluconazole to uninfected neonates, and proper management of human milk. The study demonstrated the clinical importance of emerged non-albicans Candida species in NICU. For unusual pathogen isolated from immunocompromised hosts, more attention should be paid to monitor the possibility of an outbreak. Copyright © 2012. Published by Elsevier B.V.

Ethical issues recognized by critical care nurses in the intensive care units of a tertiary hospital during two separate periods.

PubMed

Park, Dong Won; Moon, Jae Young; Ku, Eun Yong; Kim, Sun Jong; Koo, Young-Mo; Kim, Ock-Joo; Lee, Soon Haeng; Jo, Min-Woo; Lim, Chae-Man; Armstrong, John David; Koh, Younsuck

2015-04-01

This research aimed to investigate the changes in ethical issues in everyday clinical practice recognized by critical care nurses during two observation periods. We conducted a retrospective analysis of data obtained by prospective questionnaire surveys of nurses in the intensive care units (ICU) of a tertiary university-affiliated hospital in Seoul, Korea. Data were collected prospectively during two different periods, February 2002-January 2003 (Period 1) and August 2011-July 2012 (Period 2). Significantly fewer cases with ethical issues were reported in Period 2 than in Period 1 (89 cases [2.1%] of 4,291 ICU admissions vs. 51 [0.5%] of 9,302 ICU admissions, respectively; P < 0.001). The highest incidence of cases with identified ethical issues in both Periods occurred in MICU. The major source of ethical issues in Periods 1 and 2 was behavior-related. Among behaviorrelated issues, inappropriate healthcare professional behavior was predominant in both periods and mainly involved resident physicians. Ethical issue numbers regarding end-oflife (EOL) care significantly decreased in the proportion with respect to ethical issues during Period 2 (P = 0.044). In conclusion, the decreased incidence of cases with identified ethical issues in Period 2 might be associated with ethical enhancement related with EOL and improvements in the ICU care environment of the studied hospital. However, behaviorrelated issues involving resident physicians represent a considerable proportion of ethical issues encountered by critical care nurses. A systemic approach to solve behavior-related issues of resident physicians seems to be required to enhance an ethical environment in the studied ICU.

Resident reflections on end-of-life education: a mixed-methods study of the 3 Wishes Project.

PubMed

Centofanti, J; Swinton, M; Dionne, J; Barefah, A; Boyle, A; Woods, A; Shears, M; Heels-Ansdell, D; Cook, D

2016-03-31

The objectives of this study were to describe residents' experiences with end-of-life (EOL) education during a rotation in the intensive care unit (ICU), and to understand the possible influence of the 3 Wishes Project. We enrolled dying patients, their families and 1-3 of their clinicians in the 3 Wishes Project, eliciting and honouring a set of 3 wishes to bring peace to the final days of a critically ill patient's life, and ease the grieving process for families. We conducted semistructured interviews with 33 residents who had cared for 50 dying patients to understand their experiences with the project. Interviews were recorded, transcribed verbatim, then analysed using a qualitative descriptive approach. 21-bed medical surgical ICU in a tertiary care, university-affiliated hospital. 33 residents participated from internal medicine (24, 72.7%), anaesthesia (8, 24.2%) and laboratory medicine (1, 3.0%) programmes in postgraduate years 1-3. 3 categories and associated themes emerged. (1) EOL care is a challenging component of training in that (a) death in the ICU can invoke helplessness, (b) EOL education is inadequate, (c) personal connections with dying patients is difficult in the ICU and (d) EOL skills are valued by residents. (2) The project reframes the dying process for residents by (a) humanising this aspect of practice, (b) identifying that family engagement is central to the dying process, (c) increasing emotional responsiveness and (d) showing that care shifts, not stops. (3) The project offers experiential education by (a) intentional role modelling, (b) facilitating EOL dialogue, (c) empowering residents to care in a tangible way and (d) encouraging reflection. For residents, the 3 Wishes Project integrated many forms of active learning for residents. Practice-based rather than classroom-based programmes may engage trainees to develop EOL skills transferable to other settings. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

A comprehensive palliative care program at a tertiary cancer center in Jordan.

PubMed

Shamieh, Omar; Hui, David

2015-03-01

The palliative care program in King Hussein Cancer Center (KHCC) is growing rapidly to serve the needs of patients with cancer and their families. To describe the KHCC palliative care program and its integration into the oncology care. Narrative review of our palliative care program. Patients with cancer at KHCC have access to an interprofessional palliative care at different settings. In 2012, the inpatient team saw 400 consultations and 979 referrals and admissions. The outpatient clinic had a total of 1133 patient visits. The home care program provided a total of 1501 visits. Our program is a regional center for education and training and actively conducts research. Our palliative care program may be a model for successful delivery of comprehensive cancer care in the Middle East. © The Author(s) 2013.

Microstructural development and mechanical properties of a near-eutectic directionally solidified Sn–Bi solder alloy

DOE Office of Scientific and Technical Information (OSTI.GOV)

Silva, Bismarck Luiz, E-mail: bismarck_luiz@yahoo.com.br; Reinhart, Guillaume; Nguyen-Thi, Henri

2015-09-15

Sn–Bi solders may be applied for electronic applications where low-temperature soldering is required, i.e., sensitive components, step soldering and soldering LEDs. In spite of their potential to cover such applications, the mechanical response of soldered joints of Sn–Bi alloys in some cases does not meet the strength requirements due to inappropriate resulting microstructures. Hence, careful examination and control of as-soldered microstructures become necessary with a view to pre-programming reliable final properties. The present study aims to investigate the effects of solidification thermal parameters (growth rate — V{sub L} and cooling rate — T-dot{sub L}) on the microstructure of the Sn–52more » wt.%Bi solder solidified under unsteady-state conditions. Samples were obtained by upward directional solidification (DS), followed by characterization through metallography and scanning electron microscopy (SEM). The microstructures are shown to be formed by Sn-rich dendrites decorated with Bi precipitates surrounded by a complex regular eutectic mixture, with alternated Bi-rich and Sn-rich phases. Experimental correlations of primary (λ{sub 1}), secondary (λ{sub 2}), tertiary (λ{sub 3}) dendritic and eutectic spacings (λ{sub coarse} and λ{sub fine}) with cooling rate and growth rate are established. Two ranges of lamellar eutectic sizes were determined, described by two experimental equations λ = 1.1 V{sub L}{sup −1/2} and λ = 0.67 V{sub L}{sup −1/2}. The onset of tertiary branches within the dendritic array along the Sn–52 wt.%Bi alloy DS casting is shown to occur for cooling rates lower than 1.5 °C/s. - Highlights: • The Sn–52 wt.%Bi solder was shown to have two eutectic sizes. • The fishbone eutectic is preferably located adjacent to the Bi-rich lamellar phases. • The onset of tertiary dendritic branches in Sn–Bi is associated with T-dot{sub L} < 1.5 °C/s. • Higher eutectic fraction and λ{sub 3} provoked a reverse increase in σ{sub u} and σ{sub y}.« less

C5 palsy after posterior cervical decompression and fusion: cost and quality-of-life implications.

PubMed

Miller, Jacob A; Lubelski, Daniel; Alvin, Matthew D; Benzel, Edward C; Mroz, Thomas E

2014-12-01

C5 palsy is a debilitating postoperative complication of cervical decompression surgery. Although the prognosis is typically good, patients may be unable to perform basic activities of daily living, resulting in a decreased quality of life. No studies have investigated the quality-of-life and financial implications. The aim of the study was to determine the impact on quality-of-life and costs of C5 palsy after posterior cervical decompression and fusion (PCDF). A 2:1 matched retrospective cohort study was conducted at a single tertiary-care institution between 2007 and 2012. Individuals who had undergone PCDF were included. Self-reported: Euroqol-5 Dimensions quality-of-life survey. Physiologic: postoperative change in deltoid and biceps strength via manual muscle testing. Functional: cost of interventions and missed workdays postoperatively. Individuals with postoperative C5 palsy were matched to controls based on age, gender, body mass index, and diagnosis. Demographic, operative, postoperative, quality-of-life, and cost data were collected for both the C5 palsy and control groups, with 1-year follow-up. We reviewed 245 patients who underwent PCDF and 17 were identified (6.9%) with C5 palsy and matched to 34 controls. No significant differences in demographic or operative characteristics were observed between groups. The C5 palsy group had a significantly reduced capacity for self-care in the immediate postoperative (2.0±0.71 vs. 1.2±0.4, p<.001) and long-term (1.6±0.6 vs. 1.2±0.4, p=.004) periods and a significantly reduced capacity for completion of usual activities (2.4±0.7 vs. 1.9±0.6, p=.014) compared with controls. Furthermore, the C5 group had a significantly greater cost of physical/occupational therapy, an increase of $2,078 ($4,386±$2,801 vs. $2,307±$1,907, p=.013). There were no significant differences between groups in the cost of hospital stay, surgery, or other direct or indirect costs. Overall, there was a significantly greater cost ($1,918) for the C5 palsy group compared with the control group ($7,584±$3,992 vs. $5,666±$2,359, respectively, p=.038). This study represents the first quantification of the impact of C5 palsy on patients' quality of life and the associated costs for care. We found that C5 palsy adds a significant burden on patients' quality of life and presents a financial burden to the health-care system. Copyright © 2014 Elsevier Inc. All rights reserved.

The roles of tertiary amine structure, background organic matter and chloramine species on NDMA formation.

PubMed

Selbes, Meric; Kim, Daekyun; Ates, Nuray; Karanfil, Tanju

2013-02-01

N-nitrosodimethylamine (NDMA), a probable human carcinogen, is a disinfection by-product that has been detected in chloraminated and chlorinated drinking waters and wastewaters. Formation mechanisms and precursors of NDMA are still not well understood. The main objectives of this study were to systematically investigate (i) the effect of tertiary amine structure, (ii) the effect of background natural organic matter (NOM), and (iii) the roles of mono vs. dichloramine species on the NDMA formation. Dimethylamine (DMA) and 20 different tertiary aliphatic and aromatic amines were carefully examined based on their functional groups attached to the basic DMA structure. The wide range (0.02-83.9%) of observed NDMA yields indicated the importance of the structure of tertiary amines, and both stability and electron distribution of the leaving group of tertiary amines on NDMA formation. DMA associated with branched alkyl groups or benzyl like structures having only one carbon between the ring and DMA structure consistently gave higher NDMA yields. Compounds with electron withdrawing groups (EWG) reacted preferentially with monochloramine, whereas compounds with electron donating group (EDG) showed tendency to react with dichloramine to form NDMA. When the selected amines were present in NOM solutions, NDMA formation increased for compounds with EWG while decreased for compounds with EDG. This impact was attributed to the competitions between NOM and amines for chloramine species. The results provided additional information to the commonly accepted mechanism for NDMA formation including chloramine species reacting with tertiary amines and the role of the leaving group on overall NDMA conversion. Copyright © 2012 Elsevier Ltd. All rights reserved.

Detection of carbapenemases and other mechanisms of enzymatic resistance to β-lactams in Enterobacteriaceae with diminished susceptibility to carbapenems in a tertiary care hospital.

PubMed

Gómara, Marta; López-Calleja, Ana Isabel; Iglesia, Berta María Pilar Vela; Cerón, Isabel Ferrer; López, Antonio Rezusta; Pinilla, María José Revillo

2018-05-01

Our objective was to characterize the enzymatic β-lactam resistance in clinical Enterobacteriaceae isolates with diminished susceptibility to carbapenems from 2013 to 2014 at Hospital Universitario Miguel Servet. A total of 63 clinical isolates were analyzed for the presence of carbapenemases (KPC, OXA-48 and MBL), ESBLs and AmpC enzymes by combined disk methods and PCR detection of carbapenemase-encoding and beta-lactamase-encoding genes. Fifteen isolates had a phenotypic test compatible with carbapenemase production; two of these were confirmed by PCR as OXA-48 producers. ESBL detection was positive in 27 isolates (43%); plasmid-mediated AmpC was detected in nine isolates (14.2%) and derepressed AmpC β-lactamase was present in 18 isolates (28%). During the study period, the decreased susceptibility to carbapenems in Enterobacteriaceae in our area was not due to true carbapenemases but rather to β-lactamase activity (82.5% were ESBL or AmpC producers), probably in combination with decreased permeability of the outer membrane. Copyright © 2017 Elsevier España, S.L.U. and Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica. All rights reserved.

Accumulation of multiple mutations in linezolid-resistant Staphylococcus epidermidis causing bloodstream infections; in silico analysis of L3 amino acid substitutions that might confer high-level linezolid resistance.

PubMed

Ikonomidis, Alexandros; Grapsa, Anastasia; Pavlioglou, Charikleia; Demiri, Antonia; Batarli, Alexandra; Panopoulou, Maria

2016-12-01

Fifty-six Staphylococcus epidermidis clinical isolates, showing high-level linezolid resistance and causing bacteremia in critically ill patients, were studied. All isolates belonged to ST22 clone and carried the T2504A and C2534T mutations in gene coding for 23SrRNA as well as the C189A, G208A, C209T and G384C missense mutations in L3 protein which resulted in Asp159Tyr, Gly152Asp and Leu94Val substitutions. Other silent mutations were also detected in genes coding for ribosomal proteins L3 and L22. In silico analysis of missense mutations showed that although L3 protein retained the sequence of secondary motifs, the tertiary structure was influenced. The observed alteration in L3 protein folding provides an indication on the putative role of L3-coding gene mutations in high-level linezolid resistance. Furthermore, linezolid pressure in health care settings where linezolid consumption is of high rates might lead to the selection of resistant mutants possessing L3 mutations that might confer high-level linezolid resistance.

Effects of a lifestyle education program on glycemic control among patients with diabetes at Kigali University Hospital, Rwanda: A randomized controlled trial.

PubMed

Amendezo, Etienne; Walker Timothy, David; Karamuka, Vincent; Robinson, Brian; Kavabushi, Patrick; Ntirenganya, Cyprien; Uwiragiye, Joseph; Mukantagwabira, Donatille; Bisimwa, Jeanne; Uwintwali Marie, Henriette; Umulisa, Henriette; Niyomwungeri, Scholastique; Ndayambaje, Bernard; Dusabejambo, Vincent; Bavuma, Charlotte

2017-04-01

Evidence to show whether lifestyle intervention programs are beneficial for patients with diabetes in resource-limited countries is lacking. The present study assessed the additional efficacy of a structured lifestyle education program, as compared to the current standard of diabetic care in Rwanda. 251 consecutive adult patients attending a tertiary diabetic care practice were randomly assigned to either an intervention group (standard of care plus monthly lifestyle group education sessions of 45min duration) or to a control group. The primary outcome was between-groups difference in glycated hemoglobin (HbA1c) observed after 12-months follow up. Outcome measures in the intervention and control groups were compared using the ANCOVA test with a two-sided significance of 5%. Of the 251 subjects recruited, 223 were included in the analysis; of whom 115 were assigned to the intervention group, and 108 to the control group. After 12-months, the median HbA1c levels reduced by 1.70 (95% CI: -2.09 to -1.31; p<0.001) in the intervention group; and by 0.52 (95% CI: -0.95 to -0.10; p=0.01) in the control group. The difference in HbA1c reduction between the intervention and control groups was statistically significant (p<0.001) after adjustment for subjects' age, sex, education level, BMI, diabetes duration and diabetic medications. This study demonstrated that a structured lifestyle group education program for people with diabetes is an attractive option in a resource-limited setting, as it showed significant benefits in improved glycemic control over a 12-month period. ClinicalTrials.gov: NCT02032108. Copyright © 2017 Elsevier B.V. All rights reserved.

Fever control and application of hypothermia using intravenous cold saline

PubMed Central

Fink, Ericka L.; Kochanek, Patrick M.; Clark, Robert S. B.; Bell, Michael J.

2013-01-01

Objective To describe the use and feasibility of cold saline to decrease body temperature in pediatric neurocritical care. Design Retrospective chart review. Setting Pediatric tertiary care university hospital. Patients Children between 1 week and 17 yrs of age admitted to the pediatric intensive care unit with acute brain injury and having received intravenous cold saline between June-August 2009. Intervention(s) None. Measurements and Main Results Eighteen subjects accounted for 20 infusions with mean infusion volume 18 ± 10 cc/kg. Eight subjects had traumatic brain injury (TBI), 2 had intracranial hemorrhage, 6 had cardiac arrest, and one each had ischemic stroke and status epilepticus. The mean age was 9.5 ± 4.8 yrs. Temperature decreased from 38.7 ± 1.1°C to 37.7 ± 1.2°C and 37.0 ± 2.0 to 35.3 ± 1.6°C one h after infusion for fever (n=14, p<.05) or hypothermia (HT) induction (n=6, p=.05), respectively. Cold saline was not bolused, rather infused over 10–15 minutes. Mean arterial blood pressure and oxygenation parameters (PaO2/FiO2 ratio, mean airway pressure) were unchanged, but heart rate decreased in HT subjects (121 ± 4 vs. 109 ± 12; p<.05). Serum sodium concentration and International normalized ratio were significantly increased after cold saline infusion. There were no differences between pre- and post-infusion serum glucose and hematocrit, nor cerebral perfusion pressure or intracranial pressure in TBI patients. Conclusions Cold saline was an effective method of reducing temperature in children with acute brain injury. This approach can be considered to treat fever or to induce HT. Prospective study comparing safety and efficacy versus other cooling measures should be considered. PMID:21037507

Nonplanar tertiary amides in rigid chiral tricyclic dilactams. Peptide group distortions and vibrational optical activity.

PubMed

Pazderková, Markéta; Profant, Václav; Hodačová, Jana; Sebestík, Jaroslav; Pazderka, Tomáš; Novotná, Pavlína; Urbanová, Marie; Safařík, Martin; Buděšínský, Miloš; Tichý, Miloš; Bednárová, Lucie; Baumruk, Vladimír; Maloň, Petr

2013-08-22

We investigate amide nonplanarity in vibrational optical activity (VOA) spectra of tricyclic spirodilactams 5,8-diazatricyclo[6,3,0,0(1,5)]undecan-4,9-dione (I) and its 6,6',7,7'-tetradeuterio derivative (II). These rigid molecules constrain amide groups to nonplanar geometries with twisted pyramidal arrangements of bonds to amide nitrogen atoms. We have collected a full range vibrational circular dichroism (VCD) and Raman optical activity (ROA) spectra including signals of C-H and C-D stretching vibrations. We report normal-mode analysis and a comparison of calculated to experimental VCD and ROA. The data provide band-to-band assignment and offer a possibility to evaluate roles of constrained nonplanar tertiary amide groups and rigid chiral skeletons. Nonplanarity shows as single-signed VCD and ROA amide I signals, prevailing the couplets expected to arise from the amide-amide interaction. Amide-amide coupling dominates amide II (mainly C'-N stretching, modified in tertiary amides by the absence of a N-H bond) transitions (strong couplet in VCD, no significant ROA) probably due to the close proximity of amide nitrogen atoms. At lower wavenumbers, ROA spectra exhibit another likely manifestation of amide nonplanarity, showing signals of amide V (δ(oop)(N-C) at ~570 cm(-1)) and amide VI (δ(oop)(C'═O) at ~700 cm(-1) and ~650 cm(-1)) vibrations.

Zirconia toughened SiC whisker reinforced alumina composites small business innovation research

NASA Technical Reports Server (NTRS)

Loutfy, R. O.; Stuffle, K. L.; Withers, J. C.; Lee, C. T.

1987-01-01

The objective of this phase 1 project was to develop a ceramic composite with superior fracture toughness and high strength, based on combining two toughness inducing materials: zirconia for transformation toughening and SiC whiskers for reinforcement, in a controlled microstructure alumina matrix. The controlled matrix microstructure is obtained by controlling the nucleation frequency of the alumina gel with seeds (submicron alpha-alumina). The results demonstrate the technical feasibility of producing superior binary composites (Al2O3-ZrO2) and tertiary composites (Al2O3-ZrO2-SiC). Thirty-two composites were prepared, consolidated, and fracture toughness tested. Statistical analysis of the results showed that: (1) the SiC type is the key statistically significant factor for increased toughness; (2) sol-gel processing with a-alumina seed had a statistically significant effect on increasing toughness of the binary and tertiary composites compared to the corresponding mixed powder processing; and (3) ZrO2 content within the range investigated had a minor effect. Binary composites with an average critical fracture toughness of 6.6MPam sup 1/2, were obtained. Tertiary composites with critical fracture toughness in the range of 9.3 to 10.1 MPam sup 1/2 were obtained. Results indicate that these composites are superior to zirconia toughened alumina and SiC whisker reinforced alumina ceramic composites produced by conventional techniques with similar composition from published data.

Mineralogical characteristics of Cretaceous-Tertiary kaolins of the Douala Sub-Basin, Cameroon

NASA Astrophysics Data System (ADS)

Bukalo, Nenita N.; Ekosse, Georges-Ivo E.; Odiyo, John O.; Ogola, Jason S.

2018-05-01

As a step in evaluating the quality of Cretaceous-Tertiary kaolins of the Douala Sub-Basin, their mineralogical characteristics were determined. The X-ray diffractometry technique was used to identify and quantify the mineral phases present in bulk and <2 μm fractions. Scanning electron microscopy was used to determine the micromorphology of <2 μm fractions kaolins. Thermal analyses (derivative thermal gravimetric analysis, thermal gravimetric analysis, and heat flow) were conducted to further characterise the kaolins. The main mineral phases present in the studied Cretaceous-Tertiary kaolins of the Douala Sub-Basin were kaolinite > smectite > illite, with mean values of 33.01 > 11.20 > 4.41 wt %; and 72.23 > 10.69 > 4.69 wt %, in bulk and <2 μm fractions, respectively. The kaolins, micromorphologically, consisted of pseudo-hexagonal and thin platy particles; swirl-textured particles; and books or stacks of kaolinite particles. Three main reactions occurred during heating of the kaolins: a low temperature endothermic reaction, observed between 48 and 109 °C; a second low temperature peak, observed between 223 and 285 °C; and a third endothermic peak was found between 469 and 531 °C. In addition, an exothermic reaction also occurred between 943 and 988 °C in some of the samples. The absence of primary minerals such as feldspars and micas in most of these kaolins is an indication of intensive weathering, probably due to the humid tropical climate of the region. The different morphologies suggested that these kaolins might have been transported. Therefore, a humid tropical climate was responsible for the formation of Cretaceous-Tertiary kaolins of the Douala Sub-Basin through intense weathering of surrounding volcanic and metamorphic rocks.

Delay in presentation to the hospital and factors affecting it in breast cancer patients attending tertiary care center in Central India.

PubMed

Thakur, N A; Humne, A Y; Godale, L B

2015-01-01

Despite lower incidence of breast cancer in India, the total number of cases and the net mortality is high. To reduce this increasing load of mortality due to breast cancer we need to lay emphasis on early detection and increased use of systemic therapy. Early detection itself depends on early presentation to a health facility; thus, it is important to identify factors affecting delay in a presentation to hospital. To study the clinico-social profile of breast carcinoma patients attending a tertiary care hospital and to study the time lag since detection of lump by women and presentation to the hospital and factors affecting them. A total of 120 primary breast cancer patients visiting a tertiary care hospital over a period of 7 months (August 2010 to February 2011) were taken up for study. A detailed retrospective analysis of patients was done according to planned proforma. Maximum study subjects were in the age group of 41-50 years. Right and left breasts were equally affected. The most common histo-pathological type of breast carcinoma observed was invasive ductal carcinoma (NOS) in 105 (87.50%) cases. Majority of the cases were in stage III or stage II. The median time lag self-detection of lump in the breast by women and presentation to the hospital was 6 months. Women living in a rural area, those with lower socio-economic status and those with older age tend to assess health-care late. Carcinoma of the breast is a common cancer affecting young to middle age group with invasive ductal carcinoma being the most common histological type. Delay in presentation and late stage presentation is a major concern. Hence, proper awareness and screening programmers are needed to identify, inform and educate these categories of women.

Decentralizing provision of mental health care in Sri Lanka.

PubMed

Fernando, Neil; Suveendran, Thirupathy; de Silva, Chithramalee

2017-04-01

In the past, mental health services in Sri Lanka were limited to tertiary-care institutions, resulting in a large treatment gap. Starting in 2000, significant efforts have been made to reconfigure service provision and to integrate mental health services with primary health care. This approach was supported by significant political commitment to establishing island-wide decentralized mental health care in the wake of the 2004 tsunami. Various initiatives were consolidated in The mental health policy of Sri Lanka 2005-2015, which called for implementation of a comprehensive community-based, decentralized service structure. The main objectives of the policy were to provide mental health services of good quality at primary, secondary and tertiary levels; to ensure the active involvement of communities, families and service users; to make mental health services culturally appropriate and evidence based; and to protect the human rights and dignity of all people with mental health disorders. Significant improvements have been made and new cadres of mental health workers have been introduced. Trained medical officers (mental health) now provide outpatient care, domiciliary care, mental health promotion in schools, and community mental health education. Community psychiatric nurses have also been trained and deployed to supervise treatment adherence in the home and provide mental health education to patients, their family members and the wider community. A total of 4367 mental health volunteers are supporting care and raising mental health literacy in the community. Despite these important achievements, more improvements are needed to provide more timely intervention, combat myths and stigma, and further decentralize care provision. These, and other challenges, will be targeted in the new mental health policy for 2017-2026.

Preparing rehabilitation healthcare providers in the 21st century: implementation of interprofessional education through an academic-clinical site partnership.

PubMed

Sheldon, Michael; Cavanaugh, James T; Croninger, William; Osgood, Wendy; Robnett, Regi; Seigle, Janice; Simonsen, Linda

2012-01-01

Health profession education programs often struggle with barriers to implementing interprofesssional educational (IPE) initiatives, limiting early and consistent exposure of students to core IPE competencies. Few published reports are available to guide the implementation of IPE programs into practice. This article describes a successful and evolving partnership between an independent university and a tertiary care hospital. The IPE goals of this partnership were to expose students to roles of other disciplines in the complex hospital environment and integrate acute care exposure throughout the Doctor of Physical Therapy and Master of Science in Occupational Therapy curricula. Faculty and students, patients and families, and occupational and physical therapy clinicians participated in a series of learning activities in an acute care setting involving interprofessional teams of students. Activities included observations of OT and PT clinicians providing standard patient care, practice conducting team patient interviews, and interactive treatment planning sessions conducted live via videoconferencing technology between a patient's hospital room and an academic classroom on the university campus. The activities generally were designed to improve student preparedness for working as part of an interprofessional team in an acute care setting. Student and clinician feedback support the early development of student IPE competencies, including the appreciation and understanding of professional roles in the team approach to patient care and the development of effective communication skills. The partnership between the academic institution and tertiary care hospital is an effective vehicle to deliver and sustain IPE educational initiatives in the acute care setting. Current and planned IPE curriculum integration are discussed along with a preliminary analysis of IPE outcomes.

The epidemiological profile of candidemia at an Indian trauma care center.

PubMed

Tak, Vibhor; Mathur, Purva; Varghese, Prince; Gunjiyal, Jacinta; Xess, Immaculata; Misra, Mahesh C

2014-07-01

Candida spp. is a common cause of bloodstream infections. Candidemia is a potentially fatal infection that needs urgent intervention to salvage the patients. Trauma patients are relatively young individuals with very few comorbidities, and the epidemiology of candidemia is relatively unknown in this vulnerable and growing population. In this study, we report the epidemiology of candidemia in a tertiary care Trauma Center of India. The study was conducted from January 2009 to July 2012. All patients from whose blood samples a Candida spp. was recovered were included in this study. A detailed history and follow up of the patients was done. The isolates of Candida were identified to the species level. The speciation was done by conventional methods, including morphology on Corn Meal Agar, color development on Triphenyl Tetrazolium Chloride Agar and CHROMagar, and germ tube tests. The VITEK 2 YST ID colorometric card, a fully automated identification system was also used. Antifungal susceptibility was performed using the VITEK 2 system. A total of 212 isolates of the Candida species were recovered from blood samples of 157 patients over the study period. Candida tropicalis, 82 (39%), was the most common, followed by C. parapsilosis, 43 (20%), C. albicans, 29 (14%), C. glabrata, 24 (11%), C. rugosa, 20 (9%), C. hemulonii,; 6 (3%), C. guilliermondii, 4 (2%), C. famata, 3 (1.5%), and C. lusitaniae 1 (0.5%). Out of all the candidemia patients, 68 (43%) had a fatal outcome. Fluconazole and Amphotericin B resistance was seen in seven (3.3%) and seven (3.3%) of the isolates, respectively. Candidemia is a significant cause of mortality in trauma patients in our center, with C. tropicalis and C. parapsilosis being the predominant pathogens. Resistance to antifungal drugs is a matter of concern. Better hospital infection control practices and good antibiotic stewardship policies could possibly help in reducing the morbidity and mortality associated with candidemia.

Managing patient pathways to achieve lung cancer waiting time targets: mixed methods study

PubMed Central

Ip, Hugh; Amer, Tarik; Dangoor, Michael; Zamir, Affan; Gibbings-Isaac, Darryl; Kochhar, Ranjeev; Heymann, Timothy

2012-01-01

Objectives England's National Health Service (NHS) introduced a 62-day target, from referral to treatment, to make lung cancer patient pathways more efficient. This study aims to understand pathway delays that lead to breaches of the target when patients need care in both secondary and tertiary setting, so more than one institution is involved. Design Mixed methods cross case analysis. Setting Two tertiary referral hospitals in London. Participants Database records of 53 patients were analysed. Nineteen sets of patient notes were used for pathway mapping. Seventeen doctors, four nurses, eight managers and administrators were interviewed. Main outcome measures Qualitative methods include pathway mapping and semi-structured interviews. Quantitative analysis of patient pathway times from cancer services records. Results The majority of the patient pathway (68.4%) is spent in secondary centres. There is more variability in the processes of secondary centres but tertiary centres do not have perfect processes either. Three themes emerged from discussions: information flows, pathway performance and the role of the multidisciplinary approach. Conclusions The actions of secondary centres have a greater influence on whether a patient breaches the 62-day target, compared with tertiary centres. Nevertheless variability exists in both, with potential for improvement. PMID:23162682

Evaluating acceptance of an electronic data management system at a tertiary care institution.

PubMed

Young, Wendy; Klima, George; Isaac, Winston

2011-01-01

This research reports on satisfaction with the introduction of an electronic document management system in a tertiary hospital environment. A buffet of training and familiarization options were offered: one-on-one training, open house, drop-in, e-learning, classroom training, and self-study. It was found that professions differ in their pattern of satisfaction with training and they also differ in their satisfaction with both the usefulness and the ease of use of the system. Satisfaction among administrators was highest and that among nurses lowest. There was an association between attendance at the open house event and satisfaction with the system.

Biomedical waste management: study on the awareness and practice among healthcare workers in a tertiary teaching hospital.

PubMed

Joseph, L; Paul, H; Premkumar, J; Paul, R; Michael, J S

2015-01-01

Bio-medical waste has a higher potential of infection and injury to the healthcare worker, patient and the surrounding community. Awareness programmes on their proper handling and management to healthcare workers can prevent the spread of infectious diseases and epidemics. This study was conducted in a tertiary care hospital to assess the impact of training, audits and education/implementations from 2009 to 2012 on awareness and practice of biomedical waste segregation. Our study reveals focused training, strict supervision, daily surveillance, audits inspections, involvement of hospital administrators and regular appraisals are essential to optimise the segregation of biomedical waste.

Assessment of maternal risk factors associated with low birth weight neonates at a tertiary hospital, Nanded, Maharashtra.

PubMed

Domple, Vijay Kishanrao; Doibale, Mohan K; Nair, Abhilasha; Rajput, Pinkesh S

2016-01-01

To assess the maternal risk factors associated with low birth weight (LBW) neonates at a tertiary hospital, Nanded, Maharashtra. This study was carried out in a tertiary care hospital in Nanded city of Maharashtra between January 2014 and July 2014 among 160 cases (LBW-birth weight ≤2499 g) and 160 controls (normal birth weight-birth weight >2499. Data collection was done by using predesigned questionnaire and also related health documents were checked and collected the expected information during the interview after obtaining informed consent from mothers. The data were analyzed by Epi Info 7 Version. The present study found the significant association among gestational age, sex of baby, type of delivery, maternal age, religion, education of mother and husband, occupation of mother and husband, type of family, maternal height, weight gain, hemoglobin level, planned/unplanned delivery, bad obstetric history, interval between pregnancies, previous history of LBW, underlying disease, tobacco chewing, timing of first antenatal care (ANC) visit, total number of ANC visit, and iron and folic acid (IFA) tablets consumption with LBW. No significant association was found among maternal age, residence, caste, consanguinity of marriage, socioeconomic status, gravida, birth order, multiple pregnancy, and smoking with LBW in our study. It was concluded that hemoglobin level, weight gain during pregnancy, gestational age, planned/unplanned delivery, bad obstetric history, and IFA tablets consumption during pregnancy were independent risk factors for LBW.

AMEDD Clinical Psychology Short Course, 10 - 15 May 1992, Eisenhower Army Medical Center, Augusta, Georgia

DTIC Science & Technology

1993-01-01

creatively incorporated primary/preventative considerations, as well a tertiary considerations such as the use of hypnosis in assisting with post crash...Psychological Association, seems to have difficulty in recognizing the reality of managed care and in developing a consistent response to it. The...for the new realities are essential. And, don’t equate managed or coordinated care issues with other ongoing professional and guild concerns. There is

Adjusting to Random Demands of Patient Care: A Predictive Model for Nursing Staff Scheduling at Naval Medical Center San Diego

DTIC Science & Technology

2008-09-01

rich mix of medical services that range from simple ambulatory visits to plastic surgery , neuro- surgery , general surgery , bariatric , ophthalmology...CENTER SAN DIEGO NMCSD is a 266-bed tertiary care facility providing patient services ranging from same day surgery to brain surgery . The hospital...orthopedics, cardiology, thoracic surgery , vascular surgery , transient ischemic attack/cerebro vascular accident (TIA/CVA), OB/GYN, urology, non

Universal health care in India: Panacea for whom?

PubMed

Qadeer, Imrana

2013-01-01

This paper examines the current notion of universal health care (UHC) in key legal and policy documents and argues that the recommendations for UHC in these entail further abdication of the State's responsibility in health care with the emphasis shifting from public provisioning of services to merely ensuring universal access to services. Acts of commission (recommendations for public private partnership [PPPs], definition and provision of an essential health package to vulnerable populations to ensure universal access to care) and omission (silence maintained on tertiary care) will eventually strengthen the private and corporate sector at the cost of the public health care services and access to care for the marginalized. Thus, the current UHC strategy uses equity as a tool for promoting the private sector in medical care rather than health for all.

Management of food allergy: a survey of Australian paediatricians.

PubMed

Morawetz, Deborah Y; Hiscock, Harriet; Allen, Katrina J; Davies, Sarah; Danchin, Margie H

2014-06-01

The prevalence of Immunoglobulin E (IgE)-mediated food allergy in the developed world is increasing, overwhelming tertiary allergy services. Alternative models of care are required. General paediatricians could provide this care but may require further training to do so. We aimed to determine Australian general paediatricians': (i) knowledge and management of IgE-mediated food allergy; (ii) access to and use of diagnostic services; and (iii) interest in further training. Members of the Australian Paediatric Research Network completed an online survey in 2011/12. A case study elicited paediatrician's knowledge of diagnostic history taking, testing and key management principles. Study-designed questions assessed paediatricians' current practice, access to allergy services and interest in further training. One hundred sixty-eight (43%) of 390 paediatricians responded; 93 paediatricians reported managing food allergy. Diagnostic and management practices varied widely. Paediatricians had high levels of agreement (>90%) for only three of 13 questions pertaining to diagnosis and management. Only 56 (61%) correctly identified that a diagnosis of IgE-mediated food allergy requires a history consistent with a clinical reaction and a positive specific serum IgE antibody or skin prick test result. Reported waiting times for tertiary allergy services ranged from 5.4 (private) to 10.6 months (public). Most (91%) paediatricians expressed interest in further training. General paediatricians would benefit from further training if they are to practice allergy care as their diagnosis and management is often inconsistent with international guidelines. Training could be delivered online to maximise reach and uptake. If effective, such a model could relieve some of the burden experienced by Australian tertiary allergy services. © 2014 The Authors. Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians).

Gestational Trophoblastic Disease - Clinicopathological Study at Tertiary Care Hospital

PubMed Central

Aher, Vidhya; Gadhiya, Suchi; Jagtap, Swati Sunil

2017-01-01

Introduction Gestational Trophoblastic Disease (GTD) is a term used for a group of pregnancy-related tumours. These consist of various tumours and tumour like lesions characterized by proliferation of trophoblastic tissue. Amongst GTD, hydatidiform moles are the most common form. These lesions sometimes may develop into invasive moles, or, in rare cases, into choriocarcinoma. Aim To study the clinicopathologic characteristics and prevalence of different forms of gestational trophoblastic disease in a tertiary care hospital. Materials and Methods The present study was descriptive, observational, analytical type done in Department of Pathology at tertiary care hospital from May 2012 to April 2016. All cases clinically suspected of GTD were included and confirmation was done by histopathological study on H&E stained slides. The cases of GTD were classified according to WHO classification. Detailed histomorphological features and beta human Chorionic Gonadotropin (hCG) levels were correlated. Results During study period, 18345 deliveries were reported; out of which 77 cases were diagnosed as GTD. Almost 97.40% cases were of hydatidiform moles, 1.30% cases of choriocarcinoma and 1.30% cases of Placental Site Trophoblastic Tumour (PSTT). Among the cases of hydatidiform mole 57.34% were complete mole and 41.33% cases were of partial mole. The common clinical presentation was per vaginal bleeding and amenorrhea. The blood group A was most commonly observed in patient (49.35%). In majority of cases beta hCG levels were between 50,000 to 100000 mIU/ml. The correlation between beta hCG level and GTD were done. Conclusion Pregnant females clinically presenting with abnormal vaginal bleeding must be evaluated for GTD. Histopathological examination is helpful for confirmatory diagnosis. Follow up of such patients is essential for early detection of malignant trophoblastic tumours. PMID:28969138

Diagnostic performance of influenza viruses and RSV rapid antigen detection tests in children in tertiary care.

PubMed

Moesker, F M; van Kampen, J J A; Aron, G; Schutten, M; van de Vijver, D A M C; Koopmans, M P G; Osterhaus, A D M E; Fraaij, P L A

2016-06-01

Rapid antigen detection tests (RADTs) are increasingly used to detect influenza viruses and respiratory syncytial virus (RSV). However, their sensitivity and specificity are a matter of debate, challenging their clinical usefulness. Comparing diagnostic performances of BinaxNow Influenza AB(®) (BNI) and BinaxNow RSV(®) (BNR), to those of real-time reverse transcriptase PCR (RT-PCR), virus isolation and direct immunofluorescence (D-IF) in paediatric patients. Between November 2005 and September 2013, 521 nasal washings from symptomatic children (age <5 years) attending our tertiary care centre were tested, with a combination of the respective assays using RT-PCR as gold standard. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of BNI were 69% (confidence interval [CI] [51-83]), 96% [94-97], 55% [39-70] and 98% [96-99] respectively. Of eleven false-negative samples, RT-PCR Ct-values were higher than all RT-PCR positive test results (27 vs 22, p=0.012). Of twenty false-positive samples, none were culture positive and two tested positive in D-IF. Sensitivity, specificity, PPV and NPV for BNR were 79% [73-85], 98% [96-99], 97% [93-99] and 88% [84-91]. Of the 42 false-negative samples the median Ct-value was higher than that of all RT-PCR positive samples (31 vs 23, p<0.0001). Five false-positive samples were detected. Three of these tested positive for RSV in virus isolation and D-IF. RADTs have a high specificity with BNR being superior to BNI. However, their relative low sensitivity limits their usefulness for clinical decision making in a tertiary care paediatric hospital. Copyright © 2016 The Authors. Published by Elsevier B.V. All rights reserved.

Listeriosis at a Tertiary Care Hospital in Beijing, China: High Prevalence of Nonclustered Healthcare-Associated Cases Among Adult Patients

PubMed Central

Wang, Huan-ling; Ghanem, Khalil G.; Wang, Peng; Yang, Shuang; Li, Tai-sheng

2013-01-01

Background. Listeriosis is an emerging infectious disease associated with high mortality. There are few published reports from East Asia and developing countries. Our goal was to describe the clinical characteristics and outcomes of patients diagnosed with Listeria monocytogenes at a tertiary care hospital in Beijing, China. Methods. Peking Union Medical College Hospital (PUMCH), an 1800-bed hospital, consists of 2 campuses that house different medical departments. We retrospectively reviewed all culture-proven cases of listeriosis occurring at PUMCH between 1999 and 2011. Point estimates and 95% confidence intervals are presented. Results. There were 38 patients with listeriosis: 5 neonatal, 8 maternal, and 25 nonmaternal. The median age of the adult nonmaternal patients was 47 (range, 18–79) years with a female predominance (72%). Forty percent (n = 10) had an underlying rheumatic disease. Forty-four percent of cases (n = 11) were healthcare-associated infections occurring a median of 20 (range, 3–44) days after hospital admission. Only 2 of the 11 healthcare-associated cases clustered in space and time. One healthcare-associated case occurred in a patient receiving KHI-272 therapy, an oral, irreversible dual EGFR/HER2 inhibitor. The neonatal and maternal listeriosis cases were similar to those reported in the literature. Conclusions. Nonclustered healthcare-associated cases of L. monocytogenes occurred at a large tertiary care hospital in Beijing, China. The source of these infections is unclear. Although rare, in the setting of immunosuppression, Listeria should be considered in the differential diagnosis of healthcare-associated infections, even in the absence of a point-source outbreak. PMID:23175565

Effectiveness of an intervention package on knowledge, attitude, and practices of food handlers in a tertiary care hospital of north India: A before and after comparison study.

PubMed

Dudeja, Puja; Singh, Amarjeet; Sahni, Nancy; Kaur, Sukhpal; Goel, Sonu

2017-01-01

Food-borne illnesses have been a recognized hazard for decades. Recent promulgation of Food Safety and Standards Act (FSSA), 2006, indicates the concern of our Govt. for food safety. Research on effectiveness of food safety interventions in our country is remarkably scarce. Hence, the present study was conducted in a tertiary care hospital of north India to create evidence-based results for food safety interventions. The study was before and after intervention trial which was registered with CTRI. Data collection was paperless using a software. All food handlers ( n  = 280) working inside the hospital were recruited. Intervention package comprised Self-Instructional Manual in Hindi for food handlers, short film for sensitization of food handlers on food safety titled 'Gravy Extra', and a documentary titled 'Food Safety from farm to Fork'. Chi square test, paired t test, and Wilcoxon sign rank test were used. The mean age of food handlers was 35 ± 2 years. Majority (61.7%) of food handlers were educated less than 10th standard. Nearly 60% of them had up to five years of experience. At base line majority (68.9%) had a fair knowledge about food safety issues. There was a significant improvement in food safety knowledge and practice score of food handlers after the intervention ( p  < 0.05). Their attitude toward food safety changed in a positive direction ( p  < 0.05). The intervention package was useful in improving the knowledge, creating a positive attitude and enhancing the food safety practices of food handlers working inside a tertiary care hospital.

Neuro-Ophthalmology at a Tertiary Eye Care Centre in India.

PubMed

Dhiman, Rebika; Singh, Digvijay; Gantayala, Shiva P; Ganesan, Vaitheeswaran L; Sharma, Pradeep; Saxena, Rohit

2017-11-09

Neuro-ophthalmology as a specialty is underdeveloped in India. The aim of our study was to determine the spectrum and profile of patients presenting to a tertiary eye care center with neuro-ophthalmic disorders. A retrospective hospital-based study was conducted, and records of all patients seen at the neuro-ophthalmology clinic of Dr. Rajendra Prasad Centre for Ophthalmic Sciences, All India Institute of Medical Sciences, New Delhi, India, over a 1-year period were retrieved and evaluated. Of a total of 30,111 patients referred to various specialty clinics in a span of 1 year, 1597 (5%) were referred for neuro-ophthalmology evaluation. The mean patient age was 30.8 ± 19.5 years, with a male dominance (M:F = 2.02:1). Among these patients, optic nerve disorders were noted in 63.8% (n = 1,020), cranial nerve palsy in 7% (n = 114), cortical visual impairment in 6.5% (n = 105), and others (eye/optic nerve hypophasia, blepharospasm, and optic disc drusen) in 6% (n = 95). Among the patients with optic nerve disorders, optic neuropathy without disc edema/(traumatic optic neuropathy, hereditary, tumor-related, retrobulbar neuritis, toxic, and idiopathic) was noted in 42.8% (n = 685) and optic neuropathy with disc edema (ischemic optic neuropathy, papilledema, post-papilledema optic atrophy, papillitis, neuroretinitis, and inflammatory optic neuropathy) in 20.9% (n = 335). Sixteen percent of patients (n = 263) were incorrect referrals. The neuro-ophthalmic clinic constitutes a significant referral unit in a tertiary eye care center in India. Traumatic and ischemic optic neuropathies are the most common diagnoses. Neuro-ophthalmology requires further development as a subspecialty in India to better serve the nation's population.

Impact of an educational program on antibiotic use in a tertiary care hospital in a developing country.

PubMed

Thamlikitkul, V; Danchaivijitr, S; Kongpattanakul, S; Ckokloikaew, S

1998-09-01

A multi-cross-sectional study was conducted in a 2000-bed tertiary care university hospital in Bangkok, Thailand, from September 1993 to May 1994 to assess the effectiveness of an educational program on the use of antibiotics. Data on the study covered antibiotic usage both in-patients and out-patients. Data were collected for a 24-hour period every 2 weeks for 7 days for each 3-month period. The target population were residents, general practitioners, and sixth-year medical students. The educational program provided information derived from the data of inappropriate use of antibiotics during the pre-intervention period and guidelines on the use of antibiotics which were agreed to by a consensus among the faculty in all clinical departments. The study revealed: (1) the prevalence of antibiotic use and the cost of antibiotics during post-intervention period was significantly decreased by 20%; (2) the use of antibiotic prophylaxis for obstetrics patients and patients undergoing cataract surgery decreased significantly; (3) there was a shift from second or third generation cephalosporins to cefazolin for surgical prophylaxis; (4) the duration of perioperative antibiotic prophylaxis was reduced to under 2 days; (5) there was a shift from netilmicin or amikacin to gentamicin for the treatment of community acquired infection; and (6) the mortality, median length of hospital stay, and nosocomial infection rate among the patients who received antibiotics during the post-intervention period were not significantly different from those during the pre-intervention period. These results suggest that this educational program comprising information feedback and antibiotic usage guidelines was effective in improving antibiotic use at this tertiary care university hospital in Thailand.

How Do Patients Perceive and Expect Quality of Surgery, Diagnostics, and Emergency Services in Tertiary Care Hospitals? An Evidence of Gap Analysis From Pakistan.

PubMed

Fatima, Iram; Humayun, Ayesha; Anwar, Muhammad Imran; Iftikhar, Adil; Aslam, Muhammad; Shafiq, Muhammad

2017-07-01

Service quality is one of the important gears to appraise services and determine the gray areas that need improvement. In countries with a resource-poor health system, the first step of measuring quality is yet to be taken. This study seeks to inform policy makers in developing contextual service quality models by identifying service quality gaps in tertiary care teaching hospitals using patients' perspective. A cross-sectional study was performed using multistage cluster sampling, and a modified version of the SERVQUAL (SERV-service, QUAL-quality) instrument was administered to determine patient's expectations and perceptions. A total of 817 completed questionnaires were obtained from patients and/or their attendants using convenience sampling. Data analysis revealed statistically significant negative quality gaps between expectations and perceptions of tangibility, reliability, empathy, assurance, responsiveness, and communication. The difference in mean expectation and perception for responsiveness across the sexes was significant ( p < 0.003; p < 0.037, respectively) as well as in perception of communication ( p < 0.026). Other dimensions and overall hospital expected and perceived quality were independent of sex. Educational status showed significant difference in expectation and perception in responsiveness ( p < 0.005), but the perception of each dimension was significantly different in different educational categories (assurance: p < 0.001; empathy: p < 0.001; reliability: p < 0.001; tangibility: p < 0.001; responsiveness: p < 0.001; communication: p < 0.001; and for overall service quality: p < 0.001). Age and service departments showed no relationship with any of the perceived or expected dimension of service quality of hospitals. Tertiary care hospitals failed to meet patients' expectations in all major areas of service quality, posing a question of how hospitals implement and evaluate their quality assurance policy.

Self Esteem and Organizational Commitment Among Health Information Management Staff in Tertiary Care Hospitals in Tehran

PubMed Central

Sadoughi, Farahnaz; Ebrahimi, Kamal

2015-01-01

Background: Self esteem (SE) and organizational commitment (OC) have significant impact on the quality of work life. Aim: This study aims to gain a better understanding of the relationships between SE and OC among health information management staff in tertiary care hospitals in Tehran (Iran). Methods: This was a descriptive correlational and cross sectional study conducted on the health information management staff of tertiary care hospitals in Tehran, Iran. A total of 155 participants were randomly selected from 400 staff. Data were collected by two standard questionnaires. The SE and OC was measured using Eysenck SE scale and Meyer and Allen’s three component model, respectively. The collected data were analyzed with the SPSS (version 16) using statistical tests of of independent T-test, Pearson Correlation coefficient, one way ANOVA and F tests. Results: The OC and SE of the employees’ were 67.8, out of 120 (weak and 21.0 out of 30 (moderate), respectively. The values for affective commitment, normative commitment, and continuance commitment were respectively 21.3 out of 40 (moderate), 23.9 out of 40 (moderate), and 22.7 out of 40 (moderate). The Pearson correlation coefficient test showed a significant OC and SE was statistically significant (P<0.05). The one way ANOVA test (P<0.05) did not show any significant difference between educational degree and work experience with SE and OC. Conclusion: This research showed that SE and OC are moderate. SE and OC have strong correlation with turnover, critical thinking, job satisfaction, and individual and organizational improvement. Therefore, applying appropriate human resource policies is crucial to reinforce these measures. PMID:25716374

Nocturnal enuresis: A topic review and institution experience

PubMed Central

DiBianco, John Michael; Morley, Chad; Al-Omar, Osama

2014-01-01

The objective is to provide a review of nocturnal enuresis (NE), including its epidemiology, etiology, pathophysiology, evaluation, and current management. We also set to provide further insight on the treatment of this condition from the experience derived from patients cared for at our tertiary-care institution. NE affects approximately 15% of all children at 5-year-old, affecting boys more frequently than girls. At our large university tertiary pediatric urology center, NE and incontinence, in general, is one the most common chief complaints prompting urologic care. In this review, we examine the condition in detail, highlighting specific goals of the initial evaluation and treatment. We contrast the commonly implemented treatment recommendations, available from the literature with strategies we have found valuable from our extensive experience in treating patients with this disorder. Using current urologic reference textbooks, book chapters, Medline, journal articles and reviews describing the many aspects of NE were reviewed in order to describe NE and the current practices at our institution. Although, this is not a systematic literature review, it includes relevant available research, institutional experience and urological expert opinion and current practices at a tertiary state health facility. The treatment of NE remains a challenge for many pediatricians and pediatric urologists. This likely stems from the multiple possible etiologies of the disorder. We have established a treatment algorithm at our institution, which we have found successful in the majority of our patients. This consists of starting patients on urotherapy, then offering both the enuresis alarm device and medication therapy as first line treatments, and finally adding anticholingerics for combination therapy. Our hope is with further research the treatment of NE will continue to improve. PMID:25506580

Reducing preterm birth by a statewide multifaceted program: an implementation study.

PubMed

Newnham, John P; White, Scott W; Meharry, Suzanne; Lee, Han-Shin; Pedretti, Michelle K; Arrese, Catherine A; Keelan, Jeffrey A; Kemp, Matthew W; Dickinson, Jan E; Doherty, Dorota A

2017-05-01

A comprehensive preterm birth prevention program was introduced in the state of Western Australia encompassing new clinical guidelines, an outreach program for health care practitioners, a public health program for women and their families based on print and social media, and a new clinic at the state's sole tertiary level perinatal center for referral of those pregnant women at highest risk. The initiative had the single aim of safely lowering the rate of preterm birth. The objective of the study was to evaluate the outcomes of the initiative on the rates of preterm birth both statewide and in the single tertiary level perinatal referral center. This was a prospective population-based cohort study of perinatal outcomes before and after 1 full year of implementation of the preterm birth prevention program. In the state overall, the rate of singleton preterm birth was reduced by 7.6% and was lower than in any of the preceding 6 years. This reduction amounted to 196 cases relative to the year before the introduction of the initiative and the effect extended from the 28-31 week gestational age group onward. Within the tertiary level center, the rate of preterm birth in 2015 was also significantly lower than in the preceding years. A comprehensive and multifaceted preterm birth prevention program aimed at both health care practitioners and the general public, operating within the environment of a government-funded universal health care system can significantly lower the rate of early birth. Further research is now required to increase the effect and to determine the relative contributions of each of the interventions. Copyright © 2016 The Author(s). Published by Elsevier Inc. All rights reserved.

Does rural or urban residence make a difference to neonatal outcome in premature birth? A regional study in Australia

PubMed Central

Abdel‐Latif, M E; Bajuk, B; Oei, J; Vincent, T; Sutton, L; Lui, K

2006-01-01

Background Patients living in rural areas may be at a disadvantage in accessing tertiary health care. Aim To test the hypothesis that very premature infants born to mothers residing in rural areas have poorer outcomes than those residing in urban areas in the state of New South Wales (NSW) and the Australian Capital Territory (ACT) despite a coordinated referral and transport system. Methods “Rural” or “urban” status was based on the location of maternal residence. Perinatal characteristics, major morbidity and case mix adjusted mortality were compared between 1879 rural and 6775 urban infants <32 weeks gestational age, born in 1992–2002 and admitted to all 10 neonatal intensive care units in NSW and ACT. Results Rural mothers were more likely to be teenaged, indigenous, and to have had a previous premature birth, prolonged ruptured membrane, and antenatal corticosteroid. Urban mothers were more likely to have had assisted conception and a caesarean section. More urban (93% v 83%) infants were born in a tertiary obstetric hospital. Infants of rural residence had a higher mortality (adjusted odds ratio (OR) 1.26, 95% confidence interval (CI) 1.07 to 1.48, p  =  0.005). This trend was consistently seen in all subgroups and significantly for the tertiary hospital born population and the 30–31 weeks gestation subgroup. Regional birth data in this gestational age range also showed a higher stillbirth rate among rural infants (OR 1.20, 95% CI 1.09 to 1.32, p<0.001). Conclusions Premature births from rural mothers have a higher risk of stillbirth and mortality in neonatal intensive care than urban infants. PMID:16428354

Primary Immunodeficiency Diseases in Oman: 10-Year Experience in a Tertiary Care Hospital.

PubMed

Al-Tamemi, Salem; Naseem, Shafiq Ur Rehman; Al-Siyabi, Nabila; El-Nour, Ibtisam; Al-Rawas, Abdulhakim; Dennison, David

2016-11-01

Primary immunodeficiency (PID) diseases are rare, complex medical disorders that often are overlooked in clinical settings. There are emerging reports of PID from Middle Eastern populations. This study describes the features of PID patients in a tertiary care setting in Oman and compares them with regional and worldwide reports. Sultan Qaboos University Hospital (SQUH) is an academic tertiary care-level hospital for specialized healthcare, including PID patients. At the time of diagnosis, patients' sociodemographics, clinical features, laboratory investigations, and management were entered in electronic form. This study included patients seen between August 2005 and July 2015. One hundred forty patients were registered with a minimum estimated population prevalence of 7.0/100,000. The male/female ratio was 1.6:1, the median age of onset of symptoms was 8 months, and diagnosis was 21 months with a delay of 13 months. Family history was positive in 44 %, consanguinity was present in 76 %, death of a previous sibling was present in 36 %, and there was an overall mortality in 18 %, with an 85 % probability of survival 10 years following diagnosis. The most common type of immunodeficiency was phagocytic disorders (35.0 %), followed by predominantly antibody disorders (20.7 %), combined immunodeficiency (17.8 %), other well-defined PID syndromes (15.0 %), immune dysregulation syndromes (3.5 %), complement deficiencies (3.5 %), and unclassified immunodeficiency (4.2 %). The commonest presenting infection was pneumonia (47.1 %). PID is not a rare condition in Oman. The prevalence is in concordance with reports from the region but higher than in Western populations. The findings of the current study would help to improve the awareness and management of, and policy making for PID.

Steroid profiling for congenital adrenal hyperplasia by tandem mass spectrometry as a second-tier test reduces follow-up burdens in a tertiary care hospital: a retrospective and prospective evaluation.

PubMed

Seo, Ja Young; Park, Hyung-Doo; Kim, Jong Won; Oh, Hyeon Ju; Yang, Jeong Soo; Chang, Yun Sil; Park, Won Soon; Lee, Soo-Youn

2014-01-01

Newborn screening for congenital adrenal hyperplasia (CAH) based on measuring 17-hydroxyprogesterone (17-OHP) by immunoassay generates a number of false-positive results, especially in preterm neonates. We applied steroid profiling by using liquid chromatography-tandem mass spectrometry (LC-MS/MS) as a second-tier test in newborns with positive CAH screening and evaluated its clinical utility in a tertiary care hospital setting. By performing a 4-year retrospective data review, we were able to test 121 dried blood spots from newborns with positive CAH screening for 17-OHP, androstenedione and cortisol levels by LC-MS/MS. We prospectively evaluated the clinical utility of steroid profiling after the implementation of steroid profiling as a second-tier test in our routine clinical practice. During the 2-year prospective study period, 104 cases with positive initial screening by FIA were tested by LC-MS/MS. Clinical and laboratory follow-up were performed for at least 6 months. The preterm neonates accounted for 50.7% (76/150) and 70.4% (88/125) of screening-positive cases in retrospective and prospective cohorts, respectively. By applying steroid profiling as a second-tier test for positive CAH screening, we eliminated all false-positive results and decreased the median follow-up time from 75 to 8 days. Our data showed that steroid profiling reduced the burden of follow-up exams by improving the positive predictive value of the CAH screening program. The use of steroid profiling as a second-tier test for positive CAH screening will improve clinical practice particularly in a tertiary care hospital setting where positive CAH screening from preterm neonates is frequently encountered.

Care for post-stroke patients at Malaysian public health centres: self-reported practices of family medicine specialists

PubMed Central

2014-01-01

Background Provision of post stroke care in developing countries is hampered by discoordination of services and limited access to specialised care. Albeit shortcomings, primary care continues to provide post-stroke services in less than favourable circumstances. This paper aimed to review provision of post-stroke care and related problems among Family Medicine Specialists managing public primary health care services. Methods A semi-structured questionnaire was distributed to 121 Family Physicians servicing public funded health centres in a pilot survey focused on improving post stroke care provision at community level. The questionnaire assessed respondents background and practice details i.e. estimated stroke care burden, current service provision and opinion on service improvement. Means and frequencies described quantitative data. For qualitative data, constant comparison method was used until saturation of themes was reached. Results Response rate of 48.8% was obtained. For every 100 patients seen at public healthcentres each month, 2 patients have stroke. Median number of stroke patients seen per month is 5 (IQR 2-10). 57.6% of respondents estimated total stroke patients treated per year at each centre was less than 40 patients. 72.4% lacked a standard care plan although 96.6% agreed one was needed. Patients seen were: discharged from tertiary care (88.1%), shared care plan with specialists (67.8%) and patients who developed stroke during follow up at primary care (64.4%). Follow-ups were done at 8-12 weekly intervals (60.3%) with 3.4% on ‘as needed’ basis. Referrals ranked in order of frequency were to physiotherapy services, dietitian and speech and language pathologists in public facilities. The FMS’ perceived 4 important ‘needs’ in managing stroke patients at primary care level; access to rehabilitation services, coordinated care between tertiary centres and primary care using multidisciplinary care approach, a standardized guideline and family and caregiver support. Conclusions Post discharge stroke care guidelines and access to rehabilitation services at primary care is needed for post stroke patients residing at home in the community. PMID:24580779

Worrisome trends in incidence and mortality of candidemia in intensive care units (Paris area, 2002-2010).

PubMed

Lortholary, Olivier; Renaudat, Charlotte; Sitbon, Karine; Madec, Yoann; Denoeud-Ndam, Lise; Wolff, Michel; Fontanet, Arnaud; Bretagne, Stéphane; Dromer, Françoise

2014-09-01

To analyze trends in incidence and mortality of candidemia in intensive care units (ICUs) vs. non-ICU hospitalized patients and to determine risk factors for infection by specific species and for death. Active hospital-based surveillance program of incident episodes of candidemia due to common species in 24 tertiary care hospitals in the Paris area, France between October 2002 and September 2010. Among 2,507 adult cases included, 2,571 Candida isolates were collected and species were C. albicans (56 %), C. glabrata (18.6 %), C. parapsilosis (11.5 %), C. tropicalis (9.3 %), C. krusei (2.9 %), and C. kefyr (1.8 %). Candidemia occurred in ICU in 1,206 patients (48.1 %). When comparing ICU vs. non-ICU patients, the former had significantly more frequent surgery during the past 30 days, were more often preexposed to fluconazole and treated with echinocandin, and were less frequently infected with C. parapsilosis. Risk factors and age remained unchanged during the study period. A significant increased incidence in the overall population and ICU was found. The odds of being infected with a given species in ICU was influenced by risk factors and preexposure to fluconazole and caspofungin. Echinocandins initial therapy increased over time in ICU (4.6 % first year of study, to 48.5 % last year of study, p < 0.0001). ICU patients had a higher day-30 death rate than non-ICU patients (odds ratio [OR] 2.12; 95 % confidence interval [CI] 1.66-2.72; p < 0.0001). The day-30 and early (

The competencies required by professional hospice palliative care spiritual care providers.

PubMed

Cooper, Dan; Aherne, Michael; Pereira, José

2010-07-01

The Canadian Hospice Palliative Care Association (2002) identifies spiritual care of the dying and their families as a core service for Hospice Palliative Care programs. Yet, until the Spiritual Care Development Initiative of the Canadian Pallium Project, there was no published literature indicating systematic profiling of occupationally relevant core competencies or competency-based training programs specific to this specialized field of practice. This article describes a Canadian Community of Practice process to develop an occupational analysis-based competency profile for the Professional Hospice Palliative Care Spiritual Care Provider utilizing a modified Developing a Curriculum (DACUM) methodology. Competency profiles are important contributions to the development of curricula to train care providers who are recognized by other professions and by institutions as possessing the requisite theoretical and clinical expertise, particularly in academic tertiary care settings.

Prevalence of multi drug resistant Acinetobacter baumannii in the clinical samples from Tertiary Care Hospital in Islamabad, Pakistan

PubMed Central

Begum, Shahzeera; Hasan, Fariha; Hussain, Shagufta; Ali Shah, Aamer

2013-01-01

Background & Objectives: Acinetobacter baumannii can cause a wide range of infections, including bacteremia, pneumonia, urinary tract infection, peritonitis, etc. This organism is becoming resistant to a large group of antibiotics, especially β-lactam antibiotics. The reason for multi-drug resistance may be the production of extended- spectrum β-lactamses (ESBLs), carbapenemases/metallo β-lactamases or AmpC β-lactamases. The aim of the present study was to determine the prevalence of multi-drug resistant Acinetobacter baumannii isolated from the patients in Surgical Intensive Care Units (SICUs) of Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan. Methods: A total of 91 A. baumanni isolates were collected from PIMS during the period from February 2011 to December 2011. The antibiotic susceptibility testing was performed by standard disc diffusion method as recommended by CLSI. Combination disc method, Modified Hodge test, EDTA disc synergy test and AmpC disc test were performed for detection of ESBLs, carbapenemases, metallo β-lactamases, and AmpC β-lactamases, respectively. Results: The prevalence of MDRs was reported 100% among A. baumannii. The antibiotic susceptibility profile showed that minocycline and tigecycline were the most effective drugs against A. baumannii. Almost all of A. baumannii isolates were carbapenemase and metallo β-lactamase producers. AmpC prevalence was observed in 41.76%, while none of the isolates was ESBL producer. Antibiogram and minimal inhibitory concentrations (MICs) indicated tetracycline is relatively effective against A. baumanii. Conclusions: Increased frequency of multi-drug resistance supports the need for continuous surveillance to determine prevalence and evolution of these enzymes in Pakistan. PMID:24353731

Structure-Function Study of Tertiary Amines as Switchable Polarity Solvents

DOE Office of Scientific and Technical Information (OSTI.GOV)

Aaron D. Wilson; Frederick F. Stewart

2014-02-01

A series of tertiary amines have been screened for their function as switchable polarity solvents (SPS). The relative ratios of tertiary amine and carbonate species as well as maximum possible concentration were determined through quantitative 1H and 13C NMR spectroscopy. The viscosities of the polar SPS solutions were measured and ranged from near water in dilute systems through to gel formation at high concentrations. The van't Hoff indices for SPS solutions were measured through freezing point depression studies as a proxy for osmotic pressures. A new form of SPS with an amine : carbonate ratio significantly greater than unity hasmore » been identified. Tertiary amines that function as SPS at ambient pressures appear to be limited to molecules with fewer than 12 carbons. The N,N-dimethyl-n-alkylamine structure has been identified as important to the function of an SPS.« less

CONTROLLED METHYL TERTIARY BUTYL ETHER (MTBE) EXPOSURE TO HUMANS THROUGH DERMAL, INGESTION, AND INHALATION ROUTES AND THE RESULTANT BIOMARKER TERTIARY BUTYL ALCOHOL (TBA) AS MEASURED IN EXHALED BREATH AND VENOUS BLOOD

EPA Science Inventory

Radiocarbon (14C) measurements provide an estimate of the fraction of carbon in a sample that is biogenic. In September 1997 during SCOS97 a series of 3-h canister samples of ambient air were collected at the Azusa air monitoring station during morning and afternoon periods. ...

Occurrence of enteric parasitic infections among HIV-infected individuals and its relation to CD4 T-cell counts with a special emphasis on coccidian parasites at a tertiary care centre in South India.

PubMed

Swathirajan, Chinnambedu R; Vignesh, Ramachandran; Pradeep, Ambrose; Solomon, Sunil S; Solomon, Suniti; Balakrishnan, Pachamuthu

2017-01-01

Diarrhoea is one of the major complications occurring in over 90% of HIV-infected individuals in developing countries. Coccidian group of parasites, being opportunistic pathogens, have been implicated as the most common causative agents of diarrhoea among HIV-infected population. The aim was to study the magnitude of parasitic diarrhoea with special context to coccidian parasitic infections in HIV-infected individuals and their association with the patient's immunological status measured by CD4 T-cell counts. This investigation was performed between January 2002 and December 2014 at a tertiary HIV care centre in Chennai, South India. Stool samples were collected and microscopically observed for parasites using direct, formal-ether-concentrated wet mounts and modified acid-fast staining for coccidian parasites. CD4 T-cell counts were done by FACScount. All statistical analyses were performed using GraphPad Prism software, version 5.0, andP < 0.05 was considered statistically significant. Coccidian parasitic infection accounted for about 23.4% of parasitic infections, and of these, Cystoisospora belli was observed to be the most common cause of diarrhoea (88.8%), followed by Cryptosporidium spp. (9.9%) and Cyclospora spp. (1.3%). Trend analysis of coccidian aetiology during the study period revealed a significant rise in the positivity of C. belli and Cryptosporidium spp. (P = 0.001). Among the HIV patients with CD4+ T-cell counts <200 cells/μL, Cryptosporidium infection was most common (90%), followed by infection with C. belli(61.4%). Coccidian parasites continue to be the most common aetiological agent of diarrhoea among patients with HIV. The increasing trend of positivity of both cystoisosporiasis and cryptosporidiosis over the study period and the high positivity of cryptosporidiosis in patients with lower CD4+ T-cell counts are issues of serious concern. The findings call for the need for the early diagnosis of coccidian parasites and appropriate intervention among HIV-infected patients.

High burden of hepatocellular carcinoma and viral hepatitis in Southern and Central Vietnam: Experience of a large tertiary referral center, 2010 to 2016

PubMed Central

Nguyen-Dinh, Song-Huy; Do, Albert; Pham, Trang Ngoc Doan; Dao, Doan Y; Nguy, Trinh Nhu; Chen, Moon S

2018-01-01

AIM To examine the largest tertiary referral center in southern and central Vietnam from 2010 to 2016, evaluating epidemiological trends of hepatocellular carcinoma (HCC) and viral hepatitis B-C in this resource-limited setting. METHODS We extracted data of patients receiving care from Cho Ray Hospital (Ho Chi Minh City), the largest oncology referral center in southern and central Vietnam, from 2010 to 2016. We collected information on patient age, gender, geographic distribution, and disease characteristics including disease stage, tumor biomarker levels [serum alpha-fetoprotein (AFP), AFP-L3 isoform percentage, and prothrombin induced by induced by vitamin K absence-II], and serological testing for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. RESULTS Data from 24091 HCC patients were extracted, with sample demographics comprising mostly male (81.8%) and older age (however with 8.5% younger than 40 years old). This patient sample included a geographic catchment population of 56 million people (60% of the country’s total population of 92.7 million), derived from 38 provinces and municipalities in Vietnam. Chronic HBV infection was found in 62.3% of cases, and chronic HCV infection in 26.0%. HBV and HCV co-infection was seen in 2.7%. Cirrhosis was found in an estimated 30% to 40% of cases. Nine percent of patients were not found to have chronic viral hepatitis. Twenty three point two percent of the patients had a normal AFP level. A total of 2199 patients were tested with AFP-L3 and PIVKA II over two years, with 57.7% having elevated AFP-L3%, and 88.5% with elevated PIVKA II levels. Over this 7-year period, the incidence of HCC increased, with a large proportion of cases (overall 40.8%) presenting initially an advanced stage, not amendable to surgical or locoregional therapy. CONCLUSION HCC contributes significant health care burden in southern and central Vietnam, with increasing case volume over this seven-year period. Viral hepatitis likely explains this high HCC prevalence. PMID:29399285

High burden of hepatocellular carcinoma and viral hepatitis in Southern and Central Vietnam: Experience of a large tertiary referral center, 2010 to 2016.

PubMed

Nguyen-Dinh, Song-Huy; Do, Albert; Pham, Trang Ngoc Doan; Dao, Doan Y; Nguy, Trinh Nhu; Chen, Moon S

2018-01-27

To examine the largest tertiary referral center in southern and central Vietnam from 2010 to 2016, evaluating epidemiological trends of hepatocellular carcinoma (HCC) and viral hepatitis B-C in this resource-limited setting. We extracted data of patients receiving care from Cho Ray Hospital (Ho Chi Minh City), the largest oncology referral center in southern and central Vietnam, from 2010 to 2016. We collected information on patient age, gender, geographic distribution, and disease characteristics including disease stage, tumor biomarker levels [serum alpha-fetoprotein (AFP), AFP-L3 isoform percentage, and prothrombin induced by induced by vitamin K absence-II], and serological testing for hepatitis B virus (HBV) and hepatitis C virus (HCV) infections. Data from 24091 HCC patients were extracted, with sample demographics comprising mostly male (81.8%) and older age (however with 8.5% younger than 40 years old). This patient sample included a geographic catchment population of 56 million people (60% of the country's total population of 92.7 million), derived from 38 provinces and municipalities in Vietnam. Chronic HBV infection was found in 62.3% of cases, and chronic HCV infection in 26.0%. HBV and HCV co-infection was seen in 2.7%. Cirrhosis was found in an estimated 30% to 40% of cases. Nine percent of patients were not found to have chronic viral hepatitis. Twenty three point two percent of the patients had a normal AFP level. A total of 2199 patients were tested with AFP-L3 and PIVKA II over two years, with 57.7% having elevated AFP-L3%, and 88.5% with elevated PIVKA II levels. Over this 7-year period, the incidence of HCC increased, with a large proportion of cases (overall 40.8%) presenting initially an advanced stage, not amendable to surgical or locoregional therapy. HCC contributes significant health care burden in southern and central Vietnam, with increasing case volume over this seven-year period. Viral hepatitis likely explains this high HCC prevalence.

The interfacility transport of critically ill newborns

PubMed Central

Whyte, Hilary EA; Jefferies, Ann L

2015-01-01

The practice of paediatric/neonatal interfacility transport continues to expand. Transport teams have evolved into mobile intensive care units capable of delivering state-of-the-art critical care during paediatric and neonatal transport. While outcomes are best for high-risk infants born in a tertiary care setting, high-risk mothers often cannot be safely transferred. Their newborns may then have to be transported to a higher level of care following birth. The present statement reviews issues relating to transport of the critically ill newborn population, including personnel, team competencies, skills, equipment, systems and processes. Six recommendations for improving interfacility transport of critically ill newborns are highlighted, emphasizing the importance of regionalized care for newborns. PMID:26175564

Structural specificity of Rn nuclease I as probed on yeast tRNA(Phe) and tRNA(Asp).

PubMed Central

Przykorska, A; el Adlouni, C; Keith, G; Szarkowski, J W; Dirheimer, G

1992-01-01

A single-strand-specific nuclease from rye germ (Rn nuclease I) was characterized as a tool for secondary and tertiary structure investigation of RNAs. To test the procedure, yeast tRNA(Phe) and tRNA(Asp) for which the tertiary structures are known, as well as the 3'-half of tRNA(Asp) were used as substrates. In tRNA(Phe) the nuclease introduced main primary cuts at positions U33 and A35 of the anticodon loop and G18 and G19 of the D loop. No primary cuts were observed within the double stranded stems. In tRNA(Asp) the main cuts occurred at positions U33, G34, U35, C36 of the anticodon loop and G18 and C20:1 positions in the D loop. No cuts were observed in the T loop in intact tRNA(Asp) but strong primary cleavages occurred at positions psi 55, C56, A57 within that loop in the absence of the tertiary interactions between T and D loops (use of 3'-half tRNA(Asp)). These results show that Rn nuclease I is specific for exposed single-stranded regions. Images PMID:1542562

Antibiotic susceptibilities, streptococcal pyrogenic exotoxin gene profiles among clinical isolates of group C or G Streptococcus dysgalactiae subsp. equisimilis & of group G S. anginosus group at a tertiary care centre.

PubMed

Behera, Bijayini; Mathur, Purva; Bhardwaj, Nidhi; Jain, Neetu; Misra, M C; Kapil, Arti; Singh, Sarman

2014-03-01

Group C and group G streptococci (together GCGS) are often regarded as commensal bacteria and their role in streptococcal disease burden is under-recognized. While reports of recovery of GCGS from normally sterile body sites are increasing, their resistance to macrolides, fluoroquinolone further warrants all invasive β haemolytic streptococci to be identified to the species level and accurately tested for antimicrobial susceptibility. This study was aimed to determine the prevalence, clinical profile, antimicrobial susceptibility and streptococcal pyrogenic exotoxin gene profile (speA, speB, speC, speF, smeZ, speI, speM, speG, speH and ssa) of GCGS obtained over a period of two years at a tertiary care centre from north India. The clinical samples were processed as per standard microbiological techniques. β-haemolytic streptococci (BHS) were characterized and grouped. Antimicrobial susceptibility of GCGS was performed using disk diffusion method. All GCGS were characterized for the presence of streptococcal pyrogenic exotoxins (spe) and spe genes were amplified by PCR method. GCGS (23 GGS, 2GCS) comprised 16 per cent of β haemolytic streptococci (25/142 βHS, 16%) isolated over the study period. Of the 25 GCGS, 22 (88%) were recovered from pus, two (8%) from respiratory tract, whereas one isolate was recovered from blood of a fatal case of septicaemia. Of the total 23 GGS isolates, 18 (78%) were identified as Streptococcus dysgalactiae subsp equisimilis (SDSE, large-colony phenotype), five (21%) were Streptococcus anginosus group (SAG, small-colony phenotype). The two GCS were identified as SDSE. All GCGS isolates were susceptible to penicillin, vancomycin, and linezolid. Tetracycline resistance was noted in 50 per cent of SDSE isolates. The rates of macrolide and fluoroquinolone resistance in SDSE were low. Twelve of the 20 SDSE isolates were positive for one or more spe genes, with five of the SDSE isolates simultaneously carrying speA+ speB+ smeZ+ speF or speB+ smeZ+speF, speI+speM+speG+speH or, speI+spe M+speH or speA+ speB+ speC+ smeZ+ speF. One notable finding was the presence of spe B in four of the five isolates of the Streptococcus anginosus group. No isolate was positive for ssa. Our study showed no association between GCGS isolates harbouring streptococcal pyrogenic exotoxins and disease severity. This might be attributed to the small sample size of spe-positive isolates.

Linezolid-resistant mucoid Staphylococcus haemolyticus from a tertiary-care centre in Delhi.

PubMed

Matlani, M; Shende, T; Bhandari, V; Dawar, R; Sardana, R; Gaind, R

2016-05-01

We report an unusual morphological mucoid variant of Staphylococcus haemolyticus associated with linezolid resistance from a patient with sepsis. Linezolid resistance and mucoid character together made this pathogen difficult to treat. To our knowledge this is the first such report.

Severe Plasmodium knowlesi Malaria in a Tertiary Care Hospital, Sabah, Malaysia

PubMed Central

William, Timothy; Menon, Jayaram; Rajahram, Giri; Chan, Leslie; Ma, Gordon; Donaldson, Samantha; Khoo, Serena; Fredrick, Charlie; Jelip, Jenarun; Anstey, Nicholas M.

2011-01-01

The simian parasite Plasmodium knowlesi causes severe human malaria; the optimal treatment remains unknown. We describe the clinical features, disease spectrum, and response to antimalarial chemotherapy, including artemether-lumefantrine and artesunate, in patients with P. knowlesi malaria diagnosed by PCR during December 2007–November 2009 at a tertiary care hospital in Sabah, Malaysia. Fifty-six patients had PCR-confirmed P. knowlesi monoinfection and clinical records available for review. Twenty-two (39%) had severe malaria; of these, 6 (27%) died. Thirteen (59%) had respiratory distress; 12 (55%), acute renal failure; and 12, shock. None experienced coma. Patients with uncomplicated disease received chloroquine, quinine, or artemether-lumefantrine, and those with severe disease received intravenous quinine or artesunate. Parasite clearance times were 1–2 days shorter with either artemether-lumefantrine or artesunate treatment. P. knowlesi is a major cause of severe and fatal malaria in Sabah. Artemisinin derivatives rapidly clear parasitemia and are efficacious in treating uncomplicated and severe knowlesi malaria. PMID:21762579

Susceptibility of Rubella Among Pregnant Women Attending the Antenatal Clinic in a Tertiary Care Hospital, Jabalpur, Central India.

PubMed

Kori, Bhupesh K; Singh, Kavita N; Sharma, Ravendra K; Sharma, Bhagwati S; Badkur, Poorva; Barde, Pradip V

2017-03-01

The purpose of this study was to evaluate rubella susceptibility of pregnant women from central India as rubella infection can be devastating for the newborn if it occurs in the mother in the first trimester of pregnancy, which may lead to congenital rubella syndrome (CRS). There are very few studies about seroprevalence of rubella from India and none from central India. The study was conducted among women attending the obstetric department of a tertiary care hospital, in which 369 antenatal cases were tested for the presence of immunoglobulin G antibody for rubella and its titer. Data were analyzed using statistical tests. A total of 141 (38.2%) women were found susceptible to rubella. There was no significant difference in rubella susceptibility among different socioeconomic classes, ages, and gravidity. A large proportion of pregnant women were found to be rubella susceptible, posing immense threat of CRS to their newborns. A robust program for rubella immunization targeting young adult women is needed to avoid CRS.

Prevalence of methicillin-resistant Staphylococcus aureus based on culture and PCR in inpatients at a tertiary care center in Tokyo, Japan.

PubMed

Taguchi, Hirokazu; Matsumoto, Tetsuya; Ishikawa, Hiroki; Ohta, Shoichi; Yukioka, Tetsuo

2012-10-01

We investigated active screening for colonization with methicillin-resistant Staphylococcus aureus (MRSA) on admission and weekly follow-up surveillance after admission to a tertiary care center (TCC) between June 2007 and 31 December 2007. Eleven percent (30/267) of patients were found to be positive for MRSA by polymerase chain reaction (PCR) and/or culture on admission; 5% (12/267) became positive during the TCC stay. The major primary diagnoses in MRSA-positive patients were pneumonia and cerebrovascular diseases. Twenty-two (52%) of 42 patients were found to be MRSA positive by both PCR and culture, compared with 19 (45%) of 42 who were PCR positive and culture negative. These findings suggest that active surveillance with PCR is highly sensitive and useful for the detection of MRSA colonization. To our knowledge, this is the first report of active surveillance of MRSA by PCR and bacterial culture in critically ill inpatients in Japan.

Acid-base disorders in critically ill neonates

PubMed Central

Lekhwani, S.; Shanker, V.; Gathwala, G.; Vaswani, N. D.

2010-01-01

Objective: To study acid–base imbalance in common pediatric diseases (such as sepsis, bronchopneumonia, diarrhea, birth-asphyxia etc.) in neonates. Design and Setting: An observational study was conducted in an emergency room of a tertiary teaching care hospital in Haryana, India. Patients and Methods: Fifty neonates (from first hour to one month) attending pediatric emergency services with various ailments. Blood gas analysis, electrolytes, plasma lactate, and plasma albumin were estimated in neonates. Results: Metabolic acidosis was the most common acid–base disorder. Hyperlactatemia was observed in more than half of such cases. Birth asphyxia was another common disorder with the highest mortality in neonates followed by bronchopneumonia and sepsis. Significant correlation between mortality and critical values of lactate was observed. Conclusion: Birth asphyxia with high-lactate levels in neonates constituted major alterations in acid–base disorders seen in an emergency room of a tertiary teaching care hospital. Plasma lactate concentration measurement provides an invaluable tool to assess type of metabolic acidosis in addition to predicting mortality in these neonates. PMID:20859489

Analysis of association between type of amblyopia and gender at a tertiary care hospital in Karachi.

PubMed

Siddiqui, Abdul Hameed; Raza, Syed Akhtar; Ghazipura, Arifa; Hussain, Muhammad Azhar; Iqbal, Sarwat; Ahsan, Kamran; Nadeem, Adnan

2016-05-01

To analyse the frequency of different types of amblyopia and its association with gender. The cross-sectional study was conducted from March 2014 to October 2014 at the Department of Ophthalmology of a tertiary care hospital inKarachi. The patients were classified into different types of amblyopia like anisometropic, strabismic, sensory deprivation and meridional amblyopia. Stratification was done according to age, gender and type of amblyopia by using SPSS version 21. Out of 130 patients, 71 were male and 59 were female. The amblyopia rate determined was anisometropic 69.23%, strabismic amblyopia 21.51% and others 9.23%. The mean age of subjects was 18.02±9 years. Type of amblyopia was independent of gender, and anisometropic amblyopia was the most common type of amblyopia found in both genders. This study found no significant association between gender and types of amblyopia and anisometropic amblyopia was the most common type of amblyopia in the data collected.

Study of adverse drug reactions in patients with diabetes attending a tertiary care hospital in New Delhi, India.

PubMed

Singh, Abhishank; Dwivedi, Shridhar

2017-02-01

The present prospective observational study was carried out in a tertiary care hospital in New Delhi, India from May 2014 to June 2015 to report adverse drug reactions (ADRs) in patients with type 2 diabetes mellitus (T2DM) using antidiabetic drugs. A total of 220 patients (121 males, 99 females) were enrolled. ADRs were recorded on the prescribed form. Causality and severity assessment was done using Naranjo's probability scale and modified Hartwig and Siegel's severity scale, respectively. Commonly prescribed drugs were biguanides, peptide hormone and sulphonylurea. A total of 26 ADRs were recorded (16 in males and 10 in females). Most commonly observed ADRs were related to endocrine and gastrointestinal system. Severity assessment of ADRs showed seven (26.9%) ADRs as moderate, and 19 (73.1%) as mild. No severe reactions were observed. ADRs were mostly related to endocrine and gastrointestinal system. More information on prescribed drugs and their side effects is required for ensuring patient safety.

Treatment outcome in patients with presumed tubercular uveitis at a tertiary referral eye care centre in Singapore.

PubMed

Ang, Leslie; Kee, Aera; Yeo, Tun Hang; Dinesh, V G; Ho, Su Ling; Teoh, Stephen C; Agrawal, Rupesh

2018-02-01

To report the clinical features and outcome of patients with presumed tubercular uveitis (TBU). Retrospective analysis of patients with presumed TBU at a tertiary referral eye care centre in Singapore between 2007 and 2012 was done. Main outcome measures were failure of complete resolution of uveitis or recurrence of inflammation. Fifty three patients with mean age of 44.18 ± 15.26 years with 54.72% being males were included. 19 (35.85%) had bilateral involvement, with panuveitis and anterior uveitis being the most common presentations. 36 (67.92%) patients received antitubercular therapy (ATT), and 28 received concurrent systemic steroids. 15 (28.30%) eyes of 11 (30.55%) patients in the ATT group and 4 (21.05%) eyes of 3 (17.64%) patients in the non-ATT group had treatment failure (p value = 0.51). The use of ATT, with or without concurrent corticosteroid, may not have a statistically significant impact in improving treatment success in patients with presumed TBU.

Epidemiology of Candida isolates from Intensive Care Units in Colombia from 2010 to 2013.

PubMed

Motoa, Gabriel; Muñoz, Juan Sebastián; Oñate, José; Pallares, Christian José; Hernández, Cristhian; Villegas, María Virginia

The frequency of Candida isolates as a cause of hospital infections has risen in recent years, leading to high rates of morbidity and mortality. The knowledge of the epidemiology of those hospital acquired fungal infections is essential to implement an adequate antifungal therapy. To describe the epidemiology of Candida infections in Intensive Care Units (ICUs) from a surveillance network in Colombia. Information was collected from the microbiology laboratories of 20 tertiary healthcare institutions from 10 Colombian cities using the Whonet® software version 5.6. A general descriptive analysis of Candida species and susceptibility profiles focusing on fluconazole and voriconazole was completed between 2010 and 2013, including a sub-analysis of healthcare associated infections (HAIs) during the last year. Candida isolates made up 94.5% of the 2680 fungal isolates considered, with similar proportions for Candida albicans and non-C. albicans Candida species (48.3% and 51.7%, respectively). Among the latter, Candida tropicalis (38.6%) and Candida parapsilosis (28.5%) were the most frequent species. Of note, among the blood isolates C. albicans was not the main species. Most of the species isolated were susceptible to fluconazole and voriconazole. From the HAIs reported, 25.5% were caused by Candida; central line-associated bloodstream infection was the most common HAI (58.8%). There were no statistically significant differences regarding length of hospital stay and device days among HAIs. In ICUs of Colombia, non-C. albicans Candida species are as frequent as C. albicans, except in blood samples where non-C. albicans Candida isolates predominate. Further studies are needed to evaluate Candida associated risk factors and to determine its clinical impact. Copyright © 2016 Asociación Española de Micología. Publicado por Elsevier España, S.L.U. All rights reserved.

Initial Benchmarking of the Quality of Medical Care in Childhood-Onset Systemic Lupus Erythematosus.

PubMed

Mina, Rina; Harris, Julia G; Klein-Gitelman, Marisa S; Appenzeller, Simone; Centeville, Maraisa; Eskra, Diane; Huggins, Jennifer L; Johnson, Anne L; Khubchandani, Raju; Khandekar, Prachi; Lee, Jiha; Liu, Hai Mei; Pendl, Joshua D; Silva, Clovis A; Silva, Marco F; Zaal, Ahmad I; DeWitt, Esi Morgan; Ardoin, Stacy P; Brunner, Hermine I

2016-02-01

To assess the quality of medical care in childhood-onset systemic lupus erythematosus (SLE) at tertiary pediatric rheumatology centers as measured by observance of SLE quality indicators (SLE-QIs). International consensus has been achieved for childhood-onset SLE-QIs capturing medical care provision in 9 domains: diagnostic testing, education of cardiovascular (CV) risk and lifestyles, lupus nephritis (LN), medication management, bone health, ophthalmologic surveillance, transition, pregnancy, and vaccination. Using medical record information, the level of performance of these childhood-onset SLE-QIs was assessed in childhood-onset SLE populations treated at 4 tertiary pediatric rheumatology centers in the US, 2 in Brazil, and 1 center in India. A total of 483 childhood-onset SLE patients were assessed. Care for the 310 US patients differed markedly for childhood-onset SLE-QIs addressing LN, bone health, vaccinations, education on CV risk, and transition planning. Performance of safety blood testing for medications was high at all centers. Despite often similar performance on the childhood-onset SLE-QI, access to kidney biopsies was lower in Brazil than in the US. Irrespective of the country of practice, larger centers tended to meet the childhood-onset SLE-QIs more often than smaller centers. The childhood-onset SLE-QIs, evidence-based minimum standards of medical care, are not consistently met in the US or some other countries outside the US. This has the potential to contribute to suboptimal childhood-onset SLE outcomes. © 2016, American College of Rheumatology.

Ventilator-associated pneumonia at a tertiary-care center in a developing country: incidence, microbiology, and susceptibility patterns of isolated microorganisms.

PubMed

Kanafani, Zeina A; Kara, Layla; Hayek, Shady; Kanj, Souha S

2003-11-01

Ventilator-associated pneumonia (VAP) complicates the course of up to 24% of intubated patients. Data from the Middle East are scarce. The objective of this study was to evaluate the incidence, microbiology, and antimicrobial susceptibility patterns of isolated microorganisms in VAP in a developing country. Prospective observational cohort study. The American University of Beirut Medical Center, a tertiary-care center that serves as a major referral center for Lebanon and neighboring countries. All patients admitted to the intensive care and respiratory care units from March to September 2001, and who had been receiving mechanical ventilation for at least 48 hours, were included in the study. Results of samples submitted for culture were recorded and antimicrobial susceptibility testing of isolated pathogens was performed. Seventy patients were entered into the study. The incidence of VAP was 47%. Gram-negative bacilli accounted for 83% of all isolates. The most commonly identified organism was Acinetobacter anitratus, followed by Pseudomonas aeruginosa. Fifty percent of all gram-negative bacterial isolates were classified as antibiotic resistant. Compared with patients without VAP, patients with VAP remained intubated for a longer period and stayed in the intensive care unit longer. VAP was not associated with an increased mortality rate. Compared with other studies, the results from this referral center in Lebanon indicate a higher incidence of VAP and a high prevalence of resistant organisms. These data are relevant because they direct the choice of empiric antibiotic therapy for VAP.

[Implementation of a residency program in anesthesiology in the Northeast of Brazil: impact on work processes and professional motivation].

PubMed

Fernandes, Cláudia Regina; Sousa, Rafael Queiroz de; Arcanjo, Francisco Sávio Alves; Neto, Gerardo Cristino de Menezes; Gomes, Josenília Maria Alves; Giaxa, Renata Rocha Barreto

2015-01-01

Understand, through the theory of social representations, the influence exerted by the establishment a residency program in anesthesiology on anesthetic care and professional motivation in a tertiary teaching hospital in the Northeast of Brazil. Qualitative methodology. The theoretical framework comprised the phenomenology and the Social Representation Theory. Five multidisciplinary focus groups were formed with 17 health professionals (five surgeons, five anesthesiologists, two nurses, and five nursing technicians), who work in operating rooms and post-anesthesia care units, all with prior and posterior experience to the establishment of residency. From the response content analysis, the following empirical categories emerged: motivation to upgrade, recycling of anesthesiologists and improving anesthetic practice, resident as an interdisciplinary link in perioperative care, improvements in the quality of perioperative care, recognition of weaknesses in the perioperative process. It was evident upper gastrointestinal bleeding secondary to prolonged intubation that the creation of a residency in anesthesiology brings advancements that are reflected in the motivation of anesthesiologists; the resident worked as an interdisciplinary link between the multidisciplinary team; there was recognition of weaknesses in the system, which were identified and actions to overcome it were proposed. The implementation of a residency program in anesthesiology at a tertiary education hospital in the Northeast of Brazil promoted scientific updates, improved the quality of care and processes of interdisciplinary care, recognized the weaknesses of the service, developed action plans and suggested that this type of initiative may be useful in remote areas of developing countries. Copyright © 2014 Sociedade Brasileira de Anestesiologia. Publicado por Elsevier Editora Ltda. All rights reserved.

Interhospital Transfer of Neurosurgical Patients to a High-Volume Tertiary Care Center: Opportunities for Improvement.

PubMed

Holland, Christopher M; McClure, Evan W; Howard, Brian M; Samuels, Owen B; Barrow, Daniel L

2015-08-01

Neurosurgical indications for patient transfer include absence of local or available neurosurgical coverage, subspecialty or interdisciplinary requirements, and family preference. Transfer of patients to regional centers will increase with further centralization of medical care. To report the transfer records of a large tertiary care center to identify trends, failures, and opportunities to improve interhospital transfer of neurosurgical patients. All consecutive, prospectively documented requests for interhospital patient transfer to the adult neurosurgical service of Emory University Hospitals were retrospectively identified from a centralized transfer center database for a 1-year study period. Requests for neurosurgical care constituted 1323 of the 9087 calls (14.6%); 81.1% of these requests were accepted, and a total of 984 patients (74.4%) arrived at our institutions. Patients arrived from 133 unique facilities throughout a catchment area of 66 287 sq miles. Although the median travel time for transfer patients was 36 minutes, the median interval between the request and patient arrival was 4 hours 2 minutes. The most frequent diagnoses were intracranial hemorrhage (31.8%), subarachnoid hemorrhage (31.2%), and intracranial tumor (15.2%). The overall diagnostic error rate was 10.3%. Only 42.5% of patients underwent neurosurgical intervention, and 57 patients admitted to intensive care were immediately transitioned to a lower level of care. Interhospital transfer requires a coordinated effort among hospital administrators, physicians, and staff to make complex decisions that govern this important and costly process. These data suggest common failures and numerous opportunities for improvement in transfer efficiency, diagnostic accuracy, triage, and resource allocation.

Patient issues in health research and quality of care: an inventory and data synthesis.

PubMed

Teunissen, Truus; Visse, Merel; de Boer, Pim; Abma, Tineke A

2013-12-01

The purpose of this review is to generate an inventory of issues that matter from a patient perspective in health research and quality of care. From these issues, criteria will be elicited to support patient(s) (groups) in their role as advisor or advocate when appraising health research, health policy and quality of health care. Literature shows that patients are beginning to develop their own voice and agenda's with issues in order to be prepared for the collaboration with professionals. Yet, patient issues have not been investigated systematically. This review addresses what patients find important and help to derive patient criteria for appraising research and quality of care. METHODS/SEARCH STRATEGY: Information was gathered from Western countries with similar economic, societal and health-care situations. We searched (from January 2000 to March 2010) for primary sources, secondary sources and tertiary sources; non-scientific publications were also included. The international inventory of issues that were defined by patients is covering a large array of domains. In total, 35 issue clusters further referred to as criteria were found ranging from dignity to cost effectiveness and family involvement. Issues from a patient perspective reveal patient values and appear to be adding to professional issues. Patient issues cover a broad domain, including fundamental values, quality of life, quality of care and personal development. Quite a few issues do not find its reflection in the scientific literature in spite of their clear and obvious appearance from tertiary sources. This may indicate a gap between the scientific research community and patient networks. © 2011 John Wiley & Sons Ltd.

Patient issues in health research and quality of care: an inventory and data synthesis

PubMed Central

Teunissen, Truus; Visse, Merel; de Boer, Pim; Abma, Tineke A.

2011-01-01

Abstract Aim  The purpose of this review is to generate an inventory of issues that matter from a patient perspective in health research and quality of care. From these issues, criteria will be elicited to support patient(s) (groups) in their role as advisor or advocate when appraising health research, health policy and quality of health care. Background  Literature shows that patients are beginning to develop their own voice and agenda’s with issues in order to be prepared for the collaboration with professionals. Yet, patient issues have not been investigated systematically. This review addresses what patients find important and help to derive patient criteria for appraising research and quality of care. Methods/search strategy  Information was gathered from Western countries with similar economic, societal and health‐care situations. We searched (from January 2000 to March 2010) for primary sources, secondary sources and tertiary sources; non‐scientific publications were also included. Results  The international inventory of issues that were defined by patients is covering a large array of domains. In total, 35 issue clusters further referred to as criteria were found ranging from dignity to cost effectiveness and family involvement. Issues from a patient perspective reveal patient values and appear to be adding to professional issues. Conclusions  Patient issues cover a broad domain, including fundamental values, quality of life, quality of care and personal development. Quite a few issues do not find its reflection in the scientific literature in spite of their clear and obvious appearance from tertiary sources. This may indicate a gap between the scientific research community and patient networks. PMID:21771226

Activity based costing of diagnostic procedures at a nuclear medicine center of a tertiary care hospital

PubMed Central

Hada, Mahesh Singh; Chakravarty, Abhijit; Mukherjee, Partha

2014-01-01

Context: Escalating health care expenses pose a new challenge to the health care environment of becoming more cost-effective. There is an urgent need for more accurate data on the costs of health care procedures. Demographic changes, changing morbidity profile, and the rising impact of noncommunicable diseases are emphasizing the role of nuclear medicine (NM) in the future health care environment. However, the impact of emerging disease load and stagnant resource availability needs to be balanced by a strategic drive towards optimal utilization of available healthcare resources. Aim: The aim was to ascertain the cost of diagnostic procedures conducted at the NM Department of a tertiary health care facility by employing activity based costing (ABC) method. Materials and Methods: A descriptive cross-sectional study was carried out over a period of 1 year. ABC methodology was utilized for ascertaining unit cost of different diagnostic procedures and such costs were compared with prevalent market rates for estimating cost effectiveness of the department being studied. Results: The cost per unit procedure for various procedures varied from Rs. 869 (USD 14.48) for a thyroid scan to Rs. 11230 (USD 187.16) for a meta-iodo-benzyl-guanidine (MIBG) scan, the most cost-effective investigations being the stress thallium, technetium-99 m myocardial perfusion imaging (MPI) and MIBG scan. The costs obtained from this study were observed to be competitive when compared to prevalent market rates. Conclusion: ABC methodology provides precise costing inputs and should be used for all future costing studies in NM Departments. PMID:25400363

The Nordic maintenance care program: what is maintenance care? Interview based survey of Danish chiropractors

PubMed Central

2013-01-01

Objective To describe and interpret Danish Chiropractors’ perspectives regarding the purpose and rationale for using MC (maintenance care), its content, course and patient characteristics. Methods Semi-structured interviews were conducted with 10 chiropractors identified using a stratified, theoretical sampling framework. Interviews covered four domains relating to MC, namely: purpose, patient characteristics, content, and course and development. Data was analysed thematically. Results Practitioners regard MC primarily as a means of providing secondary or tertiary care and they primarily recommend it to patients with a history of recurrence. Initiating MC is often a shared decision between clinician and patient. The core elements of MC are examination and manipulation, but exercise and general lifestyle advice are often included. Typically, treatment intervals lie between 2 and 4 months. Clinician MC practices seem to evolve over time and are informed by individual practice experiences. Chiropractors are more likely to offer MC to patients whose complaints include a significant muscular component. Furthermore, a successful transition to MC appears dependent on correctly matching complaint with management. A positive relationship between chiropractor and patient facilitates the initiation of MC. Finally; MC appears grounded in a patient-oriented approach to care rather than a market-oriented one. Conclusion MC is perceived as both a secondary and tertiary preventative measure and its practice appears grounded in the tenet of patient-oriented care. A positive personal relationship between chiropractor and patient facilitates the initiation of MC. The results from this and previous studies should be considered in the design of studies of efficacy. PMID:23962318

Barriers to Early Initiation and Continuation of Breastfeeding in a Tertiary care Institute of Haryana: A Qualitative Study in Nursing Care Providers.

PubMed

Majra, Jai Pal; Silan, Vijay Kumar

2016-09-01

Ever increasing institutional deliveries in India has shifted the responsibility of timely initiation and continuation of breastfeeding from peripheral health workers and families to the nursing care providers of health facilities where the births take place. While institutional deliveries have increased to 72.6%, only 44.6% of the newborns enjoy early breastfeeding in India. To study the barriers to early initiation of breastfeeding in institutional delivery. A total 34 nursing care providers were selected randomly and five Focus Group Discussions (FGDs) were carried out. This Qualitative Study was conducted through FGDs among the nursing care providers of a tertiary care institute in the Indian State of Haryana, India. The analyses continued throughout the group discussions as the newly emerged themes were tested in the subsequent discussion. FGDs transcripts were analysed to enhance the robustness of the emerged domain. Major barriers to initiation of breast feeding identified included: lack of awareness regarding proper technique of breastfeeding and benefits of colostrum; breast abnormality like inverted/retracted nipples; obstetric/neonatal complications requiring specialised care; and cultural practices like giving pre-lacteals and gender discrimination. It was further reported that the manpower has not been rationalised with ever increasing number of institutional deliveries. The respondents though willing to promote early initiation and continuation of breastfeeding felt excessive workload as one of the major barriers due to multi-tasking nature of their job. The new challenges to the early initiation and continuation of breastfeeding are emerging due to change in the place of delivery which needs to be addressed at the policy level.

Parents' Perceived Satisfaction of Care, Communication and Environment of the Pediatric Intensive Care Units at a Tertiary Children's Hospital.

PubMed

Abuqamar, Maram; Arabiat, Diana H; Holmes, Sandra

2016-01-01

This study aims to identify parental perceptions on pediatric intensive care-related satisfaction within three domains: environment, child's care provided and communication. In addition, it aims to identify whether parent's socio-demographics and child's clinical variables predict parents' perceived satisfaction. In this study, a total of 123 parents whose child received care in the PICU of a tertiary children's hospital in Amman completed the Arabic version of the parents satisfaction survey (PSS). A cross-sectional, descriptive-correlational design was used to collect data. All data were collected between June and October of 2013. Central tendency measures and percentages of replies for each domain revealed that at least 7 items were rated poorly satisfied. More than half of the parents were not satisfied with the noise level of the PICU, the time nurses spent at the child's bedside, as well as the way the healthcare team prepare them for the child's admission. Almost 90% of the parents believed that the nurses ignored their child's needs by not listening to parents and by responding slowly to child's needs. Stepwise regression analysis showed that that the number of hospital admissions, health insurance and the severity of illness was the main predictor of parents' satisfaction. In conclusion, the availability of health care professionals, the support and the information they share with the child's parents are all significant to parent's satisfaction and hence to better quality of care. Targeting the domains of low satisfaction reported by the parents could increase parent's satisfaction and achieve quality improvement required for this population. Copyright © 2016 Elsevier Inc. All rights reserved.

Development of an instrument to measure patient perception of the quality of nursing care and related hospital services at the national hospital of sri lanka.

PubMed

Senarat, Upul; Gunawardena, Nalika S

2011-06-01

This study aimed to develop and validate an instrument to measure patient perception of quality of nursing care and related hospital services in a tertiary care setting. We compiled an instrument with 72 items that patients may perceive as quality of nursing care and related hospital services, following an extensive literature search, discussions with patients and care pro-I viders and a brainstorming session with an expert panel. A cross-sectional study was conducted at the National Hospital of Sri Lanka. A sample (n = 120) of patients stayed in general surgical or medical units responded to the interviewer administered instrument upon discharge. Item analysis and principal component factor analysis were performed to assess validity, and internal consistency was calculated to measure reliability. Of the 72 items, 18 had greater than 20% of responses as 'not relevant'. A further 11 items were eliminated since item-total correlations were less than .2. Factor analysis was performed on remaining 43 items which resulted in 36 items classifying into eight factors accounting for 71% of the variation. Factor loadings in the final solution after Varimax rotation were interpersonal aspects (.68-.85), efficiency (.62-.79), competency (.66-.68), comfort (.60-.84), physical environment (.65-.82), cleanliness (.81-.85), personalized information (.76-.83), and general instructions (.61-.78). The instrument had high Internal consistency (Cronbach's alpha = .91). We developed a comprehensive, reliable and valid, 36-item instrument that may be used to measure patient perception of quality of nursing care in tertiary care settings. Copyright © 2011 Korean Society of Nursing Science. Published by Elsevier B.V. All rights reserved.

Self-referral patterns among federal civil servants in oyo state, South-Western Nigeria.

PubMed

Okoli, Henry; Obembe, Taiwo; Osungbade, Kayode; Adeniji, Folashayo; Adewole, David

2017-01-01

Primary health care is widely accepted as the first point of care; yet, individuals requiring healthcare engage in self-referrals to higher levels of care thereby by-passing primary care. Little is known of the extent to which self-referrals are carried out when care is needed. This study thus sought to determine the prevalence of self-referral, its patterns and factors influencing self-referrals amongst federal civil servants in Southwestern Nigeria. A cross-sectional study was carried out among 300 federal civil servants who were interviewed using validated and pre-tested interviewer-administered semi structured questionnaires. Data was analyzed using univariate and Chi-square test at level of significance set at P <0.05. Mean age of the respondents was 39.96 ± 9.1 years with majority being married (80.7%); 90.7% completed tertiary education (and 76.7 % were middle grade (7-12) level officers. Most (60.0%) of the respondents had ever engaged in self-referral. Malaria was the commonest health problem (39.7%) for self-referral to secondary or tertiary facilities. Desire for quality service (35.7%) and competent staff (35.2%) were the commonest reasons for self-referral to a higher level of health care. More female respondents (76.0%) compared to male respondents (64.0%) significantly engaged in self-referral (p = 0.02, X2 = 5.14). Respondents having good knowledge of referral practices engaged less in self-referral compared to those with poor knowledge. (p = 0.02, X2 = 5.43). Having good knowledge of referral practices and being male are positively associated with referral practices. Creating awareness and improving knowledge on referral practices with special emphasis on women population are desirable strategies for encouraging the use of primary health care as first of point of contact with health systems.

The financial burden of cancer: estimates from patients undergoing cancer care in a tertiary care hospital.

PubMed

Zaidi, Adnan A; Ansari, Tayyaba Z; Khan, Aziz

2012-10-15

The emotional burden associated with the diagnosis of cancer is sometimes overshadowed by financial burden sustained by patient and the family. This is especially relevant for a developing country as there is limited state support for cancer treatment. We conducted this study to estimate the cost of cancer care for two major types of cancer and to assess the perception of patients and families regarding the burden of the cost for undergoing cancer treatment at a private tertiary care hospital. This cross-sectional study was conducted at day care and radiotherapy unit of Aga Khan University, Hospital (AKUH) Karachi, Pakistan. All adult patients with breast and head & neck cancers diagnosed for 3 months or more were included. Data was collected using a structured questionnaire and analysed using SPSS. Sixty seven patients were interviewed during the study period. The mean and median monthly income of these patients was 996.4 USD and 562.5 USD respectively. Comparatively the mean and median monthly cost of cancer care was 1093.13 USD and 946.42 USD respectively. The cost of the treatment either fully or partially was borne by the family in most cases (94%). The financial burden of cancer was perceived as significant by 28 (42%) patients and unmanageable by 18 (27%) patients. This perceived level of burden was associated significantly with average monthly income (p = <0.001). Our study indicates that the financial burden of cancer care is substantial and can be overwhelming. There is a desperate need for treatment support programs either by the government or other welfare organisations to support individuals and families who are already facing a difficult and challenging situation.

Health care Professionals' Experiences and Needs When Delivering End-of-Life Care to Children: A Qualitative Study.

PubMed

Bergsträsser, Eva; Cignacco, Eva; Luck, Patricia

2017-01-01

Pediatric end-of-life care (EOL care) entails challenging tasks for health care professionals (HCPs). Little is known about HCPs' experiences and needs when providing pediatric EOL care in Switzerland. This study aimed to describe the experiences and needs of HCPs in pediatric EOL care in Switzerland and to develop recommendations for the health ministry. The key aspect in EOL care provision was identified as the capacity to establish a relationship with the dying child and the family. Barriers to this interaction were ethical dilemmas, problems in collaboration with the interprofessional team, and structural problems on the level of organizations. A major need was the expansion of vocational training and support by specialized palliative care teams. We recommend the development of a national concept for the provision of EOL care in children, accompanied by training programs and supported by specialized pediatric palliative care teams located in tertiary children's hospitals.

Extended reaction scope of thiamine diphosphate dependent cyclohexane-1,2-dione hydrolase: from C-C bond cleavage to C-C bond ligation.

PubMed

Loschonsky, Sabrina; Wacker, Tobias; Waltzer, Simon; Giovannini, Pier Paolo; McLeish, Michael J; Andrade, Susana L A; Müller, Michael

2014-12-22

ThDP-dependent cyclohexane-1,2-dione hydrolase (CDH) catalyzes the CC bond cleavage of cyclohexane-1,2-dione to 6-oxohexanoate, and the asymmetric benzoin condensation between benzaldehyde and pyruvate. One of the two reactivities of CDH was selectively knocked down by mutation experiments. CDH-H28A is much less able to catalyze the CC bond formation, while the ability for CC bond cleavage is still intact. The double variant CDH-H28A/N484A shows the opposite behavior and catalyzes the addition of pyruvate to cyclohexane-1,2-dione, resulting in the formation of a tertiary alcohol. Several acyloins of tertiary alcohols are formed with 54-94 % enantiomeric excess. In addition to pyruvate, methyl pyruvate and butane-2,3-dione are alternative donor substrates for CC bond formation. Thus, the very rare aldehyde-ketone cross-benzoin reaction has been solved by design of an enzyme variant. © 2014 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

An Examination of Referral Physician Attitudes Toward Brooke Army Medical Center as a Tertiary Care Medical Center

DTIC Science & Technology

1986-09-01

William B. Handbook in Research and Evaluation. San Diego: Edits Publishers, 1977. Kotler , Philip . Marketing for Nonprofit Organizations. 2nd ed. Englewood...Marketing and the Regional Model." Hospital & Health Services Administration 28 (May-June 1983): p. 65. 18 Philip D. Cooper and Larry M. Robinson...34 Hospital & Health Services Administration 23 (Winter 1978): p. 11. 20 Philip 0. Cooper and Larry M. Robinson, Health Care Marketing Management, pp

Development, implementation, and evaluation of a community- and hospital-based respiratory syncytial virus prophylaxis program.

PubMed

Bracht, Marianne; Heffer, Michael; O'Brien, Karel

2005-02-01

To implement and deliver a respiratory syncytial virus prophylaxis (RSVP) program in response to the Canadian Pediatric Society recommendations. A novel program was designed to provide inpatient RSVP for at-risk infants cared for in 1 tertiary care newborn intensive care unit (NICU). This inpatient program was part of a coordinated approach to RSVP, designed and implemented by 3 hospitals. An RSVP program logic model was created and used by a multidisciplinary team to evaluate the in-house program and identify areas of program activity requiring improvement. Following the 2000 to 2001 RSV season, a compliance and outcomes audit was performed in the tertiary center; 193 infants were enrolled in the RSVP program and 162 infants had received RSVP in the NICU [Mean = 1.64 doses]. Telephone follow-up with the parents of discharged infants identified that 159 infants (98%) had successfully completed their full course of RSVP. Using the RSVP program logic model, 5 areas for program improvement were identified including infant recruitment, patient transfer/discharge processes, product procurement, preparation/distribution/administration of doses, and healthcare team communication. Interdisciplinary collaboration is an important factor in the success of the RSVP program and has supported a consistent model of care for the delivery of RSVP. The program logic model provided a useful structure to systematically review the RSVP program in this organization.

Off-label and unlicensed drug use in hospitalized newborns in a Saudi tertiary care hospital: a cohort study.

PubMed

Mazhar, Faizan; Akram, Shahzad; Haider, Nafis; Hadi, Muhammad Abdul; Sultana, Jabeen

2018-06-01

Objective To determine the extent of off-label and unlicensed prescribing in hospitalized newborns and to identify patient-related risk factors associated with off-label prescribing. Methods A prospective cohort study was conducted between January and March 2016 at a neonatology department of a tertiary-care hospital in the Eastern province. All consecutive admissions to all neonatal care levels meeting the inclusion and exclusion criteria were eligible for enrollment. All prescriptions were classified as off-label or unlicensed according to drug product monograph. Clinical and prescription data were extracted using a pilot-tested structured data collection sheet. Results During the study period 583 prescriptions were made for 138 newborns, of which 29.7% (173/583) and 12.9% (75/583) were classified as off-label and unlicensed drugs respectively for use in neonates. Thirty-four percent (47/138) of patients received at least one off-label/unlicensed medicine. Mechanical ventilation, admission to the neonatal intensive care unit and length of hospital stay were identified as independent risk factors associated with prescribing of at least one off-label medication. Conclusion Use of off-label and unlicensed drugs in hospitalized newborns seems to be a common practice in this Saudi hospital. Future research should evaluate safety and efficacy of off-label and/or unlicensed use of drugs in neonates.

Tertiary-care facility's seniors association attracts its highest number of referrals through word-of-mouth. University Hospital, Denver, CO.

PubMed

Lewicki, G

1999-01-01

University Hospital, Denver, has started its University Seniors Assn. to promote health and wellness to people 50 and older. Within four months the organization had 500 members. Now the association is 3,500 members strong.

Education in Lithuania: Reviews of National Policies for Education

ERIC Educational Resources Information Center

OECD Publishing, 2016

2016-01-01

Lithuania has achieved steady expansion of participation in education, substantially widening access to early childhood education and care and tertiary education, coupling this with nearly universal participation in secondary education. However, if Lithuania's education system is to help the nation respond effectively to economic opportunities and…

Prospective economic evaluation of an electronic discharge communication tool: analysis of a randomised controlled trial

PubMed Central

Sevick, Laura K; Santana, Maria-Jose; Ghali, William A; Clement, Fiona

2017-01-01

Objective To complete an economic evaluation within a randomised controlled trial (RCT) comparing the use of an electronic discharge communication tool (eDCT) compared with usual care. Setting Patients being discharged from a single tertiary care centre’s internal medicine Medical Teaching Units. Participants Between January 2012 and December 2013, 1399 patients were randomised to a discharge mechanism. Forty-five patients were excluded from the economic evaluation as they did not have data for the index hospitalisation cost; 1354 patients contributed to the economic evaluation. Intervention eDCT generated at discharge containing structured content on reason for admission, details of the hospital stay, treatments received and follow-up care required. The control group was discharged via traditional dictation methods. Primary and secondary outcome measures The primary economic outcome was the cost per quality-adjusted life year (QALY) gained. Secondary outcomes included the cost per death avoided and the cost per readmission avoided. Results The average transcription cost was $C22.28 per patient, whereas the estimated cost of the eDCT was $C13.33 per patient. The cost per QALY gained was $C239 933 in the eDCT arm compared with usual care due to the very small gains in effectiveness and approximately $C800difference in resource utilisation costs. The bootstrap analyses resulted in eDCT being more effective and more costly in 29.2% of samples, less costly and more effective in 29.2% of samples, less effective and more costly in 23.9% of samples and finally, less costly and less effective in 17.7% of samples. Conclusions The eDCT reduced per patient costs of the generation of discharge summaries. The bootstrap estimates demonstrate considerable uncertainty supporting the finding of neutrality reported in the clinical component of the RCT. The immediate transcription cost savings and previously documented provider and patient satisfaction may increase the impetus for organisations to invest in such systems, provided they have a foundation of eHealth infrastructure and readiness. Trial registration number NCT01402609. PMID:29247110

Nutritional support in the tertiary care of patients affected by chronic renal insufficiency: report of a step-wise, personalized, pragmatic approach.

PubMed

Cupisti, Adamasco; D'Alessandro, Claudia; Di Iorio, Biagio; Bottai, Anna; Zullo, Claudia; Giannese, Domenico; Barsotti, Massimiliano; Egidi, Maria Francesca

2016-09-06

Dietary treatment is helpful in CKD patients, but nutritional interventions are scarcely implemented. The main concern of the renal diets is its feasibility with regards to daily clinical practice especially in the elderly and co-morbid patients. This study aimed to evaluate the effects of a pragmatic, step-wise, personalized nutritional support in the management of CKD patients on tertiary care. This is a case-control study. It included 823 prevalent out-patients affected by CKD stage 3b to 5 not-in-dialysis, followed by tertiary care in nephrology clinics; 305 patients (190 males, aged 70 ± 12 years) received nutritional support (nutritional treatment Group, NTG); 518 patients (281 males, aged 73 ± 13 years) who did not receive any dietary therapy, formed the control group (CG). In the NTG patients the dietary interventions were assigned in order to prevent or correct abnormalities and to maintain a good nutritional status. They included manipulation of sodium, phosphate, energy and protein dietary intakes while paying special attention to each patient's dietary habits. Phosphate and BUN levels were lower in the NTG than in the CG, especially in stage 4 and 5. The prevalence of hyperphosphatemia was lower in the NTG than in CG in stage 5 (13.3 % vs 53.3 %, p < 001, respectively), in stage 4 (4.1 % vs 18.3 % vs, p < 0.001) and stage 3b (2.8 % vs 9.5 % p < 0.05). Serum albumin was higher in NTG than in CG especially in stage 5 . The use of calcium-free intestinal phosphate binders was significantly lower in NTG than in CG (11 % vs 19 % p < 0.01), as well as that of Erythropoiesis stimulating agents (11 % vs 19 %, p < 0.01), and active Vitamin D preparations (13 % vs 21 %, p < 0.01). This case-control study shows the usefulness of a nutritional support in addition to the pharmacological good practice in CKD patients on tertiary care. Lower phosphate and BUN levels are obtained together with maintenance of serum albumin levels. In addition, a lower need of erythropoiesis stimulating agents, phosphate binders and active Vitamin D preparations was detected in NTG. This study suggests that a nutritional support may be useful in the management of the world-wide growing CKD burden.

Utility of urinary biomarkers as a diagnostic tool for early diabetic nephropathy in patients with type 2 diabetes mellitus.

PubMed

Vijay, Soorampally; Hamide, Abdoul; Senthilkumar, Gandhipuram Periyasamy; Mehalingam, Vadivelan

2018-04-12

Renal tubulo-interstitial damage has an important role in the pathogenesis of early diabetic nephropathy. Urinary biomarkers can help in the detection of early nephropathy in type 2 diabetic patients. The aim of this study was to estimate the levels of urinary neutrophil gelatinase associated lipocalin (NGAL) and cystatin-C in type 2 diabetic patients with early diabetic nephropathy & to compare them with diabetic patients without nephropathy and to correlate urinary NGAL and cystatin-C levels with microalbuminuria in them. Cross-sectional comparative study. The study was conducted on 126 patients with type 2 diabetes along with 30 control subjects attending the outpatient care department of a tertiary care teaching hospital. There were 3 study groups-diabetic patients with microalbuminuria, diabetic patients without albuminuria and control subjects who were non-diabetic without any renal disease. Details on duration of diabetes and glycemic status were obtained from the patients. Urine examination was done for subjects in all the groups to look for microalbuminuria along with estimation of NGAL and cystatin-C levels. Samples were stored at -20 °C in the deep freezer. Urinary NGAL and cystatin-C levels were significantly elevated in patients with microalbuminuria (228.18 & 3.23 ng/ml) as compared to those without albuminuria (146.12 & 2.61 ng/ml) and in control subjects (26.56 & 0.30 ng/ml). Urinary NGAL and cystatin-C levels showed a linear correlation with microalbuminuria in diabetic patients. Urinary NGAL and cystatin-C levels were increased in type 2 diabetic patients with early diabetic nephropathy as compared to patients without nephropathy. Urine NGAL and cystatin-C levels also showed a positive correlation with microalbuminuria (urine albumin-creatinine ratio) in patients with type 2 diabetes mellitus. Copyright © 2018 Diabetes India. Published by Elsevier Ltd. All rights reserved.

Tertiary to secondary reduction of aminomethylphosphane derived from 1-ethylpiperazine as a result of its coordination to ruthenium(II) centre - The first insight into the nature of process

NASA Astrophysics Data System (ADS)

Płotek, Michał; Starosta, Radosław; Komarnicka, Urszula K.; Skórska-Stania, Agnieszka; Kołoczek, Przemysław; Dudek, Karol; Kyzioł, Agnieszka

2016-10-01

Introduction of tertiary aminomethylphosphane P{CH2N(CH2CH2)2NCH2CH3}3 (B; tris{1-[4-ethyl(tetrahydro-1,4-diazino)]methyl}phosphane) to methanolic solution of [Ru(η5-C5H5)Cl(PPh3)2] (1) and NaBF4, instead of straightforward substitution of the chloride leads to concomitant cleavage of aminomethylphosphane's Psbnd CH2 bond. The obtained complex [Ru(η5-C5H5)PH{CH2N(CH2CH2)2NCH2CH3}2(PPh3)2]BF4 (2B‧) was fully characterized by spectroscopic methods ((NMR, IR, ESI-MS) and its solid state structure was determined with single crystal X-ray diffraction method. It was proven that the structure of 2B‧ is similar to the previously synthesized morpholine counterpart [Ru(η5-C5H5)PH{CH2N(CH2CH2)2O}2(PPh3)2]BF4 (2A‧). DFT calculations (B3LYP with the D95V(d,p) basis set for C, N, H and O and LanL2DZ with Los Alamos ECPs for Ru, P and Cl) revealed that the binding of aminomethylphosphanes to the ruthenium centre leads to the Psbnd C bonds elongation, which may finally result in breaking one of them and phosphane's reduction from tertiary to secondary ones.

Moral distress in physicians and nurses: Impact on professional quality of life and turnover.

PubMed

Austin, Cindy L; Saylor, Robert; Finley, Phillip J

2017-07-01

The purpose of this study was to investigate moral distress (MD) and turnover intent as related to professional quality of life in physicians and nurses at a tertiary care hospital. Health care providers from a variety of hospital departments anonymously completed 2 validated questionnaires (Moral Distress Scale-Revised and Professional Quality of Life Scale). Compassion fatigue (as measured by secondary traumatic stress [STS] and burnout [BRN]) and compassion satisfaction are subscales which make up one's professional quality of life. Relationships between these constructs and clinicians' years in health care, critical care patient load, and professional discipline were explored. The findings (n = 329) demonstrated significant correlations between STS, BRN, and MD. Scores associated with intentions to leave or stay in a position were indicative of high verses low MD. We report highest scoring situations of MD as well as when physicians and nurses demonstrate to be most at risk for STS, BRN and MD. Both physicians and nurses identified the events contributing to the highest level of MD as being compelled to provide care that seems ineffective and working with a critical care patient load >50%. The results from this study of physicians and nurses suggest that the presence of MD significantly impacts turnover intent and professional quality of life. Therefore implementation of emotional wellness activities (e.g., empowerment, opportunity for open dialog regarding ethical dilemmas, policy making involvement) coupled with ongoing monitoring and routine assessment of these maladaptive characteristics is warranted. (PsycINFO Database Record (c) 2017 APA, all rights reserved).

Most children with cancer are not enrolled on a clinical trial in Canada: a population-based study.

PubMed

Pole, Jason D; Barber, Randy; Bergeron, Rose-Émilie; Carret, Anne Sophie; Dix, David; Kulkarni, Ketan; Martineau, Emilie; Randall, Alicia; Stammers, David; Strahlendorf, Caron; Strother, Douglas R; Truong, Tony H; Sung, Lillian

2017-06-05

Primary objective was to describe the proportion of children newly diagnosed with cancer enrolled on a therapeutic clinical trial. Secondary objectives were to describe reasons for non-enrollment and factors associated with enrollment on trials. In this retrospective cohort study, we included children newly diagnosed with cancer between 0 and 14 years of age and diagnosed from 2001 to 2012. We used data from the Cancer in Young People in Canada (CYP-C) national pediatric cancer population-based database. CYP-C captures all cases of pediatric cancer (0-14 years) diagnosed and treated at one of the 17 tertiary pediatric oncology centers in Canada. Non-enrollment was evaluated using univariate and multiple logistic regression analysis. There were 9204 children with cancer included, of whom 2533 (27.5%) were enrolled on a clinical trial. The most common reasons cited for non-enrollment were lack of an available trial (52.2%) and physician choice (11.2%). In multiple regression, Asian and Arab/west Asian race were associated with lower enrollment (P = 0.006 and P = 0.032 respectively). All cancer diagnoses were more likely to be enrolled compared to astrocytoma and children with acute lymphoblastic leukemia had an almost 18-fold increased odds of enrollment compared to astrocytoma (P < 0.0001). Greater distance from the tertiary care center was independently associated with non-enrollment (P < 0.0001). In Canada, 27.5% of children with cancer are enrolled onto therapeutic clinical trials and lack of an available trial is the most common reason contributing to non-enrollment. Future research should better understand reasons for lack of trial availability and physician preferences to not offer trials.

Impact of Oncologists’ Attitudes Toward End-of-Life Care on Patients’ Access to Palliative Care

PubMed Central

Cerana, Maria Agustina; Park, Minjeong; Hess, Kenneth; Bruera, Eduardo

2016-01-01

Background. It is unclear how oncologists’ attitudes toward end-of-life (EOL) care affect the delivery of care. The present study examined the association between oncologists’ EOL care attitudes and (a) timely specialist palliative care referral, (b) provision of supportive care, and (c) EOL cancer treatment decisions. Methods. We randomly surveyed 240 oncology specialists at our tertiary care cancer center to assess their attitudes toward EOL care using a score derived from the Jackson et al. qualitative conceptual framework (0 = uncomfortable and 8 = highly comfortable with EOL care). We determined the association between this score and clinicians’ report of specialist palliative care referral, provision of supportive care, and EOL cancer treatment decisions. Results. Of the 182 respondents (response rate of 76%), the median composite EOL care score was 6 (interquartile range, 5–7). A higher EOL score was significantly associated with solid tumor oncology (median 7 vs. 6 for hematologic oncology; p = .003), a greater willingness to refer patients with newly diagnosed cancer to specialist palliative care (median, 7 vs. 6; p = .01), greater comfort with symptom management (median, 6 vs. 5; p = .01), and provision of counseling (median, 7 vs. 4; p < .001) but not with cancer treatment decisions. We observed a gradient effect, with higher scores associated with a greater proportion of patients referred to palliative care (score 0–4, 27%; 5, 31%; 6, 32%; 7, 35%; and 8, 45%; p = .007). Conclusion. Greater comfort with EOL care was associated with higher rates of specialist palliative care referral and self-reported primary palliative care delivery. More support and education are needed for oncologists who are less comfortable with EOL care. Implications for Practice: In the present survey of oncology specialists, most reported that they were comfortable with end-of-life (EOL) care, which was in turn, associated with greater provision of primary palliative care and higher rates of referral to specialist palliative care. The results of the present study highlight the need for more support and education for oncologists less comfortable with EOL care because their patients might receive lower levels of both primary and secondary palliative care. PMID:27412394

Impact of Oncologists' Attitudes Toward End-of-Life Care on Patients' Access to Palliative Care.

PubMed

Hui, David; Cerana, Maria Agustina; Park, Minjeong; Hess, Kenneth; Bruera, Eduardo

2016-09-01

It is unclear how oncologists' attitudes toward end-of-life (EOL) care affect the delivery of care. The present study examined the association between oncologists' EOL care attitudes and (a) timely specialist palliative care referral, (b) provision of supportive care, and (c) EOL cancer treatment decisions. We randomly surveyed 240 oncology specialists at our tertiary care cancer center to assess their attitudes toward EOL care using a score derived from the Jackson et al. qualitative conceptual framework (0 = uncomfortable and 8 = highly comfortable with EOL care). We determined the association between this score and clinicians' report of specialist palliative care referral, provision of supportive care, and EOL cancer treatment decisions. Of the 182 respondents (response rate of 76%), the median composite EOL care score was 6 (interquartile range, 5-7). A higher EOL score was significantly associated with solid tumor oncology (median 7 vs. 6 for hematologic oncology; p = .003), a greater willingness to refer patients with newly diagnosed cancer to specialist palliative care (median, 7 vs. 6; p = .01), greater comfort with symptom management (median, 6 vs. 5; p = .01), and provision of counseling (median, 7 vs. 4; p < .001) but not with cancer treatment decisions. We observed a gradient effect, with higher scores associated with a greater proportion of patients referred to palliative care (score 0-4, 27%; 5, 31%; 6, 32%; 7, 35%; and 8, 45%; p = .007). Greater comfort with EOL care was associated with higher rates of specialist palliative care referral and self-reported primary palliative care delivery. More support and education are needed for oncologists who are less comfortable with EOL care. In the present survey of oncology specialists, most reported that they were comfortable with end-of-life (EOL) care, which was in turn, associated with greater provision of primary palliative care and higher rates of referral to specialist palliative care. The results of the present study highlight the need for more support and education for oncologists less comfortable with EOL care because their patients might receive lower levels of both primary and secondary palliative care. ©AlphaMed Press.

The physical examination in telecardiology and televascular consultations: a study using conversation analysis.

PubMed

Pappas, Yannis; Seale, Clive

2010-10-01

This paper describes communication in the physical examination phases of telemedicine consultations. Using the method of conversation analysis, we draw on 10 telemedicine consultations (five telecardiology and five televascular) between primary and tertiary care in the UK. Physical examination is absent in telecardiology consultations. In televascular consultations the professionals try to compensate for the lack of physical proximity by getting involved in a form of collaboration that constitutes a novel environment for all. Separated from the patient by physical space, the specialist orchestrates the positioning of the patient, the camera and the primary care nurse's activity via the use of a video-link. Telemedicine offers primary care nurses a unique opportunity to engage in active collaboration with hospital specialists. The nurses' examination skills are recruited because physical examination is conducted from distance and the specialist cannot touch the patient or see parts of the body with ease. We speculate that difficulties with the physical examination may have contributed to the relatively slow adoption of telemedicine. The analysis reveals some new communication practices that participants in telemedicine are called to adopt. This can be used to inform training interventions that focus both on patient and professional. (c) 2010 Elsevier Ireland Ltd. All rights reserved.

Association of good glycemic control and cost of diabetes care: Experience from a tertiary care hospital in Bangladesh.

PubMed

Afroz, Afsana; Chowdhury, Hasina Akhter; Shahjahan, Md; Hafez, Md Abdul; Hassan, Md Nazmul; Ali, Liaquat

2016-10-01

The present study was undertaken to assess the cost-effectiveness of good glycemic control in a population of Bangladeshi people with type 2 diabetes mellitus (T2DM). A cross-sectional study was conducted among 496 registered patients with >1year duration of diabetes. Glycated hemoglobin A1c level <7% was judged as the cut-off value for good glycemic control. All treatment-related records from the last year were collected from patients' guide books and all cost components were calculated. Among patients, 31% had good glycemic control. The average annual cost was US$ 314 per patient. Patients with poor glycemic control were significantly more likely to have complications [(p=0.049) OR 1.5] and comorbidities [(p=0.02) OR 1.5]. The annual cost increased rapidly with complications/comorbidities. In multivariable logistic regression analysis, gender (p=0.003) and cost of care (p=0.006) were significantly associated with glycemic control, and the presence of any comorbidities/complications was associated with 1.8-fold higher odds of poor glycemic control (p=0.013 95% CI: 1.131-2.786). Good glycemic control can lead to substantial cost saving through prevention and control of complications. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Challenges and priorities in the management of HIV/HBV and HIV/HCV coinfection in resource-limited settings.

PubMed

Easterbrook, Philippa; Sands, Anita; Harmanci, Hande

2012-05-01

Liver disease due to chronic hepatitis B virus (HBV) and hepatitis C virus (HCV) infection is now emerging as an increasing cause of morbidity and mortality in human immunodeficiency virus- (HIV-) infected persons in resource-limited settings (RLS). Existing management guidelines have generally focused on care in tertiary level facilities in developed countries. Less than half of low-income countries have guidance, and in those that do, there are important omissions or disparities in recommendations. There are multiple challenges to delivery of effective hepatitis care in RLS, but the most important remains the limited access to antiviral drugs and diagnostic tests. In 2010, the World Health Assembly adopted a resolution calling for a comprehensive approach for the prevention, control, and management of viral hepatitis. We describe activities at the World Health Organization (WHO) in three key areas: the establishment of a global hepatitis Program and interim strategy; steps toward the development of global guidance on management of coinfection for RLS; and the WHO prequalification program of HBV and HCV diagnostic assays. We highlight key research gaps and the importance of applying the lessons learned from the public health scale-up of ART to hepatitis care. Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Three-residue turns in alpha/beta-peptides and their application in the design of tertiary structures.

PubMed

Sharma, Gangavaram V M; Nagendar, Pendem; Ramakrishna, Kallaganti V S; Chandramouli, Nagula; Choudhary, Madavi; Kunwar, Ajit C

2008-06-02

A new three-residue turn was serendipitously discovered in alpha/beta hybrid peptides derived from alternating C-linked carbo-beta-amino acids (beta-Caa) and L-Ala residues. The three-residue beta-alpha-beta turn at the C termini, nucleated by a helix at the N termini, resulted in helix-turn (HT) supersecondary structures in these peptides. The turn in the HT motif is stabilized by two H bonds-CO(i-2)-NH(i), with a seven-membered pseudoring (gamma turn) in the backward direction, and NH(i-2)-CO(i), with a 13-membered pseudoring in the forward direction (i being the last residue)--at the C termini. The study was extended to generalize the new three-residue turn (beta-alpha-beta) by using different alpha- and beta-amino acids. Furthermore, the HT motifs were efficiently converted, by an extension with helical oligomers at the C termini, into peptides with novel helix-turn-helix (HTH) tertiary structures. However, this resulted in the destabilization of the beta-alpha-beta turn with the concomitant nucleation of another three-residue turn, alpha-beta-beta, which is stabilized by 11- and 15-membered bifurcated H bonds. Extensive NMR spectroscopic studies were carried out to delineate the secondary and tertiary structures in these peptides, which are further supported by molecular dynamics (MD) investigations.

A patient with autism and severe depression: medical and ethical challenges for an adolescent medicine unit.

PubMed

Skinner, S Rachel; Ng, Cindy; McDonald, Ann; Walters, Tamara

2005-10-17

An adolescent with autism and intellectual disability presented with severe depression related to menstruation. Because of the complex medical, psychiatric and ethical issues involved, her care was coordinated by a hospital-based adolescent medicine unit. After trials of other therapies over an extended period and interdisciplinary and intersectoral case conferencing, it was decided that hysterectomy was the most appropriate management. This case highlights the complexity of adolescent health care in a tertiary hospital, the importance of intersectoral cooperation between hospital and community, and the integral role of interdisciplinary care of adolescent patients with chronic conditions.

[Effect of methyl tertiary butyl ether on the expression of proto-oncogenes and function genes].

PubMed

Zhou, W; Huang, G; Zhang, H

1999-05-30

Methyl tertiary butyl ether (MTBE) is a new gasoline additive, which is used to increase the combustion of gasoline and to reduce the emission of harmful exhaust from automobile. The mechanism for the carcinogenesis of MTBE in animals is not clear. Immunohistochemistry method was used to detect the effect of MTBE on the expression of c-myc and p21 proteins in NIH3T3 cells. Dot hybridization method was used to explore the expression of c-myc gene and GST-P(glutathione S-transferase-P) gene in the of MTBE treated rats. The results showed that MTBE could enhance the expression of c-myc protein, but had no effect on p21 protein. MTBE could induce high expression of c-myc gene, and had no effect on the expression of GST-P gene. These results suggest that the high expression of c-myc gene induced by MTBE might be one of the mechanisms of its carcinogenicity in animal.

[Iatrogeny: implications for nursing care].

PubMed

Ferraz, Estela Regina; Ishii, Shizuka; Ciosak, Suely Itsuko; Miyadahira, Ana Maria Kazue; Chaves, Eliane Corrêa

1982-08-01

The authors describe the theoretical aspects of iatrogeny which are due to drugs, patient reactions, and failure in the application of drugs by nursing personnel. They discuss nursing intervention on primary, secondary and tertiary level of prevention and they alert the nurses of the importance of introducing the topic in nursing education programs.

Pancreatitis in Children.

PubMed

Sathiyasekaran, Malathi; Biradar, Vishnu; Ramaswamy, Ganesh; Srinivas, S; Ashish, B; Sumathi, B; Nirmala, D; Geetha, M

2016-11-01

Pancreatic disease in children has a wide clinical spectrum and may present as Acute pancreatitis (AP), Acute recurrent pancreatitis (ARP), Chronic pancreatitis (CP) and Pancreatic disease without pancreatitis. This article highlights the etiopathogenesis and management of pancreatitis in children along with clinical data from five tertiary care hospitals in south India [Chennai (3), Cochin and Pune].

Geothermal studies in oil field districts of North China

NASA Astrophysics Data System (ADS)

Wang, Ji-An; Wang, Ji-Yang; Yan, Shu-Zhen; Lu, Xiu-Wen

In North China, Tertiary sediments give the main oil-genetic series. The mean value of terrestrial heat flow density has been considered to be 60 - 65 mW/m2, and the geothermal gradient in Tertiary sediments usually ranges from 30 to 40° C/km in the region studied. Supposing that the onset of oil generation lies at about 90° C, the upper limit of the depth of oil-generation is at about 2000 to 2500 m depth. Recent paleogeothermal studies using vitrinite reflectance, clay and authigenic minerals, as well as other methods showed that in Eocene the geothermal gradient has been higher than at present. Some results were obtained and discussed.

Process evaluation of community care centers providing care, support, and treatment to people living with human immunodeficiency virus in India.

PubMed

Sogarwal, Ruchi; Bachani, Damodar

2011-01-01

Since 2007, the concept of community care centers (CCC) has evolved to provide care, support, and treatment services to the people living with human immunodeficiency virus in a community-based environment so as to bridge the gap between secondary/tertiary level institutional and home-based care. Monitoring and evaluation, including process evaluation (PE), are integral parts of this scheme. This article presents the design of the "PE" for CCC and the results pertaining to the gaps and constraints in the implementation of the scheme. The CCC PE was conducted in 197 of the 273 CCCs that have been functioning for at least 1 year as on November 30, 2009. Data were collected by structured observations and individual interviews through checklists and semistructured tools. The targeted population for PE was inpatient/outpatient beneficiaries, caregivers, and service providers of CCCs. The findings revealed that of 197 CCCs evaluated, 55, 57, 52, and 33 were graded as A, B, C, and D, respectively. Of the 33 grade-D CCCs, 22 were from 4 high-prevalence states (Andhra Pradesh, Karnataka, Maharashtra, and Tamil Nadu). There was dearth of good nongovernment organizations in the Northeastern region of the country with more nongovernment organizations in C and D category. The PE indicated some critical constraints in the services, such as shortage of medicines for treatment of opportunistic infections, poor coordination with anti-retroviral treatment centers, and transportation for referral cases. In spite of various constraints in the scheme, the majority of the patients were satisfied with the services available at CCC. The PE had provided an invaluable base to improve the CCC scheme, which will enhance the quality of service delivery system. The results of our experience may help other researchers and managers plan similar and more improved assessment.

Molecular data and ecological niche modelling reveal a highly dynamic evolutionary history of the East Asian Tertiary relict Cercidiphyllum (Cercidiphyllaceae).

PubMed

Qi, Xin-Shuai; Chen, Chen; Comes, Hans Peter; Sakaguchi, Shota; Liu, Yi-Hui; Tanaka, Nobuyuki; Sakio, Hitoshi; Qiu, Ying-Xiong

2012-10-01

East Asia's temperate deciduous forests served as sanctuary for Tertiary relict trees, but their ages and response to past climate change remain largely unknown. To address this issue, we elucidated the evolutionary and population demographic history of Cercdiphyllum, comprising species in China/Japan (Cercdiphyllum japonicum) and central Japan (Cercdiphyllum magnificum). Fifty-three populations were genotyped using chloroplast and ribosomal DNA sequences and microsatellite loci to assess molecular structure and diversity in relation to past (Last Glacial Maximum) and present distributions based on ecological niche modelling. Late Tertiary climate cooling was reflected in a relatively recent speciation event, dated at the Mio-/Pliocene boundary. During glacials, the warm-temperate C. japonicum experienced massive habitat losses in some areas (north-central China/north Japan) but increases in others (southwest/-east China, East China Sea landbridge, south Japan). In China, the Sichuan Basin and/or the middle-Yangtze were source areas of postglacial northward recolonization; in Japan, this may have been facilitated through introgressive hybridization with the cool-temperate C. magnificum. Our findings challenge the notion of relative evolutionary and demographic stability of Tertiary relict trees, and may serve as a guideline for assessing the impact of Neogene climate change on the evolution and distribution of East Asian temperate plants. © 2012 The Authors. New Phytologist © 2012 New Phytologist Trust.

What impact did a Paediatric Early Warning system have on emergency admissions to the paediatric intensive care unit? An observational cohort study.

PubMed

Sefton, G; McGrath, C; Tume, L; Lane, S; Lisboa, P J G; Carrol, E D

2015-04-01

The ideology underpinning Paediatric Early Warning systems (PEWs) is that earlier recognition of deteriorating in-patients would improve clinical outcomes. To explore how the introduction of PEWs at a tertiary children's hospital affects emergency admissions to the Paediatric Intensive Care Unit (PICU) and the impact on service delivery. To compare 'in-house' emergency admissions to PICU with 'external' admissions transferred from District General Hospitals (without PEWs). A before-and-after observational study August 2005-July 2006 (pre), August 2006-July 2007 (post) implementation of PEWs at the tertiary children's hospital. The median Paediatric Index of Mortality (PIM2) reduced; 0.44 vs 0.60 (p<0.001). Fewer admissions required invasive ventilation 62.7% vs 75.2% (p=0.015) for a shorter median duration; four to two days. The median length of PICU stay reduced; five to three days (p=0.002). There was a non-significant reduction in mortality (p=0.47). There was no comparable improvement in outcome seen in external emergency admissions to PICU. A 39% reduction in emergency admission total beds days reduced cancellation of major elective surgical cases and refusal of external PICU referrals. Following introduction of PEWs at a tertiary children's hospital PIM2 was reduced, patients required less PICU interventions and had a shorter length of stay. PICU service delivery improved. Copyright © 2014 Elsevier Ltd. All rights reserved.

A comparative study of the quality of care and glycemic control among ambulatory type 2 diabetes mellitus clients, at a Tertiary Referral Hospital and a Regional Hospital in Central Kenya.

PubMed

Mwavua, Shillah Mwaniga; Ndungu, Edward Kiogora; Mutai, Kenneth K; Joshi, Mark David

2016-01-05

Peripheral public health facilities remain the most frequented by the majority of the population in Kenya; yet remain sub-optimally equipped and not optimized for non-communicable diseases care. We undertook a descriptive, cross sectional study among ambulatory type 2 diabetes mellitus clients, attending Kenyatta National Referral Hospital (KNH), and Thika District Hospital (TDH) in Central Kenya. Systematic random sampling was used. HbA1c was assessed for glycemic control and the following, as markers of quality of care: direct client costs, clinic appointment interval and frequency of self monitoring test, affordability and satisfaction with care. We enrolled 200 clients, (Kenyatta National Hospital 120; Thika District Hospital 80); Majority of the patients 66.5% were females, the mean age was 57.8 years; and 58% of the patients had basic primary education. 67.5% had diabetes for less than 10 years and 40% were on insulin therapy. The proportion (95% CI) with good glycemic was 17% (12.0-22.5 respectively) in the two facilities [Kenyatta National Hospital 18.3% (11.5-25.6); Thika District Hospital 15% (CI 7.4-23.7); P = 0.539]. However, in Thika District Hospital clients were more likely to have a clinic driven routine urinalysis and weight, they were also accorded shorter clinic appointment intervals; incurred half to three quarter lower direct costs, and reported greater affordability and satisfactions with care. In conclusion, we demonstrate that in Thika district hospital, glycemic control and diabetic care is suboptimal; but comparable to that of Kenyatta National Referral hospital. Opportunities for improvement of care abound at peripheral health facilities.

End-of-life practices at a Lebanese hospital: courage or knowledge?

PubMed

Gebara, Jouhayna; Tashjian, Hera

2006-10-01

End-of-life care requires knowledgeable and culturally sensitive clinicians to assist patients and families dealing with the difficult journey of death. The authors present important end-of-life considerations for health care providers dealing with culturally diversified patients. A case study approach is used illustrating two case vignettes derived from the practice of an intensive care setting of a tertiary teaching facility in a large urban area in Lebanon. In a multidisciplinary fashion, practices of end of life were explored and a protocol developed to guide health care providers. Special cultural values were identified such as importance of family involvement and religious beliefs. Implications for practice are described.

The 3C study: coverage cost and care of type 1 diabetes in China--study design and implementation.

PubMed

McGuire, Helen; Kissimova-Skarbek, Katarzyna; Whiting, David; Ji, Linong

2011-11-01

To describe coverage, cost and care of type 1 diabetes (T1D) in 2 regions of China--Beijing and Shantou--including: This is a mixed-methods descriptive study with three arms--coverage, cost and care. It is taking place in 4 tertiary hospitals, 3 secondary hospitals and 4 primary health facilities in Beijing, and 2 tertiary hospitals, 2 secondary hospitals and 2 primary health centres in Shantou, China. Two additional hospitals are involved in the coverage arm of the study. T1D participants are recruited from a 3-year list generated by each hospital and from those attending the outpatient clinic or admitted to the inpatient ward. Participants also include health care professionals and government officials. To determine coverage of care, a list of people with T1D is being developed including information on diagnosis, age, sex and vital status. The age and sex distribution will be compared with the expected distribution. To estimate the economic burden of T1D three groups of costs will be calculated - direct medical costs, direct non-medical costs and indirect costs from different perspectives of analysis (patients and their families, health system, insurer and societal perspective). The data are being collected from people with T1D (patient-parents face-to-face interviews), hospital billing departments, medical records and government officials using a combined "top-down, bottom-up" approach developed to validate the data. Quality of life is assessed using the EQ-5D tool and burden of disease is measured based on clinical outcomes and complications. Standard care will be defined, costed and compared to the cost of current care identified within the study to determine the investment required to improve outcomes. The third arm includes three components - health policy, clinical care and education, and information management. Face-to-face, semi-structured interviews are conducted with people with T1D (for those <15 years of age parents are interviewed), health care professionals, senior hospital management and government officials. The core Summary of Diabetes Self-Care Activities Measure plus an additional 6 questions from the revised SDSCA scale are used to assess patient self-care. A medical records audit tool is used to assess care [7]. Clinical outcomes and self-care activities will be analysed for associations with care and education. Information management and care processes will be described using the Standard for Integration Definition for Function Modelling (IDEF0) [8]. At the time of writing (early October) the 3-year case list includes 1269 people with type 1 diabetes from Beijing and 481 people for Shantou, a total of 1750. In addition, two hundred and twenty people with T1D or their parents participated in face-to-face interviews in Beijing and 183 in Shantou, a total of 403. Key implementation considerations were identified early in the project. Project success is dependent on strong local partnerships with local opinion leaders and key officials. It is important that a physician is the first point of contact to build the case list and recruit participants. July, August and January are peak months for recruiting school-age children in the Children's Hospital as this is school vacation period when they are more likely to attend clinics. Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.

A Bunch-Like Tertiary Amine Grafted Polysulfone Membrane for VRFBs with Simultaneously High Proton Conductivity and Low Vanadium Ion Permeability.

PubMed

Tan, Qinglong; Lu, Shanfu; Si, Jiangju; Wang, Haining; Wu, Chunxiao; Li, Xianfeng; Xiang, Yan

2017-04-01

Novel polysulfone membranes with bunch-like tertiary amine groups are synthesized with high ion selectivity and outstanding chemical stability for vanadium redox flow batteries (VRFBs). The bunch-like tertiary amine groups simultaneously act as an ionic conductor for proton hopping and vanadium ion transport obstacles. The performance of the membrane is tuned via controlling the grafting degree of the chloromethylated polysulfone. The results show that membranes show increasing proton over vanadium ion (σ/p) selectivity with increasing functional tertiary groups. VRFBs assembled with the prepared membranes demonstrate an impressive Coulombic efficiency of 98.9% and energy efficiency of 90.9% at a current density of 50 mA cm -2 . Furthermore, the prepared membrane reported in this work shows excellent stability in 1 m VO 2 + solution at 35 °C over 240 h. Overall, the synthesized polymers provide a new insight into the design of high-performance membranes toward VRFB applications. © 2017 WILEY-VCH Verlag GmbH & Co. KGaA, Weinheim.

Disparities in health care outcomes between immigrants and the majority population in Germany: A trend analysis, 2006-2014.

PubMed

Brzoska, Patrick

2018-01-01

Immigrants often encounter barriers in the health system that may affect their health care outcomes. In order to better cater to the needs of immigrants, many health care institutions have increased their efforts in recent years to provide services which are more sensitive to the needs of an increasingly diverse population. Little is known about whether these efforts are successful. This study examines difference in outcomes of tertiary prevention between immigrants and the autochthonous population in Germany over the period of 2006-2014. The analysis is based on a 10% random sample of routine data on completed tertiary preventive treatments in Germany during 2006-2014. Four different indicators of treatment effectiveness were compared between patients with a nationality from Germany, Portugal/Spain/Italy/Greece, Turkey and Former Yugoslavia using logistic regression adjusted for demographic/socioeconomic factors. Interaction terms for year were modeled to examine group differences over time. Depending on the outcome, Turkish and Former Yugoslavian nationals had an 23%-69% higher chance of a poor treatment effectiveness than Germans (OR = 1.23 [95%-CI = 1.15,1.32] and OR = 1.69 [95%-CI = 1.55,1.83], respectively). Fewer differences were observed between nationals from Portugal/Spain/Italy/Greece and Germans. Disparities did not significantly differ between the years in which services were utilized. Measures implemented by health care institutions did not reduce existing health care disparities between immigrants and the majority population in Germany. One potential reason is that existing approaches are unsystematic and often not properly evaluated. More targeted strategies and a thorough evaluation is needed in order to improve health care for immigrants sustainably.

Staff Perception on Biomedical or Health Care Waste Management: A Qualitative Study in a Rural Tertiary Care Hospital in India

PubMed Central

Joshi, Rita; Shah, Harshada; Sharma, Megha; Pathak, Ashish; Macaden, Ragini; Stålsby Lundborg, Cecilia

2015-01-01

Background Health care or biomedical waste, if not managed properly, can be of high risk to the hospital staff, the patients, the community, public health and the environment, especially in low and middle income settings where proper disposal norms are often not followed. Our aim was to explore perceptions of staff of an Indian rural tertiary care teaching hospital on hospital waste management. Method A qualitative study was conducted using 10 focus group discussions (FGDs), with different professional groups, cleaning staff, nurses, medical students, doctors and administrators. The FGD guide included the following topics: (i) role of Health Care Waste Management (HCWM) in prevention of health care associated infections, (ii) awareness of and views about HCWM-related guidelines/legislation, (iii) current HCWM practices, (iv) perception and preparedness related to improvements of the current practices, and (v) proper implementation of the available guidelines/legislation. The FGDs were recorded, transcribed verbatim, translated to English (when conducted in Hindi) and analysed using content analysis. Results Two themes were identified: Theme (A), ‘Challenges in integration of HCWM in organizational practice,’ with the categories (I) Awareness and views about HCWM, (II) Organizational practices regarding HCWM, and (III) Challenges in Implementation of HCWM; and Theme (B), ‘Interventions to improve HCWM,’ with three categories, (I) Educational and motivational interventions, (II) Organizational culture change, and (III) Policy-related interventions. Conclusion A gap between knowledge and actual practice regarding HCWM was highlighted in the perception of the hospital staff. The participants suggested organizational changes, training and monitoring to address this. The information generated is relevant not merely to the microsystem studied but to other institutions in similar settings. PMID:26023783

Analyzing quality of colorectal cancer care through registry statistics: a small community hospital example.

PubMed

Hopewood, Ian

2011-01-01

As the quantity of elderly Americans requiring oncologic care grows, and as cancer treatment and medicine become more advanced, assessing quality of cancer care becomes a necessary and advantageous practice for any facility.' Such analysis is especially practical in small community hospitals, which may not have the resources of their larger academic counterparts to ensure that the care being provided is current and competitive in terms of both technique and outcome. This study is a comparison of the colorectal cancer care at one such center, Falmouth Community Hospital (FCH)--located in Falmouth, Massachusetts, about an hour and a half away from the nearest metropolitan center--to the care provided at a major nearby Boston Tertiary Center (BTC) and at teaching and research facilities across New England and the United States. The metrics used to measure performance encompass both outcome (survival rate data) as well as technique, including quality of surgery (number of lymph nodes removed) and the administration of adjuvant treatments, chemotherapy, and radiation therapy, as per national guidelines. All data for comparison between FCH and BTC were culled from those hospitals' tumor registries. Data for the comparison between FCH and national tertiary/referral centers were taken from the American College of Surgeons' Commission on Cancer, namely National Cancer Data Base (NCDB) statistics, Hospital Benchmark Reports and Practice Profile Reports. The results showed that, while patients at FCH were diagnosed at both a higher age and at a more advanced stage of colorectal cancer than their BTC counterparts, FCH stands up favorably to BTC and other large centers in terms of the metrics referenced above. Quality assessment such as the analysis conducted here can be used at other community facilities to spotlight, and ultimately eliminate, deficiencies in cancer programs.

Clinical unity and community empowerment: the use of smartphone technology to empower community management of chronic venous ulcers through the support of a tertiary unit.

PubMed

Quinn, Edel Marie; Corrigan, Mark A; O'Mullane, John; Murphy, David; Lehane, Elaine A; Leahy-Warren, Patricia; Coffey, Alice; McCluskey, Patricia; Redmond, Henry Paul; Fulton, Greg J

2013-01-01

Chronic ulcers affect roughly 60,000 Irish people, at a total cost of €600,000,000, or €10,000 per patient annually. By virtue of their chronicity, these ulcers also contribute a significant burden to tertiary outpatient vascular clinics. We propose utilizing mobile phone technology to decentralise care from tertiary centres to the community, improving efficiency and patient satisfaction, while maintaining patient safety. Bespoke mobile software was developed for Apples iPhone 4 platform. This allowed for the remote collection of patient images prospectively and their transmission with clinical queries, from the primary healthcare team to the tertiary centre. Training and iPhones were provided to five public health nurses in geographically remote areas of the region. Data were uploaded securely and user end software was developed allowing the review and manipulation of images, along with two way communication between the teams. Establishing reliability, patients were reviewed clinically as well as remotely, and concordance analysed. Qualitative data were collected through focus group discussion. From October to December 2011 eight patients (61-83 yrs, mean 75.3 yrs) with chronic venous ulceration and their five public health nurses were recruited. Data were transmitted using 3 G, Edge, GPRS and WiFi, at a mean speed of 69.03 kps. Concordance was 100% for wound bed assessment, 80% for skin integrity/colour and 60% for exudate assessment. Focus group analysis explored the concept, practicalities and future applications of the system. With an evolving national data network, the secure transmission of clinical images is a safe alternative to regular clinic appointments for patients with chronic venous ulceration. With further development, and packaged as a freely downloadable application, this has the potential to support the community care of chronic wounds.

The effect of a gold coin fine on C-reactive protein test ordering in a tertiary referral emergency department.

PubMed

Mallows, James L

2013-12-16

To examine the effect of an education campaign based around a gold coin fine on ordering of C-reactive protein (CRP) tests. A retrospective analysis of CRP test ordering before and after the intervention in the emergency department (ED) of a tertiary referral hospital in metropolitan Sydney that sees about 60,000 patients per annum. The date of the intervention - 2 August 2013 - corresponded with Jeans for Genes Day. Number of CRP tests ordered in the ED. 1290 CRP tests were ordered before the intervention (1-31 July), and 394 were ordered after the intervention (2-31 August). This decrease in CRP test ordering was despite an increased number of ED presentations in August compared with July (5219 v 5497 presentations). This represented an absolute reduction in the rate of CRP test ordering of 17.6% (95% CI, 16.2%-18.9%; P < 0.001). The threat of a gold coin fine for ordering a CRP test, as part of a broader education campaign, significantly reduced the number of CRP tests ordered in a tertiary referral ED.

Factors associated with high stress levels in adults with diabetes mellitus attending a tertiary diabetes care center, Chennai, Tamil Nadu, India

PubMed Central

Sendhilkumar, Muthappan; Tripathy, Jaya Prasad; Harries, Anthony D.; Dongre, Amol R.; Deepa, Mohan; Vidyulatha, Ashok; Poongothai, Subramanian; Venkatesan, Ulaganathan; Anjana, Ranjit Mohan; Mohan, Viswanathan

2017-01-01

Objective: We aimed to determine perceived stress levels among adults aged >20 years with type 2 diabetes mellitus (DM) in a tertiary care diabetes center, Chennai, Tamil Nadu, India, assess their association with sociodemographic and clinical characteristics and assess the possible risk factors for stress and coping strategies. Methods: A mixed-methods (triangulation design) study with quantitative methodology (survey) and qualitative methodology (interviews) was carried out. Stress levels were assessed among type 2 DM patients attending a diabetes clinic using a 5-point perceived stress scale-10. One-on-one interviews were carried out with 376 participants with DM having high/very high stress levels to understand the reasons for perceived stress and explore their coping mechanisms. Results: The prevalence of high/very high stress was 35% among DM patients. Age 30–40 years, working in professional jobs, and lack of physical activity were factors significantly associated with stress. The perceived major stress inducers were related to family, work, financial issues, and the disease itself. Conclusions: This study showed high levels of stress in more than one-third of DM patients. Potential solutions include regular, formal assessment of stress levels in the clinic, providing integrated counseling and psychological care for DM patients, and promoting physical activity. PMID:28217499

Medical Device-Associated Candida Infections in a Rural Tertiary Care Teaching Hospital of India.

PubMed

Deorukhkar, Sachin C; Saini, Santosh

2016-01-01

Health care associated infections (HCAIs) add incrementally to the morbidity, mortality, and cost expected of the patient's underlying diseases alone. Approximately, about half all cases of HCAIs are associated with medical devices. As Candida medical device-associated infection is highly drug resistant and can lead to serious life-threatening complications, there is a need of continuous surveillance of these infections to initiate preventive and corrective measures. The present study was conducted at a rural tertiary care hospital of India with an aim to evaluate the rate of medical device-associated Candida infections. Three commonly encountered medical device-associated infections (MDAI), catheter-associated urinary tract infection (CA-UTI), intravascular catheter-related blood stream infections (CR-BSI), and ventilator-associated pneumonia (VAP), were targeted. The overall rate of MDAI in our hospital was 2.1 per 1000 device days. The rate of Candida related CA-UTI and CR-BSI was noted as 1.0 and 0.3, respectively. Untiring efforts taken by team members of Hospital Acquired Infection Control Committee along with maintenance of meticulous hygiene of the hospital and wards may explain the low MDAI rates in our institute. The present surveillance helped us for systematic generation of institutional data regarding MDAI with special reference to role of Candida spp.

Birth setting, labour experience, and postpartum psychological distress.

PubMed

MacKinnon, Anna L; Yang, Lisa; Feeley, Nancy; Gold, Ian; Hayton, Barbara; Zelkowitz, Phyllis

2017-07-01

although psychosocial risk factors have been identified for postpartum depression (PPD) and perinatal posttraumatic stress disorder (PTSD), the role of labour- and birth-related factors remains unclear. The present investigation explored the impact of birth setting, subjective childbirth experience, and their interplay, on PPD and postpartum PTSD. in this prospective longitudinal cohort study, three groups of women who had vaginal births at a tertiary care hospital, a birthing center, and those transferred from the birthing centre to the tertiary care hospital were compared. Participants were followed twice during pregnancy (12-14 and 32-34 weeks gestation) and twice after childbirth (1-3 and 7-9 weeks postpartum). symptoms of PPD and PTSD did not significantly differ between birth groups; however, measures of subjective childbirth experience and obstetric factors did. Moderation analyses indicated a significant interaction between pain and birth group, such that higher ratings of pain among women who were transferred was associated with greater symptoms of postpartum PTSD. women who are transferred appear to have a unique experience that may put them at greater risk for postpartum psychological distress. It may be beneficial for care providers to help prepare women for pain management and potential unexpected complications, particularly if it is their first childbirth. Copyright © 2017 Elsevier Ltd. All rights reserved.

Awareness of do-not-resuscitate orders in the outpatient setting in Saudi Arabia. Perception and implications.

PubMed

Al Sheef, Mohammed A; Al Sharqi, Maha S; Al Sharief, Lina H; Takrouni, Tharaa Y; Mian, Arshad M

2017-03-01

To determine the level of awareness of outpatients, their preferences regarding the appropriate time for discussions regarding do-not-resuscitate (DNR) order  in Saudi Arabia. Methods: This cross-sectional, self-administered survey was conducted at King Fahd Medical City, a tertiary care hospital in Riyadh, Saudi Arabia between December 2012 and January 2013. Demographic parameters of the participants were analyzed by frequency distribution, and the data on their responses by percentage analysis. Results: The survey participants constituted 307 randomly selected outpatients/caregivers presenting for outpatient care at primary and tertiary care centers, 70% were female. Three-fourths of the participants had heard of DNR order, of which 50% defined it accurately. Ninety percent preferred a discussion while ill, and 10% while healthy. More than 70% expressed willingness to share the decision with their spouses/family members. Almost one-third believed DNR orders were consistent with Islamic beliefs, almost as many believed they were inconsistent, and almost a third did not take either position. Almost all the participants showed a willingness to learn more about the order. Conclusion: A divided opinion exists regarding religious and ethical aspects of the issue among the participants. However, almost all the participants showed a willingness to learn more about the DNR order.

Evaluation of a cardiopulmonary resuscitation curriculum in a low resource environment.

PubMed

Chang, Mary P; Lyon, Camila B; Janiszewski, David; Aksamit, Deborah; Kateh, Francis; Sampson, John

2015-11-07

To evaluate whether a 2-day International Liaison Committee on Resuscitation (ILCOR) Universal Algorithm-based curriculum taught in a tertiary care hospital in Liberia increases local health care provider knowledge and skill comfort level. A combined basic and advanced cardiopulmonary resuscitation (CPR) curriculum was developed for low-resource settings that included lectures and low-fidelity manikin-based simulations. In March 2014, the curriculum was taught to healthcare providers in a tertiary care hospital in Liberia. In a quality assurance review, participants were evaluated for knowledge and comfort levels with resuscitation before and after the workshop. They were also videotaped during simulation sessions and evaluated on standardized performance metrics. Fifty-two hospital staff completed both pre-and post-curriculum surveys. The median score was 45% pre-curriculum and 82% post-curriculum (p<0.00001). The median provider comfort level score was 4 of 5 pre-curriculum and 5 of 5 post-curriculum (p<0.00001). During simulations, 93.2% of participants performed the pulse check within 10 seconds, and 97.7% performed defibrillation within 180 seconds. Clinician knowledge of and comfort level with CPR increased significantly after participating in our curriculum. A CPR curriculum based on lectures and low-fidelity manikin simulations may be an effective way to teach resuscitation in this low-resource setting.

Factors associated with high stress levels in adults with diabetes mellitus attending a tertiary diabetes care center, Chennai, Tamil Nadu, India.

PubMed

Sendhilkumar, Muthappan; Tripathy, Jaya Prasad; Harries, Anthony D; Dongre, Amol R; Deepa, Mohan; Vidyulatha, Ashok; Poongothai, Subramanian; Venkatesan, Ulaganathan; Anjana, Ranjit Mohan; Mohan, Viswanathan

2017-01-01

We aimed to determine perceived stress levels among adults aged >20 years with type 2 diabetes mellitus (DM) in a tertiary care diabetes center, Chennai, Tamil Nadu, India, assess their association with sociodemographic and clinical characteristics and assess the possible risk factors for stress and coping strategies. A mixed-methods (triangulation design) study with quantitative methodology (survey) and qualitative methodology (interviews) was carried out. Stress levels were assessed among type 2 DM patients attending a diabetes clinic using a 5-point perceived stress scale-10. One-on-one interviews were carried out with 376 participants with DM having high/very high stress levels to understand the reasons for perceived stress and explore their coping mechanisms. The prevalence of high/very high stress was 35% among DM patients. Age 30-40 years, working in professional jobs, and lack of physical activity were factors significantly associated with stress. The perceived major stress inducers were related to family, work, financial issues, and the disease itself. This study showed high levels of stress in more than one-third of DM patients. Potential solutions include regular, formal assessment of stress levels in the clinic, providing integrated counseling and psychological care for DM patients, and promoting physical activity.

Identification of tertiary butyl alcohol (TBA)-utilizing organisms in BioGAC reactors using 13C-DNA stable isotope probing.

PubMed

Aslett, Denise; Haas, Joseph; Hyman, Michael

2011-09-01

Biodegradation of the gasoline oxygenates methyl tertiary-butyl ether (MTBE) and ethyl tertiary-butyl ether (ETBE) can cause tertiary butyl alcohol (TBA) to accumulate in gasoline-impacted environments. One remediation option for TBA-contaminated groundwater involves oxygenated granulated activated carbon (GAC) reactors that have been self-inoculated by indigenous TBA-degrading microorganisms in ground water extracted from contaminated aquifers. Identification of these organisms is important for understanding the range of TBA-metabolizing organisms in nature and for determining whether self-inoculation of similar reactors is likely to occur at other sites. In this study (13)C-DNA-stable isotope probing (SIP) was used to identify TBA-utilizing organisms in samples of self-inoculated BioGAC reactors operated at sites in New York and California. Based on 16S rRNA nucleotide sequences, all TBA-utilizing organisms identified were members of the Burkholderiales order of the β-proteobacteria. Organisms similar to Cupriavidus and Methylibium were observed in both reactor samples while organisms similar to Polaromonas and Rhodoferax were unique to the reactor sample from New York. Organisms similar to Hydrogenophaga and Paucibacter strains were only detected in the reactor sample from California. We also analyzed our samples for the presence of several genes previously implicated in TBA oxidation by pure cultures of bacteria. Genes Mpe_B0532, B0541, B0555, and B0561 were all detected in (13)C-metagenomic DNA from both reactors and deduced amino acid sequences suggested these genes all encode highly conserved enzymes. One gene (Mpe_B0555) encodes a putative phthalate dioxygenase-like enzyme that may be particularly appropriate for determining the potential for TBA oxidation in contaminated environmental samples.

A picture is worth a thousand words: needs assessment for multimedia radiology reports in a large tertiary care medical center.

PubMed

Nayak, Lina; Beaulieu, Christopher F; Rubin, Daniel L; Lipson, Jafi A

2013-12-01

Radiology reports are the major, and often only, means of communication between radiologists and their referring clinicians. The purposes of this study are to identify referring physicians' preferences about radiology reports and to quantify their perceived value of multimedia reports (with embedded images) compared with narrative text reports. We contacted 1800 attending physicians from a range of specialties at large tertiary care medical center via e-mail and a hospital newsletter linking to a 24-question electronic survey between July and November 2012. One hundred sixty physicians responded, yielding a response rate of 8.9%. Survey results were analyzed using Statistical Analysis Software (SAS Institute Inc, Cary, NC). Of the 160 referring physicians respondents, 142 (89%) indicated a general interest in reports with embedded images and completed the remainder of the survey questions. Of 142 respondents, 103 (73%) agreed or strongly agreed that reports with embedded images could improve the quality of interactions with radiologists; 129 respondents (91%) agreed or strongly agreed that having access to significant images enhances understanding of a text-based report; 110 respondents (77%) agreed or strongly agreed that multimedia reports would significantly improve referring physician satisfaction; and 85 respondents (60%) felt strongly or very strongly that multimedia reports would significantly improve patient care and outcomes. Creating accessible, readable, and automatic multimedia reports should be a high priority to enhance the practice and satisfaction of referring physicians, improve patient care, and emphasize the critical role radiology plays in current medical care. Copyright © 2013 AUR. Published by Elsevier Inc. All rights reserved.

The effect of referral and transfer patients on hospital funding in a capitated health care delivery system.

PubMed

Pietz, Kenneth; Byrne, Margaret M; Daw, Christina; Petersen, Laura A

2007-10-01

(1) To investigate whether inpatients referred or transferred between facilities result in increased financial loss compared with those admitted directly, in a health care delivery system funded by capitation methods. (2) To determine whether the higher cost of those patients transferred or referred is fairly compensated by a diagnosis-based risk adjustment system, and whether tertiary care facilities bear an unfair financial burden for such patients in a capitated financing environment. The study cohort included all Veterans Affairs (VA) beneficiaries who received inpatient care during fiscal year (FY) 2004. Referral was defined as an outpatient visit to 1 facility followed by an admission to another facility. Transfers were consecutive inpatient stays at different hospitals. We defined loss as cost minus the share of budget determined by a Diagnostic Cost Group-based allocation. Both t tests and linear regression were used to compare the effect on cost and loss for patients transferred or not and referred or not. Mean loss to a facility for patients transferred in was 1231 dollars more than for those not transferred. Mean loss for referred patients was 3341 dollars more than for those not referred, controlling for disease burden. For tertiary hospitals, the difference in losses for transfer patients was less than for other hospitals but greater for referral patients. Patients referred or transferred from other facilities are more costly than those who are not. The difference may not be compensated by a diagnosis-based allocation system. A capitated health care system may consider additional funding to cover the cost of such patients.

Outcome and hospital cost for infants weighing less than 500 grams: a tertiary centre experience in Taiwan.

PubMed

Hsieh, Wu-Shiun; Jeng, Suh-Fang; Hung, Yi-Li; Chen, Pau-Chung; Chou, Hung-Chieh; Tsao, Po-Nien

2007-09-01

To determine the outcome and hospital cost for infants weighing < or =500 g at a tertiary centre in Taiwan. We retrospectively reviewed the medical records of infants who were born alive with birthweight < or =500 g at the National Taiwan University Hospital from 1997 to 2004. Their outcome and hospital cost were analysed. A total of 168 infants were included for analysis that 146 of them died after compassionate care in the delivery room and 22 received postnatal resuscitation. The infants who received resuscitation were more likely to have higher birthweights, older gestational ages and multiple births compared with those who received compassionate care. After resuscitation, five of the infants died and 17 were admitted to neonatal intensive care unit (NICU) for further management. Subsequently, 12 infants died and five infants survived to discharge. Two infants were discharged against advice and died within days. After exclusion of those receiving compassionate care, the NICU survival rate was 22.7% and the long-term survival rate was 13.6%. The most common early morbidities were respiratory distress syndrome, intraventricular haemorrhage and patent ductus arteriosus, whereas the late morbidities included cholestatic jaundice, retinopathy of prematurity and chronic lung disease. The average total hospital costs for the NICU survivors with birthweight < or =500 g was US $42,411 and the average hospital cost per day was US $350. Exclusive compassionate care was given to the majority of the infants weighing < or =500 g in Taiwan. The survival rate remained low in these marginally viable infants.

Cost of curative pediatric services in a public sector setting.

PubMed

Krishnan, Anand; Arora, Narendra K; Pandav, Chandrakant S; Kapoor, Suresh K

2005-08-01

To estimate the cost of ambulatory (out-patient) and in-patient pediatric health services for the year 1999 provided by All India Institute of Medical Sciences (AIIMS) at all the three levels-primary, secondary and tertiary level. The costing module developed by Children's Vaccines Initiative (CVI) was used. This rapid assessment tool focuses on collection of data at macro level by using key informants like doctors, nursing staff, accountant, store keeper, engineer etc. Cost per beneficiary was estimated separately for in-patients and out-patients and was calculated by dividing the total cost of the services by the number of beneficiaries for the year 1999. For the out-patient, the beneficiaries were the total out-patient attendees and for the in-patient, it was the total pediatric admissions multiplied by mean duration of stay in days. The cost per out-patient visit was INR.20.2 (US0.44 dollars@1US dollars=INR.46) at primary level, higher than INR14.5 (US0.31 dollars) at the secondary level, while at tertiary level it was INR 33.8 (US 0.73 dollars). At the primary and secondary level, non-physician cost was more than the physician cost, and for tertiary level, physician cost was much higher than the other costs. There were no in-patient services at primary level. The cost of in-patient services at secondary level was estimated as INR 419.30 (US 9.1 dollars) per patient per day with a bed occupancy rate of 60%. Two-fifths of the cost was due to nursing and other supportive staff and one fifth due to the doctor costs and overhead costs. The unit cost of INR 928 (US 20.2 dollars) per patient per day incurred at AIIMS with a bed occupancy rate of 100% was almost twice that of secondary level. In contrast to the secondary level, almost half the total costs at tertiary level was due to the doctors costs. Effective use of resources at lower level of care especially ambulatory care at primary level and inpatient care at secondary level can result in much higher savings for the system and also, the society. These would need to be appropriately strengthened.

Awareness of the role of general practitioners in primary care among outpatient populations: evidence from a cross-sectional survey of tertiary hospitals in China.

PubMed

Liu, Xiaojun; Tan, Anran; Towne, Samuel D; Hou, Zhaoxun; Mao, Zongfu

2018-03-16

General practitioners (GPs) are highly underutilised in China with many patients going directly to hospitals when seeking routine care. Multiple countries around the world have successfully used GPs in routine care, and as such, China may benefit from the use of GPs. This study examines the status of, and factors associated with, knowledge related to GPs among outpatient populations from China's tertiary hospitals. This is a cross-sectional survey study. The questionnaires were completed by 565 outpatients from four tertiary hospitals in China during 2016. Convenience sampling on different floors and throughout the outpatient building was carried out. We used the logistic regression models to identify GP-related knowledge among different populations. Overall, 50.27% of respondents said they had never heard of GPs. This was also true among females (adjusted OR (AOR)=1.57, 95% CI 1.43 to 2.71), older adults (AOR 46-65 =1.61, 95% CI 1.39 to 2.98; AOR >65 =2.01, 95% CI 1.62 to 3.59), those with lower education level (AOR Bachelor's degree =0.61, 95% CI 0.20 to 0.81; AOR ≥Master's degree =0.49, 95% CI 0.23 to 0.76), rural residents (AOR=1.51, 95% CI 1.35 to 2.82) and those with chronic disease (AOR without chronic disease =0.61, 95% CI 0.22 to 0.71). What is more, less than one-in-ten (9.03%) outpatients were able to accurately describe what a GP was, with less than 30% accurately describing a GP among those receiving GPs' services. Outpatients who could have received less costly health services from GPs in primary medical institutions were more likely to choose costlier specialist physicians in tertiary hospitals, which is likely linked to limited knowledge about GPs. Policy makers should invest in outreach efforts to improve public awareness of GPs, while at the same time conducting continued surveillance of these efforts to evaluate progress towards this goal. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

C-GRApH: A Validated Scoring System for Early Stratification of Neurologic Outcome After Out-of-Hospital Cardiac Arrest Treated With Targeted Temperature Management.

PubMed

Kiehl, Erich L; Parker, Alex M; Matar, Ralph M; Gottbrecht, Matthew F; Johansen, Michelle C; Adams, Mark P; Griffiths, Lori A; Dunn, Steven P; Bidwell, Katherine L; Menon, Venu; Enfield, Kyle B; Gimple, Lawrence W

2017-05-20

Out-of-hospital cardiac arrest (OHCA) results in significant morbidity and mortality, primarily from neurologic injury. Predicting neurologic outcome early post-OHCA remains difficult in patients receiving targeted temperature management. Retrospective analysis was performed on consecutive OHCA patients receiving targeted temperature management (32-34°C) for 24 hours at a tertiary-care center from 2008 to 2012 (development cohort, n=122). The primary outcome was favorable neurologic outcome at hospital discharge, defined as cerebral performance category 1 to 2 (poor 3-5). Patient demographics, pre-OHCA diagnoses, and initial laboratory studies post-resuscitation were compared between favorable and poor neurologic outcomes with multivariable logistic regression used to develop a simple scoring system ( C-GRApH ). The C-GRApH score ranges 0 to 5 using equally weighted variables: ( C ): coronary artery disease, known pre-OHCA; ( G ): glucose ≥200 mg/dL; ( R ): rhythm of arrest not ventricular tachycardia/fibrillation; ( A ): age >45; ( pH ): arterial pH ≤7.0. A validation cohort (n=344) included subsequent patients from the initial site (n=72) and an external quaternary-care health system (n=272) from 2012 to 2014. The c-statistic for predicting neurologic outcome was 0.82 (0.74-0.90, P <0.001) in the development cohort and 0.81 (0.76-0.87, P <0.001) in the validation cohort. When subdivided by C-GRApH score, similar rates of favorable neurologic outcome were seen in both cohorts, 70% each for low (0-1, n=60), 22% versus 19% for medium (2-3, n=307), and 0% versus 2% for high (4-5, n=99) C-GRApH scores in the development and validation cohorts, respectively. C-GRApH stratifies neurologic outcomes following OHCA in patients receiving targeted temperature management (32-34°C) using objective data available at hospital presentation, identifying patient subsets with disproportionally favorable ( C-GRApH ≤1) and poor ( C-GRApH ≥4) prognoses. © 2017 The Authors. Published on behalf of the American Heart Association, Inc., by Wiley.

Multidisciplinary treatment in children with problematic severe asthma: A prospective evaluation.

PubMed

Verkleij, Marieke; Beelen, Anita; van Ewijk, Bart E; Geenen, Rinie

2017-05-01

For children with problematic severe asthma, achieving adequate control of asthma is difficult. The aim of this prospective observational study was to evaluate the effects of intensive multidisciplinary inpatient treatment on multiple outcome variables in children with problematic severe asthma. Participants were 89 children with problematic severe asthma (mean age 13.6 ± 2.5 years) treated in tertiary care clinics at high altitude (Switzerland) or sea level (Netherlands) and their parents (85 mothers, 55 fathers). The primary outcome variable was the Childhood Asthma Control Test (C-ACT). Other outcome variables were forced expiratory volume in 1 sec (FEV 1 ), fractional concentration of exhaled nitric oxide (FeNO), quality of life [PAQLQ(S)], children's coping (UCL-A), parents' report of behavioral problems (CBCL), and parenting stress (PSI/NOSI). Evaluations were taken pre-treatment, post-treatment, and 3-6 months follow-up. Median [P25;P75] treatment duration 74 [56;80] days; Median follow-up interval 131 [103;177] days. The percentages of children showing controlled asthma (C-ACT) were 18% (pre-treatment), 69% (post-treatment), and 44% (follow-up). The vast majority of the children (80%) showed an improvement on C-ACT with 4% showing a deterioration. On C-ACT, FeNO, quality of life, and behavioral problems, improvements at post-treatment were highly significant. Improvements generally remained at a functional level at follow-up. Children's coping and parenting stress in parents did not change. The improvement in asthma control and other outcome variables suggests that multidisciplinary inpatient treatment is an effective approach for a heterogeneous group of children with asthma that remained uncontrolled in secondary care. Pediatr Pulmonol. 2017;52:588-597. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Keep the brain cool--endovascular cooling in patients with severe traumatic brain injury: a case series study.

PubMed

Fischer, Marlene; Lackner, Peter; Beer, Ronny; Helbok, Raimund; Klien, Stephanie; Ulmer, Hanno; Pfausler, Bettina; Schmutzhard, Erich; Broessner, Gregor

2011-04-01

As brain temperature is reported to be extensively higher than core body temperature in traumatic brain injury (TBI) patients, posttraumatic hyperthermia is of particular relevance in the injured brain. To study the influence of prophylactic normothermia on brain temperature and the temperature gradient between brain and core body in patients with severe TBI using an intravascular cooling system and to assess the relationship between brain temperature and intracranial pressure (ICP) under endovascular temperature control. Prospective case series study conducted in the neurologic intensive care unit of a tertiary care university hospital. Seven patients with severe TBI with a Glasgow Coma Scale score of 8 or less were consecutively enrolled. Prophylactic normothermia, defined as a target temperature of 36.5°C, was maintained using an intravascular cooling system. Simultaneous measurements of brain and urinary bladder temperature and ICP were taken over a 72-hour period. The mean bladder temperature in normothermic patients was 36.3 ± 0.4°C, and the mean brain temperature was determined as 36.4 ± 0.5°C. The mean temperature difference between brain and bladder was 0.1°C. We found a significant direct correlation between brain and bladder temperature (r = 0.95). In 52.4% of all measurements, brain temperature was higher than core body temperature. The mean ICP was 18 ± 8 mm Hg. Intravascular temperature management stabilizes both brain and body core temperature; prophylactic normothermia reduces the otherwise extreme increase of intracerebral temperature in patients with severe TBI. The intravascular cooling management proved to be an efficacious and feasible method to control brain temperature and to avoid hyperthermia in the injured brain. We could not find a statistically significant correlation between brain temperature and ICP.

Laboratory diagnosis of Clostridium difficile infection: Comparison of Techlab C. diff Quik Chek Complete, Xpert C. difficile, and multistep algorithmic approach.

PubMed

Seo, Ja Young; Jeong, Ji Hun; Kim, Kyung Hee; Ahn, Jeong-Yeal; Park, Pil-Whan; Seo, Yiel-Hea

2017-11-01

Clostridium difficile is a major pathogen responsible for nosocomial infectious diarrhea. We explored optimal laboratory strategies for diagnosis of C. difficile infection (CDI) in our clinical settings, a 1400-bed tertiary care hospital. Using 191 fresh stool samples from adult patients, we evaluated the performance of Xpert C. difficile (Xpert CD), C. diff Quik Chek Complete (which simultaneously detects glutamate dehydrogenase [GDH] and C. difficile toxins [CDT]), toxigenic culture, and a two-step algorithm composed of GDH/CDT as a screening test and Xpert CD as a confirmatory test. Clostridium difficile was detected in 35 samples (18.3%), and all isolates were toxigenic strains. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value of each assay for detecting CDI were as follows: Quik Chek Complete CDT (45.7%, 100%, 100%, 89.1%), Quik Chek Complete GDH (97.1%, 99.4%, 97.1%, 99.4%), Xpert CD (94.3%, 100%, 100%, 98.7%), and toxigenic culture (91.4%, 100%, 100%, 98.1%). A two-step algorithm performed identically with Xpert CD assay. Our data showed that most C. difficile isolates from adult patients were toxigenic. We demonstrated that a two-step algorithm based on GDH/CDT assay followed by Xpert CD assay as a confirmatory test was rapid, reliable, and cost effective for diagnosis of CDI in an adult patient setting with high prevalence of toxigenic C. difficile. © 2017 Wiley Periodicals, Inc.

Candida profiles and antifungal resistance evolution over a decade in Lebanon.

PubMed

Araj, George Farah; Asmar, Rima George; Avedissian, Aline Zakaria

2015-09-27

Infection with and antifungal resistance of Candida species have been on the rise globally. Relevant data on these pathogens are relatively few in our region, including Lebanon, thus warranting this study. This retrospective study of Candida spp. profiles and their in vitro antifungal susceptibility was based on analysis requests for 186 Candida non-albicans and 61 C. albicans during three periods (2005-2007, 2009-2011, and 2012-2014) over the span of the last 10 years at the American University of Beirut Medical Center (AUBMC), a major tertiary care center in Lebanon. Identification of Candida was done using the API 20C AUX system, and the E-test was used to determine the minimum inhibitory concentrations (MICs) of antifungal agents. Among the 1,300-1,500 Candida isolates recovered yearly, C. albicans rates decreased from 86% in 2005 to around 60% in 2014. Simultaneously, the non-albicans rates increased from 14% in 2005 to around 40% in 2014, revealing 11 species, the most frequent of which were C. tropicalis, C. glabrata, and C. parapsilosis. All these demonstrated high resistance (35%-79%) against itraconazole, but remained uniformly susceptible (100%) to amphotericin B. Though C. albicans and the other species maintained high susceptibility against fluconazole and voriconazole, their MIC90 showed an elevated trend over time, and C. glabrata had the highest resistance rates. The observed rise in resistance among Candida spp. in Lebanon mandates the need for close surveillance and monitoring of antifungal drug resistance for both epidemiologic and treatment purposes.

A Dedicated Satellite Trauma Orthopaedic Program Operating Room Safely Increases Capacity.

PubMed

Waters, Peter M; Yang, Brian W; White, Doreen; Barth, Ellen; Chiang, Vincent; Mizrahi-Arnaud, Arielle; Sparks, William

2018-05-16

Providing high-value care for urgent orthopaedic trauma patients requires effective and timely treatment. Herein, we describe the implementation of an innovative program utilizing the operating room (OR) capacity of a satellite campus to decrease stress on a pediatric tertiary care center without jeopardizing patient safety. In addition to the daily emergency surgical room on the main campus, a dedicated orthopaedic trauma surgery OR was established in a satellite hospital location for 3 days per week in the summer and for 2 days per week for the rest of the year. Nonemergency, non-multitrauma operative fracture cases presenting to our tertiary care facility emergency department or orthopaedic clinic were considered for satellite referral. Eligible patients required clearance for transfer via orthopaedic, emergency department, and anesthesia checklists. An opt-out policy was established for provider judgment or patient family concern to overrule transfer decisions. Selected patients were discharged home with satellite OR scheduling or approved for same-day satellite location admission. Short elective cases were performed when openings existed in the schedule. From June 1, 2016, through June 30, 2017, 480 cases (372 trauma, 108 elective) were completed in our satellite OR. The most common trauma cases that were treated in the satellite OR were type-II supracondylar humeral fractures (n = 76). Summer months averaged 41.75 trauma cases and 11.25 elective cases per month, with 3.15 trauma cases and 0.85 elective cases per day. Nonsummer months averaged 22.78 trauma cases and 7.00 elective cases per month, with 2.93 trauma and 0.90 elective cases per day. Of the 17 postoperative issues, the greatest number (n = 7 [41%]) involved symptomatic hardware. The remaining complications were not surgeon or geographic-site-specific. There were no intraoperative complications, compartment syndrome episodes, or patients who required transfer back to our tertiary care facility for unexpected or serious medical issues. With the proper screening protocols in place for appropriate patient selection, the use of a dedicated satellite orthopaedic trauma OR can increase capacity without compromising patient safety.

Healthcare resource use and costs of managing children and adults with lysosomal acid lipase deficiency at a tertiary referral centre in the United Kingdom.

PubMed

Guest, Julian F; Ingram, Andy; Ayoub, Nadia; Hendriksz, Christian J; Murphy, Elaine; Rahman, Yusof; McKiernan, Patrick; Mundy, Helen; Deegan, Patrick

2018-01-01

To estimate clinical progression and resource utilisation together with the associated costs of managing children and adults with LAL Deficiency, at a tertiary referral centre in the UK. A retrospective chart review was undertaken of patients in the UK with a confirmed diagnosis of LAL Deficiency who were managed at a LAL Deficiency tertiary referral treatment centre. Patients' pathways, treatment patterns, health outcomes and resource use were quantified over differing lengths of time for each patient enabling the NHS cost of patient management in tertiary care to be estimated. The study population comprised 19 patients of whom 58% were male. Mean age at the time of initial presentation was 15.5 years and the mean age at diagnosis was 18.0 years. 63%, 53% and 42% of patients had hepatomegaly, abnormal lipid storage and splenomegaly at a mean age of presentation of 17.8, 17.1 and 20.9 years, respectively. Over a period of 50 years there were a mean of 48.5 clinician visits and 3.4 hospital admissions per patient. The mean NHS cost of patient management at a LAL Deficiency tertiary referral treatment centre, spanning a period of over 50 years was £61,454 per patient. This study provides important insights into a number of aspects of the disease that are difficult to ascertain from published case reports. Additionally, it provides the best estimate available of NHS resource use and costs with which to inform policy and budgetary decisions pertaining to managing this ultra-orphan disease.

Obstetric and perinatal outcomes in IVF versus ICSI-conceived pregnancies at a tertiary care center--a pilot study.

PubMed

Nouri, Kazem; Ott, Johannes; Stoegbauer, Lucia; Pietrowski, Detlef; Frantal, Sophie; Walch, Katharina

2013-08-31

Although most pregnancies after IVF result in normal healthy outcomes, an increased risk for a number of obstetric and neonatal complications, compared to naturally conceived pregnancies, has been reported. While there are many studies that compare pregnancies after assisted reproductive techniques with spontaneously conceived pregnancies, fewer data are available that evaluate the differences between IVF and ICSI-conceived pregnancies. The aim of our present study was, therefore, to compare obstetric and perinatal outcomes in pregnancies conceived after in vitro fertilization (IVF) versus intracytoplasmatic sperm injection (ICSI). Three-hundred thirty four women who had become pregnant after an IVF or ICSI procedure resulted in a total of 530 children referred between 2003 und 2009 to the Department of Obstetrics and Gynecology of the Medical University of Vienna, a tertiary care center, and were included in this retrospective cohort study. We assessed maternal and fetal parameters in both groups (IVF and ICSI). The main study outcomes were preterm delivery, the need for neonatal intensive care, and congenital malformations. Moreover, we compared the course of pregnancy between both groups and the occurrence of complications that led to maternal hospitalization during pregnancy. There were 80 children conceived via ICSI and 450 children conceived via IVF.Mean gestational age was significantly lower in the ICSI group (p = 0.001). After ICSI, the birth weight (p = 0.008) and the mean APGAR values after 1 minute and after 10 minutes were lower compared to that of the IVF group (p = 0.016 and p = 0.047, respectively). Moreover, ICSI-conceived children had to be hospitalized more often at a neonatal intensive care unit (p = 0.004). There was no difference in pH of the umbilical artery or in major congenital malformations between the two groups. Pregnancy complications (i.e., premature rupture of membranes, cervical insufficiency, and premature uterine contractions) and the need for maternal hospitalization during pregnancy were found significantly more often after IVF (p = 0.0016 and p = 0.0095, respectively), compared to the ICSI group. When comparing IVF versus ICSI-conceived pregnancies at a tertiary care center, we found the course of pregnancy to be more complicated after IVF, whereas the primary fetal outcome seemed to be better in this group than after ICSI treatment.

Obstetric and perinatal outcomes in IVF versus ICSI-conceived pregnancies at a tertiary care center - a pilot study

PubMed Central

2013-01-01

Background Although most pregnancies after IVF result in normal healthy outcomes, an increased risk for a number of obstetric and neonatal complications, compared to naturally conceived pregnancies, has been reported. While there are many studies that compare pregnancies after assisted reproductive techniques with spontaneously conceived pregnancies, fewer data are available that evaluate the differences between IVF and ICSI-conceived pregnancies. The aim of our present study was, therefore, to compare obstetric and perinatal outcomes in pregnancies conceived after in vitro fertilization (IVF) versus intracytoplasmatic sperm injection (ICSI). Methods Three-hundred thirty four women who had become pregnant after an IVF or ICSI procedure resulted in a total of 530 children referred between 2003 und 2009 to the Department of Obstetrics and Gynecology of the Medical University of Vienna, a tertiary care center, and were included in this retrospective cohort study. We assessed maternal and fetal parameters in both groups (IVF and ICSI). The main study outcomes were preterm delivery, the need for neonatal intensive care, and congenital malformations. Moreover, we compared the course of pregnancy between both groups and the occurrence of complications that led to maternal hospitalization during pregnancy. Results There were 80 children conceived via ICSI and 450 children conceived via IVF. Mean gestational age was significantly lower in the ICSI group (p = 0.001). After ICSI, the birth weight (p = 0.008) and the mean APGAR values after 1 minute and after 10 minutes were lower compared to that of the IVF group (p = 0.016 and p = 0.047, respectively). Moreover, ICSI-conceived children had to be hospitalized more often at a neonatal intensive care unit (p = 0.004). There was no difference in pH of the umbilical artery or in major congenital malformations between the two groups. Pregnancy complications (i.e., premature rupture of membranes, cervical insufficiency, and premature uterine contractions) and the need for maternal hospitalization during pregnancy were found significantly more often after IVF (p = 0.0016 and p = 0.0095, respectively), compared to the ICSI group. Conclusions When comparing IVF versus ICSI-conceived pregnancies at a tertiary care center, we found the course of pregnancy to be more complicated after IVF, whereas the primary fetal outcome seemed to be better in this group than after ICSI treatment. PMID:24004836

Distribution of 16S rRNA Methylases Among Different Species of Aminoglycoside-Resistant Enterobacteriaceae in a Tertiary Care Hospital in Poland.

PubMed

Piekarska, Katarzyna; Zacharczuk, Katarzyna; Wołkowicz, Tomasz; Rzeczkowska, Magdalena; Bareja, Elżbieta; Olak, Monika; Gierczyński, Rafał

2016-01-01

Aminoglycosides are a group of antimicrobial agents still the most commonly used in the treatment of life-threatening bacterial infections in human and animals. The emergence and spread of 16S rRNA methylases, which confer high-level resistance to the majority of clinically relevant aminoglycosides, constitute a major public health concern. Our goal was to evaluate the distribution of 16S rRNA methylases among different species of Enterobacteriaceae during a five month-long survey in a tertiary hospital in Warszawa, Poland. In the survey, a total of 1770 non-duplicate clinical isolates were collected from all hospital wards in a tertiary hospital in Warszawa, Poland. The survey was conducted between 19 April and 19 September 2010. The ability to produce 16S rRNA methylase was examined by determining MICs for gentamicin, kanamycin, amikacin by means of the agar dilution method. The isolates resistant to high concentration of aminoglycosides were PCR tested for genes: armA, rmtA, rmtB and rmtC. PCR products were subjected to DNA sequencing by the Sanger method. The genetic similarity of the ArmA-producing isolates was analysed by pulsed-filed gel electrophoresis (PFGE). ArmA was the only 16S rRNA methylase detected in 20 of 1770 tested isolates. The overall prevalence rate of ArmA was 1.13%. In K. pneumoniae (n = 742), P. mirabilis (n = 130), and E. cloacae (n = 253) collected in the survey, the prevalence of ArmA was 0.4%, 0.8% and 5.9%, respectively. The PFGE revealed both horizontal and clonal spread of the armA gene in the hospital. The prevalence of 16S rRNA methylase ArmA reported in this study is significantly higher than observed in other countries in Europe.

What Do Expectant Mothers Know about Neonatal Jaundice?

ERIC Educational Resources Information Center

Ogunfowora, Olusoga B.; Adefuye, Peter O.; Fetuga, Musili B.

2006-01-01

Neonatal jaundice (NNJ) is a common disorder worldwide and many affected babies become brain-damaged due to delay in seeking medical consultation. In order to assess the awareness and knowledge of expectant mothers about NNJ, women who registered for antenatal care at a tertiary health facility in the South-western part of Nigeria were…

Higher Education Research, Policy, and the Challenges of Reform

ERIC Educational Resources Information Center

Tierney, William G.

2014-01-01

Postsecondary institutions always have been in a state of change. The author discusses four key areas of higher education--systems of tertiary education, privatization, academic work, and technology--that demand careful analysis that have always been of concern but now are entering a new phase of change. The author offers an interpretation of the…

Telephone-Based Coping Skills Training for Patients Awaiting Lung Transplantation

ERIC Educational Resources Information Center

Blumenthal, James A.; Babyak, Michael A.; Keefe, Francis J.; Davis, R. Duane; LaCaille, Rick A.; Carney, Robert M.; Freedland, Kenneth E.; Trulock, Elbert; Palmer, Scott M.

2006-01-01

Impaired quality of life is associated with increased mortality in patients with advanced lung disease. Using a randomized controlled trial with allocation concealment and blinded outcome assessment at 2 tertiary care teaching hospitals, the authors randomly assigned 328 patients with end-stage lung disease awaiting lung transplantation to 12…

76 FR 51957 - Notice of Intent To Prepare an Environmental Impact Statement for the Medical Facilities...

Federal Register 2010, 2011, 2012, 2013, 2014

2011-08-19

...: NSA Bethesda is a 243-acre health care, medical education and research installation located in... tertiary medical services to NNMC and its transformation to WRNMMCB, the facility will become the premier... training and post-graduate level education to the military medical community and serve as a critical...