Search results for: high risk cardiac patients

Authors: Etienne Sugewe

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Purpose: The establishment of a positive HIV serologic status of an individual could have been an inhibitory factor to prevent risk behaviours in people living with HIV/AIDS. We conducted a cross-sectional study in order to assess the prevalence and predictors of risk behaviors among HIV-positive people in Douala-Cameroon. Methods: We used pre-checked questionnaires to systematically collect data from four HIV treatment centers in Douala. This was done to some of them during the distribution of drugs and to others during their classical rendezvous between the months of May and July 2012. The Chi-Square and Student t-test were used for cross tabulation of variables; multiple regression analysis was performed to identify predictors of risky sexual behaviours. Results: Of the 330 persons interviewed, sixty percent were reported to have had sexual intercourse after the diagnosis of HIV. We obtained 37% HIV-positive partners, and 63% had HIV- negative partners or partners with unknown status. Among our patients, 45% of the subjects with regular partners reported to have had anal or vaginal sex. Those whose score on the knowledge about HIV/AIDS was < 50% and where 90% of them were less susceptible to the condom during intercourse (p: 0.01). About 74% of patients on ARV were less susceptible to the use of condoms during sexual intercourse (p: 0.03). Conclusion: Risk sexual behaviours among people living with HIV/AIDS are common and potentially expose their partners. For HIV-positive partners, these habits pose a real risk of suprainfection by other strains of HIV. The need to increase awareness and education among people living with HIV is therefore highly recommended.

Keywords: HIV/AIDS, behaviours, HIV positive, Douala, 2012

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Authors: Greg Zimmerman

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Background: Major depression is a common illness that affects millions of people globally. It is the leading cause of disability and is projected to become the number one cause of the global burden of disease by 2030. Many of those who suffer from depression also suffer from Irritable Bowel Syndrome (IBS). Acupuncture has been shown to help depression. The aim of this study was to investigate the effectiveness of acupuncture in reducing the risk of IBS in patients with depression. Methods: We enrolled patients diagnosed with depression through the Taiwanese National Health Insurance Research Database (NHIRD). Propensity score matching was used to match equal numbers (n=32971) of the acupuncture cohort and no-acupuncture cohort based on characteristics including sex, age, baseline comorbidity, and medication. The Cox regression model was used to compare the hazard ratios (HRs) of IBS in the two cohorts. Results: The basic characteristics of the two groups were similar. The cumulative incidence of IBS was significantly lower in the acupuncture cohort than in the no-acupuncture cohort (Log-rank test, p<0.001). Conclusion: The results provided real-world evidence that acupuncture may have a beneficial effect on IBS risk reduction in patients with depression.

Keywords: acupuncture, depression, irritable bowel syndrome, national health insurance research database, real-world evidence

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Authors: Salima R. Rajwani, Tazeen Ali, Rubina Barolia, Yasmin Parpio, Nasreen Alwani, Salima B. Virani

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Introduction: Nurses and physicians have a critical role in initiating lifesaving interventions during cardiac arrest. It is important that timely delivery of high quality Cardio Pulmonary Resuscitation (CPR) with advanced resuscitation skills and management of cardiac arrhythmias is a key dimension of code during cardiac arrest. It will decrease the chances of patient survival if the healthcare professionals are unable to initiate CPR timely. Moreover, traditional training will not prepare physicians and nurses at a competent level and their knowledge level declines over a period of time. In this regard, simulation training has been proven to be effective in promoting resuscitation skills. Simulation teaching learning strategy improves knowledge level, and skills performance during resuscitation through experiential learning without compromising patient safety in real clinical situations. The purpose of the study is to evaluate the effectiveness of simulation training in Advanced Cardiac Life Support Courses by using the selfefficacy tool. Methods: The study design is a quantitative research design and non-randomized quasi-experimental study design. The study examined the effectiveness of simulation through self-efficacy in two instructional methods; one is Medium Fidelity Simulation (MFS) and second is Traditional Training Method (TTM). The sample size was 220. Data was compiled by using the SPSS tool. The standardized simulation based training increases self-efficacy, knowledge, and skills and improves the management of patients in actual resuscitation. Results: 153 students participated in study; CG: n = 77 and EG: n = 77. The comparison was done between arms in pre and post-test. (F value was 1.69, p value is <0.195 and df was 1). There was no significant difference between arms in the pre and post-test. The interaction between arms was observed and there was no significant difference in interaction between arms in the pre and post-test. (F value was 0.298, p value is <0.586 and df is 1. However, the results showed self-efficacy scores were significantly higher within experimental group in post-test in advanced cardiac life support resuscitation courses as compared to Traditional Training Method (TTM) and had overall (p <0.0001) and F value was 143.316 (mean score was 45.01 and SD was 9.29) verses pre-test result showed (mean score was 31.15 and SD was 12.76) as compared to TTM in post-test (mean score was 29.68 and SD was 14.12) verses pre-test result showed (mean score was 42.33 and SD was 11.39). Conclusion: The standardized simulation-based training was conducted in the safe learning environment in Advanced Cardiac Life Suport Courses and physicians and nurses benefited from self-confidence, early identification of life-threatening scenarios, early initiation of CPR, and provides high-quality CPR, timely administration of medication and defibrillation, appropriate airway management, rhythm analysis and interpretation, and Return of Spontaneous Circulation (ROSC), team dynamics, debriefing, and teaching and learning strategies that will improve the patient survival in actual resuscitation.

Keywords: advanced cardiac life support, cardio pulmonary resuscitation, return of spontaneous circulation, simulation

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Authors: Giselle Tran, Ralitza Parina, Phuong T. Nguyen

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Background/Aims: Pancreatic cysts (PC) have recently become an increasingly common entity, often diagnosed as incidental findings on cross-sectional imaging. Clinically, management of the lesions is difficult because of uncertainties in their potential for malignant degeneration. Prior series have reported that carcinoembryonic antigen (CEA), a biomarker collected from cyst fluid aspiration, has a high diagnostic accuracy for discriminating between mucinous and non-mucinous lesions, at the patient’s initial presentation. To the author’s best knowledge, no prior studies have reported PC CEA levels obtained from endoscopic ultrasound fine-needle aspiration (EUS-FNA) over years of serial EUS surveillance imaging. Methods: We report a consecutive retrospective series of 624 patients who underwent EUS evaluation for a PC between 11/20/2009 and 11/13/2018. Of these patients, 401 patients had CEA values obtained at the point of entry. Of these, 157 patients had two or more CEA values obtained over the course of their EUS surveillance. Of the 157 patients (96 F, 61 M; mean age 68 [range, 62-76]), the mean interval of EUS follow-up was 29.7 months [3.5-128]. The mean number of EUS procedures was 3 [2-7]. To assess CEA value fluctuations, we defined an appreciable increase in CEA as "spikes" – two-times increase in CEA on a subsequent EUS-FNA of the same cyst, with the second CEA value being greater than 1000 ng/mL. Using this definition, cysts with a spike in CEA were compared to those without a spike in a bivariate analysis to determine if a CEA spike is associated with poorer outcomes and the presence of high-risk features. Results: Of the 157 patients analyzed, 29 had a spike in CEA. Of these 29 patients, 5 had a cyst with size increase >0.5cm (p=0.93); 2 had a large cyst, >3cm (p=0.77); 1 had a cyst that developed a new solid component (p=0.03); 7 had a cyst with a solid component at any time during surveillance (p=0.08); 21 had a complex cyst (p=0.34); 4 had a cyst categorized as "Statistically Higher Risk" based on molecular analysis (p=0.11); and 0 underwent surgical resection (p=0.28). Conclusion: With serial EUS imaging in the surveillance of PC, an increase in CEA level defined as a spike did not predict poorer outcomes. Most notably, a spike in CEA did not correlate with the number of patients sent to surgery or patients with an appreciable increase in cyst size. A spike in CEA did not correlate with the development of a solid nodule within the PC nor progression on molecular analysis. Future studies should focus on the selected use of CEA analysis when patients undergo EUS surveillance evaluation for PCs.

Keywords: carcinoembryonic antigen (CEA), endoscopic ultrasound (EUS), fine-needle aspiration (FNA), pancreatic cyst, spike

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Authors: Maryam Rafraf, Aida Ghaffari

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Objectives: Nonalcoholic fatty liver disease (NAFLD) is considered as an independent risk factor for cardiovascular disease (CVD). Dyslipidemia contributes to the enhanced risk of CVD in persons with NAFLD. This study aimed to investigate the effects of turmeric supplementation on serum lipids levels in patients with NAFLD. Methods: In this double-blind, randomized, controlled clinical trial, 46 NAFLD patients (21 males and 25 females; age range, 20 – 60 years) were randomly assigned in the two groups. The intervention and control groups received 3g of turmeric (n = 23) and placebo (n = 23), daily for 12 weeks. Fasting blood samples were collected at baseline and at the end of the trial. Results: Turmeric supplementation significantly increased serum levels of HDL-C compared with the placebo group at the end of the study (by 12.73%, P < 0.05). Serum levels of triglyceride, total cholesterol, and low-density lipoprotein cholesterol were significantly reduced within turmeric group at the end of the study (P < 0.05). Conclusions: Turmeric consumption had beneficial effects on serum lipids levels of subjects and may be useful in controlling of CVD risk factors in NAFLD patients.

Keywords: nonalcoholic fatty liver, serum lipids, supplementation, turmeric

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Authors: Yinglisong, Jingge Chen, Jingxuan Chen, Yan Wang, Hui Huang, Jing Zhnag, Qianqian Zhang, Zhenzhen Zhang, Ji Zhang

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Purpose: The study aims to establish a nomogram prediction model for postpartum hemorrhage (PPH) in vaginal delivery. Patients and Methods: Clinical data were retrospectively collected from vaginal delivery patients admitted to a hospital in Zhengzhou, China, from June 1, 2022 - October 31, 2022. Univariate and multivariate logistic regression were used to filter out independent risk factors. A nomogram model was established for PPH in vaginal delivery based on the risk factors coefficient. Bootstrapping was used for internal validation. To assess discrimination and calibration, receiver operator characteristics (ROC) and calibration curves were generated in the derivation and validation groups. Results: A total of 1340 cases of vaginal delivery were enrolled, with 81 (6.04%) having PPH. Logistic regression indicated that history of uterine surgery, induction of labor, duration of first labor, neonatal weight, WBC value (during the first stage of labor), and cervical lacerations were all independent risk factors of hemorrhage (P <0.05). The area-under-curve (AUC) of ROC curves of the derivation group and the validation group were 0.817 and 0.821, respectively, indicating good discrimination. Two calibration curves showed that nomogram prediction and practical results were highly consistent (P = 0.105, P = 0.113). Conclusion: The developed individualized risk prediction nomogram model can assist midwives in recognizing and diagnosing high-risk groups of PPH and initiating early warning to reduce PPH incidence.

Keywords: vaginal delivery, postpartum hemorrhage, risk factor, nomogram

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Authors: Hyun Chang Kim, Yong Hun Jung, Kyung Woon Jeung

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Background: From the viewpoint of cardiac pump theory, the area of the left ventricle (LV) subjected to compression increases as the LV lies closer to the sternum, possibly resulting in higher blood flow in patients with LV closer to the sternum. However, no study has evaluated LV position during cardiac arrest or its relationship with hemodynamic parameters during cardiopulmonary resuscitation (CPR). The objectives of this study were to determine whether the position of the LV relative to the anterior-posterior axis representing the direction of chest compression shifts during cardiac arrest and to examine the relationship between LV position and hemodynamic parameters during CPR. Methods: Subcostal view echocardiograms were obtained from 15 pigs with the transducer parallel to the long axis of the sternum before inducing ventricular fibrillation (VF) and during cardiac arrest. Computed tomography was performed in three pigs to objectively observe LV position during cardiac arrest. LV position parameters including the shortest distance between the anterior-posterior axis and the mid-point of the LV chamber (DAP-MidLV), the shortest distance between the anterior-posterior axis and the LV apex (DAP-Apex), and the area fraction of the LV located on the right side of the anterior-posterior axis (LVARight/LVATotal) were measured. Results: DAP-MidLV, DAP-Apex, and LVARight/LVATotal decreased progressively during untreated VF and basic life support (BLS), and then increased during advanced cardiovascular life support (ACLS). A repeated measures analysis of variance revealed significant time effects for these parameters. During BLS, the end-tidal carbon dioxide and systolic right atrial pressure were significantly correlated with the LV position parameters. During ACLS, systolic arterial pressure and systolic right atrial pressure were significantly correlated with DAP-MidLV and DAP-Apex. Conclusions: LV position changed significantly during cardiac arrest compared to the pre-arrest baseline. LV position during CPR had significant correlations with hemodynamic parameters.

Keywords: heart arrest, cardiopulmonary resuscitation, heart ventricle, hemodynamics

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Authors: Hansraj Bookun, Rachel Xuan, Angela Tan, Kejia Wang, Animesh Singla, David Kim, Christopher Loupos, Jim Iliopoulos

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Introduction: Complex endovascular aortic aneursymal repairs with fenestrated and branched endografts require customised devices to exclude the pathology while reducing morbidity and mortality, which was historically associated with open repair of complex aneurysms. Such endovascular procedures have predominantly been performed in a large volume dedicated tertiary centres. We present here our nine year multidisciplinary experience with this technology in an Australian tertiary centre. Method: This was a cross-sectional, single-centre observational study of 670 patients who had undergone complex endovascular aortic aneurysmal repairs with conventional endografts, fenestrated endografts, and iliac-branched devices from January 2010 to July 2019. Descriptive statistics were used to characterise our sample with regards to demographic and perioperative variables. Homogeneity of the sample was tested using multivariant regression, which did not identify any statistically significant confounding variables. Results: 670 patients of mean age 74, were included (592 males) and the comorbid burden was as follows: ischemic heart disease (55%), diabetes (18%), hypertension (90%), stage four or greater kidney impairment (8%) and current or ex-smoking (78%). The main indications for surgery were elective aneurysms (86%), symptomatic aneurysms (5%), and rupture aneurysms (5%). 106 patients (16%) underwent fenestrated or branched endograft repairs. The mean length of stay was 7.6 days. 2 patients experienced reactionary bleeds, 11 patients had access wound complications (6 lymph fistulae, 5 haematoms), 11 patients had cardiac complications (5 arrhythmias, 3 acute myocadial infarctions, 3 exacerbation of congestive cardiac failure), 10 patients had respiratory complications, 8 patients had renal impairment, 4 patients had gastrointestinal complications, 2 patients suffered from paraplegia, 1 major stroke, 1 minor stroke, and 1 acute brain syndrome. There were 4 vascular occlusions requiring further arterial surgery, 4 type I endoleaks, 4 type II endoleaks, 3 episodes of thromboembolism, and 2 patients who required further arterial operations in the setting of patient vessels. There were 9 unplanned returns to the theatre. Discussion: Our numbers of 10 years suggest that we are not a dedicated high volume centre focusing on aortic repairs. However, we have achieved significantly low complication rates. This can be attributed to our multidisciplinary approach with the intraoperative involvement of skilled interventional radiologists and vascular surgeons as well as postoperative protocols with particular attention to spinal cord protection. Additionally, we have a ratified perioperative pathway that involves multidisciplinary team discussions of patient-related factors and lesion-centered characteristics, which allows for holistic, patient-centered care.

Keywords: aneurysm, aortic, endovascular, fenestrated

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Authors: Shokoufeh Abrisham, Seyed Mahmoud Hossieni, Elham Pishbin

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In this paper, a hybrid method based on the fault tree analysis (FTA) and Bayesian networks (BNs) are employed to evaluate the team performance quality of advanced cardiac life support (ACLS) procedures in emergency department. According to American Heart Association (AHA) guidelines, a category relying on staff action leading to clinical incidents and also some discussions with emergency medicine experts, a fault tree model for ACLS procedure is obtained based on the human performance. The obtained FTA model is converted into BNs, and some different scenarios are defined to demonstrate the efficiency and flexibility of the presented model of BNs. Also, a sensitivity analysis is conducted to indicate the effects of team leader presence and uncertainty knowledge of experts on the quality of ACLS. The proposed model based on BNs shows that how the results of risk analysis can be closed to reality comparing to the obtained results based on only FTA in medical procedures.

Keywords: advanced cardiac life support, fault tree analysis, Bayesian belief networks, numan performance, healthcare systems

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Authors: Daniel Thompson, Muhammad Peerbux, Sophie Cerutti, Hansraj Riteesh Bookun

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Patients with carotid stenosis, which may be asymptomatic or symptomatic in the form of transient ischaemic attack (TIA), amaurosis fugax, or stroke, often require an endarterectomy to reduce stroke risk. Risks of this procedure include stroke, death, myocardial infarction, and cranial nerve damage. Carotid endarterectomy is most commonly performed under general anaesthetic, however, it can also be undertaken with a regional anaesthetic approach. Our tertiary centre generally performs carotid endarterectomy under regional anaesthetic. Our major tertiary hospital mostly utilises regional anaesthesia for carotid endarterectomy. We completed a cross-sectional analysis of all cases of carotid endarterectomy performed under regional anaesthesia across a 10-year period between January 2010 to March 2020 at our institution. 350 patients were included in this descriptive analysis, and demographic details for patients, indications for surgery, procedural details, length of surgery, and complications were collected. Data was cross tabulated and presented in frequency tables to describe these categorical variables. 263 of the 350 patients in the analysis were male, with a mean age of 71 ± 9. 172 patients had a history of ischaemic heart disease, 104 had diabetes mellitus, 318 had hypertension, and 17 patients had chronic kidney disease greater than Stage 3. 13.1% (46 patients) were current smokers, and the majority (63%) were ex-smokers. Most commonly, carotid endarterectomy was performed conventionally with patch arterioplasty 96% of the time (337 patients). The most common indication was TIA and stroke in 64% of patients, 18.9% were classified as asymptomatic, and 13.7% had amaurosis fugax. There were few general complications, with 9 wound complications/infections, 7 postoperative haematomas requiring return to theatre, 3 myocardial infarctions, 3 arrhythmias, 1 exacerbation of congestive heart failure, 1 chest infection, and 1 urinary tract infection. Specific complications to carotid endarterectomy included 3 strokes, 1 postoperative TIA, and 1 cerebral bleed. There were no deaths in our cohort. This analysis of a large cohort of patients from a major tertiary centre who underwent carotid endarterectomy under regional anaesthesia indicates the safety of such an approach for these patients. Regional anaesthesia holds the promise of less general respiratory and cardiac events compared to general anaesthesia, and in this vulnerable patient group, calls for comparative research between local and general anaesthesia in carotid surgery.

Keywords: anaesthesia, carotid endarterectomy, stroke, carotid stenosis

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Authors: Wan Azuati Wan Omar, Selva Rani John Jasudass, Siti Rohaiza Md. Saad

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Introduction & objective: The objectives of this study were to assess patient’s knowledge of appropriate sublingual glyceryl trinitrate (GTN) use as well as to investigate how patients commonly store and carry their sublingual GTN tablets. Methodology: This was a cross-sectional survey, using a validated researcher-administered questionnaire. The study involved cardiac patients receiving sublingual GTN attending the outpatient and inpatient departments of Taiping Hospital, a non-academic public care hospital. The minimum calculated sample size was 92, but 100 patients were conveniently sampled. Respondents were interviewed on 3 areas, including demographic data, knowledge and use of sublingual GTN. Eight items were used to calculate each subject’s knowledge score and six items were used to calculate use score. Results: Of the 96 patients who consented to participate, majority (96.9%) were well aware of the indication of sublingual GTN. With regards to the mechanism of action of sublingual GTN, 73 (76%) patients did not know how the medication works. Majority of the patients (66.7%) knew about the proper storage of the tablet. In relation to the maximum number of sublingual GTN tablets that can be taken during each angina episode, 36.5% did not know that up to 3 tablets of sublingual GTN can be taken during each episode of angina. Fifty four (56.2%) patients were not aware that they need to replace sublingual GTN every 8 weeks after receiving the tablets. Majority (69.8%) of the patients demonstrated lack of knowledge with regards to the use of sublingual GTN as prevention of chest pain. Conclusion: Overall, patients’ knowledge regarding the self administration of sublingual GTN is still inadequate. The findings support the need for more frequent reinforcement of patient education, especially in the areas of preventive use, storage and drug stability.

Keywords: glyceryl trinitrate, knowledge, adherence, patient education

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Authors: Piotr Prewysz-Kwinto

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The market of financial instruments with high risk is developing very dynamically in recent years and attracts more and more interest of investors. It consists essentially of two groups of instruments, i.e. derivatives and exchange traded product (ETP), and each year new types are introduced and offered to investors. The aim of this paper is to present the principles concerning financial instruments with high investment risk available on the Warsaw Stock Exchange (WSE), because they have quite complex constructions, and to evaluate the development of this market. In order to achieve this aim, statistical data from 2014-2016 was analyzed. The results confirm that the financial instruments with high investment risk available on the WSE constitute a diversified and the most numerous group of financial instruments and attract the most interest of investors. Responsible investing requires, however, a good knowledge of how they work and how they can generate profit to not expose oneself to unexpected losses.

Keywords: derivatives, exchange traded products (ETP), financial instruments, financial market, risk, stock exchange

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Authors: Faiz N. K. Yusufi, Aquil Ahmed, Jamal Ahmad

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Diabetes in India is growing at an alarming rate and the complications caused by it need to be controlled. Coronary heart disease (CHD) is one of the complications that will be discussed for prediction in this study. India has the second most number of diabetes patients in the world. To the best of our knowledge, there is no CHD risk score for Indian type 2 diabetes patients. Any form of CHD has been taken as the event of interest. A sample of 750 was determined and randomly collected from the Rajiv Gandhi Centre for Diabetes and Endocrinology, J.N.M.C., A.M.U., Aligarh, India. Collected variables include patients data such as sex, age, height, weight, body mass index (BMI), blood sugar fasting (BSF), post prandial sugar (PP), glycosylated haemoglobin (HbA1c), diastolic blood pressure (DBP), systolic blood pressure (SBP), smoking, alcohol habits, total cholesterol (TC), triglycerides (TG), high density lipoprotein (HDL), low density lipoprotein (LDL), very low density lipoprotein (VLDL), physical activity, duration of diabetes, diet control, history of antihypertensive drug treatment, family history of diabetes, waist circumference, hip circumference, medications, central obesity and history of CHD. Predictive risk scores of CHD events are designed by cox proportional hazard regression. Model calibration and discrimination is assessed from Hosmer Lemeshow and area under receiver operating characteristic (ROC) curve. Overfitting and underfitting of the model is checked by applying regularization techniques and best method is selected between ridge, lasso and elastic net regression. Youden’s index is used to choose the optimal cut off point from the scores. Five year probability of CHD is predicted by both survival function and Markov chain two state model and the better technique is concluded. The risk scores for CHD developed can be calculated by doctors and patients for self-control of diabetes. Furthermore, the five-year probabilities can be implemented as well to forecast and maintain the condition of patients.

Keywords: coronary heart disease, cox proportional hazard regression, ROC curve, type 2 diabetes Mellitus

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Authors: Helen Huang, Francisco Javier Quesada Ocet, Blanca Quesada Oce, Javier Jimenez Bello, Victor Palanca Gil, Alba Cervero Rubio, Ana Paya Chaume, Alejandro Herreros-Pomares, Fernando Vidal-Vanaclocha, Rafael Paya Serrano, Aurelio Quesada Dorador, Monica Soliman

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Background: Cancer favors both the pro-inflammatory state and autonomic dysfunction, two important mechanisms in the genesis of AF. Atrial remodeling might be caused as a result of paraneoplastic conditions or the result of direct expression of neoplasia. Here, we hypothesize that cancer, through inflammatory mediators, may favor the appearance of AF and patients with the first episode of AF could have a higher risk of developing cancer. Method: Data was collected from patients who attended the emergency department of our hospital for the first episode of AF, diagnosed electrocardiographically, between 2010-2015 (n = 712). The minimum follow-up was 2 years, recording the appearance of cancer, total mortality, recurrences of AF and other events. Patients who developed cancer and those who did not during the 2 years after the onset of AF were compared, as well as with the incidence of cancer in Spain in 2012. Results: After 2 years, 35 patients (4.91%) were diagnosed with cancer, with an annual incidence of 2.45%. Hematological neoplasms were the most frequent (34.28%). The cancer group was older (76.68 +/-12.75 years vs 74.16 +/-12.71; p <0.05) and had fewer typical symptoms (palpitations) (33.38% vs 14.28% , p <0.05). The incidence of cancer in Spain during 2012 was 0.46%, much lower than our sample. When comparing the incidence by age, these differences were maintained both in those over 65 years of age and in those under 65 years of age (2.17% vs. 0.28%; 0.28% vs. 0.18% respectively). Discussion: Therefore, a high incidence of cancer in patients with the first episode of AF was observed (the annual incidence of 2.45% after the onset of AF is 6.1 times that of the general population). After the evaluation of patients with AF in their first detected episode, surveillance of the appearance of cancer should be considered in clinical practice.

Keywords: cancer, cardiovascular outcomes, atrial fibrillation, inflammation

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Authors: Pranee Suecharoen, Ratchadaporn Soontornpas, Jaturat Kanpittaya

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Background: Contrast media has an important role for disease diagnosis through detection of pathologies. Contrast media can, however, cause adverse reactions after administration of its agents. Although non-ionic contrast media are commonly used, the incidence of adverse events is relatively low. The most common reactions found (10.5%) were mild and manageable and/or preventable. Pharmacists can play an important role in evaluating adverse reactions, including awareness of the specific preparation and the type of adverse reaction. As most common types of adverse reactions are idiosyncratic or pseudo-allergic reactions, common standards need to be established to prevent and control adverse reactions promptly and effectively. Objective: To measure the effect of using tools for symptom evaluation in order to reduce the severity, or prevent the occurrence, of adverse reactions from contrast media. Methods: Retrospective review descriptive research with data collected on adverse reactions assessment and Naranjo’s algorithm between June 2015 and May 2016. Results: 158 patients (10.53%) had adverse reactions. Of the 1,500 participants with an adverse event evaluation, 137 (9.13%) had a mild adverse reaction, including hives, nausea, vomiting, dizziness, and headache. These types of symptoms can be treated (i.e., with antihistamines, anti-emetics) and the patient recovers completely within one day. The group with moderate adverse reactions, numbering 18 cases (1.2%), had hypertension or hypotension, and shortness of breath. Severe adverse reactions numbered 3 cases (0.2%) and included swelling of the larynx, cardiac arrest, and loss of consciousness, requiring immediate treatment. No other complications under close medical supervision were recorded (i.e., corticosteroids use, epinephrine, dopamine, atropine, or life-saving devices). Using the guideline, therapies are divided into general and specific and are performed according to the severity, risk factors and ingestion of contrast media agents. Patients who have high-risk factors were screened and treated (i.e., prophylactic premedication) for prevention of severe adverse reactions, especially those with renal failure. Thus, awareness for the need for prescreening of different risk factors is necessary for early recognition and prompt treatment. Conclusion: Studying adverse reactions can be used to develop a model for reducing the level of severity and setting a guideline for a standardized, multidisciplinary approach to adverse reactions.

Keywords: role of pharmacist, management of adverse reactions, guideline for contrast media, non-ionic contrast media

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Authors: Nabiha Bouafia, Asma Ben Cheikh, Asma Ammar, Olfa Ezzi, Mohamed Mahjoub, Khaoula Meddeb, Imed Chouchene, Hamadi Boussarsar, Mansour Njah

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Background: Hospital acquired infections (HAI) cause significant morbidity, mortality, length of stay and hospital costs, especially in the intensive care unit (ICU), because of the debilitated immune systems of their patients and exposure to invasive devices. The aims of this study were to determine the rate and the risk factors of HAI in an ICU of a university hospital in Tunisia. Materials/Methods: A prospective study was conducted in the 8-bed adult medical ICU of a University Hospital (Sousse Tunisia) during 14 months from September 15th, 2015 to November 15th, 2016. Patients admitted for more than 48h were included. Their surveillance was stopped after the discharge from ICU or death. HAIs were defined according to standard Centers for Disease Control and Prevention criteria. Risk factors were analyzed by conditional stepwise logistic regression. The p-value of < 0.05 was considered significant. Results: During the study, 192 patients had admitted for more than 48 hours. Their mean age was 59.3± 18.20 years and 57.1% were male. Acute respiratory failure was the main reason of admission (72%). The mean SAPS II score calculated at admission was 32.5 ± 14 (range: 6 - 78). The exposure to the mechanical ventilation (MV) and the central venous catheter were observed in 169 (88 %) and 144 (75 %) patients, respectively. Seventy-three patients (38.02%) developed 94 HAIs. The incidence density of HAIs was 41.53 per 1000 patient day. Mortality rate in patients with HAIs was 65.8 %( n= 48). Regarding the type of infection, Ventilator Associated Pneumoniae (VAP) and central venous catheter Associated Infections (CVC AI) were the most frequent with Incidence density: 14.88/1000 days of MV for VAP and 20.02/1000 CVC days for CVC AI. There were 5 Peripheral Venous Catheter Associated Infections, 2 urinary tract infections, and 21 other HAIs. Gram-negative bacteria were the most common germs identified in HAIs: Multidrug resistant Acinetobacter Baumanii (45%) and Klebsiella pneumoniae (10.96%) were the most frequently isolated. Univariate analysis showed that transfer from another hospital department (p= 0.001), intubation (p < 10-4), tracheostomy (p < 10-4), age (p=0.028), grade of acute respiratory failure (p=0.01), duration of sedation (p < 10-4), number of CVC (p < 10-4), length of mechanical ventilation (p < 10-4) and length of stay (p < 10-4), were associated to high risk of HAIS in ICU. Multivariate analysis reveals that independent risk factors for HAIs are: transfer from another hospital department: OR=13.44, IC 95% [3.9, 44.2], p < 10-4, duration of sedation: OR= 1.18, IC 95% [1.049, 1.325], p=0.006, high number of CVC: OR=2.78, IC 95% [1.73, 4.487], p < 10-4, and length of stay in ICU: OR= 1.14, IC 95% [1.066,1.22], p < 10-4. Conclusion: Prevention of nosocomial infections in ICUs is a priority of health care systems all around the world. Yet, their control requires an understanding of epidemiological data collected in these units.

Keywords: healthcare associated infections, incidence, intensive care unit, risk factors

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Authors: Syed Sameer Aga, Saniya Nissar

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The Xeroderma pigmentosum group D gene (XPD) plays a key role in nucleotide excision repair (NER) pathway of the damaged DNA. Genetic polymorphisms in the coding region of the XPD gene may alter DNA repair capacity of the protein and hence can modulate the risk of colorectal cancer (CRC) risk. The aim of the study was to determine the genetic association of XPD Lys751Gln polymorphism with the risk of colorectal cancer (CRC) development. 120 CRC patients and 160 normal controls were assessed for genotype frequencies of XPD Lys751Gln polymorphism using PCR-RFLP technique. We observed a significant association (p < 0.05) between the XPD Lys751Gln polymorphism and the risk of developing CRC (p < 0.05). Additionally, Gln/Gln genotype of the XPD gene doubled the risk for the development of CRC [p < 0.05; OR=2.25 95% CI (1.07-4.7)]. Our results suggest that there is a significant association between the XPD Lys751Gln polymorphism and the risk of CRC.

Keywords: colorectal cancer, polymorphism, RFLP, DNA Repair, NER, XPD

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Authors: Alexander Heckman, Rohan Goswami, Zachi Attia, Paul Friedman, Peter Noseworthy, Demilade Adedinsewo, Pablo Moreno-Franco, Rickey Carter, Tathagat Narula

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Background: Postoperative atrial fibrillation (POAF) is associated with adverse health consequences, higher costs, and longer hospital stays. Utilizing existing predictive models that rely on clinical variables and circulating biomarkers, multiple societies have published recommendations on the treatment and prevention of POAF. Although reasonably practical, there is room for improvement and automation to help individualize treatment strategies and reduce associated complications. Methods and Results: In this retrospective cohort study of solid organ transplant recipients, we evaluated the diagnostic utility of a previously developed AI-based ECG prediction for silent AF on the development of POAF within 30 days of transplant. A total of 2261 non-cardiac transplant patients without a preexisting diagnosis of AF were found to have a 5.8% (133/2261) incidence of POAF. While there were no apparent sex differences in POAF incidence (5.8% males vs. 6.0% females, p=.80), there were differences by race and ethnicity (p<0.001 and 0.035, respectively). The incidence in white transplanted patients was 7.2% (117/1628), whereas the incidence in black patients was 1.4% (6/430). Lung transplant recipients had the highest incidence of postoperative AF (17.4%, 37/213), followed by liver (5.6%, 56/1002) and kidney (3.6%, 32/895) recipients. The AUROC in the sample was 0.62 (95% CI: 0.58-0.67). The relatively low discrimination may result from undiagnosed AF in the sample. In particular, 1,177 patients had at least 1 AI-ECG screen for AF pre-transplant above .10, a value slightly higher than the published threshold of 0.08. The incidence of POAF in the 1104 patients without an elevated prediction pre-transplant was lower (3.7% vs. 8.0%; p<0.001). While this supported the hypothesis that potentially undiagnosed AF may have contributed to the diagnosis of POAF, the utility of the existing AI-ECG screening algorithm remained modest. When the prediction for POAF was made using the first postoperative ECG in the sample without an elevated screen pre-transplant (n=1084 on account of n=20 missing postoperative ECG), the AUROC was 0.66 (95% CI: 0.57-0.75). While this discrimination is relatively low, at a threshold of 0.08, the AI-ECG algorithm had a 98% (95% CI: 97 – 99%) negative predictive value at a sensitivity of 66% (95% CI: 49-80%). Conclusions: This study's principal finding is that the incidence of POAF is rare, and a considerable fraction of the POAF cases may be latent and undiagnosed. The high negative predictive value of AI-ECG screening suggests utility for prioritizing monitoring and evaluation on transplant patients with a positive AI-ECG screening. Further development and refinement of a post-transplant-specific algorithm may be warranted further to enhance the diagnostic yield of the ECG-based screening.

Keywords: artificial intelligence, atrial fibrillation, cardiology, transplant, medicine, ECG, machine learning

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Authors: Ajay Gogia, Svs Deo, Dn Sharma, Atul Batra, Ashutash Mishra

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Background and Aims: Breast cancer in women aged less than 25 years (defined as very young breast cancer, VYBC) is rare and accounts for 0.25% of all breast cancer in the West. There is no data available on VYBC from developing countries. The aim of this study was to analyze the clinical, pathological, and prognostic factors and outcomes in VYBC. Methods: This retrospective analysis was performed on 80 patients aged 25 years or less (screened 8000 files of female BC) who were registered at All India Institute of Medical Sciences (AIIMS), New Delhi, India, over a 15-year period between 2011 and 2023. Results: The median age was 21.5 years (range 16-25). A positive family history (siblings and parents) was elicited in 30% of cases, and breast cancer gene (BRCA1/2) mutation was found in 33% of cases patients. Ten patients (12.5%) patients have pregnancy-associated breast cancer (BC detected during pregnancy or 1 year after postpartum period). The TNM stage distribution was Stage I was 0, stage II -30%, stage III –60% and Stage IV -10 %patients. Seventy percent of tumors were high grade, and 90% had pathological node-positive disease. Estrogen, Progesterone, and human epidermal growth factor receptor 2 (HER2)/neu positivity were 25%,25% and 35%, respectively. Triple-negative breast cancer constituted 40% of patients. With a median follow-up of 42 months, 3 years, relapse-free survival (nonmetastatic disease), progression-free survival (metastatic disease) and overall survival were 30%, 15% and 50%, respectively. Conclusions: Very young women constituted 1% of all breast cancer cases. Advanced disease at presentation and high-risk pathological features result in poor outcomes. One-third of VYBCs are associated with BRCA mutation, which requires genetic counseling and risk reduction surgery if required. Due to the aggressive behavior of BC in this age group, need early diagnosis and prompt treatment

Keywords: very young, breast cancer, outcome, developing country, India

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Authors: Izabela Zielinska

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Kinesio Taping is classified as physiotherapy method supporting rehabilitation and modulating some physiological processes. It is commonly used in sports medicine and orthopedics. This sensory method has influence on muscle function, pain sensation, intensifies lymphatic system as well as improves microcirculation. The aim of this study was to assess the effect of Kinesio Taping in patients with ongoing treatment of peripheral artery disease (PAD). The study group comprised 60 patients (stadium II B at Fontain's scale). All patients were divided into two groups (30 person/each), where 12 weeks long treadmill training was administrated. In the second group, the Kinesio Taping was applied to support the function of the gastrocnemius muscle. The measurements of distance and time until claudication pain, blood flow of arteries in lower limbs and ankle brachial index were taken under evaluation. Examination performed after Kinesio Taping therapy showed statistically significant increase in gait parameters and muscle strength in patients with intermittent claudication. The Kinesio Taping method has clinically significant effects on enhancement of pain-free distance and time until claudication pain in patients with peripheral artery disease. Kinesio Taping application can be used to support non-invasive treatment in patients with intermittent claudication. Kinesio Taping can be employed as an alternative way of therapy for patients with orthopedic or cardiac contraindications to be treated with treadmill training.

Keywords: intermittent claudication, kinesiotaping, peripheral artery disease, treadmill training

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Authors: Yu-Shi Ye, Jia-Min Wu, Jhih-Ci Li

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Background: Most orthopedic inpatients and primary caregivers are elderly, and patients are at high risk of falls. We set up a quality control team to analyze the root cause and found the following issues: 1. The nursing staff did not conduct cognitive assessments of patients and their primary caregivers to ensure that health education content was understood. 2. Nurses prefer to use spoken language in health education but lack the skills to use diverse teaching materials. 3. Newly recruited nurses have insufficient awareness of fall prevention. Methods: The study subjects were 16 nurses in the orthopedic ward of a teaching hospital in central Taiwan. We implemented the following strategies: 1. Developed a fall simulation teaching plan and conducted teaching courses and assessments in the morning meeting; 2. Designed and used a "fall prevention awareness card" to improve the prevention awareness of elderly patients; 3. All staff (including new staff) received experiential education training. Results: In 2021, 40% of patients in the orthopedic wards were aged 60-79 years (792/1979) with a high risk of falls. According to data collection, the incidence of falls in hospitalized patients was 0.04% (5/12651), which exceeded the threshold of 0.02% in our ward. After completing the on-the-job education training in October, the nursing staff expressed that they were more aware of the special situation of fall prevention. Through practical sharing and drills, combined with experiential teaching strategies, nurses can reconstruct the safety awareness of fall prevention and deepen their cognitive memory. Participants scored between 30 and 80 on the pretest (16 students, mean: 72.6) and between 90 and 100 on the post-test (16 students, mean: 92.6), resulting in a 73.8% improvement in overall scores. We have a total of 4 new employees who have all completed the first 3 months of compulsory PGY courses. From January to April 2022, the incidence of falls in hospitalized patients was 0.025% (1/3969). We have made good improvements and will continue to track the outcome. Discussion: In addition to enhancing the awareness of falls among nursing staff, how-to guide patients and primary caregivers to prevent falls is also the focus of improvement. The proper way of health education can be better understood through practical exercises and case sharing.

Keywords: experiential teaching strategies, fall prevention, cognitive card, elderly patients, orthopedic wards

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Authors: Ali Kassem

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Background: In the last few years, factors such as insulin resistance (IR) and hepatic steatosis have been linked to progression of hepatic fibrosis.Patients with chronic liver disease, and cirrhosis in particular, are known to be prone to IR. However, chronic HCV (hepatitis C) infection may induce IR, regardless of the presence of liver cirrhosis. Our aims are to study insulin resistance (IR) assessed by HOMA-IR (Homeostatic Model Assessment Insulin Resistance) as a possible risk factor in disease progression in cirrhotic patients and to evaluate the role of IR in hepatic fibrosis progression. The correlations of HOMA-IR values to laboratory, virological and histopathological parameters of chronic HCV are also examined. Methods: The study included 50 people divided into 30 adult chronic hepatitis C patients diagnosed by PCR (polymerase chain reaction) within previous 6 months and 20 healthy controls. The functional and morphological status of the liver were evaluated by ultrasonography and laboratory investigations including liver function tests and by liver biopsy. Fasting blood glucose and fasting insulin levels were measured and body mass index and insulin resistance were calculated. Patients having HOMA-IR >2.5 were labeled as insulin resistant. Results: Chronic hepatitis C patients with IR showed significantly higher mean values of BMI (body mass index) and fasting insulin than those without IR (P < 0.000). Patients with IR were more likely to have steatosis (p = 0.006), higher necroinflammatory activity (p = 0.05). No significant differences were found between the two groups regarding hepatic fibrosis. Conclusion: HOMA-IR measurement could represent a novel marker to identify the cirrhotic patients at greater risk for the progression of liver disease. As IR is a potentially modifiable risk factor, these findings may have important prognostic and therapeutic implications. Assessment of IR by HOMA-IR and improving insulin sensitivity are recommended in patients with HCV and related chronic liver disease.

Keywords: hepatic fibrosis, hepatitis C virus infection, hepatic steatosis, insulin resistance

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Authors: Antarip Bhattacharya, Dhritiman Maitra

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Primary hyperparathyroidism (PHPT) is the most common cause of hypercalcemia due to autonomous production of parathormone (PTH) and the third most common endocrine disorder. Upto 2% of postmenopausal women could have this condition. Primary hyperparathyroidism is characterized by hypercalcemia with a high or insufficiently suppressed level of parathyroid hormone and is caused by a solitary parathyroid adenoma in 85-90% of patients. PHPT may also be caused by parathyroid hyperplasia (involving multiple glands) or parathyroid carcinoma. Associated morbidities and sequelae include decreased bone mineral density, fractures, kidney stones, hypertension, cardiac comorbidities and psychiatric disorder which entail huge costs for treatment. In the year 2021, by virtue of running a Breast and Endocrine Surgery clinic in a Tier 1 city at a tertiary care hospital, the opportunity to be associated with patients of hyperparathyroidism came our way. Here, we shall describe the spectrum of clinical presentations and customisation of treatment for parathyroid diseases with reference to the above patients. A retrospective analysis of the data of all patients presenting with symptoms of parathyroid diseases was made and classified according to the cause. 13 patients had presented with symptoms of hyperparathyroidism and each case presented with unique symptoms and necessitated detailed evaluation. The treatment or surgery offered to each patient was tailored to his/her individual disease and led to favourable outcomes. Diseases affecting parathyroid are not as rare as we believe. Each case merits detailed clinical evaluation, investigations and tailoring of suitable treatment with regard to medical management and extent of surgery. Intra-operative frozen section/iOPTH monitoring are really useful adjuncts for intra-operative decision making.

Keywords: hyperparathyroidism, parathyroid adenoma, parathyroid surgery, PTH

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Authors: Zi-Han Li, Zi-Jun Sun, Dong-Yuan Chang, Li Zhu, Min Chen, Ming-Hui Zhao

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Aims: A genome-wide association study (GWAS) reported that patients with the rs55703767 minor allele in collagen type IV α3 chain encoding gene COL4A3 showed protection against diabetic kidney disease (DKD) in type 1 diabetes mellitus (T1DM). However, the role of rs55703767 in type 2 DKD has not been elucidated. The aim of the current study was to investigate the association between COL4A3 variant rs55703767 and DKD risk in Chinese patients with type 2 diabetes mellitus (T2DM). Methods: This nested case-control study was performed on 1311 patients who had T2DM for at least 10 years, including 580 with DKD and 731 without DKD. We detected the genotypes of all patients by TaqMan SNP Genotyping Assay and analyzed the association between COL4A3 variant rs55703767 and DKD risk. Results: Genetic analysis revealed that there was no significant difference between T2DM patients with DKD and those without DKD regarding allele or genotype frequencies of rs55703767, and the effect of this variant was not hyperglycemia specific. Conclusion: Our findings suggested that there was no detectable association between the COL4A3 variant rs55703767 and the susceptibility to DKD in the Chinese T2DM population.

Keywords: collagen type IV α3 chain, gene polymorphism, type 2 diabetes, diabetic kidney disease

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Authors: Heru Al Amin

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Sarcoidosis is a granulomatous inflammatory disorder of unclear etiology that can affect multiple different organ systems. Isolated cardiac sarcoidosis is a very rare condition that causes lethal arrhythmia and heart failure. A definite diagnosis of cardiac sarcoidosis remains challenging. The use of multimodality imaging plays a pivotal role in the diagnosis of this entity. Case summary: In this report, we discuss a case of a 50-year-old woman who presented with recurrent palpitation, dizziness, vertigo and presyncope. Electrocardiogram revealed variable heart blocks, including first-degree AV block, second-degree AV block, high-degree AV block, complete AV block, trifascicular block and sometimes supraventricular arrhythmia. Twenty-four hours of Holter monitoring show atrial bigeminy, first-degree AV block and trifascicular block. Transthoracic echocardiography showed Thinning of basal anteroseptal and inferred septum with LV dilatation with reduction of Global Longitudinal Strain. A dual-chamber pacemaker was implanted. CT Coronary angiogram showed no coronary artery disease. Cardiac magnetic resonance revealed basal anteroseptal and inferior septum thinning with focal edema with LGE suggestive of sarcoidosis. Computed tomography of the chest showed no lymphadenopathy or pulmonary infiltration. 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) of the whole body showed. We started steroids and followed up with the patient. Conclusion: This case serves to highlight the challenges in identifying and managing isolated CS in a young patient with recurrent syncope with variable heart block. Early, even late initiation of steroids can improve arrhythmia as well as left ventricular function.

Keywords: cardiac sarcoidosis, conduction abnormality, syncope, cardiac MRI

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Authors: Mohammad Lutfur Rahman

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School students of Dhaka are in extreme risk of natural disasters. However, the study on assessment of the real scenario of high school students about perceptions of earthquake is very little. The purpose of this cross-sectional study is to assess the seismic risk perception and preparedness levels about earthquake among high school students in Shavar, Dhaka. A questionnaire was developed, and data collection was done about a group of high school students in seven classrooms. The author uses a method of surveying high school students to identify and describe the factors that influence their knowledge and perceptions about earthquake. This study examines gender and grade differences in perceived risk and communication behavior in response to the earthquake. Female students’ preparation, participation, and communication with family are more frequent than that of male students. Female students have been found to be more likely to learn about a disaster than male students. Higher grade students have more awareness but less preparedness about earthquake than that of the younger one. This research concludes that irrespective of grades, high school students are vulnerable to earthquake due to the lack of a seismic education program.

Keywords: awareness, earthquake, risk perception, seismic

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Authors: F. DelGaudio, H. Gill

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Resuscitation during cardiopulmonary (CPA) arrest is dynamic, high stress, high acuity situation, which can easily lead to communication breakdown, and errors. The care of these high acuity patients has also been shown to increase physiologic stress and task saturation of providers, which can negatively impact the care being provided. These difficulties are further complicated during a global pandemic and pose a significant safety risk to bedside providers. Nurse-led codes are a relatively new concept that may be a potential solution for alleviating some of these difficulties. An experienced nurse who has completed advanced cardiac life support (ACLS), and additional training, assumed the responsibility of directing the mechanics of the appropriate ACLS algorithm. This was done in conjunction with a physician who also acted as a physician leader. The additional nurse-led code training included a multi-disciplinary in situ simulation of a CPA on a suspected COVID-19 patient. During the CPA, the nurse leader’s responsibilities include: ensuring adequate compression depth and rate, minimizing interruptions in chest compressions, the timing of rhythm/pulse checks, and appropriate medication administration. In addition, the nurse leader also functions as a last line safety check for appropriate personal protective equipment and limiting exposure of staff. The use of nurse-led codes for CPA has shown to decrease the cognitive overload and task saturation for the physician, as well as limiting the number of staff being exposed to a potentially infectious patient. The real-world application has allowed physicians to perform and oversee high-risk procedures such as intubation, line placement, and point of care ultrasound, without sacrificing the integrity of the resuscitation. Nurse-led codes have also given the physician the bandwidth to review pertinent medical history, advanced directives, determine reversible causes, and have the end of life conversations with family. While there is a paucity of research on the effectiveness of nurse-led codes, there are many potentially significant benefits. In addition to its value during a pandemic, it may also be beneficial during complex circumstances such as extracorporeal cardiopulmonary resuscitation.

Keywords: cardiopulmonary arrest, COVID-19, nurse-led code, task saturation

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Authors: Rabeab Khunpukdee, Aranya Sukchoui, Nonluk Somgit, Chitima Bunnaul

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Endotracheal displacement is a major risk of life threatening among critically ill patients. Standard nursing protocol is needed to minimize this risk and to improve clinical outcomes. To evaluate the effectiveness of the endothacheal care nursing guideline. The incidence rates of endochacheal displacement, oxygen deficiency after extubation, re-intubation, and nurse’s satisfaction on the utilization of the endotracheal care nursing guideline. An evidence-based nursing practice framework was used to develop the endotracheal care nursing guideline. The guideline valid content was review by a 3 panel of experts. The index of item objective (IOC) of the guideline was 0.93. The guideline was implemented in 130 patients (guideline group) and 19 registered nurses at a medicine ward, Had Yai hospital, Thailand. Patient’s outcomes were evaluated by comparison with those 155 patients who received the routine nursing care (routine care group). Descriptive statistics, frequency, percentage, mean, standard deviation and Mann Whitney U-test was analyzed using the computer program. All significantly and better outcomes were found in the guideline group compared to the routine care group. The guideline group has less incidence rates of endotracheal displacement (1.54 % vs 9.03 %, p < 0.05), and none of the guideline group had oxygen deficiency after extubation (0 % vs 83.33%) compared to the routine care group. All of the 2 patients in the guideline group, compared to 6 of 14 patients in the routine care group were re-intubation. The overall rate of re-intubation in the total group (n = 130 vs 155) was seen less in the guideline group than the routine care group (1.54 % vs 3.87). Overall, nurses satisfaction was at high-level (89.50%) on the utilization of the guideline.

Keywords: endotracheal care, nursing guideline, re-intubation, satisfaction

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Authors: Catelyn Coyle, Helena Kwakwa

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Objective: As novel and better tolerated therapies become available, effective HCV testing and care models become increasingly necessary to not only identify individuals with active infection but also link them to HCV providers for medical evaluation and treatment. Our aim is to describe an effective HCV testing and linkage to care model piloted in a network of five community health centers located in Philadelphia, PA. Methods: In October 2012, National Nursing Centers Consortium piloted a routine opt-out HCV testing model in a network of community health centers, one of which treats HCV, HIV, and co-infected patients. Key aspects of the model were medical assistant initiated testing, the use of laboratory-based reflex test technology, and electronic medical record modifications to prompt, track, report and facilitate payment of test costs. Universal testing on all adult patients was implemented at health centers serving patients at high-risk for HCV. The other sites integrated high-risk based testing, where patients meeting one or more of the CDC testing recommendation risk factors or had a history of homelessness were eligible for HCV testing. Mid-course adjustments included the integration of dual HIV testing, development of a linkage to care coordinator position to facilitate the transition of HIV and/or HCV-positive patients from primary to specialist care, and the transition to universal HCV testing across all testing sites. Results: From October 2012 to June 2015, the health centers performed 7,730 HCV tests and identified 886 (11.5%) patients with a positive HCV-antibody test. Of those with positive HCV-antibody tests, 838 (94.6%) had an HCV-RNA confirmatory test and 590 (70.4%) progressed to current HCV infection (overall prevalence=7.6%); 524 (88.8%) received their RNA-positive test result; 429 (72.7%) were referred to an HCV care specialist and 271 (45.9%) were seen by the HCV care specialist. The best linkage to care results were seen at the test and treat the site, where of the 333 patients were current HCV infection, 175 (52.6%) were seen by an HCV care specialist. Of the patients with active HCV infection, 349 (59.2%) were unaware of their HCV-positive status at the time of diagnosis. Since the integration of dual HCV/HIV testing in September 2013, 9,506 HIV tests were performed, 85 (0.9%) patients had positive HIV tests, 81 (95.3%) received their confirmed HIV test result and 77 (90.6%) were linked to HIV care. Dual HCV/HIV testing increased the number of HCV tests performed by 362 between the 9 months preceding dual testing and first 9 months after dual testing integration, representing a 23.7% increment. Conclusion: Our HCV testing model shows that integrated routine testing and linkage to care is feasible and improved detection and linkage to care in a primary care setting. We found that prevalence of current HCV infection was higher than that seen in locally in Philadelphia and nationwide. Intensive linkage services can increase the number of patients who successfully navigate the HCV treatment cascade. The linkage to care coordinator position is an important position that acts as a trusted intermediary for patients being linked to care.

Keywords: HCV, routine testing, linkage to care, community health centers

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Authors: Marek Kuźniewski, Magdalena B. Kaziuk , Danuta Fedak, Paulina Dumnicka, Ewa Stępień, Beata Kuśnierz-Cabala, Władysław Sułowicz

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Background: The high prevalence of cardiovascular morbidity and mortality among patients with chronic kidney disease (CKD) is observed especially in those undergoing dialysis. Osteoprotegerin (OPG) and its ligands, receptor activator of nuclear factor kappa-B ligand (RANKL) and tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) have been associated with cardiovascular complications. Our aim was to study their role as cardiovascular risk factors in stage 5 CKD patients. Methods: OPG, RANKL and TRAIL concentrations were measured in 69 hemodialyzed CKD patients and 35 healthy volunteers. In CKD patients, cardiovascular dysfunction was assessed with aortic pulse wave velocity (AoPWV), carotid artery intima-media thickness (CCA-IMT), coronary artery calcium score (CaSc) and N-terminal pro-B-type natriuretic peptide (NT-proBNP) serum concentration. Cardiovascular and overall mortality data were collected during a 7-years follow-up. Results: OPG plasma concentrations were higher in CKD patients comparing to controls. Total soluble RANKL was lower and OPG/RANKL ratio higher in patients. Soluble TRAIL concentrations did not differ between the groups and OPG/TRAIL ratio was higher in CKD patients. OPG and OPG/TRAIL positively predicted long-term mortality (all-cause and cardiovascular) in CKD patients. OPG positively correlated with AoPWV, CCA-IMT and NT-proBNP whereas OPG/TRAIL with AoPWV and NT-proBNP. Described relationships were independent of classical and non-classical cardiovascular risk factors, with exception of age. Conclusions: Our study confirmed the role of OPG as a biomarker of cardiovascular dysfunction and a predictor of mortality in stage 5 CKD. OPG/TRAIL ratio can be proposed as a predictor of cardiovascular dysfunction and mortality.

Keywords: osteoprotegerin, tumor necrosis factor-related apoptosis-inducing ligand, receptor activator of nuclear factor kappa-B ligand, hemodialysis, chronic kidney disease, cardiovascular disease

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