Search results for: patient waiting time

Authors: Emily Saurman, David Lyle

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In Australia, a well serviced rural town might have a psychiatrist visit once-a-month with more frequent visits from a psychiatric nurse, but many have no resident access to mental health specialists. Access to specialist care, would not only reduce patient distress and benefit outcomes, but facilitate the effective use of limited resources. The Mental Health Emergency Care-Rural Access Program (MHEC-RAP) was developed to improve access to specialist emergency mental health care in rural and remote communities using telehealth technologies. However, there has been no current benchmark to gauge program efficiency or capacity; to determine whether the program activity is justifiably sufficient. The evaluation of MHEC-RAP used multiple methods and applied a modified theory of access to assess the program and its aim of improved access to emergency mental health care. This was the first evaluation of a telepsychiatry service to include a time and motion study design examining program time expenditure, efficiency, and capacity. The time and motion study analysis was combined with an observational study of the program structure and function to assess the balance between program responsiveness and efficiency. Previous program studies have demonstrated that MHEC-RAP has improved access and is used and effective. The findings from the time and motion study suggest that MHEC-RAP has the capacity to manage increased activity within the current model structure without loss to responsiveness or efficiency in the provision of care. Enhancing program responsiveness and efficiency will also support a claim of the program’s value for money. MHEC-RAP is a practical telehealth solution for improving access to specialist emergency mental health care. The findings from this evaluation have already attracted the attention of other regions in Australia interested in implementing emergency telepsychiatry programs and are now informing the progressive establishment of mental health resource centres in rural New South Wales. Like MHEC-RAP, these centres will provide rapid, safe, and contextually relevant assessments and advice to support local health professionals to manage mental health emergencies in the smaller rural emergency departments. Sharing the application of this methodology and research activity may help to improve access to and future evaluations of telehealth and telepsychiatry services for others around the globe.

Keywords: access, emergency, mental health, rural, time and motion

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Authors: Abderrahmane Diaf, Kamel Benabdellaziz

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Remote arid areas of the vast expanses of the African deserts hold huge subterranean reserves of brackish water resources waiting for economic development. This work presents design guidelines as well as initial performance data of new autonomous solar desalination equipment which could help local communities produce their own fresh water using solar energy only and, why not, contribute to transforming desert lands into lush gardens. The output of solar distillation equipment is typically low and in the range of 3 l/m2/day on the average. This new design with an integrated, water-based, environmentally-friendly solar heat storage system produced 5 l/m2/day in early spring weather. Equipment output during summer exceeded 9 liters per m2 per day.

Keywords: multiple trough distillation, solar desalination, solar distillation with heat storage, water based heat storage system

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Authors: Paul Holmes, Mike N. G.

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Foundation-year doctors face increased stress, pressure and uncertainty when starting new rotations throughout their first years of work. This research questionnaire resulted in an induction cheat sheet and induction video that enhanced the Junior doctor's understanding of how to work effectively within the plastic surgery department at NHS Tayside. The objectives and goals were to improve the transition between cohorts of junior doctors in ward 26 at Ninewells Hospital. Before this quality improvement project, the induction pack was 74 pages long and over eight years old. With the support of consultant Mike Ng a new up-to-date induction was created. This involved a questionnaire and cheat sheet being developed. The questionnaire covered clerking, venipuncture, ward pharmacy, theatres, admissions, specialties on the ward, the cardiac arrest trolley, clinical emergencies, discharges and escalation. This audit has three completed cycles between August 2022 and August 2023. The cheat sheet developed a concise two-page A4 document designed for doctors to be able to reference easily and understand the essentials. The document format is a table containing ward layout; specialty; location; physician associate, shift patterns; ward rounds; handover location and time; hours coverage; senior escalation; nights; daytime duties, meetings/MDTs/board meetings, important bleeps and codes; department guidelines; boarders; referrals and patient stream; pharmacy; absences; rota coordinator; annual leave; top tips. The induction video is a 10-minute in-depth explanation of all aspects of the ward. The video explores in more depth the contents of the cheat sheet. This alternative visual format familiarizes the junior doctor with all aspects of the ward. These were provided to all foundation year 1 and 2 doctors on ward 26 at Ninewells Hospital at NHS Tayside Scotland. This work has since been adopted by the General Surgery Department, which extends to six further wards and has improved the effective handing over of the junior doctor’s role between cohorts. There is potential to further expand the cheat sheet to other departments as the concise document takes around 30 minutes to complete by a doctor who is currently on that ward. The time spent filling out the form provides vital information to the incoming junior doctors, which has a significant possibility to improve patient care.

Keywords: induction, junior doctor, handover, plastic surgery

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Authors: Gerard Bray, Derek Mao, Arya Bahadori, Sachinka Ranasinghe

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The EAU currently recommends partial nephrectomy as the preferred management for localised cT1 renal tumours, irrespective of surgical approach. With the advent of robotic assisted partial nephrectomy, there is growing evidence that warm ischaemia time may be reduced compared to the traditional laparoscopic approach. There is still no clear differences between the two approaches with regards to other peri-operative and oncological outcomes. Current limitations in the field denote the lack of single surgeon series to compare the two approaches as other studies often include multiple operators of different experience levels. To the best of our knowledge, this study is the first single surgeon series comparing peri-operative outcomes of robotic assisted and laparoscopic PN. The current study aims to reduce intra-operator bias while maintaining an adequate sample size to assess the differences in outcomes between the two approaches. We retrospectively compared patient demographics, peri-operative outcomes, and renal function derangements of all partial nephrectomies undertaken by a single surgeon with experience in both laparoscopic and robotic surgery. Warm ischaemia time, length of stay, and acute renal function deterioration were all significantly reduced with robotic partial nephrectomy, compared to laparoscopic nephrectomy. This study highlights the benefits of robotic partial nephrectomy. Further prospective studies with larger sample sizes would be valuable additions to the current literature.

Keywords: partial nephrectomy, robotic assisted partial nephrectomy, warm ischaemia time, peri-operative outcomes

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Authors: Ahmed Gendia, Waseem Kamran

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Objective: Total Laparoscopic hysterectomy (TLH) remains a common approach among laparoscopic surgeons. However, this approach depends on the use of uterine manipulator to facilitate the surgery. Although many studies reported the effectiveness of TLH with uterine manipulator, only few reported TLH without the use of any uterine or vaginal manipulation. the aim of this report is to demonstrate our Technique (kamran's TLH) in performing TLH without the use of any uterine or vaginal manipulation in benign conditions and report our intra- and post-operative outcomes. Methodology : surgical technique will be demonstrated through a short video highlighting the easy and safe to learn surgical steps. Additionally, the data of 86 patients who underwent KTLH for benign condition were retrospectively analyzed. the data included intra- and postoperative finding and complications. Results : A total of 86 hysterectomies were performed utilizing the Kamran's TLH ( KTHL). Mean age was 52.2 (±11) years old and BMI was 28.2(±7). Mean operative time was 64.7(±27.9) minutes and estimated bloods loss was 46.2(±54.6) ml. No intraoperative complications were recorded and there was no conversion to open surgery. Only one patient required readmission and surgery for vaginal vault dehiscence. Conclusion & Significance: Uterine manipulator is a key component in performing laparoscopic hysterectomy. However, our approach demonstrated that TLH can be safely performed without the use of any uterine or vaginal manipulation.

Keywords: laparoscopic hystrectomy, TLH, uterine manipulator, surgery

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Authors: Farahnaz Amini, Woo Yun Kin, Lazwani Kolandaiveloo

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Availability of different genetic tests after completion of Human Genome Project increases the physicians’ responsibility to keep themselves update on the potential implementation of these genetic tests in their daily practice. However, due to numbers of barriers, still many of physicians are not either aware of these tests or are not willing to offer or refer their patients for genetic tests. This study was conducted an anonymous, cross-sectional, mailed-based survey to develop a primary data of Malaysian physicians’ level of knowledge and perception of gene profiling. Questionnaire had 29 questions. Total scores on selected questions were used to assess the level of knowledge. The highest possible score was 11. Descriptive statistics, one way ANOVA and chi-squared test was used for statistical analysis. Sixty three completed questionnaires was returned by 27 general practitioners (GPs) and 36 medical specialists. Responders’ age range from 24 to 55 years old (mean 30.2 ± 6.4). About 40% of the participants rated themselves as having poor level of knowledge in genetics in general whilst 60% believed that they have fair level of knowledge. However, almost half (46%) of the respondents felt that they were not knowledgeable about available genetic tests. A majority (94%) of the responders were not aware of any lab or company which is offering gene profiling services in Malaysia. Only 4% of participants were aware of using gene profiling for detection of dosage of some drugs. Respondents perceived greater utility of gene profiling for breast cancer (38%) compared to the colorectal familial cancer (3%). The score of knowledge ranged from 2 to 8 (mean 4.38 ± 1.67). Non-significant differences between score of knowledge of GPs and specialists were observed, with score of 4.19 and 4.58 respectively. There was no significant association between any demographic factors and level of knowledge. However, those who graduated between years 2001 to 2005 had higher level of knowledge. Overall, 83% of participants showed relatively high level of perception on value of gene profiling to detect patient’s risk of disease. However, low perception was observed for both statements of using gene profiling for general population in order to alter their lifestyle (25%) as well as having the full sequence of a patient genome for the purpose of determining a patient’s best match for treatment (18%). The lack of clinical guidelines, limited provider knowledge and awareness, lack of time and resources to educate patients, lack of evidence-based clinical information and cost of tests were the most barriers of ordering gene profiling mentioned by physicians. In conclusion Malaysian physicians who participate in this study had mediocre level of knowledge and awareness in gene profiling. The low exposure to the genetic questions and problems might be a key predictor of lack of awareness and knowledge on available genetic tests. Educational and training workshop might be useful in helping Malaysian physicians incorporate genetic profiling into practice for eligible patients.

Keywords: gene profiling, knowledge, Malaysia, physician

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Authors: Fayez Hanna, Viet Tran

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A 20 years old lady- primigravida 6 weeks pregnant with unremarkable past history, presented to the emergency department at the Royal Hobart Hospital, Tasmania, Australia, with hyperemesis gravidarum associated with, dehydration and complicated with hematemesis and chest pain resistant. Accordingly, we conducted laboratory investigations which revealed: FBC: WBC 23.9, unremarkable U&E, LFT, lipase and her VBG showed a pH 7.4, pCo2 36.7, cK+ 3.2, cNa+ 142. The decision was made to do a chest X-ray (CXR) after explaining the risks/benefit of performing radiographic investigations during pregnancy and considering the patient's plan for the termination of the pregnancy as she was not ready for motherhood for shared decision-making and consent to look for pneumoperitoneum to suggest perforated viscus that might cause the hematemesis. However, the CXR showed pneumomediastinum but no evidence of pneumoperitoneum or pneumothorax. Consequently, a decision was made to proceed with CT oesophagography with imaging pre and post oral contrast administration to identify a potential oesophageal tear since it could not be excluded using a plain film of the CXR. The CT oesophagography could not find a leak for the administered oral contrast and thus, no oesophageal tear could be confirmed but could not exclude the Mallory-Weiss tear (lower oesophageal tear). Further, the CT oesophagography showed an extensive pneumomediastinum that could not be confirmed to be pulmonary in origin noting the presence of bilateral pulmonary interstitial emphysema and pneumothorax in the apex of the right lung that was small. The patient was admitted to the Emergency Department Inpatient Unit for monitoring, supportive therapy, and symptomatic management. Her hyperemesis was well controlled with ondansetron 8mg IV, metoclopramide 10mg IV, doxylamine 25mg PO, pyridoxine 25mg PO, esomeprazole 40mg IV and oxycodone 5mg PO was given for pain control and 2 litter of IV fluid. The patient was stabilized after 24 hours and discharged home on ondansetron 8mg every 8 hours whereas the patient had a plan for medical termination of pregnancy. Three weeks later, the patient represented with nausea and vomiting complicated by a frank hematemesis. Her observation chart showed HR 117- other vital signs were normal. Pathology showed WBC 14.3 with normal U&E and Hb. The patient was managed in the Emergency Department with the same previous regimen and was discharged home on same previous regimes. Five days later, she presented again with nausea, vomiting and hematemesis and was admitted under obstetrics and gynaecology for stabilization then discharged home with a plan for surgical termination of pregnancy after 3-days rather than the previously planned medical termination of pregnancy to avoid extension of potential oesophageal tear. The surgical termination and follow up period were uneventful. The case is considered rare as pneumomediastinum is a very rare complication of hyperemesis gravidarum where vomiting-induced barotrauma leads to a ruptured oesophagus and air leak into the mediastinum. However no rupture oesophagus in our case. Although the combination of pneumothorax and pneumomediastinum without oesophageal tear was reported only 8 times in the literature, but none of them was due to hyperemesis gravidarum.

Keywords: Pneumothorax, pneumomediastinum, hyperemesis gravidarum, pneumopericardium

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Authors: Ilana Margalith, Yaron Niv

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One of the most important factors of professional health treatment is teamwork, in which each discipline contributes its expert knowledge, thus ensuring quality and a high standard of care as well as efficient communication (one of the International Patient Safety Goals). However, in most countries, students are educated separately by each health discipline. They are exposed to teamwork only during their clinical experience, which in some cases is short and skill-oriented. In addition, health organizations in most countries are hierarchical and although changes have occurred in the hierarchy of the medical system, there are still disciplines that underrate the unique contributions of other health professionals, thus, young graduates of health professions develop and base their perception of their peers from other disciplines on insufficient knowledge. In order to establish a wide-ranging perception among nursing students as to the contribution of different health professionals to the health of their patients, students at the Clalit Nursing Academy, Rabin Campus (Dina), Israel, participated in an interdisciplinary clinical discussion with students from several different professions, other than nursing, who were completing their clinical experience at Rabin Medical Center in medicine, health psychology, social work, audiology, physiotherapy and occupational therapy. The discussion was led by a medical-surgical nursing instructor. Their tutors received in advance, a case report enabling them to prepare the students as to how to present their professional theories and interventions regarding the case. Mutual stimulation and acknowledgment of the unique contribution of each part of the team enriched the nursing students' understanding as to how their own nursing interventions could be integrated into the entire process towards a safe and speedy recovery of the patient.

Keywords: health professions' students, interdisciplinary clinical discussion, nursing education, patient safety

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Authors: Albert Suryaprawira

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The Nasion-Sella Line (NSL) has been used for several years as a reference line in longitudinal growth study. Therefore this line is considered to be stable not only to evaluate treatment outcome and to predict relapse possibility but also to manage prognosis. This is a radiographic superimposition of an adult male aged 19 years who complained of difficulty in aesthetic, talking and chewing. Patient has a midface hypoplasia profile (concave). He was diagnosed to have a severe Skeletal Class III with Class III malocclusion, increased lower vertical height, and an anterior open bite. A pre-treatment cephalometric radiograph was taken to analyse the skeletal problem and to measure the amount of bone movement and the prediction soft tissue response. A panoramic radiograph was also taken to analyse bone quality, bone abnormality, third molar impaction, etc. Before the surgery, a pre-surgical cephalometric radiograph was taken to re-evaluate the plan and to settle the final amount of bone cut. After the surgery, a post-surgical cephalometric radiograph was taken to confirm the result with the plan. The superimposition using NSL as a reference line between those radiographs was performed to analyse the outcome. It is important to describe the amount of hard and soft tissue movement and to predict the possibility of relapse after the surgery. The patient also needs to understand all the surgical plan, outcome and relapse prevention. The surgical management included maxillary impaction and advancement of Le Fort I osteotomy. The evaluation using NSL as a reference was a very useful method in determining the outcome and prognosis.

Keywords: Nasion-Sella Line, midface hypoplasia, Le Fort 1, maxillary advancement

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Authors: Asaad Alhabsi, Alyaqdan Algafri

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Aim: Reporting 83 years old man with history of left upper eyelid swelling post 4-lids blepharoplasty diagnosed based on clinical presentation and Radiological imaging with pseudoaneurysm of frontal branch of Superficial Temporal Artery post blepharoplasty. METHODS: 83 years old who presented to a Tertiary ophthalmic center with painless left upper eyelids swelling for 2 months post 4-lids blepharoplasty. Left subcutaneous, sub-brow lesion, in the supertemporal pre-septal area, large mass found and excised surgically. Then he developed recurrent larger mass twice first time treated with aspiration of blood, second time diagnosed with superficial temporal artery (STA) pseudoaneurysm of frontal branch treated with endovascular embolization. RESULTS: Pseudoaneurysm of superficial temporal artery (STA) is a rare, presenting usual post head or face trauma .literature reported few cases of such conditions post operatively, and no reported cases post blepharoplasty. CONCLUSIONS: Surgical intervention is the gold standard of treatment either directly by dissecting the aneurysmal sac and ligate both ends, or endovascular method of injecting thrombin or embolization which was done in this patient by interventional radiologist.

Keywords: superficial temporal artery, pseudoaneurysm, blepharoplasty, Oculoplasty

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Authors: Ghadeer M Alkusayer, Adelicia Yu, Pamela Orr

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Study objective: To report a case of postpartum pulmonary cryptococcal infection (CCI) in an otherwise healthy 35-year-old woman. Additionally, the cases of pulmonary cryptococcal infections either in the antepartum or the postpartum period with pregnancy outcomes, were systematically reviwed. Methods: A systematic search of Cochrane Library, MEDLINE, and EMBASE was conducted for peer-reviewed studies without date restrictions, published in English and relating to CCI during pregnancy or postpartum period. Conference press, editorials, opinion pieces and letters were excluded. Two authors independently screened citations and full-text articles, extracted data and assessed study quality. Given the heterogeneity of study designs, a narrative synthesis was conducted. Results: The search identified 128 references, of which 22 case reports and series met the inclusion criteria. This is a total of 29 women (including the current case) . The mean age of the women was 28.3 ± 12.3 years. Nine (31.03%) presented and were diagnosed in the postpartum period. Two (6.90%) of the patients were reported as immunocompromised with HIV. Four maternal deaths (13.79%) were found in this case series with one (4.3%) patient with severe neurological deficits. Four (17.4%) infant deaths were reported. Women primary presentation varied with chest pain 13 (44.82%), headache 10 (35.70%), dyspnea 19 (65.51%), or fever 12 (41.38%). Three studies reported placental pathology positive for C. neoformans. Conclusion: This case of pulmonary cryptococcal infection in the postpartum period is an important addition to the literature of this rare infection in pregnancy. The patient is not immunocompromised. The patient was successfully treated with 4 months of Fluconazole 400 mg and continued to breastfeed the healthy baby.

Keywords: pulmonary cryptococcus, pregnancy, cryptococci , postpartum

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Authors: Deanne McArthur, Melinda Wall, Claire Hanlon, Dana Agnolin, Krista Davis, Melanie Dennis, Elizabeth Glidden, Anne Marie Smith, Claudette Thomson

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Background and significance: Patients with eating disorders have traditionally been an underserviced population within the publicly-funded Canadian healthcare system. This situation was worsened by the COVID-19 pandemic and accompanying public health measures, such as “lockdowns” which led to increased isolation, changes in routine, and other disruptions. Illness severity and prevalence rose significantly with corresponding increases in patient suffering and poor outcomes. In Ontario, Canada, the provincial government responded by increasing funding for the treatment of eating disorders, including the launch of a new day program at an intermediate, regional health centre that already housed an outpatient treatment service. The funding was received in March 2022. The care team sought to optimize this opportunity by designing a program that would fit well within the resource-constrained context in Ontario. Methods: This case study will detail how the team consulted the literature and sought patient and family input to design a program that optimizes patient outcomes and supports for patients and families while they await treatment. Early steps include a review of the literature, expert consultation and patient and family focus groups. Interprofessional consensus was sought at each step with the team adopting a shared leadership and patient-centered approach. Methods will include interviews, observations and document reviews to detail a rich description of the process undertaken to design the program, including evaluation measures adopted. Interim findings pertaining to the early stages of the program-building process will be detailed as well as early lessons and ongoing evolution of the program and design process. Program implementation and outcome evaluation will continue throughout 2022 and early 2023 with further publication and presentation of study results expected in the summer of 2023. The aim of this study is to contribute to the body of knowledge pertaining to the design and implementation of eating disorder treatment services that combine outpatient and day treatment services in a resource-constrained context.

Keywords: eating disorders, day program, interprofessional, outpatient, adolescents, transitional aged youth

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Authors: Alireza Javadzadeh

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Background: The purpose of this prospective, randomized study was to compare the safety and efficacy of oral versus i.v. midazolam in providing sedation for pediatric upper gastrointestinal (GI) endoscopy. Methods: Sixty-one children (age < 16 years) scheduled for upper GI endoscopy were studied. Patients were randomly assigned to receive oral or i.v. midazolam. Measurements were made and compared for vital signs, level of sedation, pre- and post-procedure comfort, anxiety during endoscopy, ease of separation from parents, ease and duration of procedure, and recovery time. Results: Patients were aged 1–16 years (mean 7.5 ± 3.42 years); 30 patients received oral medication, and 31 received i.v. medication. There were no statistically significant differences in age or gender between groups. There were no significant differences in level of sedation, ease of separation from parents, ease of ability to monitor the patient during the procedure, heart rate, systolic arterial pressure, or respiratory rate. Oxygen saturation was significantly lower in the i.v. group than the oral group 10 and 30 min after removal of the endoscope, and recovery time was longer in the oral than the i.v. group. Conclusions: Oral administration of midazolam is a safe and effective method of sedation that significantly reduces anxiety and improves overall tolerance for children undergoing esophagogastroduodenoscopy.

Keywords: children, endoscopy, midazolam, oral, sedation

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Authors: Yutong Xu, Wanting Zhang, Jia Wang, Zihan Guo, Weiguang Ma

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Background: The resilience education of intern nursing students has significant implications for the development and improvement of the nursing workforce. The clinical internship period is a critical time for enhancing resilience. Aims: To evaluate the resilience level of Chinese nursing interns and identify the factors affecting resilience early in their careers. Methods: The cross-sectional study design was adopted. From March 2022 to May 2023, 512 nursing interns in tertiary care hospitals were surveyed online with the Connor-Davidson Resilience Scale, the Clinical Learning Environment scale for Nurse, and the Career Adapt-Abilities Scale. Structural equation modeling was used to clarify the relationships among these factors. Indirect effects were tested using bootstrapped Confidence Intervals. Results: The nursing interns showed a moderately high level of resilience[M(SD)=70.15(19.90)]. Gender, scholastic attainment, had a scholarship, career adaptability and clinical learning environment were influencing factors of nursing interns’ resilience. Career adaptability and clinical learning environment positively and directly affected their resilience level (β = 0.58, 0.12, respectively, p＜0.01). career adaptability also positively affected career adaptability (β = 0.26, p < 0.01), and played a fully mediating role in the relationship between clinical learning environment and resilience. Conclusion: Career adaptability can enhance the influence of clinical learning environment on resilience. The promotion of career adaptability and the clinical teaching environment should be the potential strategies for nursing interns to improve their resilience, especially for those female nursing interns with low academic performance. Implications for Nursing Educators Nursing educators should pay attention to the cultivation of nursing students' resilience; for example, by helping them integrate to the clinical learning environment and improving their career adaptability. Reporting Method: The STROBE criteria were used to report the results of the observations critically. Patient or Public Contribution No patient or public contribution.

Keywords: resilience, clinical learning environment, career adaptability, nursing interns

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Authors: Mohammad Hossein Ahmadi, Vahid Haghighatdoost

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Spatial databases have been an active area of research over years. In this paper, we study how to answer the General Time-Dependent Sequenced Route queries. Given the origin and destination of a user over a time-dependent road network graph, an ordered list of categories of interests and a departure time interval, our goal is to find the minimum travel time path along with the best departure time that minimizes the total travel time from the source location to the given destination passing through a sequence of points of interests belonging to each of the specified categories of interest. The challenge of this problem is the added complexity to the optimal sequenced route queries, where we assume that first the road network is time dependent, and secondly the user defines a departure time interval instead of one single departure time instance. For processing general time-dependent sequenced route queries, we propose two solutions as Discrete-Time and Continuous-Time Sequenced Route approaches, finding approximate and exact solutions, respectively. Our proposed approaches traverse the road network based on A*-search paradigm equipped with an efficient heuristic function, for shrinking the search space. Extensive experiments are conducted to verify the efficiency of our proposed approaches.

Keywords: trip planning, time dependent, sequenced route query, road networks

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Authors: Augustina Konadu Larbi-Ampofo, Ekemini Umoinwek

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Background: Hypercalcaemia is a common electrolyte imbalance that increases mortality if poorly controlled. Primary hyperparathyroidism often presents like this with a prevalence of 0.1-0.3%. Management due to an ectopic parathyroid adenoma in the mediastinum is challenging, especially in a patient with a pacemaker. Case Presentation: A 79-year-old woman with a history of a previous cardiac arrest, permanent pacemaker, ischaemic heart disease, bilateral renal calculi, rectal polyps, liver cirrhosis, and a family history of hyperthyroidism presented to the emergency department with acute back pain. Management and Outcome: The patient was diagnosed with primary hyperparathyroidism due to her elevated corrected calcium and parathyroid hormone levels. Parathyroid investigations consisting of an NM MIBI scan, SPECT-CT, 4D parathyroid scan, and an ultrasound scan of the neck and thorax confirmed an ectopic parathyroid adenoma in the mediastinum at the level of the aortic arch, along with benign thyroid nodules. The location of the adenoma warranted a thoracoscopic surgical approach; however, the presence of her pacemaker and other cardiovascular conditions predisposed her to a potentially poorer post-operative outcome. Discussion: Mediastinal ectopic parathyroid adenomas are rare and difficult to diagnose and treat, often needing a multimodal imaging approach for accurate localisation. Surgery is a definitive treatment; however, in this patient, long-term medical treatment with cinacalcet was the only next suitable treatment option. The difficulty with this is that cinacalcet tackles the biochemical markers of the disease entity and not the disease itself, leaving room for what happens next if there is refractory/uncontrolled hypercalcaemia in this patient with a pacemaker. Moreover, the coexistence of her multiple conditions raises the suspicion of an underlying multisystemic or multiple endocrine disorder, with multiple endocrine neoplasia coming to mind, necessitating further genetic or autoimmune investigations. Conclusion: Mediastinal ectopic parathyroid adenomas are rare, with diagnostic and management challenges.

Keywords: mediastinal ectopic parathyroid adenoma, hyperparathyroidism, SPECT/CT, nuclear medicine, multimodal imaging

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Authors: Vivek Saxena, Shreshtha Saxena

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Background: Gestational diabetes mellitus (GDM) is defined as impaired glucose tolerance first recognized during pregnancy. Uncontrolled or untreated GDM is associated with various adverse outcomes to the maternal and fetal health. Overt diabetes mellitus may also develop in such patients. It is universally accepted fact that first and foremost management to treat GDM is dietary control and lifestyle modification even before starting any oral hypoglycemic agent (OHA) or insulin. So, proper dietary management and little changes in the patient’s lifestyle are very effective for reducing her plasma glucose level. Objectives: Proper counselling of the patients and flexibility in their lifestyle and diet can effectively control the plasma glucose level in GDM patients. Methods: Total 60 GDM patients of age > 18 years were taken. We had three counselling sessions with the patient and other members of the family like husband, parents, and in-laws at different intervals, discussed their lifestyle and diet pattern, helped them to eliminate the factors those had an adverse effect on plasma glucose level and promoted them to acquire a healthy lifestyle. We have counselled the patient and her family member separately and then together also. They have explained how increased plasma glucose level can be effectively controlled with the little modification in their diet and routine activities. They were also taught to remain stress-free during their rest of antenatal period. We have excluded the patients from our study who were diabetic before pregnancy and patients with other comorbid illnesses like hypothyroidism and valvular heart disease. Results and conclusions: Results were very rewarding as patients could acquire a lifestyle of their choice. They were happy because extra pill burden was not there. All the 60 patients were normoglycemic in remaining antenatal period, 48 patients were delivered normally and 12 patients underwent cesarean section due to various reasons.Regular counselling of the patients regarding their disease and little alterations in diet and lifestyle controlled the plasma glucose level much effectively. The things were more easier and effective when we included other family members during our counselling session because they play a major role in patient’s day to day activity and influence her life.

Keywords: dietary management, gestational diabetes mellitus, impaired glucose tolerance, oral hypoglycemic agent, pregnancy

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Authors: Ling-Lang Huang

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Research Background: Historically, the evolution of medicine has not only aimed to extend life but has also inadvertently introduced suffering in the process of maintaining life, presenting a contemporary challenge. We must carefully assess the conflict between the length of life and the quality of living. Evidence-Based Medicine (EBM) exists primarily to ensure the quality of cures. However, EBM alone does not fulfill our ultimate medical goals; we must also evaluate Value-Based Medicine (VBM) to find the best treatment for patients. Research Methodology: We can attempt to integrate EBM with VBM. Within the five steps of EBM, the first three steps (Ask—Acquire—Appraise) focus on the physical aspect of humans. However, in the fourth and fifth steps (Apply—Assess), the focus shifts from the physical to applying evidence-based treatment to the patient and assessing its effectiveness, considering a holistic approach to the individual. To consider VBM for patients, we can divide the process into three steps: The first step is "awareness," recognizing that each patient inhabits a different life-world and possesses unique differences. The second step is "integration," akin to the hermeneutic concept of the Fusion of Horizons. This means being aware of differences and also understanding the origins of these patient differences. The third step is "respect," which involves setting aside our adherence to medical objectivity and scientific rigor to respect the ultimate healthcare decisions made by individuals regarding their lives. Discussion and Conclusion: After completing these three steps of VBM, we can return to the fifth step of EBM: Assess. Our assessment can now transcend the physical treatment focus of the initial steps to align with a holistic care philosophy.

Keywords: shared decision-making, evidence-based medicine, values-based medicine, holistic healthcare

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Authors: A. Poukens, I. Sluyts, A. Krings, J. Swartenbroekx, D. Geeroms, J. Poukens

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Introduction and Objectives: It has been known for many years that with the administration of intravenous medication, a rather significant part of the planned to be administered infusion solution, the residual volume ( the volume that remains in the IV line and or infusion bag), does not reach the patient and is wasted. This could possibly result in under dosage and diminished therapeutic effect. Despite the important impact on the patient, the reduction of residual volume lacks attention. An optimized and clearly stated protocol concerning the reduction of residual volume in an IV line is necessary for each hospital. As described in my Master’s thesis, acquiring the degree of Master in Hospital Pharmacy, administration of intravenous medication can be optimized by reduction of the residual volume. Herewith effectiveness, user-friendliness, cost efficiency and safety were taken into account. Material and Methods: By usage of a literature study and an online questionnaire sent out to all Flemish hospitals and hospitals in the Netherlands (province Limburg), current flush methods could be mapped out. In laboratory research, possible flush methods aiming to reduce the residual volume were measured. Furthermore, a self-developed experimental method to reduce the residual volume was added to the study. The current flush methods and the self-developed experimental method were compared to each other based on cost efficiency, user-friendliness and safety. Results: There is a major difference between the Flemish and the hospitals in the Netherlands (Province Limburg) concerning the approach and method of flushing IV lines after administration of intravenous medication. The residual volumes were measured and laboratory research showed that if flushing was done minimally 1-time equivalent to the residual volume, 95 percent of glucose would be flushed through. Based on the comparison, it became clear that flushing by use of a pre-filled syringe would be the most cost-efficient, user-friendly and safest method. According to laboratory research, the self-developed experimental method is feasible and has the advantage that the remaining fraction of the medication can be administered to the patient in unchanged concentration without dilution. Furthermore, this technique can be applied regardless of the level of the residual volume. Conclusion and Recommendations: It is recommendable to revise the current infusion systems and flushing methods in most hospitals. Aside from education of the hospital staff and alignment on a uniform substantiated protocol, an optimized and clear policy on the reduction of residual volume is necessary for each hospital. It is recommended to flush all IV lines with rinsing fluid with at least the equivalent volume of the residual volume. Further laboratory and clinical research for the self-developed experimental method are needed before this method can be implemented clinically in a broader setting.

Keywords: intravenous medication, infusion therapy, IV flushing, residual volume

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Authors: J. Punj, R. K. Pandey, V. Darlong, K. Thangavel

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Background: Dural puncture epidural (DPE) technique has been introduced recently for labour analgesia however, no study has compared ropivacaine and levobupivacaine for the same. Methods: The primary aim of the study was to compare time to onset of the Numerical Pain Rating Score (NPRS) ≤ 1 in labour analgesia with both drugs. After obtaining ethics and patient consent, ASA I and ASA II parturient with single foetus in vertex presentation and cervical dilatation <5.0 cm were included. DPE was performed with 16/ 26 G combined spinal epidural (CSE) technique, and parturients randomized into two groups. In Group R ( Ropivacaine) 20 ml 0.125% ropivacaine+ fentanyl 2µg/ml was injected to a maximum of 20 ml in 20 minutes and in Group L (Levobupivacaine), 20 ml 0.125% levobupivacaine + fentanyl 2µg/ml was injected. Outcomes were assessed at 0.5,2,4,6,8,10,12,14,16,18,20 and 30 minutes, then every 90 minutes until delivery. Appropriate statistical analysis was done, and p value of <0.05 was considered statistically significant. Results: The median time to onset of NPRS ≤1 in both groups was comparable (group R= 16 minutes vs group L= 18 minutes (p = 0.076). Volume of drug for NPR ≤1 in both groups was also comparable (Group R 15.95± 2.03 ml vs Group L 16.35 ± 1.34 ml (p=0.47). Conclusion: DPE with 16 G epidural needle and 26 gauge spinal needle with both 0.125% ropivacaine and 0.125% levobupivacaine results in similar efficacy of labour analgesia.

Keywords: dural puncture epidural, labour analgesia, obstetric analgesia, hypotension

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Authors: Denisa Mackova, Andrea Pokorna

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The management of postoperative pain is a meaningful part of quality care. The experience and knowledge of registered nurses in postoperative pain management can be influenced by local know-how. Therefore, the research helps to understand the cultural differences between two countries with the aim of evaluating the management of postoperative pain management among the nurses from the Czech Republic and the Kingdom of Saudi Arabia. Both countries have different procedures on managing postoperative pain and the research will provide an understanding of both the advantages and disadvantages of the procedures and also highlight the knowledge and experience of registered nurses in both countries. Between the Czech Republic and the Kingdom of Saudi Arabia, the expectation is for differing results in the usage of opioid analgesia for the patients postoperatively and in the experience of registered nurses with Patient Controlled Analgesia. The aim is to evaluate the knowledge and awareness of registered nurses and to merge the data with the postoperative pain management in the early postoperative period in the Czech Republic and the Kingdom of Saudi Arabia. Also, the aim is to assess the knowledge and experience of registered nurses by using Patient Controlled Analgesia and epidural analgesia treatment in the early postoperative period. The criteria for those providing input into the study, are registered nurses, working in surgical settings (standard departments, post-anesthesia care unit, day care surgery or ICU’s) caring for patients in the postoperative period. Method: Research is being conducted by questionnaires. It is a quantitative research, a comparative study of registered nurses in the Czech Republic and the Kingdom of Saudi Arabia. Questionnaire surveys were distributed through an electronic Bristol online survey. Results: The collection of the data in the Kingdom of Saudi Arabia has been completed successfully, with 550 respondents, 77 were excluded and 473 respondents were included for statistical data analysis. The outcome of the research is expected to highlight the differences in treatment through Patient Controlled Analgesia, with more frequent use in the Kingdom of Saudi Arabia. A similar assumption is expected for treatment conducted by analgesia. We predict that opioids will be used more regularly in the Kingdom of Saudi Arabia, whilst therapy through NSAID’s being the most common approach in the Czech Republic. Discussion/Conclusion: The majority of respondents from the Kingdom of Saudi Arabia were female registered nurses from a multitude of nations. We are expecting a similar split in gender between the Czech Republic respondents; however, there will be a smaller number of nationalities. Relevance for research and practice: Output from the research will assess the knowledge, experience and practice of patient controlled analgesia and epidural analgesia treatment. Acknowledgement: This research was accepted and affiliated to the project: Postoperative pain management, knowledge and experience registered nurses (Czech Republic and Kingdom of Saudi Arabia) – SGS05/2019-2020.

Keywords: acute postoperative pain, epidural analgesia, nursing care, patient controlled analgesia

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Authors: Lumindu Dilumka, Ranaweera I. D., Sudusinghe S. P., Sanduni Kanchana A. M. K.

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This study was motivated by the challenges experienced by parents and guardians in ensuring the safety of children in cyberspace. In the last two or three years, online education has become very popular all over the world due to the Covid 19 pandemic. Therefore, parents, guardians and teachers must ensure the safety of children in cyberspace. Children are more likely to go astray and there are plenty of online programs are waiting to get them on the wrong track and also, children who are engaging in the online education can be distracted at any moment. Therefore, parents should keep a close check on their children's online activity. Apart from that, due to the unawareness of children, they tempt to share their sensitive information, causing a chance of being a victim of phishing attacks from outsiders. These problems can be overcome through the proposed web-based system. We use feature extraction, web tracking and analysis mechanisms, image processing and name entity recognition to implement this web-based system.

Keywords: online education, cyber bullying, social media, face recognition, web tracker, privacy data

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Authors: Komal Fizza

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Irrational and non-judicious use of antibiotics pave the way for an upsurge in antibiotic resistance, diminished effectiveness of different therapeutic regimens and as well as impounding effect on disease management leading to further morbidities. In the backdrop of this the current research is aimed to assess whether antimicrobial prescribing is in accordance with the Infectious Disease Society of America Guidelines in hospitalized patients at Shifa International Hospital, Islamabad, Pakistan. Shifa International Hospital, Islamabad is a 500 bed hospital. With the help of MIS team a form wad developed that gave the information about medical records number, name of the patient, day of start of antibiotic, the day antibiotic is supposed to be stopped and as well as the diagnosis of the patient. A ward pharmacist was employed to generate this report on a daily basis. The therapeutic regiment was reviewed by the pharmacist by monitoring the clinical progress, laboratory report and diagnosis. On the basis of this information, pharmacist made suggestions and forwarded to the hospital doctors responsible for prescribing antibiotics. If desired, changes were made regularly. In the current research our main focus was to implement this action and therefore, started monitoring patients who were on antibiotic regimens for more than 10-15 days. We took this initiative since November, 2013. At the start of the program a maximum 19 patients/day were reported to be on antibiotic regimen for more than 10-15 days. After the implementation of the initiative, the number of patients was decreased to fifteen patients per day in December, further decreased to 7 in the month of January and 9 and 6 in February and March respectively. The average patient census was 350. The current pilot study highlighted the role of pharmacist in initiating antibiotic stewardship programs in hospital settings.

Keywords: stewardship, antibiotics, resistance, clinical process

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Authors: Marah El-Beeli, Abdullah Balkhair, Zakaryia Al Muharmi, Samir Al Adawi, Mansoor Al-Jabri, Abdullah Al Rawahi, Hazaa Al Yahyae, Eman Al Balushi, Yahya M. Al-Farsi

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The health care service and the anticancer chemotherapeutics has changed the natural history of cancer into manageable chronic disease and improve the cancer patient’s lifestyle and increase the survival time. Despite that, still, infection is the major dilemma opposing the cancer patient either because of the clinical presentation of the cancer type and impaired immune system or as a consequence of anticancer therapy. This study has been conducted to1) track changes in the epidemiology of hospital-acquired bloodstream infections among patients with malignancies in the last five years. 2) To explore the causative pathogens and 3) the outcome of HA-BSIs in patients with a different types of malignancies. An ampi-directional study (retrospective and prospective follow up) of patients with malignancies admitted at Sultan Qaboos University hospital (570-bed tertiary hospital) during the study period (from January 2015 to December 2019). The cumulative frequency and prevalence rates of HA-BSIs by patients and isolates were calculated. In addition, the cumulative frequency of participants with single versus mixed infections and types of causative micro-organisms of HA-BSIs were obtained. A total of 1246 event of HA-BSIs has occurred during the study period. Nearly the third (30.25%) of the HA-BSI events was identified among 288 patients with malignancies. About 20% of cases were mixed infections (more than one isolate). Staphylococcus spp were the predominant isolated pathogen (24.7%), followed by Klebsiella spp (15.8%), Escherichia spp (13%), and Pseudomonas spp (9.3%). About half (51%) of cases died in the same year, and (64%) of the deaths occur within two weeks after the infection. According to the observations, no changes in the trends of epidemiology, causative pathogens, morbidity, and mortality rates in the last five years.

Keywords: epidemiology, haematological malignancies, hospital acquired bloodstream infections, solid malignancies

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Authors: Nadeen Eltoukhy, Sahar S. Sheta, Walaa Elnaggar, Karim Bakr

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Purpose: The aim of this study is to compare the clinical efficacy and side effects of oral versus intralesional propranolol treatment of infantile capillary hemangiomas in infants. Methods: The study enrolled 40 infants diagnosed with infantile capillary hemangiomas. Patients were divided into 2 groups: Group A (Non-invasive group) included 20 infants who received oral propranolol hydrochloride starting at a dose of 1 mg/kg/day BID, then increased to a max of 2 mg/kg/day BID gradually over 2 weeks for 3 months. Group B (Invasive group) included 20 infants who received intralesional propranolol injection at a dose of 1 mg/mL; the volume of the injected drug depended on the size of the lesion (0.2 mL injected per cm of lesion diameter), with a maximum volume of 1 mL for a lesion of 5 cm diameter under complete aseptic conditions in the operating theater. Results: At three months after initiating treatment, the circumferential size of the hemangioma showed a statistically significant decrease in both groups; in Group A from 3.66±2.89 cm to 1.56±1.26 cm with p-value <0.05 and in Group B from 2.99±2.73 cm to 1.32±1.18 cm with p-value <0.05. There is no statistically significant comparative difference between the two groups (p-value = 0.538 = insignificant). Regarding the complications of oral propranolol, one patient (5%) had bradycardia, and one patient (5%) had diarrhea. In the injection group, 20 patients (100%) had local edema, and one patient (5%) had a local infection. Conclusions: Both oral non-invasive and intralesional invasive propranolol are safely used to successfully treat and decrease the size of infantile hemangioma while showing no statistically comparative difference between both treatment techniques.

Keywords: hemangioma, oral beta blocker, intralesional beta blocker, infants

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Authors: Muhsin Kizhisseri, Jorg Schluter, Saleh Gharie

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Atherosclerosis is the main reason of stroke, which is one of the deadliest diseases in the world. The carotid artery in the brain is the prominent location for atherosclerotic progression, which hinders the blood flow into the brain. The inclusion of computational fluid dynamics (CFD) into the diagnosis cycle to understand the hemodynamics of the patient-specific carotid artery can give insights into stroke prediction. Realistic outlet boundary conditions are an inevitable part of the numerical simulations, which is one of the major factors in determining the accuracy of the CFD results. The Windkessel model-based outlet boundary conditions can give more realistic characteristics of the distal vascular branches of the carotid artery, such as the resistance to the blood flow and compliance of the distal arterial walls. This study aims to find the most influential distal branches of the carotid artery by using the Windkessel model parameters in the outlet boundary conditions. The parametric study approach to Windkessel model parameters can include the geometrical features of the distal branches, such as radius and length. The incorporation of the variations of the geometrical features of the major distal branches such as the middle cerebral artery, anterior cerebral artery, and ophthalmic artery through the Windkessel model can aid in identifying the most influential distal branch in the carotid artery. The results from this study can help physicians and stroke neurologists to have a more detailed and accurate judgment of the patient's condition.

Keywords: stroke, carotid artery, computational fluid dynamics, patient-specific, Windkessel model, distal vascular branches

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Authors: Ashish Sinha, Pushpend Agrawal

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Background: Patients with undiagnosed pulmonary TB predominantly act as reservoirs for its transmission through 10-15 secondary infections in the next 1-5 Yrs. Delays in the diagnosis and treatment may worsen the disease with increase the risk of death. Factors responsible for such delays by tracking patient pathways to treatment may help in planning better interventions. The provision of ‘free diagnosis and treatment’ forms the cornerstone of the National Tuberculosis Elimination Programme (NTEP). OOPE is defined as the money spent by the patient during TB care other than public health facilities. Free TB care at all health facilities could reduce out-of-pocket expenses to the minimum possible levels. Material and Methods: This cross-sectional study was conducted among randomly selected 252 TB patients from Nov – Oct 2022 by taking in-depth interviews following informed verbal consent. We documented their journey from initial symptoms until they reached the public health facility, along with their ‘out-of-pocket expenditure’ (OOPE) pertaining to TB care. Results: Total treatment delay was 91±72 days on average (median: 77days, IQR: 45-104 days), while the isolated patient delay was 31±45 days (median: 15 days, IQR: 0 days to 43 days); diagnostic delay; 57±60 days (median: 42days, IQR 14-78 days), treatment delay 19 ± 18 days (median: 15days, IQR: 11-19 days). A patient delay (> 30 days) was significantly associated with ignorance about classic symptoms of pulmonary TB, adoption of self-medication, illiteracy, and middle and lower social class. Diagnostic delay was significantly higher among those who contacted private health facilities, were unaware of signs and symptoms, had >2 consultations, and not getting an appropriate referral for TB care. Most (97%) of the study participants interviewed claimed to have incurred some expenditure.Median total expenses were 6155(IQR: 2625-15175) rupees. More than half 141 (56%) of the study participants had expenses >5000 rupees. Median transport expenses were 525(IQR: 200-1012) rupees; Median consultation expenses were 700(IQR: 200-1600) rupees; Median investigation expenses were 1000(IQR: 0-3025) rupees and the Median medicine expenses were 3350(IQR: 1300-7525).OOPE for consultation, investigation, and medicine was observed to be significantly higher among patients who ignored classical signs& symptoms of TB, repeated visits to private health facilities, and due to self-medication practices. Transport expenses and delays in seeking care at facilities were observed to have an upward trend with OOP Expenses (r =1). Conclusion: Delay in TB care due to low awareness about signs and symptoms of TB and poor seeking care, lack of proper consultation, and appropriate referrals reported by the study subjects indicate the areas which need proper attention by the program managers. Despite a centrally sponsored programme, the financial burden on TB patients is still in the unacceptable range. OOPE could be reduced as low as possible by addressing the responsible factors linked to it.

Keywords: patient pathway, delay, pulmonary tuberculosis, out of pocket expenses

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Authors: I. Dumand, C. Clesse, M. Decker, C. Savini, J. Lighezzolo-Alnot

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In the landscape of French psychiatry, long-term institutionalization of patients with severe and disabling chronics disorders is common. Faced with the failures of classical reinsertion, sometimes these users are hurriedly considered as 'insortables'. However, this representation is often swayed by the current behavior of the patient observed through the clinical observation. Unfortunately, it seems that this way of proceeding can not integrate the potentialities of the institutionalized patients and their possible evolution. Therefore, in order not to make hasty conclusions about the life perspectives of these individuals, it seems essential to associate with clinical observation a psycho social rehabilitation diagnosis. Multidisciplinary, it combine all the aspects that make up the life of the subject (the life aspirations, psycho social determinants, family support, cognitive potential, symptoms ...). In this paper, we will rank these different aspects necessary prerequisites to the realization of a psycho social rehabilitation diagnosis. Then, we will specifically speak of the issue of psychological evaluation. By adopting an integrative approach combining neuro psychological tools (Grober and Buschke, Stroop, WCST, AIPSS, WAIS, Eyes test ...) and projective tools interpreted under a psycho dynamic angle (Rorschach, TAT ..) we think that we can grasp the patient in his globality. Thus, during this process we will justify the interest of combining a cognitive and a psycho affective approach, we will identify the different items assessed and their future implications on the everyday life of the users. Finally, we show that this diagnosis can give a chance to reintegration to 30% of patients considered as ''insortables''. In conclusion, we will highlight the importance of this process dear to the community psychology emphasizing in the same time the interests of this approach in terms of empowerment, recovery and quality of life.

Keywords: assessment, potentiality, psychosocial rehabilitation diagnosis, tools

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Authors: Ashley L. Freeman, Jessica D. Watkins

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TeleEmergency Medicine (TeleEM) is an innovative approach leveraging virtual technology to deliver specialized emergency medical care across diverse healthcare settings, including internal acute care and critical access hospitals, remote patient monitoring, and nurse triage escalation, in addition to external emergency departments, skilled nursing facilities, and community health centers. TeleEM represents a significant advancement in the delivery of emergency medical care, providing healthcare professionals the capability to deliver expertise that closely mirrors in-person emergency medicine, exceeding geographical boundaries. Through qualitative research, the extension of timely, high-quality care has proven to address the critical needs of patients in remote and underserved areas. TeleEM’s service design allows for the expansion of existing services and the establishment of new ones in diverse geographic locations. This ensures that healthcare institutions can readily scale and adapt services to evolving community requirements by leveraging on-demand (non-scheduled) telemedicine visits through the deployment of multiple video solutions. In terms of financial management, TeleEM currently employs billing suppression and subscription models to enhance accessibility for a wide range of healthcare facilities. Plans are in motion to transition to a billing system routing charges through a third-party vendor, further enhancing financial management flexibility. To address state licensure concerns, a patient location verification process has been integrated through legal counsel and compliance authorities' guidance. The TeleEM workflow is designed to terminate if the patient is not physically located within licensed regions at the time of the virtual connection, alleviating legal uncertainties. A distinctive and pivotal feature of TeleEM is the introduction of the TeleEmergency Medicine Care Team Assistant (TeleCTA) role. TeleCTAs collaborate closely with TeleEM Physicians, leading to enhanced service activation, streamlined coordination, and workflow and data efficiencies. In the last year, more than 800 TeleEM sessions have been conducted, of which 680 were initiated by internal acute care and critical access hospitals, as evidenced by quantitative research. Without this service, many of these cases would have necessitated patient transfers. Barriers to success were examined through thorough medical record review and data analysis, which identified inaccuracies in documentation leading to activation delays, limitations in billing capabilities, and data distortion, as well as the intricacies of managing varying workflows and device setups. TeleEM represents a transformative advancement in emergency medical care that nurtures collaboration and innovation. Not only has advanced the delivery of emergency medicine care virtual technology through focus group participation with key stakeholders, rigorous attention to legal and financial considerations, and the implementation of robust documentation tools and the TeleCTA role, but it’s also set the stage for overcoming geographic limitations. TeleEM assumes a notable position in the field of telemedicine by enhancing patient outcomes and expanding access to emergency medical care while mitigating licensure risks and ensuring compliant billing.

Keywords: emergency medicine, TeleEM, rural healthcare, telemedicine

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Authors: Kamal Chafiq, Youssef Hadzine, Adel Elmekkaoui, Othmane Benlenda, Houssam Rajad, Soukaina Wakrim, Hicham Nassik

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Guillain-Barré syndrome/Miller Fishe syndrome (GBS/MFS) overlap syndrome is an extremely rare variant of Guillain-Barré syndrome (GBS) in which Miller Fisher syndrome (MFS) coexists with other characteristics of GBS, such as limb weakness, paresthesia, and facial paralysis. We report the clinical case of a 12-year-old patient, with no pathological history, who acutely presents with ophthalmoplegia, areflexia, facial diplegia, and swallowing and phonation disorders, followed by progressive, descending, and symmetrical paresis affecting first the upper limbs and then the lower limbs. An albuminocytological dissociation was found in the cerebrospinal fluid study. Magnetic resonance imaging of the spinal cord showed enhancement and thickening of the cauda equina roots. The patient was treated with immunoglobulins with a favorable clinical outcome.

Keywords: Guillain-Barré syndrome, Miller Fisher syndrome, overlap syndrome, anti-GQ1b antibodies

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