Search results for: acute care surgery

Authors: Fikri Turk, Sahika Pinar Akyer, Mevci Ozdemir, Mehmet Bulent Ozdemir, Ilgaz Akdogan

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The complications such as bleeding, thrombosis and air embolism depend on injuries emissary veins is often encountered in surgery. Detailed descriptions of the mastoid foramen, occipital foramen, parietal foramen, posterior condylar canal and foramen vesalius are lacking in the literature. For this reason, the purpose of our study was to explore and represent the morphology and morphometry of these emissary foramina in order to prevent complications and to guide for surgeons. The present study was made on 60 dry human skull in the laboratories of Pamukkale University, Faculty of Medicine Department of Anatomy. After taken photograph of emissary foramens by Canon 650D professional camera, the evaluation and measurement’s these foramens made with Matlab program by computer. The overall prevalence of mastoid foramen was 90.52%, occipital foramen was 72.52%, parietal foramen was 42.85%, posterior condylar canal was 91.25% and foramen vesalius was 78.26%. The mean diameter of the mastoid foramen was 1.81±0.76 mm, occipital foramen was 1.20±0.25 mm, parietal foramen was 1.49±0.46 mm, posterior condylar canal was 2.83±1.33 mm and foramen vesalius was 1.74±0.60 mm. Distances between emissary foramina and fixed bony landmarks were measured. Emissary veins are important in clinic practice and surgical procedures because they act a route of spread of exracranial infection to the intracranial structures and these veins may be a significant bleeding during surgery of the skull and they can be source of thrombosis and air embolism. The detailed anatomical knowledge of these veins and foraminas may help to prevent complications and to guide for surgeons.

Keywords: emissary foramina, mastoid foramen, occipital foramen, parietal foramen, posterior condylar canal, foramen vesalius, morphology, morphometry

Procedia PDF Downloads 363

Authors: N. Szczepanska, B. Kudlak, G. Yotova, S. Tsakovski, J. Namiesnik

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In the scientific literature related to the widely understood issue of packaging materials designed to have contact with food (food contact materials), there is much information on raw materials used for their production, as well as their physiochemical properties, types, and parameters. However, not much attention is given to the issues concerning migration of toxic substances from packaging and its actual influence on the health of the final consumer, even though health protection and food safety are the priority tasks. The goal of this study was to estimate the impact of particular foodstuff packaging type, food production, and storage conditions on the degree of leaching of potentially toxic compounds and endocrine disruptors to foodstuffs using the acute toxicity test Microtox and XenoScreen YES YAS assay. The selected foodstuff packaging materials were metal cans used for fish storage and tetrapak. Five stimulants respectful to specific kinds of food were chosen in order to assess global migration: distilled water for aqueous foods with a pH above 4.5; acetic acid at 3% in distilled water for acidic aqueous food with pH below 4.5; ethanol at 5% for any food that may contain alcohol; dimethyl sulfoxide (DMSO) and artificial saliva were used in regard to the possibility of using it as an simulation medium. For each packaging three independent variables (temperature and contact time) factorial design simulant was performed. Xenobiotics migration from epoxy resins was studied at three different temperatures (25°C, 65°C, and 121°C) and extraction time of 12h, 48h and 2 weeks. Such experimental design leads to 9 experiments for each food simulant as conditions for each experiment are obtained by combination of temperature and contact time levels. Each experiment was run in triplicate for acute toxicity and in duplicate for estrogen disruption potential determination. Multi-factor analysis of variation (MANOVA) was used to evaluate the effects of the three main factors solvent, temperature (temperature regime for cup), contact time and their interactions on the respected dependent variable (acute toxicity or estrogen disruption potential). From all stimulants studied the most toxic were can and tetrapak lining acetic acid extracts that are indication for significant migration of toxic compounds. This migration increased with increase of contact time and temperature and justified the hypothesis that food products with low pH values cause significant damage internal resin filling. Can lining extracts of all simulation medias excluding distilled water and artificial saliva proved to contain androgen agonists even at 25°C and extraction time of 12h. For tetrapak extracts significant endocrine potential for acetic acid, DMSO and saliva were detected.

Keywords: food packaging, extraction, migration, toxicity, biotest

Procedia PDF Downloads 180

Authors: Cheng-Kuang Hsu, Chih-Hsiang Chang, Chi-Chih Wang

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Black soybeans contain high amount of antioxidants including polyphenols, anthocyanins and flavones. The protective function of black soybean against CCl4 (a strong oxidant) induced acute and chronic liver damage was investigated in vivo using SD rats or ICR mouse. The evaluation of CCl4 induced oxidative stress in the liver tissues included the measurements of the levels of alanine aminotransferase (ALT) and aspartate aminotransferase (AST), the concentration of thiobarbituric acid reactive substances (TBARS), the activities of antioxidant enzymes (superoxide dismutase SOD, catalase, and glutathione peroxidase GPx), as well as the level of histological lesion in the liver tissues. For chronic experiment, a decoction at the concentration of 100 or 1000 mg/kg of body weight, produced by baking black soybean at 130°C for 5 min and followed by immerging in 100°C hot water for 20 min, showed the inhibitory effect against CCl4 induced liver damage in SD rats. Hot-water extract (80 °C for 30 min) from un-preheated black soybean at the concentration of 200 mg/kg of body weight could not reduce ALT and AST levels in CCl4 treated SD rats, but the hot-water extract from preheated black soybean did enhance antioxidant enzymes activities, decline ALT and AST levels. Specially, the hot-water extract from the seed cost of black soybean had the highest liver protective function since it can reduce vacuolization and necrosis in the liver tissues. For acute experiment, the hot-water extracts from black soybean and the seed coat, as well as pure cyanidin-3-glucoside (C3G) could reduce ALT and AST levels of CCl4 induced ICR mouse. The decoction and hot-water extract from the seed coat of black soybean had higher total polyphenols, anthocyanins and flavones contents than those extracts from whole black soybean. Such results agreed with high liver protective function in the decoction and hot-water from the seed coat of black soybean. Black soybean showed protective function only after preheating process (baking at 130°C for 5 to 10 min) because preheating treatment damaged the cell wall and made the extraction of the antioxidants more effectively.

Keywords: black soybean, liver protective function, antioxidant, antioxidative stress

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Authors: Hsin-Yi Lo, Huang-Ju Jiun, Yu-Chiao Chu

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Hemodynamic monitoring is an important in the intensive care unit. Advances in medical technology in recent years, more diversification of intensive care equipment, there are many kinds of instruments available for monitoring of hemodynamics, Edwards Lifesciences Hemodynamic Monitoring (FloTrac) is one of them. The recent medical safety incidents in parameters were changed, nurses have not to notify doctor in time, therefore, it is hoped to analyze the current problems and find effective improvement strategies. In August 2021, the survey found that only 74.0% of FloTrac correctness of operation, reasons include lack of education, the operation manual is difficulty read, lack of audit mechanism, nurse doesn't know those numerical changes need to notify doctor, work busy omission, unfamiliar with operation and have many nursing records then omissions. Improvement methods include planning professional nurse education, formulate the secret arts of FloTrac, enacting an audit mechanism, establish FloTrac action learning, make「follow the sun」care map, hold simulated training and establish monitoring data automatically upload nursing records. After improvement, FloTrac correctness of operation increased to 98.8%. The results are good, implement to the ICU of the hospital.

Keywords: hemodynamic monitoring, edwards lifesciences hemodynamic monitoring, multiple strategies, intensive care

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Authors: Jirapat Suriyachaisawat, Ekkit Surakarn

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Introduction: To improve early detection and mortality rate of in-hospital cardiac arrest, Emergency Response Team (ERT) system was planned and implemented since June 2009 to detect pre-arrest conditons and for any concerns. The ERT consisted of on duty physicians and nurses from emergency department. ERT calling criteria consisted of acute change of HR < 40 or > 130 beats per minute, systolic blood pressure < 90 mmHg, respiratory rate <8 or >28 breaths per minute, O2 saturation <90%, acute change in conscious state, acute chest pain or worry about the patients. From the data on ERT system implementation in our hospital in early phase (during June 2009-2011), there was no statistic significance in difference in in-hospital cardiac arrest incidence and overall hospital mortality rate. Since the introduction of the ERT service in our hospital, we have conducted continuous educational campaign to improve awareness in an attempt to increase use of the service. Methods: To investigate outcome of ERT system in in-hospital cardiac arrest and overall hospital mortality rate, we conducted a prospective, controlled before-and after examination of the long term effect of a ERT system on the incidence of cardiac arrest. We performed chi-square analysis to find statistic significance. Results: Of a total 623 ERT cases from June 2009 until December 2012, there were 72 calls in 2009, 196 calls in 2010, 139 calls in 2011 and 245 calls in 2012. The number of ERT calls per 1000 admissions in year 2009-10 was 7.69; 5.61 in 2011 and 9.38 in 2013. The number of code blue calls per 1000 admissions decreased significantly from 2.28 to 0.99 per 1000 admissions (P value < 0.001). The incidence of cardiac arrest decreased progressively from 1.19 to 0.34 per 1000 admissions and significant in difference in year 2012 (P value < 0.001 ). The overall hospital mortality rate decreased by 8 % from 15.43 to 14.43 per 1000 admissions (P value 0.095). Conclusions: ERT system implementation was associated with progressive reduction in cardiac arrests over three year period, especially statistic significant in difference in 4th year after implementation. We also found an inverse association between number of ERT use and the risk of occurrence of cardiac arrests, but we have not found difference in overall hospital mortality rate.

Keywords: cardiac arrest, outcome, in-hospital, ERT

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Authors: Vera Lúcia Raposo

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The right to health care – usually known as the right to health – is recognized in many national laws and Constitutions, as well as in international human rights documents. The kind of health care that citizens are entitled to receive, especially in the framework of the National Health Service, is usually identified with conventional medicine. However, since ancient times that a different form of medicine – alternative, traditional or nonconventional medicine – exists. In recent times it is attracting increasing interest, as it is demonstrated by the use of its specific knowledge either by pharmaceutical companies either by modern health technologies. Alternative medicine refers to a holistic approach to body and mind using herbal products, animal parts and minerals instead of technology and pharmaceutical drugs. These notes contributed to a sense of distrust towards it, accusing alternative medicine of being based on superstition and ignorance. However, and without denying that some particular practices lack indeed any kind of evidence or scientific grounds, the fact is that a substantial part of alternative medicine can actually produce satisfactory results. The paper will not advocate the substitution of conventional medicine by alternative medicine, but the complementation between the two and their specific knowledge. In terms of the right to health, as a fundamental right and a human right, this thesis leads to the implementation of a wider range of therapeutic choices for patients, who should be entitled to receive different forms of health care that complement one another, both in public and private health facilities. This scenario would demand a proper regulation for alternative medicine, which nowadays does not exist in most countries, but it is essential to protect patients and public health in general and to reinforce confidence in alternative medicine.

Keywords: alternative medicine, conventional medicine, patient’s rights, right to health

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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: S. Mantzoukis, M. Gerasimou, P. Christodoulou, N. Varsamis, G. Kolliopoulou, N. Zotos

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Purpose: Patients in Intensive Care Units (ICU) are exposed to a different spectrum of microorganisms relative to the hospital. Due to the fact that the majority of these patients are intubated, bronchial secretions should be examined. Material and Method: Bronchial secretions should be taken with care so as not to be mixed with sputum or saliva. The bronchial secretions are placed in a sterile container and then inoculated into blood, Mac Conkey No2, Chocolate, Mueller Hinton, Chapman and Saboureaud agar. After this period, if any number of microbial colonies are detected, gram staining is performed and then the isolated organisms are identified by biochemical techniques in the automated Microscan system (Siemens) followed by a sensitivity test in the same system using the minimum inhibitory concentration MIC technique. The sensitivity test is verified by a Kirby Bauer test. Results: In 2017 the Laboratory of Microbiology received 365 samples of bronchial secretions from the Intensive Care Unit. 237 were found positive. S. epidermidis was identified in 1 specimen, A. baumannii in 60, K. pneumoniae in 42, P. aeruginosa in 50, C. albicans in 40, P. mirabilis in 4, E. coli in 4, S. maltophilia in 6, S. marcescens in 6, S. aureus in 12, S. pneumoniae in 1, S. haemolyticus in 4, P. fluorescens in 1, E. aerogenes in 1, E. cloacae in 5. Conclusions: The majority of ICU patients appear to be a fertile ground for the development of infections. The nature of the findings suggests that a significant part of the bacteria found comes from the unit (nosocomial infection).

Keywords: bronchial secretions, cultures, infections, intensive care units

Procedia PDF Downloads 184

Authors: Yang Zhao, Feng Zhang, Xuanchu Duan

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Trans-differentiation of human Tenon fibroblasts (HTFs) to myo-fibroblasts and fibrosis of episcleral tissue are the most common reasons for the failure of glaucoma filtration surgery, with limited treatment options like antimetabolites which always have side-effects such as leakage of filter bulb, infection, hypotony, and endophthalmitis. Rosiglitazone, a specific thiazolidinedione is a synthetic high-affinity ligand for PPAR-r, which has been used in the treatment of type2 diabetes, and found to have pleiotropic functions against inflammatory response, cell proliferation and tissue fibrosis and to benefit to a variety of diseases in animal myocardium models, steatohepatitis models, etc. Here, in vitro we cultured primary HTFs and stimulated with TGF- β to induced myofibrogenic, then treated cells with Rosiglitazone to assess for fibrogenic response. In vivo, we used rabbit glaucoma model to establish the formation of post- trabeculectomy scarring. Then we administered subconjunctival injection with Rosiglitazone beside the filtering bleb, later protein, mRNA and immunofluorescence of fibrogenic markers are checked, and filtering bleb condition was measured. In vitro, we found Rosiglitazone could suppressed proliferation and migration of fibroblasts through macroautophagy via TGF- β /Smad signaling pathway. In vivo, on postoperative day 28, the mean number of fibroblasts in Rosiglitazone injection group was significantly the lowest and had the least collagen content and connective tissue growth factor. Rosiglitazone effectively controlled human and rabbit fibroblasts in vivo and in vitro. Its subconjunctiiva application may represent an effective, new avenue for the prevention of scarring after glaucoma surgery.

Keywords: fibrosis, glaucoma, macroautophagy, rosiglitazone

Procedia PDF Downloads 271

Authors: Carolina N. França, Jônatas B. do Amaral, Maria C.O. Izar, Ighor L. Teixeira, Francisco A. Fonseca

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Introduction: Atherosclerosis is a progressive disease, characterized by lipid and fibrotic element deposition in large-caliber arteries. Conditions related to the development of atherosclerosis, as dyslipidemia, hypertension, diabetes, and smoking are associated with endothelial dysfunction. There is a frequent recurrence of cardiovascular outcomes after acute myocardial infarction and, at this sense, cycles of mobilization of monocyte subtypes (classical, intermediate and nonclassical) secondary to myocardial infarction may determine the colonization of atherosclerotic plaques in different stages of the development, contributing to early recurrence of ischemic events. The recruitment of different monocyte subsets during inflammatory process requires the expression of chemokine receptors CCR2, CCR5, and CX3CR1, to promote the migration of monocytes to the inflammatory site. The aim of this study was to evaluate the effect of lipid-lowering treatment by six months in the monocyte phenotype and chemokine receptor levels of patients after Acute Myocardial Infarction (AMI). Methods: This is a PROBE (prospective, randomized, open-label trial with blinded endpoints) study (ClinicalTrials.gov Identifier: NCT02428374). Adult patients (n=147) of both genders, ageing 18-75 years, were randomized in a 2x2 factorial design for treatment with rosuvastatin 20 mg/day or simvastatin 40 mg/day plus ezetimibe 10 mg/day as well as ticagrelor 90 mg 2x/day and clopidogrel 75 mg, in addition to conventional AMI therapy. Blood samples were collected at baseline, after one month and six months of treatment. Monocyte subtypes (classical - inflammatory, intermediate - phagocytic and nonclassical – anti-inflammatory) were identified, quantified and characterized by flow cytometry, as well as the expressions of the chemokine receptors (CCR2, CCR5 and CX3CR1) were also evaluated in the mononuclear cells. Results: After six months of treatment, there was an increase in the percentage of classical monocytes and reduction in the nonclassical monocytes (p=0.038 and p < 0.0001 Friedman Test), without differences for intermediate monocytes. Besides, classical monocytes had higher expressions of CCR5 and CX3CR1 after treatment, without differences related to CCR2 (p < 0.0001 for CCR5 and CX3CR1; p=0.175 for CCR2). Intermediate monocytes had higher expressions of CCR5 and CX3CR1 and lower expression of CCR2 (p = 0.003; p < 0.0001 and p = 0.011, respectively). Nonclassical monocytes had lower expressions of CCR2 and CCR5, without differences for CX3CR1 (p < 0.0001; p = 0.009 and p = 0.138, respectively). There were no differences after the comparison between the four treatment arms. Conclusion: The data suggest a time-dependent modulation of classical and nonclassical monocytes and chemokine receptor levels. The higher percentage of classical monocytes (inflammatory cells) suggest a residual inflammatory risk, even under preconized treatments to AMI. Indeed, these changes do not seem to be affected by choice of the lipid-lowering strategy.

Keywords: acute myocardial infarction, chemokine receptors, lipid-lowering treatment, monocyte subtypes

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Authors: K. Rajarajeswaran, Krishna Prasad

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Introduction: Refractory shock is a typical consequence of sepsis that does not improve with standard vasopressor therapy. A possible adjuvant therapeutic option for treating refractory shock in sepsis is methylene blue. This study looked at the effects of intravenous methylene blue plus norepinephrine given as a single bolus infusion on mortality and hemodynamic improvement in patients suffering from refractory shock. Methodology: This six-month observational prospective study was carried out at an intensive care unit, teaching hospital, and medical college. It involved 112 patients who had been diagnosed with refractory septic shock and needed vasopressor medication. Group B received injection norepinephrine 0.01 µg/kg/min infusion alone, while Group A received injection methylene blue 2 mg/kg iv single bolus (fixed dose) in addition to injection norepinephrine 0.01 µg/kg/min infusion. Both groups' noradrenaline doses were titrated to reach the desired MAP of 60–75 mm Hg. The amount of norepinephrine needed to sustain a MAP of more than 60 mm Hg was the data gathered. Serum lactate, procalcitonin level, C-reactive protein, length of stay in the intensive care unit (ICU), sequential organ failure assessment (SOFA) score, and duration of mechanical ventilation, incidence of acute kidney injury (AKI), and mortality were compared. Results: A total of 112 patients with refractory shock were included in the study. With the use of IV methylene blue, 36 (59.3%) patients showed significant improvement in MAP within 2 hours (77.12 ± 8.90 vs 74.28 ± 21.84, p = 0.005). Responders were 4.009 times more likely to have vasopressor-free time within 24 hours (19.5% vs 6.1%, p = 0.022, odds ratio 5.017, 95% confidence interval, 1.110–14.283). The serum lactate was lower, and urine output was higher in group I than in group II (p <0.05). Group I had a significantly greater reduction in SOFA score in 12 hours than group II. However, there was no significant difference in terms of mortality, length of ICU stay, ventilator free days, and incidence of AKI. In the responder group, there was a significant increase in the MAP and decrease in vasopressor requirement pre- and post-infusion of methylene blue (p < 0.05). Responder had shorter vasopressor-free days as compared with non-responder (5.44 vs 6.99, p = 0.007). Conclusion: When administered as adjuvant therapy, a single-dose bolus infusion of Methylene Blue plus Norepinephrine may aid in meeting early resuscitation goals for the management of patients with septic shock. But the patients' death rate, ICU stay duration, ventilator-free days, or incidence of AKI were unchanged.

Keywords: norepinephrine, methylene blue, shock, vasopressor

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Authors: Demet Devrimsel Dogan, Ecem Deniz Kirkpantur, Muharrem Dogan, Ahmet Aykut, Ebru Unal Akoglu, Ozge Ecmel Onur

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Introduction: Median Arcuate Ligament Syndrome (MALS) is a rare cause of chronic abdominal pain due to external compression of the celiac trunk by a fibrous arch that unites diaphragmatic crura on each side of the aortic hiatus. While 10-24% of the population may suffer from compression of celiac trunk, it rarely causes patients to develop symptoms. The typical clinical triad of symptoms includes postprandial epigastric pain, weight loss and vomiting. The diagnosis can be made using thin section multi-detector computed tomography (CT) scans which delineate the ligament and the compressed vessel. The treatment of MALS is aimed at relieving the compression of the celiac artery to restore adequate blood flow through the vessel and neurolysis to address chronic pain. Case: A 68-year-old male presented to our clinic with acute postprandial epigastric pain. This was patients’ first attack, and the pain was the worst pain of his life. The patient did not have any other symptoms like nausea, vomiting, chest pain or dyspnea. In his medical history, the patient has had an ischemic cerebrovascular stroke 5 years ago which he recovered with no sequel, and he was using 75 mg clopidogrel and 100 mg acetylsalicylic acid. He was not using any other medication and did not have a story of cardiovascular disease. His vital signs were stable (BP:113/72 mmHg, Spo2:97, temperature:36.3°C, HR:90/bpm). In his electrocardiogram, there was ST depression in leads II, III and AVF. In his physical examination, there was only epigastric tenderness, other system examinations were normal. Physical examination through his upper gastrointestinal system showed no bleeding. His laboratory results were as follows: creatinine:1.26 mg/dL, AST:42 U/L, ALT:17 U/L, amylase:78 U/L, lipase:26 U/L, troponin:10.3 pg/ml, WBC:28.9 K/uL, Hgb:12.7 gr/dL, Plt:335 K/uL. His serial high-sensitive troponin levels were also within normal limits, his echocardiography showed no segmental wall motion abnormalities, an acute myocardial infarction was excluded. In his abdominal ultrasound, no pathology was founded. Contrast-enhanced abdominal CT and CT angiography reported ‘thickened diaphragmatic cruras are compressing and stenosing truncus celiacus superior, this is likely compatible with MALS’. The patient was consulted to general surgery, and they admitted the patient for laparoscopic ligament release. Results: MALS is a syndrome that causes postprandial pain, nausea and vomiting as its most common symptoms. Affected patients are normally young, slim women between the ages of 30 and 50 who have undergone extensive examinations to find the source of their symptoms. To diagnose MALS, other underlying pathologies should initially be excluded. The gold standard is aortic angiography. Although diagnosis and treatment of MALS are unclear, symptom resolution has been achieved with multiple surgical modalities, including open, laparoscopic or robotic ligament release as well as celiac ganglionectomy, which often requires celiac artery revascularisation.

Keywords: differential diagnosis, epigastric pain, median arcuate ligament syndrome, celiac trunk

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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: A. Zurraini, Syed Alwi Sar, H. Helmy, H. Nazeefah

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Early Dementia Questionnaire (EDQ) was developed as a screening tool to detect patients with early dementia in primary care. It was developed based on 20 symptoms of dementia. From a preliminary study, EDQ had been shown to be a promising alternative for screening of early dementia. This study was done to further test on EDQ’s reliability and validity. Using a systematic random sampling, 200 elderly patients attending primary health care centers in Kuching, Sarawak had consented to participate in the study and were administered the EDQ. Geriatric Depression Scale (GDS) was used to exclude patients with depression. Those who scored >21 MMSE, were retested using the EDQ. Reliability was determined by Cronbach’s alpha for internal consistency and construct validity was assessed using confirmatory factor analysis (principle component with varimax rotation). The result showed that the overall Cronbach’s alpha coefficient was good which was 0.874. Confirmatory factor analysis on 4 factors indicated that the Cronbach’s alpha for each domain were acceptable with memory (0.741), concentration (0.764), emotional and physical symptoms (0.754) and lastly sleep and environment (0.720). Pearson correlation coefficient between the first EDQ score and the retest EDQ score among those with MMSE of >21 showed a very strong, positive correlation between the two variables, r = 0.992, N=160, P <0.001. The results of the validation study showed that Early Dementia Questionnaire (EDQ) is a valid and reliable tool to be used as a screening tool to detect early dementia in primary care.

Keywords: Early Dementia Questionnaire (EDQ), screening, primary care, construct validity

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Authors: Deirdre Mc Grath, Joanne Reid

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Background: Ovarian cancer is the leading cause of mortality among gynaecologic cancers in developed countries and the seventh most common cancer worldwide, with nearly 240,000 women diagnosed each year. Although it is recognized engaging in exercise results in positive health care outcomes, women with ovarian cancer are reluctant to participate. No evidence currently exists focusing on how to successfully implement an exercise intervention program for patients with ovarian cancer, using a realist approach. There is a requirement for the implementation of exercise programmes within the oncology health care setting as engagement in such interventions has positive health care outcomes for women with ovarian cancer both during and following treatment. Aim: To co-design the implementation of an exercise intervention for women following treatment for ovarian cancer. Methods: This study is a realist evaluation using quantitative and qualitative methods of data collection and analysis. Realist evaluation is well-established within the health and social care setting and has, in relation to this study, enabled a flexible approach to investigate how to optimise implementation of an exercise intervention for this patient population. This single centre study incorporates three stages in order to identify the underlying contexts and mechanisms which lead to the successful implementation of an exercise intervention for women who have had treatment for ovarian cancer. Stage 1 - A realist literature review. Stage 2 -Co-design of the implementation of an exercise intervention with women following treatment for ovarian cancer, their carer’s, and health care professionals. Stage 3 –Implementation of an exercise intervention with women following treatment for ovarian cancer. Evaluation of the implementation of the intervention from the perspectives of the women who participated in the intervention, their informal carers, and health care professionals. The underlying programme theory initially conceptualised before and during the realist review was developed further during the co-design stage. The evolving programme theory in relation to how to successfully implement an exercise for these women is currently been refined and tested during the final stage of this realist evaluation which is the implementation and evaluation stage. Results: This realist evaluation highlights key issues in relation to the implementation of an exercise intervention within this patient population. The underlying contexts and mechanisms which influence recruitment, adherence, and retention rates of participants are identified. Conclusions: This study will inform future research on the implementation of exercise interventions for this patient population. It is anticipated that this intervention will be implemented into practice as part of standard care for this group of patients.

Keywords: exercise, ovarian cancer, co-design, implementation

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Authors: Esra Yuce, Isil D. S. Yamaner, Murude Yazan

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Aims and objective: Antiresorptive agents including bisphosphonates and denosumab as strong suppressors of osteoclasts are the most commonly used antiresorptive medications for the treatment of osteoporosis which counteract the negative quantitative alteration of trabecular and cortical bone by inhibition of bone turnover. Oral bisphosphonate therapy for the treatment of osteopenia, osteoporosis or Paget's disease is associated with the low-grade risk of osteonecrosis of the jaw, while higher-grade risk is associated with receiving intravenous bisphosphonates therapy in the treatment of multiple myeloma and bone metastases. On the other hand, there has been a remarkable increase in incidences of antiresorptive related osteonecrosis of the jaw (ARONJ) in oral bisphosphonate users. This clinical presentation will evaluate the healing outcomes via piezoelectric bone surgery under the irrigation of PVP-I solution irrigation in patients received bisphosphonate therapy. Material-Method: The study involved 8 female and 5 male patients that have been treated for ARONJ. Among 13 necrotic sites, 9 were in the mandible and 4 were in the maxilla. All of these 13 patients treated with surgical debridement via piezoelectric bone surgery under irrigation by solution with 3% PVP-I concentration in combination with long-term antibiotic therapy and 5 also underwent removal of mobile segments of bony sequestrum. All removable prosthesis in 8 patients were relined with soft liners during the healing periods in order to eliminate chronic minor traumas. Results: All patients were on oral bisphosphonate therapy for at least 2 years and 5 of which had received intravenous bisphosphonates up to 1 year before therapy with oral bisphosphonates was started. According to the AAOMS staging system, four cases were stage II, eight cases were stage I, and one case was stage III. The majority of lesions were identified at sites of dental prostheses (38%) and dental extractions (62%). All patients diagnosed with ARONJ stage I had used unadjusted removable prostheses. No recurrence of the symptoms was observed during the present follow-up (9–37 months). Conclusion: Despite their confirmed effectiveness, the prevention and treatment of osteonecrosis of the jaw secondary to oral bisphosphonate therapy remain major medical challenges. Treatment with piezoelectric bone surgery with irrigation of povidone-iodine solution was effective for management of bisphosphonate-related osteonecrosis of the jaw. Taking precautions for patients treated with oral bisphosphonates, especially also denture users, may allow for a reduction in the rate of developing osteonecrosis of the maxillofacial region.

Keywords: antiresorptive drug related osteonecrosis, bisphosphonate therapy, piezoelectric bone surgery, povidone iodine

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Authors: Çağla Aras, Kübra Bi̇nay, Aysberg Şamil önlü, Mine Baydan Aran, Dicle Aras

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The purpose of the present research was to investigate the acute effects of 30-min hatha yoga and 30-min resistance-based aerobic exercise (RBAE) on computerized dynamic posturography (CDP) and functional head impulse test (fHIT) scores in adult female yoga practitioners. To reach this aim, ten participants executed CDP and fHIT three times in total: at rest, after yoga, and after RBAE. The yoga practice lasted a total of 30 minutes, including 25 min of asanas and 5 minutes of savasana. RBAE lasted a total of 30 minutes with an intensity of 70-75% of the heart rate reserve method. When the results were examined, no change was observed in any parameters of the fHIT scores due to resting or exercise implementation. On the contrary, some changes were observed in CDP test results depending on the type of exercise. The post-RBAE somatosensory and visual systems values were higher than resting (p<0.05). The composite balance score derived after RBAE was found to be improved when compared to post-yoga and resting values (p<0.01). Lastly, the post-RBAE vestibular system score was found to be statistically significantly higher than the post-Yoga values. In addition, it was observed that body composition parameters, especially decreasing BW, LBM, PBF, MBF and TBW, were associated with improved postural stability values. According to the results, it can be stated that neither hatha yoga nor resistance-based aerobic exercise has an acute effect on functional vestibulo-ocular reflex. In addition, although there was no change in balance level after yoga, it was observed that RBAE performed at 70-75% of the heart rate reserve and for 30 minutes had positive acute effects on postural stability and balance.

Keywords: hatha yoga, resistance training, aerobic training, high intensity training, computerized dynamic posturography, functional head impulse test

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Authors: Zemenu Yohannes

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Introduction: The pandemic overstretched the weak health systems in developing countries, including Ethiopia. This study aims to assess and explore the effect of COVID-19 on antenatal care (ANC) provision. Methods: A concurrent mixed methods study was applied. An interrupted time series design was applied for the quantitative study, and in-depth interviews were implemented for the qualitative research to explore maternity care providers' perceptions of ANC provision during COVID-19. We used routine monthly collected data from the health management information system (HMIS) in fifteen hospitals in the Sidama region, Ethiopia, from March 2019 to February 2020 (12 months) before COVID-19 and from March to August 2020 (6 months) during COVID-19. We imported data into STATA V.17 for analysis. ANC provision's mean monthly incidence rate ratio (IRR) was calculated using Poisson regression with a 95% confidence interval. The qualitative data were analysed using thematic analysis. Findings from quantitative and qualitative elements were integrated with a contiguous approach. Results: Our findings indicate the rate of ANC provision significantly decreased in the first six months of COVID-19. This study has three identified main themes: barriers to ANC provision, inadequate COVID-19 prevention approach, and delay in providing ANC. Conclusion and recommendation: Based on our findings, the pandemic affected ANC provision in the study area. The health bureau and stakeholders should take a novel and sustainable approach to prevent future pandemics. The health bureau and hospital administrators should establish a task force that relies on financial self-reliance to close gaps in future pandemics of medical supply shortages. Pregnant women should receive their care promptly from maternity care providers. In order to foster contact and avoid discrimination the future pandemics, hospital administrators should set up a platform for community members and maternity care providers.

Keywords: ANC provision, COVID-19, mixed methods study, Ethiopia

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Authors: Neeti Rustagi, Naveen Dutt, Arvind Sinha, Mahaveer S. Rhodha, Pankaja R. Raghav

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Background: Pre-hospital trauma care services are in developing stage in fast-urbanizing cities of India including Jodhpur. Training of health professionals in providing necessary pre-hospital trauma care is an essential step in decreasing accident related morbidity and mortality. The current study explores the response of a medical graduate toward helping an accident victim in a pre-hospital setting before patient can be transferred to definitive trauma facility. Methodology: This study examines the perceived competence in predicting response to an accident victim by medical graduates in Jodhpur, Rajasthan. Participants completed measures of attitude, normative influence and perceived behavior control toward providing pre-hospital care to an accident victim. Likert scale was used to measure the participant responses. Preliminary and descriptive analysis were used using SPSS 21.0. Internal consistency of the responses received was measured using Cronbach’s alpha. Results: Almost all medical graduates agreed that road accidents are common in their area (male: 92%; female: 78%). More male medical graduates (28%) reported helping an accident victim as compared to female physicians (9%) in the previous three months. Majority of study participants (96%) reported that providing immediate care to an accident victim is essential to save the life of an individual. Experience of helping an accident victim was considered unpleasant by the majority of female participants (70%) as compared to male participants (36%). A large number of participants believed that their friends (80%) and colleagues (96%) would appreciate them helping an accident victim in a pre-hospital setting. A large number of participants also believed that they possess the necessary skills and competencies (80%) towards helping a roadside accident victim in the pre-hospital care environment. Perceived competence of helping a roadside accident victim until they are transferred to a health facility was reported by less than half of the participants (male: 56%; female: 43%). Conclusion: Medical graduates have necessary attitude, competencies, and intention of helping a roadside accident victim. The societal response towards helping a road side accident victim is also supportive. In spite of positive determinants, a large proportion of medical graduates have perceived lack of competence in helping a roadside accident victim. This is essential to explore further as providing pre-hospital care to a roadside accident victim is an essential step in establishing the continuum of care to an accident victim especially in countries where pre-hospital services are in developing phase.

Keywords: prehospital care, perceived behavior, perceived competence, medical graduates

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Authors: Huda Al-Awisi, Mohammed Al-Azri, Samira Al-Rasbi, Mansour Al-Moundhri

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Cancer diagnosis is invariably a profound and catastrophic life-changing experience for individuals and their families. It has been found that cancer patients and survivors are distressed with the fragility of their life and their mortality. Based on the literature, cancer patients /survivors value their spiritual experience and connecting with unknown power either related to religious belief or not as an important coping mechanism. Health care professionals including nurses are expected to provide spiritual care for cancer patients as holistic care. Yet, nurses face many challenges in providing such care mainly due to lack of clear definition of spirituality. This study aims to explore coping mechanisms of Omani women diagnosed with breast cancer throughout their cancer journey including spirituality using a qualitative approach. A purposive sample of 19 Omani women diagnosed with breast cancer at different stages of cancer treatment modalities were interviewed. Interviews were tape recorded and transcribed verbatim. The framework approach was used to analyze the data. One main theme related to spirituality was identified and called “The power of faith”. For the majority of participants, faith in God (the will of God) was most important in coping with all stages of their breast cancer experience. Some participants thought that the breast cancer is a test from God which they have to accept. Participants also expressed acceptance of death as the eventual end and reward from God. This belief gives them the strength to cope with cancer and seek medical treatment. In conclusion, women participated in this study believed faith in God imposed spiritual power for them to cope with cancer. They connected spirituality with religious beliefs. Therefore, regardless of nurses’ faith in spirituality, the spiritual care needs to be tailored and provided according to each patient individual need.

Keywords: breast cancer, spiritual, religion, coping, diagnosis, oman, women

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Authors: Philip Eappen, Narasimha Rao Vajjhala

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This chapter examines how healthcare organizations harnessed innovative healthcare informatics to navigate the challenges posed by the COVID-19 pan-demic, addressing critical needs and improving care delivery. The pandemic's un-precedented demands necessitated the adoption of new and advanced tools to manage healthcare operations more effectively. Informatics solutions played a crucial role in facilitating the smooth functioning of healthcare systems during this crisis and are anticipated to remain central to future healthcare management. Technologies such as telemedicine helped healthcare professionals minimize ex-posure to COVID-19 patients, thereby reducing infection risks within healthcare facilities. This chapter explores a range of informatics applications utilized worldwide, including telemedicine, AI-driven solutions, big data analytics, drones, robots, and digital platforms for drug delivery, all of which enabled re-mote patient care and enhanced healthcare accessibility and safety during the pan-demic.

Keywords: healthcare informatics, COVID-19 Pandemic, telemedicine, AI-driven healthcare, big data analytics, remote patient care, digital health platforms

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Authors: Joana Gato, Ahmed Abotabekh, Panayoti Bachkangi

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Introduction: Oestrogen is an essential gonadal hormone that plays a vital role in the reproductive system of women1. The average age of menopause in the UK is 512. Women who go through premature menopause should be offered Hormone replacement therapy (HRT). Similarly, women who undergo surgical menopause should be offered HRT, unless contraindicated, depending on the indication of their surgery2,3. Aim: To assess if the patients in our department are counselled regarding HRT after surgical treatment and if HRT was prescribed. Methodology: A retrospective audit in a busy district hospital, examining all the patients who had a hysterectomy. The audit examined if HRT was discussed pre-operatively, prescribed on discharge and if a follow up was arranged. For women with contraindication to HRT, the audit assessed if the reasons were discussed pre-operatively and communicated to the Inclusion criteria: woman having a total or subtotal hysterectomy, with or without bilateral salpingo-ophorectomy (BSO), between April and September 2022. Exclusion criteria: woman having a vaginal hysterectomy. Results: 40 patients in total had hysterectomy; 27 (68%) were under the age of 51. 15 out of 27 patients bad BSO. 9 women were prescribed HRT, but 8 were offered HRT immediately, and 1 of them were offered a follow up. Of women who underwent surgical menopause, 7 were not given any HRT. The HRT choice was diverse, however, the majority was prescribed oral HRT. 40% of women undergoing surgical menopause did not have a discussion about HRT prior to their surgery. In postmenopausal women (n=13; 33%), still two were given HRT for preexisting menopausal symptoms. Discussion: Only 59% of the pre-menopausal patients had oophorectomy, therefore undergoing surgical menopause. Of these, 44% were not given any HRT, and 40% had no discussion about HRT prior to surgery. Interestingly, the majority of these women have no obvious contraindication to HRT. The choice of HRT was diverse, but the majority was commenced on oral HRT. Our unit is still working towards meeting all the NICE guidance standards of offering HRT and information prior to surgery to women planning to undergo surgical menopause. Conclusion: Starting HRT at the onset of menopause has been shown to improve quality of life and reduce the risk of cardiovascular disease and osteoporotic fractures4. Our unit still has scope for improvement to comply with the current NICE guidance. All pre-menopausal women undergoing surgical menopause should have a discussion regarding HRT prior to surgery and be offered it if there are no contraindications. This discussion should be clearly documented in the notes. At the time of this report, some of the patients have not yet had a follow up, which we recognize as a limitation to our audit.

Keywords: hormone replacement therapy, menopause, premature ovarian insufficiency, surgical management

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Authors: Keshari Shrestha, Philip Vatterott

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Introduction: Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and potentially fatal drug-related syndrome. DRESS classically presents with a diffuse maculopapular rash, fevers, and eosinophilia more than three weeks after drug exposure. DRESS can present with multi-organ involvement, with liver damage being the most common and severe. Pulmonary involvement is a less common manifestation and is associated with poor clinical outcomes. Chest imaging is often nonspecific, and symptoms can range from mild cough to acute respiratory distress syndrome (ARDS) . This is a case of a 49-year-old female with a history of recent clostridium difficile colitis status post treatment with oral vancomycin who presented with rash, acute liver and kidney failure, as well as diffuse nodular alveolar lung opacities concerning for DRESS syndrome with multi-organ involvement. Clinical Course: This patient initially presented to an outside hospital with clostridium difficile colitis, acute liver injury, and acute kidney injury. She developed a desquamating maculopapular rash in the setting of recent oral vancomycin, meloxicam, and furosemide initiation. She was hospitalized on two additional occasions with worsening altered mental status, liver injury, and acute kidney injury and was initiated on intermittent hemodialysis. Notably, she was found to have systemic eosinophilia (4100 cells/microliter) several weeks prior. She was transferred to this institution for further management where she was found to have encephalopathy, jaundice, lower extremity edema, and diffuse bilateral rhonchorous breath sounds on pulmonary examination. The patient was started on methylprednisolone for suspected DRESS syndrome. She underwent an evaluation for alternative causes of her organ failure. Her workup included a negative infectious, autoimmune, metabolic, toxic, and malignant work-up. Abdominal computed tomography (CT) and ultrasound were remarkable for evidence of hepatic steatosis and possible cirrhotic morphology. Additionally, a chest CT demonstrated diffuse and symmetric nodular alveolar lung opacities with peripheral sparing not consistent with acute respiratory distress syndrome or edema. Ultimately, her condition continued to decline, and she required intubation on several occasions. On hospital day 25 she succumbed to distributive shock in the setting of probable sepsis and multi-organ failure. Discussion: DRESS syndrome occurs in 1 in 1,000 to 10,000 patients with a mortality rate of around 10%. Anti-convulsant, anti-bacterial, anti-viral, and sulfonamide drugs are the most common drugs implicated in the development of DRESS syndrome; however, the list of offending agents is extensive . The diagnosis of DRESS syndrome is made after excluding other causes of disease such as infectious and autoimmune etiologies. The RegiSCAR scoring system is used to diagnose DRESS syndrome with 2-3 points indicating possible disease, 4-5 probable disease, and >5 definite disease. This patient scored a 7 on the RegiSCAR scale for eosinophilia, rash, organ involvement, and exclusion of other causes (infectious and autoimmune). While the pharmacologic trigger in this case is unknown, it is speculated to be caused by vancomycin, meloxicam, or furosemide due to the favorable timeline of initiation. Despite aggressive treatment, DRESS syndrome can often be fatal. Because of this, early diagnosis and treatment of patients with suspected DRESS syndrome is imperative.

Keywords: drug reaction with eosinophilia and systemic symptoms, multi-organ failure, pulmonary involvement, renal failure

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Authors: Aimen Batool Bint-E-Rashid, Syed Muhammad Dawood Ali Shah, Muhammad Usman Farooq, Mahgul Anwar

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As the world is progressing, the needs and demands of the consumer market are also changing. Nowadays the trends of consumer purchase decisions are dependent upon multiple factors. This study aims to identify the influential impact of country of origin over the perception and devotion towards daily personal care products specifically in reference to the knowledge and awareness regarding that particular brand in Pakistan. To corroborate this study, a 30-item brand origin questionnaire has been used with 300 purchase decision makers belonging to different age groups. To illustrate this study, a model has been developed based on brand origin, brand awareness and brand loyalty. Correlation and regression analysis have been used to find out the results which conclude the findings on the perspective of Pakistan’s consumer market as that brand origin has a direct relationship with brand loyalty provided that the consumer has a positive brand awareness. Support for the fact that brand origin impacts brand loyalty through brand awareness has been presented in this study.

Keywords: brand awareness, brand loyalty, brand origin, personal care products, P&G, Unilever

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Authors: Luna Sequier, Florian Forelli, Maude Traulle, Amaury Vandebrouck, Pascal Duffiet, Louis Ratte, Jean Mazeas

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The study's objective is to compare the muscular activity of the flexor knee muscle in patients who underwent an anterior cruciate ligament reconstruction with hamstring autograft and the individuals who have not undergone surgery. Methods: The participants were divided into two groups: a healthy group and an experimental group who had undergone an anterior cruciate ligament reconstruction with a hamstring graft. All participants had to perform a knee flexion strength test on an isokinetic dynamometer. The medial Gastrocnemius, lateral Gastrocnemius, Biceps femoris, and medial Hamstring muscle activity were measured during this test. Each group’s mean muscle activity was tested with statistical analysis, and a muscle activity ratio of gastrocnemius and hamstring muscles was calculated Results: The results showed a significant difference in activity of the medial gastrocnemius (p = 0,004901), the biceps femoris (p = 5,394.10-6), and the semitendinosus muscles (p = 1,822.10-6), with a higher Biceps femoris and Semitendinosus activity for the experimental group. It is however noticeable that inter-subject differences were important. Conclusion: This study has shown a difference in the gastrocnemius and hamstring muscle activity between patients who underwent an anterior cruciate ligament reconstruction surgery and healthy participants. With further results, this could show a modification of muscle activity patterns after surgery which could lead to compensatory behaviors at a return to sport and eventually explain a higher injury risk for our patients.

Keywords: anterior cruciate ligament, electromyography, muscle activity, physiotherapy

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Authors: Carles Ferré, Ferran Llopis, Javier Jacob, Jordi Giol, Xavier Palom, Ignasi Bardés

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Objective: To analyze the characteristics of acute bacterial prostatitis (ABP) in elderly patients attended in the emergency department (ED). Methods: Observational and cohort study with prospective follow-up including patients with ABP presenting to the ED from January-December 2012. Data were collected for demographic variables, comorbidities, clinical and microbiological findings, treatment, outcome, and reconsultation at 30 days follow up. Findings were compared between patients ≥ 75 years (study group) and < 75 years (control group). Results: During the study period 241 episodes of ABP were included for analysis. Mean age was 62,9 ± 16 years, and 64 (26.5%) were ≥ 75 years old. A history of prostate adenoma was reported in 54 cases (22,4%), diabetes mellitus in 47 patients (19,5%) and prior manipulation of the lower urinary tract in 40 (17%). Mean symptoms duration was 3.38 ± 4.04 days, voiding symptoms were present in 176 cases (73%) and fever in 154 (64%). From 216 urine cultures, 128 were positive (59%) and 24 (17,6%) out of 136 blood cultures. Escherichia coli was the main pathogen in 58.6% of urine cultures and 64% of blood cultures (with resistant strains to fluoroquinolones in 27,7%, cotrimoxazole in 22,9% and amoxicillin/clavulanic in 27.7% of cases). Seventy patients (29%) were admitted to the hospital, and 3 died. At 30-day follow-up, 29 patients (12%) returned to the ED. In the bivariate analysis previous manipulation of the urinary tract, history of cancer, previous antibiotic treatment, resistant E. coli strains to amoxicillin-clavulanate and ciprofloxacin and extended spectrum beta-lactamase (ESBL) producers, renal impairment, and admission to the hospital were significantly more frequent (p < 0.05) among patients ≥ 75 years compared to those younger than 75 years. Conclusions: Ciprofloxacin and amoxicillin-clavulanate appear not to be good options for the empiric treatment of ABP for patients ≥ 75 years given the drug-resistance pattern in our series, and the proportion of ESBL-producing strains of E. coli should be taken into account. Awaiting bacteria identification and antibiogram from urine and/or blood cultures, treatment on an inpatient basis should be considered in older patients with ABP.

Keywords: acute bacterial prostatitits, antibiotic resistance, elderly patients, emergency

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Authors: Shannon Hearney, Jeffrey Hoch

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While all cancers are costly to treat, pancreatic cancer is a notoriously costly and deadly form of cancer. Across the world there are a variety of treatment centers ranging from small clinics to large, high-volume hospitals as well as differing structures of payment and access. It has been noted that centers that treat a high volume of pancreatic cancer patients have higher quality of care, it is unclear if that care is cost-effective. In the US there is no clear consensus on the cost-effectiveness of high-volume centers for the surgical care of pancreatic cancer. Other European countries, like Finland and Italy have shown that high-volume centers have lower mortality rates and can have lower costs, there however, is still a gap in knowledge about these centers cost-effectiveness globally. This paper seeks to review the current literature in Europe and the US to gain a better understanding of the state of high-volume pancreatic surgical centers cost-effectiveness while considering the contextual differences in health system structure. A review of major reference databases such as Medline, Embase and PubMed will be conducted for cost-effectiveness studies on the surgical treatment of pancreatic cancer at high-volume centers. Possible MeSH terms to be included, but not limited to, are: “pancreatic cancer”, “cost analysis”, “cost-effectiveness”, “economic evaluation”, “pancreatic neoplasms”, “surgical”, “Europe” “socialized medicine”, “privatized medicine”, “for-profit”, and “high-volume”. Studies must also have been available in the English language. This review will encompass European scientific literature, as well as those in the US. Based on our preliminary findings, we anticipate high-volume hospitals to provide better care at greater costs. We anticipate that high-volume hospitals may be cost-effective in different contexts depending on the national structure of a healthcare system. Countries with more centralized and socialized healthcare may yield results that are more cost-effective. High-volume centers may differ in their cost-effectiveness of the surgical care of pancreatic cancer internationally especially when comparing those in the United States to others throughout Europe.

Keywords: cost-effectiveness analysis, economic evaluation, pancreatic cancer, scientific literature review

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Authors: R. Pääkkönen, L. Korpinen, T. Kava, I. Salmi

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This study evaluates obstructive sleep apnea treatment through a case study involving a 67-year-old male driver who had a successful continuous positive airway pressure (CPAP) treatment at home but experienced difficulties with traveling and dental care. There are many cheap sleep apnea and snoring devices available, but there is little professional advice on what kind of devices can help. Professional drivers receive yearly specialized medical care follow-up.

Keywords: sleep, apnea patient, CPAP, professional driver

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Authors: Arezoo Fallahi, Fateme Aslibigi, Parvaneh Taymoori, Babak Nematshahrbabaki

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Background and Aims: Cancer of the cervix, one of cancer-related death, is the second most common cancer in women worldwide. It develops over time but it is one of the most preventable types of cancer and there is the available proper screening program for its preventing. Since Pap smear test is vital to prevent and control of disease but women do not accomplish it regularly. Therefore, this study was aimed to explore women's needs referring to health care centers for doing Pap smear test. Material and methods: In this study, an inductive qualitative method with content analysis approach was used. This survey was done in varamin city (is located capital of Iran) in year 2014. Through the purposive sampling 15 women's view of point referring to health care centers of for doing Pap smear test was surveyed. Inclusion criteria were: 20-50 years old married women, having experience Pap smear test and attendance to participate in the Study. Recorded semi- structured interviews were typed and analyzed through of content analysis method. To obtain trustworthiness and rigor of the data, the criteria of credibility, dependability, confirmability and transferability was used. Results: During the data analysis, four main categories of “role of health care team”, “role of organizations”, “social support” and “policies and administration system” were developed. The participants emphasized on making motivational rules and coordination among organizations to do behaviors related to women health. Conclusion: The findings of study showed that doing Pap smear test are attributed to appropriate and intimate interactions with health professionals, family support, encouraging legislation and policies and coordination and notification of organizations. Therefore, designers and stockholders of policies and health system should more consider to growth and involve other organizations toward women's health.

Keywords: qualitative approach, pap smear test, women, health care centers

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Authors: Palak V. Patel, Jessica Pixley, Steven R. Feldman

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Introduction: Basal cell carcinoma (BCC) is the most common skin cancer worldwide and requires substantial resources to treat. When choosing between indicated therapies, providers consider their associated adverse effects, efficacy, cosmesis, and function preservation. The patient’s tumor burden, infiltrative risk, and risk of tumor recurrence are also considered. Treatment cost is often left out of these discussions. This can lead to financial toxicity, which describes the harm and quality of life reductions inflicted by high care costs. Methods: We studied the guidelines set forth by the American Academy of Dermatology for the treatment of BCC. A PubMed literature search was conducted to identify the costs of each recommended therapy. We discuss costs alongside treatment efficacy and side-effect profile. Results: Surgical treatment for BCC can be cost-effective if the appropriate treatment is selected for the presenting tumor. Curettage and electrodesiccation can be used in low-grade, low-recurrence tumors in aesthetically unimportant areas. The benefits of cost-conscious care are not likely to be outweighed by the risks of poor cosmesis or tumor return ($471 BCC of the cheek). When tumor burden is limited, MMS offers better cure rates and lower recurrence rates than surgical excision, and with comparable costs (MMS $1263; SE $949). Surgical excision with permanent sections may be indicated when tumor burden is more extensive or if molecular testing is necessary. The utility of surgical excision with frozen sections, which costs substantially more than MMS without comparable outcomes, is less clear (SE with frozen sections $2334-$3085). Less data exists on non-surgical treatments for BCC. These techniques cost less, but recurrence-risk is high. Side-effects of nonsurgical treatment are limited to local skin reactions, and cosmesis is good. Cryotherapy, 5-FU, and MAL-PDT are all more affordable than surgery, but high recurrence rates increase risk of secondary financial and psychosocial burden (recurrence rates 21-39%; cost $100-270). Radiation therapy offers better clearance rates than other nonsurgical treatments but is associated with similar recurrence rates and a significantly larger financial burden ($2591-$3460 BCC of the cheek). Treatments for advanced or metastatic BCC are extremely costly, but few patients require their use, and the societal cost burden remains low. Vismodegib and sonidegib have good response rates but substantial side effects, and therapy should be combined with multidisciplinary care and palliative measures. Expert-review has found sonidegib to be the less expensive and more efficacious option (vismodegib $128,358; sonidegib $122,579). Platinum therapy, while not FDA-approved, is also effective but expensive (~91,435). Immunotherapy offers a new line of treatment in patients intolerant of hedgehog inhibitors ($683,061). Conclusion: Dermatologists working within resource-compressed practices and with resource-limited patients must prudently manage the healthcare dollar. Surgical therapies for BCC offer the lowest risk of recurrence at the most reasonable cost. Non-surgical therapies are more affordable, but high recurrence rates increase the risk of secondary financial and psychosocial burdens. Treatments for advanced BCC are incredibly costly, but the low incidence means the overall cost to the system is low.

Keywords: nonmelanoma skin cancer, basal cell skin cancer, squamous cell skin cancer, cost of care

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