Search results for: hospital facilities

Authors: Suphap Sikkhaphan, Muwanga Zake, Johnnie Wycliffe Frank

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The purposes of the study included a) investigating the authentic and transformational leadership model of the directors of tambon health promoting hospitals b) evaluating the relation between the authentic and transformation leadership of the directors of tambon health promoting hospitals and the effectiveness of their hospitals and c) assessing the invariance test of the authentic and transformation leadership of the directors of tambon health promoting hospitals. All 400 southern tambon health promoting hospital directors were enrolled into the study. Half were males (200), and another half were females (200). They were sampled via a stratified method. A research tool was a questionnaire paper containing 4 different sections. The Alpha-Cronbach’s Coefficient was equally to .98. Descriptive analysis was used for demographic data, and inferential statistics was used for the relation and invariance tests of authentic and transformational leadership of the directors of tambon health promoting hospitals. The findings revealed overall the authentic and transformation leadership model of the directors of tambon health promoting hospitals has the relation to the effectiveness of the hospitals. Only the factor of “strong community support” was statistically significantly related to the authentic leadership (p < .05). However, there were four latent variables statistically related to the transformational leadership including, competency and work climate, management system, network cooperation, and strong community support (p = .01). Regarding the relation between the authentic and transformation leadership of the directors of tambon health promoting hospitals and the effectiveness of their hospitals, four casual variables of authentic leadership were not related to those latent variables. In contrast, all four latent variables of transformational leadership has statistically significantly related to the effectiveness of tambon health promoting hospitals (p = .001). Furthermore, only management system variable was significantly related to those casual variables of the authentic leadership (p < .05). Regarding the invariance test, the result found no statistical significance of the authentic and transformational leadership model of the directors of tambon health promoting hospitals, especially between male and female genders (p > .05).

Keywords: authentic leadership, transformational leadership, tambon health promoting hospital

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Authors: Hatem Abou-Senna

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Interstate 4 (I-4) is a primary east-west transportation corridor between Tampa and Daytona cities, serving commuters, commercial and recreational traffic. I-4 is known to have severe recurring congestion during peak hours. The congestion spans about 11 miles in the evening peak period in the central corridor area as it is considered the only non-tolled limited access facility connecting the Orlando Central Business District (CBD) and the tourist attractions area (Walt Disney World). Florida officials had been skeptical of tolling I-4 prior to the recent legislation, and the public through the media had been complaining about the excessive toll facilities in Central Florida. So, in search for plausible mitigation to the congestion on the I-4 corridor, this research is implemented to evaluate the effectiveness of different toll pricing alternatives that might divert traffic from I-4 to the toll facilities during the peak period. The network is composed of two main diverging limited access highways, freeway (I-4) and toll road (SR 417) in addition to two east-west parallel toll roads SR 408 and SR 528, intersecting the above-mentioned highways from both ends. I-4 and toll road SR 408 are the most frequently used route by commuters. SR-417 is a relatively uncongested toll road with 15 miles longer than I-4 and $5 tolls compared to no monetary cost on 1-4 for the same trip. The results of the calibrated Orlando PARAMICS network showed that percentages of route diversion vary from one route to another and depends primarily on the travel cost between specific origin-destination (O-D) pairs. Most drivers going from Disney (O1) or Lake Buena Vista (O2) to Lake Mary (D1) were found to have a high propensity towards using I-4, even when eliminating tolls and/or providing real-time information. However, a diversion from I-4 to SR 417 for these OD pairs occurred only in the cases of the incident and lane closure on I-4, due to the increase in delay and travel costs, and when information is provided to travelers. Furthermore, drivers that diverted from I-4 to SR 417 and SR 528 did not gain significant travel-time savings. This was attributed to the limited extra capacity of the alternative routes in the peak period and the longer traveling distance. When the remaining origin-destination pairs were analyzed, average travel time savings on I-4 ranged between 10 and 16% amounting to 10 minutes at the most with a 10% increase in the network average speed. High propensity of diversion on the network increased significantly when eliminating tolls on SR 417 and SR 528 while doubling the tolls on SR 408 along with the incident and lane closure scenarios on I-4 and with real-time information provided. The toll roads were found to be a viable alternative to I-4 for these specific OD pairs depending on the user perception of the toll cost which was reflected in their specific travel times. However, on the macroscopic level, it was concluded that route diversion through toll reduction or elimination on surrounding toll roads would only have a minimum impact on reducing I-4 congestion during the peak period.

Keywords: congestion pricing, dynamic feedback assignment, microsimulation, paramics, route diversion

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Authors: Ru-Yu Lien, Shih-Hsin Hung, Shu-Fen Lu, Shu-I Chin, Wen-Ju Yang, Wan Ming-Shang, Chien-Ying Wang

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Background: Upon recovery from critical condition, patients are normally transferred from the intensive care units (ICUs) to the general wards. However, transferring patients to a new environment causes stressful experiences for both patients and their families. Therefore, there is a necessity to communicate with the patients and their families to reduce psychological stress and unplanned return. Methods: This study was performed in the general ICUs from January 1, 2021, to December 31, 2021, in Taipei Veteran General Hospital. The patients who were evaluated by doctors and liaison nurses transferred to the general wards were selected as the research objects and ranked by the Critical Care Transition Program (CCTP). The plan was applied to 40 patients in a study group and usual care support for a control group of 40 patients. The psychological condition of patients was evaluated by a migration stress scale and a hospital anxiety and depression scale. In addition, the rate of return to ICU was also measured. Results: A total of 63 patients out of 80 (78.8%) experienced moderate to severe degrees of anxiety, and 42 patients (52.6%) experienced moderate to severe degrees of depression before being transferred. The difference between anxiety and depression changed more after the transfer; moreover, when a transition program was applied, it was lower than without a transition program. The return to ICU rate in the study group was lower than in the usual transition group, with an adjusted odds ratio of 0.21 (95% confidence interval: 0.05-0.888, P=0.034). Conclusion: Our study found that the transfer program could reduce the anxiety and depression of patients and the associated stress on their families during the transition from ICU. Before being transferred out of ICU, the healthcare providers need to assess the needs of patients to set the goals of the care plan and perform patient-centered decision-making with multidisciplinary support.

Keywords: ICU, critical care transition program, healthcare, transition program

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Authors: Ming-Juei Chang, Hui-Ing Ma, Tsung-Hsueh Lu

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Introduction: Because of the advance of medical care (e.g., ventilation techniques and gastrostomy feeding), more and more children with CP can live to adulthood. However, little is known about the use of health care services from children to adults who have CP. The patterns of utilization of ambulatory care are heavily influenced by insurance coverage and primary care gatekeeper regulation. The purpose of this study was to examine patterns of ambulatory care utilization among individuals with CP in Taiwan, a country with universal coverage and no gatekeeper regulation. Methods: A representative sample of one million patients (about 1/23 of total population) covered by Taiwan’s National Health Insurance was used to analyze the ambulatory care utilization in individuals with CP. Data were analyzed by 3 different age groups (children, youth and adults) during 2000 to 2003. Participants were identified by the presence of CP diagnosis made by pediatricians or physicians of physical and rehabilitation medicine and stated at least three times in claims data. Results: Annual rates of outpatient physician visits were 31680 for children, 16492 for youth, and 28617 for adults with CP (per 1000 persons). Individuals with CP received over 50% of their outpatient care from hospital outpatient department. Higher use of specialist physician services was found in children (54.7%) than in the other two age groups (28.4% in youth and 18.8% in adults). Diseases of respiratory system were the most frequent diagnoses for visits in both children and youth with CP. Diseases of the circulatory system were the main reasons (24.3%) that adults with CP visited hospital outpatient care department or clinics. Conclusion: This study showed different patterns of ambulatory care utilization among different age groups. It appears that youth and adults with CP continue to have complex health issues and rely heavily on the health care system. Additional studies are needed to determine the factors which influence ambulatory care utilization among individuals with CP.

Keywords: cerebral palsy, health services, lifespan, universal coverage

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Authors: Policarpio Jr. Joves

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Physicians in most teaching hospitals are commonly promoted into managerial roles, yet their training is mostly in clinical and scientific skills but not in leadership competencies. When they shift into roles of physician leadership, the majority hold on to their primary identity of physicians. These conflicting roles affect their identity and eventually their work. The physician leaders also face additional challenges related to academics which include incorporation of new knowledge into the existing curriculum, use of technology in the delivery of teaching, the need to train medical students outside of hospital wards, etc. The study aims to explore how physician leaders in teaching hospitals of private medical schools enact their leadership roles and how they face the challenges as physician leaders. The study setting shall be teaching hospitals of three private medical schools situated in the National Capital Region, Philippines. A multiple case study design shall be adopted in this research. Physicians shall be eligible to participate in the study if they are practicing clinicians limited to the five major clinical specialty: Internal Medicine, Pediatrics, Family Medicine, Surgery, Obstetrics and Gynecology. They must be teaching in the College of Medicine prior to their appointments as physician leaders in both medical school and teaching hospital. Semi-structured face-to-face interviews shall be utilized as a means of data collection, with open-ended questions, enabling physician leaders to present narratives about their identity, role enactment, conflicts, reaction of colleagues, and the challenges encountered in their day-to-day work as physician leaders. Interviews shall be combined with observations and review of records to gain more insights into how the physician leaders are 'doing' management. Within-case analysis shall be done initially followed by a thematic analysis across the cases, referred to as cross–case analysis or cross-case synthesis.

Keywords: academic leaders, academic managers, physician leaders, physician managers

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Authors: Sara Alhabli, Eman Elashiry, Osama Felemban, Abdullah Almushayt, Faisal Dardeer, Ahmed Mohammad, Fajr Orri, Nada Bamashmous

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Background: In December of 2019, the coronavirus (SARS-CoV-2) first appeared and quickly spread to become a worldwide pandemic. This study aimed to evaluate the prevalence and types of pediatric dental emergencies during the COVID-19 lockdown in Jeddah, Saudi Arabia, at the University Dental Hospital (UDH) of King Abdulaziz University (KAU) and identified the management provided for these dental emergency visits. Materials and Methods: Data collection was done retrospectively from electronic dental records for children aged 0-18 that attended the UDH emergency clinic during the period from March 1st, 2020, to September 30th, 2020. An electronic form formulated specifically for this study was used to collect the required data from electronic patient records, including demographic data, emergency classification, management, and referrals. Results: A total of 3146 patients were seen at the emergency clinics during this period, of which 661 were children (21%). Types of emergency conditions included 0.8% emergency cases, 34% urgent, and 65.2% non-urgent conditions. Severe dental pain (73.1%) and abscesses (20%) were the most common urgent dental conditions. Most non-urgent conditions presented for initial or periodic visits, recalls, or routine radiographs (74%). Treatments rarely involved restorations, with 8% among urgent conditions and 5.4% among non-urgent conditions. Antibiotics were only prescribed to 6.9% of urgent conditions. Conclusions: The largest group of children presenting at the emergency dental clinics were found to be children with non-urgent conditions. Tele dentistry can be a solution to avoid large numbers of non-urgent patients presenting to emergency clinics. Additionally, dental care for non-urgent conditions during the pandemic should focus more on procedures with less aerosol generation.

Keywords: COVID-19 pandemic, dental emergencies, oral health, pediatric dentistry, children

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Authors: Trunov V.O., Ryabov A. B., Poddubny I.V

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Introduction: cystic and solid pancreatic tumors have a relevant and disruptive position in many positions. The results of the treatment of children with tumors and pancreatic cysts aged 3 to 17 years for the period from 2008 to 2019 on the basis of the Morozov State Children's Clinical Hospital in Moscow were analyzed. The total number of children with solid tumors was 17, and 31 with cysts. In all children, the diagnosis was made on the basis of ultrasound, followed by CT and MRI. In most patients with solid tumors, they were located in the area of the pancreas tail - 58%, in the body area - 14%, in the area of the pancreatic head - 28%. In patients with pancreatic cysts, the distribution of patients by topography was as follows: head of the pancreas - 10%, body of the pancreas - 16%, tail of the pancreas - 68%, total cystic transformation of the Wirsung duct - 6%. In pancreatic cysts, the method of surgical treatment was based on the results of MRCP, the level of amylase in the contents of the cyst, and the localization of the cyst. Thus, pathogenetically substantiated treatment included: excision of cysts, internal drainage on an isolated loop according to Ru, the formation of pancreatojejunoanastomosis in a child with the total cystic transformation of the Wirsung duct. In patients with solid pancreatic lesions, pancretoduodenalresection, central resection of the pancreas, and distal resection from laparotomy and laparoscopic access were performed. In the postoperative period, in order to prevent pancreatitis, all children underwent antisecretory therapy, parenteral nutrition, and drainage of the omental bursa. Results: hospital stay ranged from 7 to 12 days. The duration of postoperative fermentemia in patients with solid formations lasted from 3 to 6 days. In all cases, according to the histological examination, a pseudopapillary tumor of the pancreas was revealed. In the group of children with pancreatic cysts, fermentemia was observed from 2 to 4 days, recurrence of cysts in the long term was detected in 3 children (10%). Conclusions: the treatment of cystic and solid pancreatic neoplasms is a difficult task in connection with the anatomical and functional features of the organ.

Keywords: pancreas, tumors, cysts, resection, laparoscopy, children

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Authors: William Gallagher, Harriet Bothwell, Lowri Evans, Kevin Jones

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Background: Worldwide, a third of adult deaths are caused by cardiovascular disease, a high proportion occurring in the developing world. Contributing to these poor outcomes are suboptimal assessments, treatments and monitoring of the acutely unwell patient. Successful training in trauma and neonates is recognised in the developing world but there is little literature supporting adult resuscitation. As far as the authors are aware no literature has been published on resuscitation training in Uganda since 2000 when a resuscitation training officer ran sessions in neonatal and paediatric resuscitation. The aim of this project was to offer training in Basic Life Support ( BLS) to staff and healthcare students based at Villa Maria Hospital in the Kalungu District, Central Uganda. This project was undertaken as a student selected component (SSC) offered by Swindon Academy, based at the Great Western Hospital, to medical students in their fourth year of the undergraduate programme. Methods: Semi-structured, informal interviews and focus groups were conducted with different clinicians in the hospital. These interviews were designed to focus on the level of training and understanding of BLS. A training session was devised which focused on BLS (excluding the use of an automatic external defribrillator) involving pre and post-training questionnaires and clinical assessments. Three training sessions were run for different cohorts: a pilot session for 5 Ugandan medical students, a second session for a group of 8 nursing and midwifery students and finally, a third was devised for physicians. The data collected was analysed in excel. Paired T-Tests determined statistical significance between pre and post-test scores and confidence before and after the sessions. Average clinical skill assessment scores were converted to percentages based on the area of BLS being assessed. Results: 27 participants were included in the analysis. 14 received ‘small group training’ whilst 13 received’ large group training’ 88% of all participants had received some form of resuscitation training. Of these, 46% had received theory training, 27% practical training and only 15% received both. 12% had received no training. On average, all participants demonstrated a significant increase of 5.3 in self-assessed confidence (p <0.05). On average, all participants thought the session was very useful. Analysis of qualitative date from clinician interviews in ongoing but identified themes identified include rescue breaths being considered the most important aspect resuscitation and doubts of a ‘good’ outcome from resuscitation. Conclusions: The results of this small study reflect the need for regular formal training in BLS in low resource settings. The active engagement and positive opinions concerning the utility of the training are promising as well as the evidence of improvement in knowledge.

Keywords: basic life support, education, resuscitation, sub-Saharan Africa, training, Uganda

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Authors: F. Christie, M. Staber

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Malnutrition is a predictor of poor clinical outcome in the elderly. Up to 60% of hip fracture patients are clinically malnourished on admission. This study assessed the perioperative nutritional state of patients admitted with a proximal femoral fracture and examined if adequate nutritional support was achieved. Methods: Prospective, the observational audit of 30 patients, admitted with a proximal femoral fracture, over a one-month period. We recorded: patient demographics; surgical delay; nutritional state on admission; documentation of Malnutrition Universal Screening Tool (MUST) score; dietician input and daily calorie intake through food charts. The nutritional state was re-assessed weekly and at discharge. The outcome was measured by the length of hospital stay and thirty-day mortality. Results: Mean age 87, M:F 1:2 and all patients were ASA three or four. Five patients (17%) had a prolonged ( >24 hours) fasting period. All patients had a MUST score completed on admission, 27% were underweight and 30% were high risk for malnutrition. Twenty-six patients (87%) were appropriately assessed for dietician referral. Thirteen patients had food charts; on average, hospital meals provided 1500kcal daily. No patient achieved > 75% of the provided calories with 69% of patients achieving 50% or less. Only three patients were started on nutritional supplements. Twenty-three patients (77%) lost weight, averaging 6% weight loss during admission. Mean length of stay (LOS) was 23 days and 30-day mortality 9%. Four patients (13%) gained weight, their mean LOS was 17 days and 30-day mortality 0%. Discussion: Malnutrition in the elderly originates in the community. Following major trauma it’s difficult to reverse nutritional deficits in hospitals. It’s therefore concerning that no high-risk patient achieved their recommended calorie intake. Perioperative optimisation needs to include early nutritional intervention, early anaesthetic review and adjusted anaesthetic techniques to support feeding.

Keywords: trauma, nutrition, neck of femur fracture

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Authors: Adelson G. Guillarte, M. D., Noel J. Belonguel, Jarungchai Anton S. Vatanagul

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Patients with malignant middle cerebral infarction (MCA) (with massive brain swelling and herniation) were reported to have a mortality rate of 80% even with the appropriate conservative medical therapy. European Trials (DECIMAL, DESTINY I, and II, HAMLET) showed significant improvement in mortality and functional outcome with hemicraniectomy. No known published local studies in the region, thus a local study is vital. This is a single center, retrospective, descriptive, cross-sectional, chart review study which includes ≥18 year-old patients with malignant MCA infarction, who underwent hemicraniectomy, and those who were given conservative medical therapy alone, from January 2008 to December 2012 at Perpetual Succour Hospital. Excluded were patients whose charts are with insufficient data, prior MCA stroke, with concomitant intracerebral hemorrhage and with other serious medical conditions or terminal illnesses. Minimum of 32 populations were needed. Data were presented in mean, standard deviation, frequency and percentage distribution. Man n Whitney U test and Chi Square test were used. P-values lesser than 0.05 alpha were considered statistically significant. A total of 672 stroke patients were admitted. 34 patients pass the inclusion criteria. 9 underwent hemicraniectomy and 25 were treated by conservative medical therapy alone. Although not statistically significant (64% vs 33%, p=0.112) there were more patients noted improved in the conservative treatment group. Meanwhile, the Hemicraniectomy group have increased percentage of mortality (67%) (p=0.112). There was a decreasing trend in the average NIHSS score in both groups from admission to post-op 7 days (p=0.198, p=0.78). A bigger multicenter prospective study is recommended to control inherent biases and limitations of a retrospective and smaller study.

Keywords: cerebral infarct, hemicraniectomy, ischemic stroke, malignant middle cerebral artery (MCA) infarct

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Authors: Nithra Kitreerawutiwong, Sunsanee Mekrungrongwong, Artitaya Wongwonsin, Chakkraphan Phetphoom, Buaploy Phromjang

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Background: Thailand has implemented a district health system based on the concept of primary health care. Since 2014, Family Care Team (FCT) was launched to improve the quality of care through a multidisciplinary team include not only the health sector but also social sector work together. FCT classified into 3 levels: district, sub-district, and community. This system now consists of 66,353 teams, including 3,890 teams at district level, 12,237 teams at the sub-district level, and 50,326 teams at the community level. There is a report regarding assessment the situation and perception on FCT, however, relatively few examined the operationality of this policy. This study aimed to explore the perception of district manager on the process of the implementation of FCT policy and the factors associating to implement FCT in the district health system. Methods/Results: Forty in-depth interviews were performed: 5 of primary care manager at the provincial medical health office, 5 of community hospital director, 5 of district administrative health office, 10 of sub-district health promoting hospital, and 10 of local organization. Semi-structure interview guidelines were used in the discussions. The data was analyzed by thematic analysis. This policy was formulated based on the demographic change and epidemiology transition to serve a long term care for elderly. Facilitator factors are social capital in district health systems such as family health leader and multidisciplinary team. Barrier factors are communication to the frontline provider and local organization. The output of this policy in relation to the structure of FCT is well-defined. Unanticipated effects include training of FCT in community level. Conclusion: Early feedback from healthcare manager is valuable information for the improvement of FCT to function optimally. Moreover, in the long term, health outcome need to be evaluated.

Keywords: family care team, district health system, primary care, qualitative study

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Authors: Mohammad H. Yarmohammadian, Mehdi Nasr Isfahani, Elham Anbari

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Introduction: The awareness of using chemical, biological, and nuclear agents in everyday industrial and non-industrial incidents has increased recently; release of these materials can be accidental or intentional. Since hospitals are the forefronts of confronting Chemical, Biological, Radiological and Nuclear( CBRN) incidents, the goal of the present research was to provide a generic protocol for CBRN incidents through a comparative review of CBRN protocols and guidelines of different countries and reviewing various books, handbooks and papers. Method: The integrative approach or research synthesis was adopted in this study. First a simple narrative review of programs, books, handbooks, and papers about response to CBRN incidents in different countries was carried out. Then the most important and functional information was discussed in the form of a generic protocol in focus group sessions and subsequently confirmed. Results: Findings indicated that most of the countries had various protocols, guidelines, and handbooks for hazardous materials or CBRN incidents. The final outcome of the research synthesis was a 50 page generic protocol whose main topics included introduction, definition and classification of CBRN agents, four major phases of incident and disaster management cycle, hospital response management plan, equipment, and recommended supplies and antidotes for decontamination (radiological/nuclear, chemical, biological); each of these also had subtopics. Conclusion: In the majority of international protocols, guidelines, handbooks and also international and Iranian books and papers, there is an emphasis on the importance of incident command system, determining the safety degree of decontamination zones, maps of decontamination zones, decontamination process, triage classifications, personal protective equipment, and supplies and antidotes for decontamination; these are the least requirements for such incidents and also consistent with the provided generic protocol.

Keywords: hospital, CBRN, decontamination, generic protocol, CBRN Incidents

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Authors: Abdul Aziz, Muhammad Qamar Masood, Saadia Sattar, Saira Fatima, Najmul Islam

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Introduction: The most common endocrine tumor is thyroid cancer. Follicular Thyroid Carcinoma (FTC) accounts for 5%–10% of all thyroid cancers. Patients with FTC frequently present with more advanced stage diseases and a higher occurrence of distant metastases because of the propensity of vascular invasion. FTC is mainly treated with surgery, while radioactive iodine therapy is the main adjuvant therapy as per ATA guidelines. In many developing countries, surgical facilities and radioactive iodine are in short supply; therefore, understanding follicular thyroid cancer trends may help developing countries plan and use resources more effectively. Methodology: It was a retrospective observational study of FTC patients of age 18 years and above conducted at Aga Khan University Hospital, Karachi, from 1st January 2010 to 31st December 2019. Results: There were 404 patients with thyroid carcinoma, out of which forty (10.1%) were FTC. 50% of the patients were in the 41-60 years age group, and the female to male ratio was 1.5: 1. Twenty-four patients (60%) presented with complain of neck swelling followed by metastasis (20%) and compressive symptoms (20%). The most common site of metastasis was bone (87.5%), followed by lung (12.5%). The pre-operative thyroglobulin level was done in six out of eight metastatic patients (75%) in which it was elevated. This emphasizes the importance of checking thyroglobulin level in unusual presentation (bone pain, fractures) of a patient having neck swelling also to help in establishing the primary source of tumor. There was no complete documentation of ultrasound features of the thyroid gland in all the patients, which is an important investigation done in the initial evaluation of thyroid nodule. On FNAC, 50% (20 patients) had Bethesda category III-IV nodules, while 10% ( 4 patients ) had Bethesda category II. In sixteen patients, FNAC was not done as they presented with compressive symptoms or metastasis. Fifty percent had a total thyroidectomy and 50% had subtotal followed by completion thyroidectomy, plus ten patients had lymph node dissection, out of which seven had histopathological lymph node involvement. On histopathology, twenty-three patients (57.5%) had minimally invasive, while seventeen (42.5%) had widely invasive follicular thyroid carcinoma. The capsular invasion was present in thirty-three patients (82.5%); one patient had no capsular invasion, but there was a vascular invasion. Six patients' histopathology had no record of capsular invasion. In contrast, the lymphovascular invasion was present in twenty-six patients (65%). In this study, 65 % of the patients had clinical stage 1 disease, while 25% had stage 2 and 10% had clinical stage 4. Seventeen patients (42.5%) had received RAI 30-100 mCi, while ten patients (25%) received more than 100 mCi. Conclusion: FTC demographic and clinicopathological presentation are the same in Pakistan as compared to other countries. Surgery followed by RAI is the mainstay of treatment. Thus understanding the trend of FTC and proper planning and utilization of the resources will help the developing countries in effectively treating the FTC.

Keywords: thyroid carcinoma, follicular thyroid carcinoma, clinicopathological features, developing countries

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Authors: Rodchares Hanrinth, Theerapong Srisil, Peeraya Sriphong, Pawich Paktipat

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The trigger tool is the low-cost, low-tech method to detect adverse events through clues called triggers. The Institute for Healthcare Improvement (IHI) has developed the Global Trigger Tool for measuring and preventing adverse events. However, this tool is not specific for detecting adverse drug events. The pharmacy-based trigger tool is needed to detect adverse drug events (ADEs). Group concept mapping is an effective method for conceptualizing various ideas from diverse stakeholders. This technique was used to identify a pharmacy-based trigger to detect adverse drug events (ADEs). The aim of this study was to involve the pharmacists in conceptualizing, developing, and prioritizing a feasible trigger tool to detect adverse drug events in a provincial hospital, the northeastern part of Thailand. The study was conducted during the 6-month period between April 1 and September 30, 2017. Study participants involved 20 pharmacists (17 hospital pharmacists and 3 pharmacy lecturers) engaging in three concept mapping workshops. In this meeting, the concept mapping technique created by Trochim, a highly constructed qualitative group technic for idea generating and sharing, was used to produce and construct participants' views on what triggers were potential to detect ADEs. During the workshops, participants (n = 20) were asked to individually rate the feasibility and potentiality of each trigger and to group them into relevant categories to enable multidimensional scaling and hierarchical cluster analysis. The outputs of analysis included the trigger list, cluster list, point map, point rating map, cluster map, and cluster rating map. The three workshops together resulted in 21 different triggers that were structured in a framework forming 5 clusters: drug allergy, drugs induced diseases, dosage adjustment in renal diseases, potassium concerning, and drug overdose. The first cluster is drug allergy such as the doctor’s orders for dexamethasone injection combined with chlorpheniramine injection. Later, the diagnosis of drug-induced hepatitis in a patient taking anti-tuberculosis drugs is one trigger in the ‘drugs induced diseases’ cluster. Then, for the third cluster, the doctor’s orders for enalapril combined with ibuprofen in a patient with chronic kidney disease is the example of a trigger. The doctor’s orders for digoxin in a patient with hypokalemia is a trigger in a cluster. Finally, the doctor’s orders for naloxone with narcotic overdose was classified as a trigger in a cluster. This study generated triggers that are similar to some of IHI Global trigger tool, especially in the medication module such as drug allergy and drug overdose. However, there are some specific aspects of this tool, including drug-induced diseases, dosage adjustment in renal diseases, and potassium concerning which do not contain in any trigger tools. The pharmacy-based trigger tool is suitable for pharmacists in hospitals to detect potential adverse drug events using clues of triggers.

Keywords: adverse drug events, concept mapping, hospital, pharmacy-based trigger tool

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Authors: O. R. Adeniyi, A. Ayandiji

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Losses are common in most vegetables because the fruit ripens rapidly and most plantain products can only be stored for a few days thereby limiting their utilization. Plantain (and banana) is highly perishable at the ambient temperature prevalent in the tropics. The specific objective of this study is to identify the socioeconomic characteristics of banana/plantain dealers and determine the perceived effect of the losses incurred in the process of marketing banana/plantain. The study was carried out in Ondo and Lagos states of south-western Nigeria. Purposive sampling technique was used to collect information from “Kolawole plantain depot”, the point of purchase in Ondo State and “Alamutu plantain market” in Mushin the point of sales in Lagos state. Preliminary study was conducted with the use of primary data collected through well-structured questionnaires administered on 60 respondents and 55 fully completed ones analysed. Budgeting, gross margin and multiple linear regression were used for analyses. Most merchants were found to be in the middle age class (30-50 years), majority of whom were female and completed their secondary school education, with eighty percent having more than 5 years’ experience of in banana/plantain marketing. The highest losses were incurred during transportation and these losses constitute about 5.62 percent of the potential total revenue. On the average, loss in gross margin is about ₦6,000.00 per merchant. The impacts of these losses are reflected in the continuously reducing level of their income. Age of the respondents played a major role in determining the level of care in the handling of the fruits. The middle age class tends to be more favoured. In conclusion, the merchants need adequate and sustainable transportation and storage facilities as a matter of utmost urgency. There is the need for government to encourage producers of the product (farmers) by giving them motivating incentives and ensuring that the environment is made conducive also for dealers by providing adequate storage facilities and ready markets locally and possibly for export.

Keywords: post-harvest, losses, plantain, banana, simple regression

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Authors: Adedolapo Taiwo Adeyemi, Success Ayodeji Fasanmi

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The emergence of the coronavirus pandemic and the rate of the spread affected a lot of activities across the world. This led to the introduction of online learning modes in several countries after institutions were shut down. Unfortunately, most public universities in Nigeria could not switch to the online mode because they were not prepared for it, as they do not have the technological capacity to support a full online learning mode. This study examines the readiness of university and the attitude of undergraduates towards online learning mode in Obafemi Awolowo University (OAU), Ile Ife. It investigated the skills and competencies of students for online learning as well as the university’s readiness towards online learning mode; the effort was made to identify challenges of online teaching and learning in the study area, and suggested solutions were advanced. OAU was selected because it is adjudged to be the leading Information and Communication Technology (ICT) driven institution in Nigeria. The descriptive survey research design was used for the study. A total of 256 academic staff and 1503 undergraduates were selected across six faculties out of the thirteen faculties in the University. Two set of questionnaires were used to get responses from the selected respondents. The result showed that students have the skills and competence to operate e-learning facilities but are faced with challenges such as high data cost, erratic power supply, and lack of gadgets, among others. The study found out that the university was not prepared for online learning mode as it lacks basic technological facilities to support it. The study equally showed that while lecturers possess certain skills in using some e-learning applications, they were limited by the unavailability of online support gadgets, poor internet connectivity, and unstable power supply. Furthermore, the assessment of student attitude towards online learning mode shows that the students found the online learning mode very challenging as they had to bear the huge cost of data. Lecturers also faced the same challenge as they had to pay a lot to buy data, and the networks were sometimes unstable. The study recommended that adequate funding needs to be provided to public universities by the government while the management of institutions must build technological capacities to support online learning mode in the hybrid form and on a full basis in case of future emergencies.

Keywords: universities, online learning, undergraduates, attitude

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Authors: Shamim Mushtaq, Moazzam Shahid

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Breast cancer (BC) claims the lives of half a million women every year and is the most common cause of death in the developing world. In 2019, it was estimated that BC alone accounts for 15% of all cancer deaths in younger women (aged < 45 years old) with advanced-stage lung metastasis. According to the World Health Organization & International Union against Cancer, in Asia, a high number of cancer-related deaths will be observed in 2020, whereas the burden will be reduced in Western countries due to awareness about the disease, better health facilities and advanced treatments. In the last 15 years, it has been reported that the incidence of BC has increased by 1.1% among Asian compared to the US population from 2003 to 2012. To date, several BC biological subtypes have been reported so far, which are associated with different treatment responses. The heterogeneity and diversity of BC reflected these different subtypes, including Luminal A (23.7% prevalence) and B (38.8% prevalence) that have pathological estrogen receptor (ER+)-positive tumors, the human epidermal growth factor receptor 2 (HER2) (11.2% prevalence) and triple-negative breast cancer (TNBC) (25% prevalence). According to Shaukat Khanum Memorial Cancer Hospital and Research Centre – Pakistan, ten years of data showed that among 636 BC patients, 30.5% had TNBC who were <40 years of age, which is an extremely alarming situation. Therefore, there is a dire need to explore and develop therapeutic targets for the treatment of early TNBC. Since the last decade, unfortunately, there has been little success in understanding the complexity of TNBC and in discovering new biological therapeutic targets. However, conventional chemotherapy is the only choice of treatment for TNBC patients. Many investigators revealed advances in multi-omics (multiple "omes", e.g., genome, proteome, transcriptome, epigenome, and microbiome) which were later identified as actionable targets and increased prevalence in TNBC patients. However, various drugs have been identified so far which are related to a particular diagnostic and prognostic biomarker. For example, Epidermal growth factor receptor ( EGFR or ErbB-1), HER-2/neu (ErbB-2), HER-3 (ErbB-3), and HER-4 (ErbB-4). Protein Transglin-2 (TAGLN 2 ) and Profilins-1 (Pfn-1 ) are the ubiquitously expressed large family of proteins present in all eukaryotes, enabling actin cytoskeletal reorganization. It is known that the oncogenic transformation of cells is accompanied by alteration in the actin cytoskeleton. There are causal connections between altered expression of actin cytoskeletal regulators and cancer progression. Our case-control study identified TAGLN-2 and Pfn-1 proteins in TNBC blood by mass spectrometry. Both TAGLN-2 and Pfn-1 proteins are differentially expressed in early and advanced stages of TNBS patients, which could be potential predictors or therapeutic targets for TNBC.

Keywords: TNBC, blood biomarkers, mass spectrometry, qPCR, ELISA

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Authors: Fathonah Siti, Ardiana Irma

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Indonesia is currently on its track to achieve Universal Health Coverage (UHC) by 2019. The program aims to address issues on disintegration in the implementation and coverage of various health insurance schemes and fragmented fund pooling. Family planning service is covered as one of benefit packages under preventive care. However, little has been done to examine how family planning program are appropriately managed across levels of governments and how family planning services are delivered to the end user. The study is performed through focus group discussion to related policy makers and selected programmers at central and district levels. The study is also benefited from relevant studies on family planning in the UHC scheme and other supporting data. The study carefully investigates some programmatic implications when family planning is integrated in the UHC program encompassing the need to recalculate contraceptive logistics for beneficiaries (eligible couple); policy reformulation for contraceptive service provision including supply chain management; establishment of family planning standard of procedure; and a call to update Management Information System. The study confirms that there is a significant increase in the numbers of contraceptive commodities needs to be procured by the government. Holding an assumption that contraceptive prevalence rate and commodities cost will be as expected increasing at 0.5% annually, the government need to allocate almost IDR 5 billion by 2019, excluded fee for service. The government shifts its focus to maintain eligible health facilities under National Population and Family Planning Board networks. By 2019, the government has set strategies to anticipate the provision of family planning services to 45.340 health facilities distributed in 514 districts and 7 thousand sub districts. Clear division of authorities has been established among levels of governments. Three models of contraceptive supply planning have been developed and currently in the process of being institutionalized. Pre service training for family planning services has been piloted in 10 prominent universities. The position of private midwives has been appreciated as part of the system. To ensure the implementation of quality and health expenditure control, family planning standard has been established as a reference to determine set of services required to deliver to the clients properly and types of health facilities to conduct particular family planning services. Recognition to individual status of program participation has been acknowledged in the Family Enumeration since 2015. The data is precisely recorded by name by address for each family and its members. It supplies valuable information to 15.131 Family Planning Field Workers (FPFWs) to provide information and education related to family planning in an attempt to generate demand and maintain the participation of family planning acceptors who are program beneficiaries. Despite overwhelming efforts described above, some obstacles remain. The program experiences poor socialization and yet removes geographical barriers for those living in remote areas. Family planning services provided for this sub population conducted outside the scheme as a complement strategy. However, UHC program has brought remarkable improvement in access and quality of family planning services.

Keywords: beneficiary, family planning services, national population and family planning board, universal health coverage

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Authors: Afolabi K. Esther, Kuye Tolulope, Babafemi, L. Olayemi, Omikunle Yemisi

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Background: Cervical cancer is a potentially preventable disease of public significance. All sexually active women are at risk of cervical cancer; however, the uptake and coverage are low in low-middle resource countries. Hence, the programme explored the feasibility of demonstrating an innovative and low-cost system approach to cervical cancer screening service delivery among reproductive-aged women in low–resource settings in Southwestern Nigeria. This was to promote the uptake and quality improvement of cervical cancer screening services. Methods: This study was an intervention project in three senatorial districts in Osun State that have primary, secondary and tertiary health facilities. The project was in three phases; Pre-intervention, Intervention, and Post-intervention. The study utilised the existing infrastructure, facilities and staff in project settings. The study population was nurse-midwives, community health workers and reproductive-aged women (30-49 years). The intervention phase entailed using innovative, culturally appropriate strategies to create awareness of cervical cancer and preventive health-seeking behaviour among women in the reproductive-aged group (30-49) years. Also, the service providers (community health workers, Nurses, and Midwives) were trained on screening methods and treatment of pre-cancerous lesions, and there was the provision of essential equipment and supplies for cervical cancer screening services at health facilities. Besides, advocacy and engagement were made with relevant stakeholders to integrate the cervical cancer screening services into related reproductive health services and greater allocation of resources. The expected results compared the pre and post-intervention using the baseline and process indicators and the effect of the intervention phase on screening coverage using a plausibility assessment design. The project lasted 12 months; visual Inspection with Acetic acid (VIA) screening for the women for six months and follow-up in 6 months for women receiving treatment. Results: The pre-intervention phase assessed baseline service delivery statistics in the previous 12 months drawn from the retrospective data collected as part of the routine monitoring and reporting systems. The uptake of cervical cancer screening services was low as the number of women screened in the previous 12 months was 156. Service personnel's competency level was fair (54%), and limited availability of essential equipment and supplies for cervical cancer screening services. At the post-intervention phase, the level of uptake had increased as the number of women screened was 1586 within six months in the study settings. This showed about a 100-%increase in the uptake of cervical cancer screening services compared with the baseline assessment. Also, the post-intervention level of competency of service delivery personnel had increased to 86.3%, which indicates quality improvement of the cervical cancer screening service delivery. Conclusion: the findings from the study have shown an effective approach to strengthening and improving cervical cancer screening service delivery in Southwestern Nigeria. Hence, the intervention promoted a positive attitude and health-seeking behaviour among the target population, significantly influencing the uptake of cervical cancer screening services.

Keywords: cervical cancer, screening, nigeria, health system strengthening

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Authors: Calvince Okome Odeny

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There is a current action to increase radiotherapy services in Kenya. The National government of Kenya, in collaboration with the county governments, has embarked on building radiotherapy centers in all 47 regions of the country. As these new centers are established in Kenya, it has to be ensured that minimum radiation safety standards are in place prior to operation. For full implementation of this, it is imperative that more Research and training for regulators are done on radiation protection, and safety and national regulatory infrastructure is geared towards ensuring radiation protection and safety in all aspects of the use of external radiotherapy practices. The present work aims at reviewing the level of protection and safety for patients and staff during external beam radiotherapy using Linac in Kenya and provides relevant guidance to improve protection and safety. A retrospective evaluation was done to verify whether those occupationally exposed workers and patients are adequately protected from the harmful effect of radiation exposure during the treatment procedures using Linac. The project was experimental Research, also including an analysis of resource documents obtained from the literature and international organizations. The critical findings of the work revealed that the key elements of protection of occupationally exposed workers and patients include a comprehensive quality Management system governing all planned activities from siting, safety, and design of the Facility, construction, acceptance testing, commissioning, operation, and decommissioning of the Facility; Government empowering the Regulatory Authority to license Medical Linear facilities and to enforce the applicable regulations to ensure adequate protection; A comprehensive Radiation Protection and Safety program must be established to ensure adequate safety and protection of workers and patients during treatment planning and treatment delivery of patients and categories of staff associated with the Facility must be well educated and trained to perform professionally with a commitment to sound safety culture. Relevant recommendations from the findings are shared with the Medical Linear Accelerator facilities and the regulatory authority to provide guidance and continuous improvement of protection and safety to improve regulatory oversight.

Keywords: oncology, radiotherapy, protection, staff

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Authors: Tadesse Melaku Abegaz

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Background: there was paucity of data on the self-reported adverse drug reactions (ADRs), level of adherence and clinical outcomes with antidepressants among major depressive disorder (MDD) patients in Ethiopia. Hence, the present study sought to determine the level of adherence for and clinical outcome with antidepressants and the magnitude of ADRs. Methods: A prospective cross-sectional study was employed on MDD patients from September 2016 to January 2017 at Gondar university hospital psychiatry clinic. All patients who were available during the study period were included under the study population. The Naranjo adverse drug reaction probability scale was employed to assess the adverse drug reaction. The rate of medication adherence was determined using morisky medication adherence measurement scale eight. Clinical Outcome of patients was measured by using patient health questionnaire. Multivariable logistic carried out to determine factors for adherence and patient outcome. Results: two hundred seventy patients were participated in the study. More than half of the respondents were males 122(56.2%). The mean age of the participants was 30.94 ± 8.853. More than one-half of the subjects had low adherence to their medications 124(57.1%). About 186(85.7%) of patients encountered ADR. The most common ADR was weight gain 29(13.2). Around 198(92.2%) ADRs were probable and 19(8.8%) were possible. Patients with long standing MDD had high risk of non-adherence COR: 2.458[4.413-4.227], AOR: 2.424[1.185-4.961]. More than one-half 125(57.6) of respondents showed improved outcome. Optimal level of medication adherence was found to be associated with reduced risk of progression of the diseases COR: 0.37[0.110-5.379] and AOR: 0.432[0.201-0.909]. Conclusion: Patient reported adverse drug reactions were more prevalent in major depressive disorder patients. Adherence to medications was very poor in the setup. However, the clinical outcome was relatively higher. Long standing depression was associated with non-adherence. In addition, clinical outcome of patients were affected by non-adherence. Therefore, adherence enhancing interventions should be provided to improve medication adherence and patient outcome.

Keywords: adverse drug reactions, clinical outcomes, Ethiopia, prospective study, medication adherence

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Authors: Khachen Kongpakwattana, Charungthai Dejthevaporn, Orapitchaya Krairit, Piyameth Dilokthornsakul, Devi Mohan, Nathorn Chaiyakunapruk

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Background: Although an increase in the burden of Alzheimer’s disease (AD) is evident worldwide, knowledge of costs and health-related quality of life (HR-QoL) associated with AD in Low- and Middle-Income Countries (LMICs) is still lacking. We, therefore, aimed to collect real-world cost and HR-QoL data, and investigate their associations with multiple disease-severity indicators among AD patients in Thailand. Methods: We recruited AD patients aged ≥ 60 years accompanied by their caregivers at a university-affiliated tertiary hospital. A one-time structured interview was conducted to collect disease-severity indicators, HR-QoL and caregiving information using standardized tools. The hospital’s database was used to retrieve healthcare resource utilization occurred over 6 months preceding the interview date. Costs were annualized and stratified based on cognitive status. Generalized linear models were employed to evaluate determinants of costs and HR-QoL. Results: Among 148 community-dwelling patients, average annual total societal costs of AD care were 8,014 US$ [95% Confidence Interval (95% CI): 7,295 US$ - 8,844 US$] per patient. Total costs of patients with severe stage (9,860 US$; 95% CI: 8,785 US$ - 11,328 US$) were almost twice as high as those of mild stage (5,524 US$; 95% CI: 4,649 US$ - 6,593 US$). The major cost driver was direct medical costs, particularly those incurred by AD prescriptions. Functional status was the strongest determinant for both total costs and patient’s HR-QoL (p-value < 0.001). Conclusions: Our real-world findings suggest the distinct major cost driver which results from expensive AD treatment, emphasizing the demand for country-specific cost evidence. Increases in cognitive and functional status are significantly associated with decreases in total costs of AD care and improvement on patient’s HR-QoL.

Keywords: Alzheimer's disease, associations, costs, disease-severity indicators, health-related quality of life

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Authors: Rahaf Mandura

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Background: Idiopathic intracranial hypertension (IIH) is a disorder with elevated intracranial pressure (ICP) more than 250 mm H₂O, without evidence of meningeal inflammation, space-occupying lesion, or venous thrombosis. The aim of this research is to study the clinical profile, evaluation, management, and visual outcome in a hospital-based population of IIH cases in Jeddah. Methodology: This is a retrospective observational study that included the medical records of all patients referred to neuro-ophthalmology service for evaluation of papilledema. The medical records have been reviewed from October 2018 to February 2020 at Jeddah Eye Hospital (JEH), Saudi Arabia. A total of fifty-one patients presented with papilledema in the studied period. Forty-seven patients met our inclusion criteria and were included in the study. Results: Most of the patients were females (43, 91.5%) with a mean age of presentation of 30.83±11.40 years. The most common presenting symptom was headache (40 patients, 85.1%), followed by transient visual obscuration (20 patients, 42.6%), and reduced visual acuity (15 patients, 31.9%). All 47 patients were started on medical treatment with oral acetazolamide with four patients (8.5%) shifted to topiramate because of the lack of response or intolerance to acetazolamide while four patients (8.5%) underwent lumbar-peritoneal shunt because of inadequate control of the disease despite the treatment with medical therapy. For both eyes, the change in visual acuity across all assessment points was statistically significant. Nevertheless, there were no significant changes in the visual field findings among all of the compared assessment points. Conclusion: The present study has shown that IIH-related papilledema is common in young female patients with headaches, transient visual obscurations and reduced visual acuity. Those are the commonest symptoms in our IIH population. Medical treatment of IIH is significantly efficacious and should be considered in order to enhance the prognosis of IIH-related complications. Therefore, the visual status should be frequently monitored for these patients.

Keywords: idiopathic intracranial hypertension, intracranial hypertension, papilledema, headache

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Authors: Lee Bih Ni

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This paper discusses that good learning involves all academic groups in the school. Blended learning is learning outside the classroom. Google Classroom is a free service learning app for schools, non-profit organizations and anyone with a personal Google account. Facilities accessed through computers and mobile phones are very useful for school teachers and students. Blended learning classrooms using both traditional and technology-based methods for teaching have become the norm for many educators. Using Google Classroom gives students access to online learning. Even if the teacher is not in the classroom, the teacher can provide learning. This is the supervision of the form of the teacher when the student is outside the school.

Keywords: blended learning, learning app, google classroom, schools

Procedia PDF Downloads 141

Authors: Alba Prats-Bisbe, Jaume López-Carballo, David Leno-Colorado, Alberto García Molina, Alicia Romero Marquez, Elena Hernández Pena, Eloy Opisso Salleras, Raimon Jané Campos

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Neurological disorders are a leading cause of disability and premature mortality worldwide. Neurorehabilitation (NRHB) is a clinical process aimed at reducing functional impairment, promoting societal participation, and improving the quality of life for affected individuals. Virtual reality (VR) technology is emerging as a promising NRHB support tool. Its immersive nature fosters a strong sense of agency and embodiment, motivating patients to engage in meaningful tasks and increasing adherence to therapy. However, the clinical benefits of VR interventions are challenging to determine due to the high heterogeneity among health applications. This study explores a stepwise development approach for creating VR-based tools to assist individuals with neurological disorders in medical practice, aiming to enhance reproducibility, facilitate comparison, and promote the generalization of findings. Building on previous research, the step-by-step methodology encompasses: Needs Identification– conducting cross-disciplinary meetings to brainstorm problems, solutions, and address barriers. Intervention Definition– target population, set goals, and conceptualize the VR system (equipment and environments). Material Selection and Placement– choose appropriate hardware and software, place the device within the hospital setting, and test equipment. Co-design– collaboratively create VR environments, user interfaces, and data management strategies. Prototyping– develop VR prototypes, conduct user testing, and make iterative redesigns. Usability and Feasibility Assessment– design protocols and conduct trials with stakeholders in the hospital setting. Efficacy Assessment– conduct clinical trials to evaluate outcomes and long-term effects. Cost-Effectiveness Validation– assess reproducibility, sustainability, and balance between costs and benefits. NRHB is complex due to the multifaceted needs of patients and the interdisciplinary healthcare architecture. VR has the potential to support various applications, such as motor skill training, cognitive tasks, pain management, unilateral spatial neglect (diagnosis and treatment), mirror therapy, and ecologically valid activities of daily living. Following this methodology was crucial for launching a VR-based system in a real hospital environment. Collaboration with neuropsychologists lead to develop A) a VR-based tool for cognitive rehabilitation in patients with acquired brain injury (ABI). The system comprises a head-mounted display (HTC Vive Pro Eye) and 7 tasks targeting attention, memory, and executive functions. A desktop application facilitates session configuration, while database records in-game variables. The VR tool's usability and feasibility were demonstrated in proof-of-concept trials with 20 patients, and effectiveness is being tested through a clinical protocol with 12 patients completing 24-session treatment. Another case involved collaboration with nurses and paediatric physiatrists to create B) a VR-based distraction tool during invasive techniques. The goal is to alleviate pain and anxiety associated with botulinum toxin (BTX) injections, blood tests, or intravenous placements. An all-in-one headset (HTC Vive Focus 3) deploys 360º videos to improve the experience for paediatric patients and their families. This study presents a framework for developing clinically relevant and technologically feasible VR-based support tools for hospital settings. Despite differences in patient type, intervention purpose, and VR system, the methodology demonstrates usability, viability, reproducibility and preliminary clinical benefits. It highlights the importance approach centred on clinician and patient needs for any aspect of NRHB within a real hospital setting.

Keywords: neurological disorders, neurorehabilitation, stepwise development approach, virtual reality

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Authors: Maryam Zahmatkesh

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Middle managers form a significant occupational category in organisations. They undertake a vital role, as they sit between the operational and strategic roles. Traditionally they were acting as diplomat administrators, and were only in power to meet the demands of professionals. Following the introduction of internal market, in line with the principles of New Public Management, middle managers have been considered as change agents. More recently, in the debates of middle managers, there is emphasis on entrepreneurialism and enacting strategic role. It was assumed that granting autonomy to the local organisations and the inception of semi-autonomous hospitals (Foundation Trusts in England and Board of Trustees in Iran) would give managers more autonomy to act proactively and innovatively. This thesis explores the hospital middle managers’ perception of and responses to public management reforms (in particular, hospital autonomy) in England and Iran. In order to meet the aims of the thesis, research was undertaken within the interpretative paradigm, in line with social constructivism. Data were collected from interviews with forty-five middle managers, observational fieldwork and documentary analysis across four teaching university hospitals in England and Iran. The findings show the different ways middle managers’ autonomy is constrained in the two countries. In England, middle managers have financial and human recourses, but their autonomy is constrained by government policy and targets. In Iran, middle managers are less constrained by government policy and targets, but they do not have financial and human resources to exercise autonomy. Unbalanced autonomy causes tension and frustration for middle managers. According to neo-institutional theory, organisations are deeply embedded within social, political, economic and normative settings that exert isomorphic and internal population-level pressures to conform to existing and established modes of operation. Health systems which are seeking to devolve autonomy to middle managers must appreciate the multidimensional nature of the autonomy, as well as the wider environment that organisations are embedded, if they are about to improve the performance of managers and their organisations.

Keywords: autonomy, healthcare organisations, middle managers, new public management

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Authors: Asma Qudrat, Abid Ullah, Rafi Ullah, Ali Raza, Shah Zeb, Syed Ali Shan Ul-Haq, Shahkar Ahmed Shah, Attiya Hameed Khan, Saad Zaheer, Umama Qasim, Kiran Jamal, Zahoor khan

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Objectives: Coronary artery disease (CAD) is the major public health issue associated with high mortality and morbidity rate worldwide. Young patients with ACS have unique characteristics with different demographic profiles and risk factors. The precise diagnosis and early risk stratification is important in guiding treatment and predicting the prognosis of young patients with ACS. To evaluate the associated demographics, risk factors, and outcomes profile of ACS in young age patients. Methods: The research follow a retrospective design, the single centre study of patients diagnosis with the first event of ACS in young age (>18 and <40) were included. Data collection included demographic profiles, risk factors, and in-hospital outcomes of young ACS patients. The patient’s data was retrieved through Electronic Medical Records (EMR) of Peshawar Institute of Cardiology (PIC), and all characteristic were assessed. Results: In this study, 77% were male, and 23% were female patients. The risk factors were assessed with CAD and shown significant results (P < 0.01). The most common presentation was STEMI, with (45%) most in ACS young patients. The angiographic pattern showed single vessel disease (SVD) in 49%, double vessel disease (DVD) in 17% and triple vessel disease (TVD) was found in 10%, and Left Artery Disease (LAD) (54%) was present to be the most common involved artery. Conclusion: It is concluded that the male sex was predominant in ACS young age patients. SVD was the common coronary angiographic finding. Risk factors showed significant results towards CAD and common presentations.

Keywords: coronary artery disease, Non-ST elevation myocardial infarction, ST elevation myocardial infarction, unstable angina, acute coronary syndrome

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Authors: Chia-Yi Wu, Jung-Chen Chang, Wen-Yu Hu, Ming-Been Lee

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In nearly all physical health conditions, suicide risk is increased compared to healthy people even after adjustment for age, gender, mental health, and substance use diagnoses. In order to highlight the importance of suicide risk assessment for the inpatients and early identification and engagement for inpatients’ mental health problems, a study was designed aiming at developing a comprehensive psychosomatic nursing engagement (PSNE) model with standardized operation procedures informing how nurses communicate, assess, and engage with the inpatients with emotional distress. The purpose of the study was to promote the gatekeeping role of clinical nurses in performing brief assessment and interventions to detect depression and anxiety symptoms among the inpatients, particularly in non-psychiatric wards. The study will be carried out in a 2000-bed university hospital in Northern Taiwan in 2019. We will select a ward for trial and develop feasible procedures and in-job training course for the nurses to offer mental health care, which will also be validated through professional consensus meeting. The significance of the study includes the following three points: (1) The study targets at an important but less-researched area of PSNE model in the cultural background of Taiwan, where hospital service is highly accessible, but mental health and suicide risk assessment are hardly provided by non-psychiatric healthcare personnel. (2) The issue of PSNE could be efficient and cost-effective in the identification of suicide risks at an early stage to prevent inpatient suicide or to reduce future suicide risk by early treatment of mental illnesses among the high-risk group of hospitalized patients who are more than three-times lethal to suicide. (3) Utilizing a brief tool with its established APP ('The Five-item Brief Symptom Rating Scale, BSRS-5'), we will invent the standardized procedure of PSNE and referral steps in collaboration with the medical teams across the study hospital. New technological tools nested within nursing assessment/intervention will concurrently be invented to facilitate better care quality. The major outcome measurements will include tools for early identification of common mental distress and suicide risks, i.e., the BSRS-5, revised BSRS-5, and the 9-item Concise Mental Health Checklist (CMHC-9). The main purpose of using the CMHC-9 in clinical suicide risk assessment is mainly to provide care and build-up therapeutic relationship with the client, so it will also be used to nursing training highlighting the skills of supportive care. Through early identification of the inpatients’ depressive symptoms or other mental health care needs such as insomnia, anxiety, or suicide risk, the majority of the nursing clinicians would be able to engage in critical interventions that alleviate the inpatients’ suffering from mental health problems, given a feasible nursing input.

Keywords: mental health care, clinical outcome improvement, clinical nurses, suicide prevention, psychosomatic nursing

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Authors: Hui-Yen Lee, Hsiu-Yun Wei, Guey-Jen Lin, Pi-Yueh Lee Lee

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Background: Unplanned hospital readmissions increase healthcare costs and have been considered a marker of poor healthcare performance. The elderly face a higher risk of unplanned readmission due to elderly-specific characteristics such as deteriorating body functions and the relatively high incidence of complications after treatment of acute diseases. Purpose: The aim of this study was exploring the factors that relate to the unplanned readmission of elderly within 14 days of discharge at our hospital in southern Taiwan. Methods: We retrospectively reviewed the medical records of patients aged ≥65 years who had been re-admitted between January 2018 and December 2018.The Charlson Comorbidity score was calculated using previous used method. Related factors that affected the rate of unplanned readmission within 14 days of discharge were screened and analyzed using the chi-squared test and logistic regression analysis. Results: This study enrolled 829 subjects aged more than 65 years. The numbers of unplanned readmission patients within 14 days were 318 cases, while those did not belong to the unplanned readmission were 511 cases. In 2018, the rate of elderly patients in unplanned 14 days readmissions was 38.4%. The majority patients were females (166 cases, 52.2%), with an average age of 77.6 ± 7.90 years (65-98). The average value of Charlson Comorbidity score was 4.42±2.76. Using logistic regression analysis, we found that the gastric or peptic ulcer (OR=1.917 , P< 0.002), diabetes (OR= 0.722, P< 0.043), hemiplegia (OR= 2.292, P< 0.015), metastatic solid tumor (OR= 2.204, P< 0.025), hypertension (OR= 0.696, P< 0.044), and skin ulcer/cellulitis (OR= 2.747, P< 0.022) have significantly higher risk of 14-day readmissions. Conclusion: The results of the present study may assist the healthcare teams to understand the factors that may affect unplanned readmission in the elderly. We recommend that these teams give efficient approach in their medical practice, provide timely health education for elderly, and integrative healthcare for chronic diseases in order to reduce unplanned readmissions.

Keywords: unplanning readmission, elderly, Charlson comorbidity score, logistic regression analysis

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Authors: Langhit Kurar, Loren Charles

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Introduction: In light of recent BOAST 12 (August 2016) published guidance on management of ankle fractures, the project aimed to highlight key discrepancies throughout the care trajectory from admission to point of discharge at a district general hospital. Wide breadth of data covering three key domains: accident and emergency, radiology, and orthopaedic surgery were subsequently stratified and recommendations on note documentation, and outpatient follow up were made. Methods: A retrospective twelve month audit was conducted reviewing results of ankle fracture management in 37 patients. Inclusion criterion involved all patients seen at Darent Valley Hospital (DVH) emergency department with radiographic evidence of an ankle fracture. Exclusion criterion involved all patients managed solely by nursing staff or having sustained purely ligamentous injury. Medical notes, including discharge summaries and the PACS online radiographic tool were used for data extraction. Results: Cross-examination of the A & E domain revealed limited awareness of the BOAST 12 recent publication including requirements to document skin integrity and neurovascular assessment. This had direct implications as this would have changed the surgical plan for acutely compromised patients. The majority of results obtained from the radiographic domain were satisfactory with appropriate X-rays taken in over 95% of cases. However, due to time pressures within A & E, patients were often left without a post manipulation XRAY in a backslab. Poorly reduced fractures were subsequently left for a long period resulting in swollen ankles and a time-dependent lag to surgical intervention. This had knocked on implications for prolonged inpatient stay resulting in hospital-acquired co-morbidity including pressure sores. Discussion: The audit has highlighted several areas of improvement throughout the disease trajectory from review in the emergency department to follow up as an outpatient. This has prompted the creation of an algorithm to ensure patients with significant fractures presenting to the emergency department are seen promptly and treatment expedited as per recent guidance. This includes timing for X-rays taken in A & E. Re-audit has shown significant improvement in both documentation at time of presentation and appropriate follow-up strategies. Within the orthopedic domain, we are in the process of creating an ankle fracture pathway to ensure imaging and weight bearing status are made clear to the consulting clinicians in an outpatient setting. Significance/Clinical Relevance: As a result of the ankle fracture algorithm we have adapted the BOAST 12 guidance to shape an intrinsic pathway to not only improve patient management within the emergency department but also create a standardised format for follow up.

Keywords: ankle, fracture, BOAST, radiology

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