Cognitive biases regarding utilization of emergency severity index among emergency nurses.

AIM: The study aimed to measure emergency nurses' prevalence of cognitive biases when utilizing Emergency Severity Index (ESI). Moreover, the study aimed to measure the differences between cognitive biases and demographic variables. BACKGROUND: Nurses use Emergency Severity Index (ESI) to prioritize the patients. Cognitive biases could compromise the clinical decisions of nurses in triage. Consequently, this hinders the delivery of safe and quality patient care. METHODS: A cross-sectional analytical approach invited 208 emergency nurses from four tertiary care hospitals. Institutional review board approval and permission from institutional heads were obtained. Informed consent was attained before data collection. Data was collected through a structured scenario-based questionnaire to measure cognitive biases at five levels of ESI. Descriptive and inferential statistics were obtained through v25.0 of SPSS. RESULTS: Among the 86.6% response rate, 56.2% of nurses were male. 62.90% had nursing diplomas. Cognitive biases were present at all ESI levels one to five, in order 51%, 45%, 90%, 89%, and 91% among nurses. Premature closure 22%, tolerance to risk 12%, satisfying bias 25%, framing effect 22%, and blind obedience 34% from level one to five consecutively. Demographic variables, including males, experience between 2 and 5 years, general nursing as qualification, and without emergency severity index certification, were identified to encounter more cognitive biases when making triage decisions. CONCLUSION: Numerous cognitive biases are considerably existing among emergency nurses when prioritizing patients. Cognitive de-biasing measures can improve triage decisions among nurses that could enhance quality care and patient safety.

Documenting response to COVID-individual and systems successes and challenges: a longitudinal qualitative study.

BACKGROUND: This study aimed to document the evolution of perceptions of frontline healthcare workers (FHCW) regarding their well-being and the quality of health systems' response to the COVID-19 pandemic over four months in Pakistan. METHODS: We conducted this prospective longitudinal qualitative study during the four months (June-September 2020) coinciding with the peak and trough of the first wave of Pakistan's COVID-19 pandemic. We approached frontline healthcare workers (physicians and nurses) working in emergency departments (ED) in two hospitals using the WhatsApp group of the Pakistan Society of Emergency Physicians (PSEM). Participants were asked to self-record their perception of their wellness and their level of satisfaction with the quality of their hospitals' response to the pandemic. We transcribed, translated, and analysed manually using MAXQDA 2020 software and conducted the thematic analysis to identify themes and sub-themes. RESULTS: We invited approximately 200 FHCWs associated with PSEM to participate in the study. Of the 61 who agreed to participate, 27 completed the study. A total of 149 audio recordings were received and transcribed. Three themes and eight sub-themes have emerged from the data. The themes were individual-level challenges, health system-level challenges, and hope for the future. Sub-themes for individual-level challenges were: fear of getting or transmitting infection, feeling demotivated and unappreciated, disappointment due to people's lack of compliance with COVID-19 protocols, physical exhaustion, and fatigue. For the healthcare system, sub-themes were: Infrastructure, logistics, management, and communications response of the hospital/healthcare system and financial stressors. For sub-themes under hope for the future were the improved disease knowledge and vaccine development. The overall perceptions and experiences of FHCWs evolved from fear, grief, and negativity to hope and positivity as the curve of COVID-19 went down. CONCLUSION: This study shows that the individuals and systems were not prepared to deal with the challenges of the COVID-19 pandemic. The findings highlight the challenges faced by individuals and health systems during the wake of the Covid-19 pandemic. The healthcare workers were emotionally and physically taxed, while the health systems were overwhelmed by COVID-19. The overall perceptions of FHCWs evolved with time and became negative to positive as the curve of COVID-19 went down during the first wave of COVID-19 in Pakistan.

Accuracy of lung ultrasound and chest X-rays in diagnosing acute pulmonary oedema in patients presenting with acute dyspnoea in emergency department.

To determine the diagnostic accuracy of lung ultrasound and chest X-ray in diagnosing Acute Pulmonary Oedema in patients presenting with acute dyspnoea in emergency department, a study was conducted at the emergency department of Shifa International Hospital, Islamabad, from July 31, 2018 to January 31, 2019. A total of 225 patients presenting with dyspnoea and satisfying the inclusion criteria were assessed through clinical examination, lung ultrasound (LUS) and chest X-ray. The results of chest X-ray and lung ultrasound were compared with clinical diagnosis. The study revealed sensitivity of chest X-ray and LUS (60.16% versus 91.05%), specificity (66.67% versus 91.18%), positive predictive value (68.52% versus 92.56%) and the negative predictive values (58.12% versus 89.42%) respectively. The present study revealed that the LUS has better accuracy than chest X-ray for diagnosis of acute pulmonary oedema.

Knowledge and attitudes of Pakistani intensive care unit nurses regarding oral care delivery to mechanically ventilated patients.

OBJECTIVE: To assess the knowledge and attitudes of intensive care unit nurses regarding oral care delivery to mechanically ventilated patients. METHODS: The cross-sectional study was conducted from January to July 2018 across four hospitals in the twin cities of Rawalpindi and Islamabad, Pakistan. Data was obtained from randomly selected nurses with the help of a 14-item self-reporting questionnaire. Data was analysed using SPSS 23. RESULTS: Out of 81 nurses, 76(93.8%) were female, and 47(58%) had experience up to 10 years. When the participants were asked if disease can be transmitted from other patients, 23(28.4%) said it was likely, 22(27.2%) said it was most likely and 16(19.8%) said they did not know. When asked if the disease can be transmitted from the aspiration of contaminated secretions from the oropharynx, 32(39.5%) nurses said it was likely, 31(38.3%) said it was not likely and 9(11.1%) did not know. Knowledge level was significantly associated with level of education (p<0.05). In terms of attitude, 54(66.7%) nurses disagreed that there were more important tasks to do for unstable patients than oral care, indicating a good attitude. CONCLUSIONS: Knowledge and attitude among the subjects were found to be good regarding oral care delivery to mechanically ventilated patients.

Knowledge and attitude of health workers regarding catheter-associated urinary tract infection in tertiary care hospitals, Pakistan.

OBJECTIVE: To assess the knowledge and attitude of house officers, residents, specialists and nurses regarding urinary catheterisation and catheter-associated urinary tract infection in tertiary care hospitals. METHODS: The cross-sectional study was conducted from February to July 2018 at 9 hospitals in Rawalpindi and Islamabad, Pakistan, and comprised doctors and nurses. Data were collected using an interviewer-administered questionnaire. Knowledge and attitude regarding urinary catheterisation were compared between doctors and nurses. Data was analysed using SPSS 23. RESULTS: Of the768 individuals approached, 485(63%) agreed to participate. Of them, 358(74%) were doctors and 127(26%) were nurses. Among the doctors, 261(73%) were house officers, 58(16%) residents and 39(11%) specialists. When asked if avoiding catheter kinking was an effective way to prevent CAUTI, 194(54.19%) doctors got it correct as opposed to 102(80.31%) nurses. When the doctors and nurses were asked if the catheter should be removed whenever it is convenient for healthcare personnel, 354(98.88) doctors and 112(88.18) nurses gave the correct answer (p=0.041). CONCLUSIONS: There was reasonable knowledge and attitude among nurses and doctors towards urinary catheterisation and preventive measures related to catheter-associated urinary tract infection.

Perceptions of plagiarism among undergraduate medical students in Rawalpindi, Pakistan.

OBJECTIVES: With the rise in the number of published papers in the biomedical field, plagiarism has become a major ethical concern as it has a direct effect on the quality of these papers. The objective of this research was to determine the perceptions of medical students towards plagiarism, the reasons students engage in plagiarism, the types of plagiarism, the consequences of plagiarism, and solutions to the problem of plagiarism. METHODS: This is a cross-sectional study conducted in two medical colleges in Rawalpindi, Pakistan from June to September, 2018, using self-administered structured questionnaires. RESULTS: Of the 1100 participants, up to 86.91% (n=956) were not aware of the existence of plagiarism, but the majority, i.e. 71.18% (n=783) have plagiarised the work of others before. Copying from colleagues or senior students is the most common type of plagiarism that medical students engage in owing to the ease with which fellow students' work can be shared and copied. However, a lack of institutional awareness of the extent to which plagiarism exists, poor vigilance in detecting it, and the absence of clear policies to deal with plagiarism are mostly to blame. CONCLUSION: Plagiarism is common among medical students in developing countries, and it is necessary to create awareness about the consequences of engaging in this unethical practice both in the academic field and in the larger medical research society, in order to reduce its prevalence.

National outcomes of in-hospital cardiopulmonary resuscitation in patients with acute kidney injury: years 2005 - 2011
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BACKGROUND: There is paucity of data on the outcomes of in-hospital cardiopulmonary resuscitation (CPR) in patients with acute kidney injury (AKI). We analyzed the impact of acute kidney injury on in-hospital CPR-related outcomes. MATERIALS AND METHODS: We analyzed data from Nationwide Inpatient Sample (NIS 2005 - 2011) including patients with and without AKI who had undergone in-hospital CPR. Baseline characteristics, in-hospital complications and discharge outcomes were compared between the two groups. We determined the effect of AKI on length of hospital stay, discharge destination, hospital mortality, survival trends, and discharge to home. RESULTS: 180,970 patients with primary or secondary diagnosis of AKI underwent in-hospital CPR compared to 323,620 patients without AKI. Unadjusted in-hospital mortality rates were higher in the AKI group (78.2 vs. 71.8%, p < 0.0001). After adjusting for age, sex, and potential confounders, patients in the AKI group had higher odds of mortality with odds ratio 1.3, 95% confidence interval 1.2 - 1.4, p < 0.0001. Survivors in the AKI group were more likely to be discharged to nursing homes and had higher mean hospitalization charges. In 2011 compared with 2005, there was an improved survival after CPR and higher rates of discharges to home. There was no significant change in the mean length of hospital stay between these time periods (p = 0.4). CONCLUSION: AKI independently increases the odds of in-hospital mortality and nursing home placement after in-hospital CPR. These data may facilitate CPR discussions and decision-making in critically ill patients.
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Outcomes of transient ischemic attack in maintenance dialysis patients and those with chronic kidney disease.

BACKGROUND: In-hospital outcomes of transient ischemic attack (TIA) in patients with chronic kidney disease (CKD) and end-stage renal disease (ESRD) requiring maintenance dialysis are largely unknown. We evaluated TIA-related in-hospital outcomes in these patients using a national database. METHODS: Our study is observational in nature. Data from all adult (≥ 18 years) patients admitted to US hospitals between 2005 and 2011 with a primary discharge diagnosis of TIA and secondary diagnosis of CKD and ESRD were included using the Nationwide In-Patient Sample. We aimed to compare the following TIA-related outcomes between CKD and ESRD patients: (i) degree of disability (mainly functional status) derived from discharge destination, (ii) length of stay, (iii) charges of hospitalization, and (iv) mortality. The comparisons of TIA-related mortality and discharge outcomes between CKD and ESRD were analyzed after adjusting for potential confounders using logistic regression analysis. We adjusted for age, sex, co-morbidities, hospital size and hospital teaching status. RESULTS: A total of 18 316 dialysis and 67 256 CKD patients were admitted with TIA in the study period (2005-11). On univariate analysis, there was no difference in the rates of moderate-to-severe disability (20.5% versus 20.2%, P = 0.7) and in-hospital mortality (0.4% versus 0.2%, P = 0.07) in ESRD patients compared with those with CKD. After adjusting for age, sex and potential confounders, ESRD patients with TIA had higher odds of moderate-to-severe disability at discharge [odds ratio (OR): 1.53, 95% confidence interval (CI): 1.37-1.71, P ≤ 0.0001] and in-hospital death (OR: 2.87, 95% CI: 1.29-6.37, P = 0.009). CONCLUSION: ESRD patients with TIA have significantly higher rates of moderate-to-severe disability at discharge and in-hospital mortality when compared with the patients of other stages of CKD who are not dialysis-dependent.

Perceptions and attitudes towards research amongst medical students at Shifa College of Medicine.

OBJECTIVE: To understand medical students' perceptions and attitudes towards research to help facilitators design specific courses according to their needs. METHODS: The cross-sectional study was conducted at Shifa College of Medicine, Islamabad, Pakistan, from May to November 2013, and comprised undergraduate medical students. A pre-tested questionnaire was used for data collection. Students' response was recorded on a Likert scale from 'strongly disagree' 1 to 'strongly agree' 5. Analysis was done using statistical SPSS17. RESULTS: Of the 195 students enrolled, 172(88%) responded. Overall, 78(45.3%) students said they were aware of research. Research was considered useful for their professional careers and relevant to their daily life by 133(65.7%) students, while 72(41.9%) did not consider it worthwhile to pursue research as a career. Besides, 71(41.3%) students enjoyed research, while 120(70%) perceived research as stressful and 107(62.2) complex. CONCLUSIONS: Most students considered research valuable but at the same time they perceived it as stressful and complex.

Giant Cell Tumour of the Patella: A Missing Differential Diagnosis in the Young.

Herein, we discuss the case of a 26-year-old male patient with a diagnosis of giant cell tumour (GCT) of the patella which is an exceptionally uncommon condition. The motive of reporting a rare case such as the giant cell tumour of the bone (GCTB) relies on its diagnostic incidence. Since the symptoms of this tumour overlap more common etiologies than GCT, the diagnosis of such a devastating malignant tumour is usually missed and hence delayed, which leads to poor treatment strategies and ultimately an irreversible fatal outcome.

Survival of an 80-Year-Old Male With a Successful Split-Thickness Skin Graft for End-Stage Necrotizing Fasciitis: A Case Report.

Herein, we report a case of an 80-year-old male who was diagnosed with a fatal condition known as necrotizing fasciitis. This devastating soft tissue infection can cause profound damage to multiple tissue planes. Despite its etiology being multifactorial, impaired immunity with increasing age weighs in as the most significant. We intend to shed light on its detrimental clinical features and how we managed to treat the patient both conservatively and surgically. Through our case findings and management plan, we hope this case to be of clinical value and knowledge to clinicians to better diagnose and treat the deleterious condition.

Research skills and the data spreadsheet: A research primer for low- and middle-income countries.

The specialty of Emergency Medicine continues to expand and mature worldwide. As a relatively new specialty, the body of research that underpins patient management in the emergency department (ED) setting needs to be expanded for optimum patient care. Research in the ED, however, is complicated by a number of issues including limited time and resources, urgency for some therapeutic investigations and interventions, and difficulties in obtaining truly informed patient consent. Notwithstanding these issues, many of the fundamental principles of medical research apply equally to ED research. In all medical disciplines, data needs to be collected, collated and stored for analysis and a data spreadsheet is employed for this purpose. Like other aspects of clinical research, the use of the data spreadsheet needs to be exacting and appropriate. This research primer explores the choice of available spreadsheets and a range of principles for their best-practice use. It is deliberately, not an exhaustive review of the subject. However, we aim to explore basic principles and some of the most accessible and widely used data spreadsheets.

Agronomic, physiological and molecular characterisation of rice mutants revealed the key role of reactive oxygen species and catalase in high-temperature stress tolerance.

Climatic variations have increased the occurrence of heat stress during critical growth stages, which negatively affects grain yield in rice. Plants adapt to harsh environments, and particularly high-temperature stress, by regulating their physiological and biochemical processes, which are key tolerance mechanisms. The identification of heat-tolerant rice genotypes and reliable selection indices are crucial for rice improvement programs. Here, we evaluated the response of a rice mutant population for high-temperature stress at the seedling and reproductive stages based on agronomic, physiological and molecular indices. Estimates of variance components revealed significant differences (P < 0.001) among genotypes, treatments and their interactions for almost all traits. The principal component analysis showed significant diversity among genotypes and traits under high-temperature stress. The mutant HTT-121 was identified as the most heat-tolerant mutant with higher grain yield, panicle fertility, cell membrane thermo-stability (CMTS) and antioxidant enzyme levels under heat stress. Various seedling-based morpho-physiological traits (leaf fresh weight, relative water contents, malondialdehyde, CMTS) and biochemical traits (superoxide dismutase, catalase and hydrogen peroxide) explained variations in grain yield that could be used as selection indices for heat tolerance in rice during early growth. Notably, heat-sensitive mutants accumulated reactive oxygen species, reduced catalase activity and upregulated OsSRFP1 expression under heat stress, suggesting their key roles in regulating heat tolerance in rice. The heat-tolerant mutants identified in this study could be used in breeding programs and to develop mapping populations to unravel the underlying genetic architecture for heat-stress adaptability.

Predictors of prolonged mechanical ventilation in patients admitted to intensive care units: A systematic review.

OBJECTIVE: Although intensive care medicine has evidenced a significant growth in recent decades, the number of patients requiring prolonged mechanical ventilation (PMV) still represents a considerable burden on health-care expenditure. The prediction of the need for PMV seems to provide a plausible cost-effective intervention. The objective of this study is to systematically review the predictors of the need for PMV of adult patients admitted to intensive care units (ICUs) due to medical and surgical needs. METHODS: We conducted a systematic search on three online databases (PubMed, Embase, and MEDLINE) till February 20, 2019. The search process employed several combinations of specific keywords and Boolean operators. RESULTS: A total of 15 articles were included in the study. Based on pooling the outcomes of odds ratios (ORs) and their respective 95% confidence intervals (CIs) as reported from logistic regression analyses, the pooled PMV incidence in 8220 patients (69.59% males) was 17.67 cases per 100 ICU admissions (95% CI 13.69-21.65). We could not conduct a meta-analysis of ORs and 95% CIs due to the significant heterogeneity observed between the included studies (P < 0.001, I2 = 97%). Pre-operative/preadmission kidney dysfunction and chronic obstructive pulmonary disease were the most significant independent predictors of the need for PMV. Following cardiac surgeries, repeated or emergency surgery, prolonged cardiopulmonary bypass time, and the need for blood transfusion were predictors of the need for PMV. CONCLUSION: Within the study limitations, several predictors were identified, which could be further investigated using a unified PMV definition. Successful prediction of the need for PMV would assist clinicians in identifying and adjusting a "weaning strategy" as well as improving patient care to reduce morbidity. Furthermore, establishing specialized weaning units could be warranted based on PMV incidence and prediction in the local settings.

Bicarbonate Therapy for Critically Ill Patients with Metabolic Acidosis: A Systematic Review.

The management of acid-base disorders always calls for precise diagnosis and treatment of the underlying disease. Sometimes additional means are necessary to combat systemic acidity itself. In this systematic review, we discuss the concept and some specific aspects of bicarbonate therapy for critically ill patients with metabolic acidosis (i.e., patients with blood pH < 7.35). We conducted a systematic literature review of three online databases (PubMed, Google Scholar, and Cochrane) in November 2018 to validate usage of bicarbonate therapy for critically ill patients with metabolic acidosis. Twelve trials and case series were included in the final analysis, from which we assessed population, intervention, comparison, and outcome data. The current literature suggests limited benefit from bicarbonate therapy for patients with severe metabolic acidosis (pH < 7.1 and bicarbonate < 6 mEq/L). However, bicarbonate therapy does yield improvement in survival for patients with accompanying acute kidney injury.

Body mass status of school children of Dera Ismail Khan, Pakistan.

BACKGROUND: Childhood obesity is a global epidemic involving both developed and developing countries. It is a stare of over-nutrition with long-term complications such as dyslipidemia, hypertension, and coronary artery disease and type-2 diabetes. Underweight is the result of under nutrition leading to reduction in growth and development of every body organ especially the Central Nervous System. Long-term under-nutrition causes failure in linear growth (height) of the child. Growth is further retarded by the repeated attacks of respiratory infections, diarrhea and anemia as a result of reduced immunity. METHODS: This study was carried, out eight primary schools of Dera Ismail Khan (Private, semi government organizations, and welfare foundations) having mixed population with some of the wards belonging to high socioeconomic group. Thorough clinical examination excluded those suffering from chronic heath problems. Height and weight of each one was taken body mass index of determined according to 'Quatelet's' index. Body mass index number was plotted on the CDC S age and gender specific growth charts 2-20 years for BMI-for age percentile and body mass status (underweight, normal weight, overweight/at the risk of overweight and obese/overweight. RESULTS: Total 1338 school going children (6-11 years) were examined with 865 (67.75%) boys and 471 (35.25%) as girls. 13.39%, 72.15%, 8.83% and 5.61% as underweight, normal weight, overweight and obese respectively. Percentage of underweight was higher in girls (25%) than boys (13.22). Percentage of obesity was higher (5.17%) in boys than girls (1.39%). CONCLUSION: Awareness about balanced diet, improvement in the level of education and socioeconomic conditions, easy access to health facilities and prevention of the gender discrimination, are the remedial measures to be taken to redress the situation.

Inoculation with the endophyte Piriformospora indica significantly affects mechanisms involved in osmotic stress in rice.

BACKGROUND: Rice is a drought susceptible crop. A symbiotic association between rice and mycorrhizal fungi could effectively protect the plant against sudden or frequent episodes of drought. Due to its extensive network of hyphae, the endophyte is able to deeply explore the soil and transfer water and minerals to the plant, some of them playing an important role in mitigating the effects of drought stress. Moreover, the endophyte could modify the expression of drought responsive genes and regulate antioxidants. RESULTS: Three rice genotypes, WC-297 (drought tolerant), Caawa (moderately drought tolerant) and IR-64 (drought susceptible) were inoculated with Piriformospora indica (P. indica), a dynamic endophyte. After 20 days of co-cultivation with the fungus, rice seedlings were subjected to 15% polyethylene glycol-6000 induced osmotic stress. P. indica improved the growth of rice seedlings. It alleviated the destructive effects of the applied osmotic stress. This symbiotic association increased seedling biomass, the uptake of phosphorus and zinc, which are functional elements for rice growth under drought stress. It boosted the chlorophyll fluorescence, increased the production of proline and improved the total antioxidant capacity in leaves. The association with the endophyte also up regulated the activity of the Pyrroline-5-carboxylate synthase (P5CS), which is critical for the synthesis of proline. CONCLUSION: A mycorrhizal association between P. indica and rice seedlings provided a multifaceted protection to rice plants under osmotic stress (- 0.295 MPa).

Outcomes of In-Hospital Cardiopulmonary Resuscitation in Patients with CKD.

BACKGROUND AND OBJECTIVES: Advance care planning, including code/resuscitation status discussion, is an essential part of the medical care of patients with CKD. There is little information on the outcomes of cardiopulmonary resuscitation in these patients. We aimed to measure cardiopulmonary resuscitation outcomes in these patients. DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Our study is observational in nature. We compared the following cardiopulmonary resuscitation-related outcomes in patients with CKD with those in the general population by using the Nationwide Inpatient Sample (2005-2011): (1) survival to hospital discharge, (2) discharge destination, and (3) length of hospital stay. All of the patients were 18 years old or older. RESULTS: During the study period, 71,961 patients with CKD underwent in-hospital cardiopulmonary resuscitation compared with 323,620 patients from the general population. Unadjusted in-hospital mortality rates were higher in patients with CKD (75% versus 72%; P<0.001) on univariate analysis. After adjusting for age, sex, and potential confounders, patients with CKD had higher odds of mortality (odds ratio, 1.24; 95% confidence interval, 1.11 to 1.34; P≤0.001) and length of stay (odds ratio, 1.11; 95% confidence interval, 1.07 to 1.15; P=0.001). Hospitalization charges were also greater in patients with CKD. There was no overall difference in postcardiopulmonary resuscitation nursing home placement between the two groups. In a separate subanalysis of patients ≥75 years old with CKD, higher odds of in-hospital mortality were also seen in the patients with CKD (odds ratio, 1.10; 95% confidence interval, 1.02 to 1.17; P=0.01). CONCLUSIONS: In conclusion, we observed slightly higher in-hospital mortality in patients with CKD undergoing in-hospital cardiopulmonary resuscitation.