Preventing Risks of Infections and Medication Errors in IV therapy (PRIME): a patient safety initiative.

BACKGROUND: Two major avoidable reasons for adverse events in hospital are medication errors and intravenous therapy-induced infections or complications. Training for clinical staff and compliance to patient safety principles could address these. METHODS: Joint Commission International (JCI) consultants created a standardised, 6-month training programme for clinical staff in hospitals. Twenty-one tertiary care hospitals from across south-east Asia took part. JCI trained the clinical consultants, who trained hospital safety champions, who trained nursing staff. Compliance and knowledge were assessed, and monthly audits were conducted. RESULTS: There was an overall increase of 29% in compliance with parameters around medication preparation and vascular access device management. CONCLUSION: The programme improved safe practice around preparing medications management and managing vascular access devices. The approach could be employed as a continuous quality improvement initiative for the prevention of medication errors and infusion-associated complications.

Knowledge, Attitudes and HPV Vaccine Intention Among Women in India.

In India, cervical cancer associated with human papillomavirus (HPV) infection is a leading cause of cancer-related mortality among women. However, uptake of the vaccine in India is low. We assessed knowledge and attitudes towards HPV, assess participants' willingness to accept the vaccination for themselves and their children, and determine factors associated with intention to receive the HPV vaccine among women in Mangalore, India. This cross-sectional study surveyed a convenient sample of 237 women aged 18-45 years using a semi-structured questionnaire. All respondents reported being aware of HPV infection. However, 22.36% (n = 53) of the respondents have never heard about genital warts and 18.57% (n = 44) have never heard about HPV vaccine. Participants displayed good general knowledge of HPV infection (median score, 1.26; Interquartile Range (IQR): 1.04-1.52) and average knowledge of HPV vaccine (e.g., median score, 1.18; IQR: 0.73-1.45). HPV general knowledge and vaccine knowledge were associated with intention to receive the HPV vaccine and recommend it to children. Participant awareness of the HPV vaccine predicted vaccine intent for themselves. Participants' willingness to recommend the vaccine for their children was associated with older age, married status, having one or more children, and having a college education. Lack of awareness about genital warts was strongly associated with participants' refusal to get the HPV vaccine or recommend it for their own children (Relative Risk Ratio RRR: 12.21; 95% C.I.: 2.33-63.99). Our study validated the questionnaire as a reliable tool for assessing HPV and HPV vaccine knowledge, attitudes, awareness, and vaccine intentions in women aged 18-45 years. Public health education should focus on increasing awareness of genital warts as a sequela of HPV, as well as promote awareness of role and safety of HPV vaccination in -children.

COVID-19 Palliative and End-of-Life Care Plan: Development and Audit of Outcomes.

Objectives: Palliative care (PC) referral in serious and critical COVID-19 improves decision-making, health resource utilisation, end-of-life symptom management and family support. In this study, we explored developing a systematic decision-making matrix for PC referral in COVID-19 and audited its outcomes. Materials and Methods: A team of interdisciplinary experts developed a hospital COVID-19 PC plan. PC referral and outcomes of PC referral in hospitalised COVID-19 patients were audited. Results: Out of 1575 inpatients, 1066 (67.7%) had mild and 509 (32.3%) had serious and critical COVID-19 illness. Among 50 (3.1%) referred to PC, 5 (0.4%) had mild and 45 (8.8%) had serious and critical COVID-19 illness. Out of 45 serious and critical COVID-19 patients referred to PC, 38 (84%) received end-of-life care (EOLC), 4 (9%) self-discharged against medical advice and 3 (7%) recovered. Forty-seven (94%) were referred for goals-of-care discussion. About 78% received opioids, 70% benzodiazepines and 42% haloperidol for symptom management. Among 45 serious and critical COVID-19 patients referred to PC, foregoing life-sustaining treatment was documented in 43 (96%) but implemented only in 23 (53%). Out of 38 who received EOLC, ICU was the place of death in 31 (82%) and ward in 7 (18%). Conclusion: Despite interdisciplinary experts developing a hospital COVID-19 PC, low referral of serious and critical COVID-19 patients to PC was observed. PC referral enabled access to management of end-of-life symptoms and facilitated limitation of life-sustaining treatment in some COVID-19 patients with serious illness. Educating critical care physicians about the scope of PC in the COVID-19 setting might improve PC referral.

Determinants of HIV status disclosure to children living with HIV in coastal Karnataka, India.

The caregivers of HIV-positive children either delay or avoid disclosure of HIV status to the child due to several reasons. Keeping the child's HIV status a secret puts them at considerable risk of stopping therapy and transmitting HIV to others. Hence this study was conducted to assess the determinants of disclosure of HIV status to infected children in coastal Karnataka. A cross-sectional study was conducted in a District Hospital in Coastal Karnataka from October 2014 to July 2015. One hundred eighty-five caregivers were recruited for the study purposively and interviewed using a pre-tested, semi-structured questionnaire after written informed consent. Of the 185 caregivers interviewed, 78 (42%) caregivers had not disclosed the HIV status to the child. The child being too young was the most common reason for non-disclosure of HIV status. The majority of the caregivers intended to disclose the HIV status fully to the child after the child attained ten years of age. Nearly two-thirds of the caregivers wanted to disclose it themselves in their own homes. The significant determinants of disclosure of HIV status were the age of the child, and person involved in childcare, and the venue of the disclosure.

Cannabis induced thermal epiglottitis in a pediatric patient.

Acute epiglottitis is an airway emergency presenting with edema and inflammation of the epiglottis and aryepiglottic folds [1]. Infectious and other non-infectious etiologies may cause significant airway injury presenting with similar clinical symptoms and radiographic findings [1]. While many causes of thermal epiglottitis have been described in the pediatric and young adult population, we describe an unusual case of an adolescent patient with cannabis induced thermal epiglottitis. A 17-year-old previously healthy, vaccinated adolescent male presented to the pediatric emergency department with dysphagia, odynophagia, drooling, and muffled voice with fever, tachypnea, and leukocytosis. Lateral plain film imaging and computed tomography (CT) scan showed significant edema of the epiglottitis. Urinary drug screen in the emergency department was positive for benzodiazepine, opiates, and cannabinoids. Transnasal flexible laryngoscopy and direct laryngoscopy demonstrated significant erythema, edema, and copious secretions. Culture of the epiglottis culture showed normal oropharyngeal flora. The patient was diagnosed with thermal induced epiglottitis secondary to cannabinoid use based on positive substance use history, urinary drug screen, and negative bacterial cultures. Clinicians must consider thermal injury of the epiglottitis due to substance use, specifically marijuana in vaccinated adolescent patients presenting with positive substance use history, progressive dysphagia, odynophagia, and drooling with a muffled voice. It is essential to obtain a thorough history and physical examination and urinary drug screen in the pediatric emergency department since the clinical and radiographic findings are similar in epiglottitis due to infectious and non-infectious etiologies. Prompt management with intubation should occur to protect and maintain airway integrity.

Impact of care at foster homes on the health-related quality of life of HIV-infected children and adolescents: a cross-sectional study from India.

PURPOSE: To assess the impact of care at foster homes on the health-related quality of life (HRQOL) of children living with HIV (CLHIV), attending a referral ART Centre, and to compare their HRQOL with children living in their own homes. METHODS: A cross-sectional study was conducted in 144 CLHIV between 5 and 18 years of age, attending a referral ART Centre in South India to assess their HRQOL using the standard PedsQL™ 4.0 questionnaire. Data were then analysed to compare the HRQOL of children living in foster homes to those children living in their own homes. The child report and the parent proxy-report on the child's HRQOL were also compared to see for any differences in their perspectives. RESULTS: 56.25% CLHIV were brought up in different foster homes. In the child's self-report, the mean HRQOL was higher for children living in foster homes [physical score (76.54 ± 12.40), psychosocial score (71.41 ± 12.40) and total score (73.20 ± 11.13)] when compared to children living in their own homes [physical score (75.09 ± 14.76), psychosocial score (70.60 ± 13.48) and total score (72.17 ± 12.00)]. There was no statistically significant difference in the HRQOL between these two groups (p > 0.05). In the parent proxy-report also, there was no statistically significant difference in the HRQOL in all the three scores. The child self-report depicted a significantly higher HRQOL in all the domains compared to the parent proxy-report (p < 0.05). CONCLUSIONS: HRQOL of children living in foster homes is at par with the quality of life enjoyed by children living in their own homes. Foster care manages to provide a reasonable HRQOL in CLHIV, and has become an inseparable component of quality health care delivery for these children.

Sudden Cardiac Arrest Due to Hemophagocytic Lymphohistiocytosis in a Child.

BACKGROUND: Hemophagocytic lymphohistiocytosis (HLH) is an uncommon hyperinflammatory condition in children that may acutely mimic septic shock. Sudden out-of-hospital cardiac arrest in children is also uncommon and may be of unclear etiology upon initial presentation. CASE REPORT: A 10-year-old previously healthy child presented with sudden cardiac arrest after an insidious course of throat pain, fever, and progressive altered mental status. He was subsequently diagnosed with Epstein-Barr virus-associated HLH and suffered cerebral edema and death. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: HLH has not previously been described as a cause of sudden out-of-hospital cardiac arrest in children. Rapid diagnosis of underlying cause of an unexpected cardiac arrest may help guide appropriate therapy to salvage organ function.

Zika Virus: A Serious Global Health Threat.

In February 2016, the World Health Organization declared Zika virus (ZIKV) infection a public health emergency of international concern, given the precipitous spread of the virus across the Americas. Unlike arboviruses such as Chikungunya and Dengue, which have also recently emerged in the western hemisphere, ZIKV was identified in communities where concurrent neurologic conditions such as microcephaly and Guillain-Barre (GB) syndrome were occurring at alarming rates. Thus, investigations to systematically evaluate the link between ZIKV, congenital malformations (including microcephaly) and GB syndrome remain a top priority.

Knowledge and Attitudes Towards Human Papillomavirus (HPV) Among Academic and Community Physicians in Mangalore, India.

Cervical cancer is the most common cancer found in Indian women. Two human papillomavirus (HPV) vaccines were approved for use in India in 2006; however, neither has become readily accepted. Physician attitudes and recommendations are crucial in the uptake of HPV vaccines among adolescent women in the USA; thus, we ought to investigate provider attitudes and practices related to HPV vaccination in India via a survey administered to 210 Indian physicians. Of the 210 physicians, 46 % were community physicians and 54 % were academic physicians. The correct response to HPV knowledge questions was identified around 50 % of the time in 6/11 questions. Only 47 % of the physicians knew that there was an HPV vaccine approved for use in India. Only 11 % and 15 % of physicians strongly agree that the HPV vaccine will lead to long-lasting immunity and has a safe side effect profile, respectively. A total of 30 % of those surveyed reported that they would recommend the HPV vaccine to their patients, while 73 % agreed that the cost of the HPV vaccine is a major barrier to acceptance. After multivariate analysis, there were two significant variables independently associated with a physician's decision to recommend HPV vaccine. These variables were as follows: "whether the vaccine was freely available from the government sector" and "uncertainty about whether HPV must be persistent to cause cervical cancer vs not." Given the lack of knowledge among practicing physicians in Mangalore, increasing the education about HPV infection and HPV vaccination towards health care providers has the potential to increase vaccine recommendations.

Cervical cytological abnormalities and human papilloma virus infection in women infected with HIV in Southern India.

AIM: The aim of this study was to examine the association between CD4 count, human papilloma virus (HPV) infection, and the risk of cervical intraepithelial neoplasia among HIV-infected women. METHODS: A cross-sectional study was conducted among 104 HIV-infected women attending an antiretroviral therapy clinic. They underwent Pap smear and cervical HPV DNA testing. RESULTS: The overall prevalence of HPV infection was 57.7%. HPV 16 was the commonest genotype found (38.5%); HPV 16 and 18 put together contributed to 73.3% of HPV infection; 27.5% of HIV-infected women had squamous cell abnormalities. Cervical intraepithelial neoplasia was less likely among women with CD4 count > 500/mm3 (12%) and in those without opportunistic infections (17.8%). The prevalence of high-risk HPV infection was higher in women with high-grade squamous intraepithelial lesions or greater lesions (85.7%) as compared to women with normal cytology (52.1%). CONCLUSION: The high prevalence of HPV infection and cervical intraepithelial neoplasia in HIV-infected women warrants the need for regular Pap smear screening in these women and routine HPV vaccination for adolescents to reduce the burden of cervical cancer in India.

Knowledge and acceptability of human papillomavirus vaccination and cervical cancer screening among women in Karnataka, India.

Cervical cancer is the leading cause of cancer-related mortality among women in India; however, participation in prevention and screening is low and the reasons for this are not well understood. In a cross-sectional survey in August 2008, 202 healthy women in Karnataka, India completed a questionnaire regarding knowledge, attitudes, and practices related to human papillomavirus (HPV) and cervical cancer. Factors associated with vaccination and Papanicolau (Pap) smear screening acceptance were explored. Thirty-six percent of women had heard of HPV while 15% had heard of cervical cancer. Five percent of women reported ever having a Pap smear, and 4% of women felt at risk of HPV infection. Forty-six percent of women were accepting of vaccination, but fewer (21%) were willing to have a Pap smear. Overall, knowledge related to HPV and cervical cancer topics was low. Women with negative attitudes toward HPV infection were 5.3 (95% confidence interval (CI) 2.8-10) times more likely to accept vaccination but were not significantly more likely to accept Pap smear (odds ratio 1.5, 95% CI 0.7-3.0). Cost and a low level of perceived risk were the most frequent factors cited as potential barriers. Improving awareness of HPV and cervical cancer through health care providers in addition to increasing access to vaccination and screening through government-sponsored programs may be feasible and effective methods to reduce cervical cancer burden in India.

Vaccine poliovirus shedding and immune response to oral polio vaccine in HIV-infected and -uninfected Zimbabwean infants.

BACKGROUND: With prolonged replication, attenuated polioviruses used in oral polio vaccine (OPV) can mutate into vaccine-derived poliovirus (VDPV) and cause poliomyelitis outbreaks. Individuals with primary humoral immunodeficiencies can become chronically infected with vaccine poliovirus, allowing it to mutate into immunodeficiency-associated VDPV (iVDPV). It is unclear if children perinatally infected with the human immunodeficiency virus (HIV), who have humoral as well as cellular immunodeficiencies, might be sources of iVDPV. METHODS: We conducted a prospective study collecting stool and blood samples at multiple time points from Zimbabwean infants receiving OPV according to the national schedule. Nucleic acid extracted from stool was analyzed by real-time polymerase chain reaction for OPV serotypes. RESULTS: We analyzed 825 stool samples: 285 samples from 92 HIV-infected children and 540 from 251 HIV-uninfected children. Poliovirus shedding was similar after 0-2 OPV doses but significantly higher in the HIV-infected versus uninfected children after ≥ 3 OPV doses, particularly within 42 days of an OPV dose, independent of seroconversion status. HIV infection was not associated with prolonged or persistent poliovirus shedding. HIV infection was associated with significantly lower polio seroconversion rates. CONCLUSIONS: HIV infection is associated with decreased mucosal and humoral immune responses to OPV but not the prolonged viral shedding required to form iVDPV.

Improving the emergency services using quality improvement project and Donabedian model in a quaternary teaching hospital in South India.

INTRODUCTION: The primary goal of quality improvement is to enhance patient outcomes, particularly in the emergency department (ED). Timely and effective care is crucial in these situations. By comprehending the challenges, evaluating current performance and implementing quality improvement projects, areas in need of enhancement can be pinpointed and addressed, resulting in better outcomes. METHODOLOGY: This interventional study explores the implementation of quality improvement in the ED of a quaternary care teaching hospital in South India. It follows the Plan-Do-Check-Act (PDCA) cycle guided by the Donabedian model. Descriptive statistics were employed to measure changes in outcomes before and after implementation. To improve processes, Donabedian principles were applied, and a performance audit was conducted based on patient feedback and stakeholder input. Various ED indicators were measured. To address identified issues, formal root cause analysis was performed, leading to the generation of PDCA rapid change cycles. These cycles were implemented over 6 months, with two cycles executed, followed by postimplementation evaluation. RESULTS: Post implementation, improvements were observed in several aspects of ED operations. These included reduced ED average length of stay, decreased time to analgesia, shorter cross-consultation time, faster transfer time from ED and improved investigation turnaround time (TAT). Additionally, there was a reduction in revisits to ED within 72 hours and a decrease in patients who left without being seen. These positive changes demonstrate the effectiveness of the quality improvement intervention using the PDCA cycle. CONCLUSION: A comprehensive understanding of patient profile in the ED and factors influencing care is essential for the hospital to ensure sufficient resources and skilled emergency medicine physicians are available 24/7. By enhancing services in the ED, reducing patient waiting times and improving TAT, the overall efficiency of services can be improved. This leads to provision of timely quality care to patients and ultimately improves their outcomes.

Bilateral parotitis as the initial presentation of childhood sarcoidosis.

The differential diagnosis of bilateral parotid gland enlargement in children includes infectious, inflammatory, and neoplastic disorders. We present the case of a 13-year-old male who presented with a 5-week history of bilateral parotid swelling. On exam, both parotid glands were nontender, smooth, and diffusely enlarged. He had slightly elevated inflammatory markers, but other lab results were normal. A neck CT revealed symmetric enlargement of the parotid, submandibular, and sublingual glands. A chest CT revealed scattered peripheral pulmonary nodules and bilateral hilar adenopathy. A parotid gland biopsy showed multiple noncaseating granulomas with multinucleated giant cells surrounded by lymphocytes, consistent with the diagnosis of sarcoidosis. Special stains for acid-fast and fungal organisms were negative. Using this illustrative case, we discuss the differential diagnosis of bilateral salivary gland enlargement in children and review the etiology, diagnosis, clinical manifestations, and treatment of pediatric sarcoidosis.

A 6-year-old girl with fever, rash, and increased intracranial pressure.

BACKGROUND: Rocky Mountain spotted fever (RMSF) is a well-described, potentially lethal, tick-borne zoonotic infection and has very effective therapy. However, the diagnosis might not be made early enough, often leading to worse outcomes. OBJECTIVE: Our aim was to discuss the diagnostic dilemmas facing the physician when evaluating patients with suspected RMSF. METHODS: We report a case of RMSF in a 6-year-old girl who presented to our hospital with a 7-day history of fever, headache, and a petechial rash. After blood cultures were obtained, the patient was treated empirically with doxycycline, vancomycin, and ceftriaxone. During the next 24 h, her clinical status worsened, with acute onset of altered mental status, posturing, and fixed and dilated pupils. A computed tomography scan of the brain demonstrated diffuse cerebral edema with evidence of tonsillar herniation. She died 24 h after admission. A serum specimen tested positive for immunoglobulin G to Rickettsia rickettsii at a titer of 128 dilutions, confirming recent infection. CONCLUSIONS: We present this case to raise awareness of RMSF in patients who present with a nonspecific febrile illness in tick-endemic areas in the United States. Early diagnosis and treatment with doxycycline before day 5 of illness is essential and can prevent morbidity and mortality.

Assessing Barriers to Human Papillomavirus (HPV) Vaccination in At-Risk Rural Communities of Western North Carolina, United States.

Human papillomavirus (HPV) vaccination among adolescents in rural, western North Carolina (NC) remains suboptimal. Data are needed to understand the barriers to HPV vaccination in these communities. We conducted a cross-sectional pilot study of parental attitudes and provider practices regarding HPV vaccination in rural western NC counties with lower HPV vaccination rates. Eight health department clinics were enrolled in the study. Further, 29 provider and 32 parent surveys were analyzed along with environmental scans. Median provider comfort regarding knowledge of HPV-associated diseases was 85% (IQR = 75-95), on a scale of 0-100% (100% representing complete comfort). Median parental comfort level regarding knowledge of HPV-associated diseases and the HPV vaccine was 75% (IQR = 50-89) and 75% (IQR = 49-96), respectively. Less than 25% of parents rated the HPV vaccine as 'extremely effective' against genital (16.7%) and anal cancers (17.9%). Parents were more likely to rate the vaccine as 'extremely effective' to 'very effective' if their child was female. There was no significant difference between parental- and provider-reported comfort with knowledge about HPV-associated diseases (p = 0.0725) and the HPV vaccine (p = 0.167). This study identified multiple opportunities to increase HPV vaccine coverage among unvaccinated adolescents at parental, provider, and clinic levels. Health education of rural NC residents and providers in public health settings may identify future interventions to increase HPV vaccine uptake.