Analysing trends of Patient Safety Non-Technical Skills among postgraduate trainees through a modified survey tool.

Objective: To analyse practices of patient safety non-technical skills among postgraduate trainees to establish the utility of organised teaching programmes in this regard, and to determine the utilisation of different teaching modes. METHODS: The multicentre, two-phase, cross-sectional study was conducted from February to August 2020 at 27 teaching hospitals across Pakistan which were part of the Patient Safety Friendly Hospital Initiative by the World Health Organisation. The Hospital Survey on Patient Safety Culture was modified with validated additional survey items before using it to gather relevant data. Data was analysed using SPSS 21. RESULTS: In the first phase, 42 additional survey items were developed with content validity ratio >0.66 and item content validity index >0.83. Cronbach's alpha of the modified survey tool was 0.790. The second phase comprised 388 postgraduate trainees; 199(51.3%) males and 189(48.7%) females. Of them, 134(34.5%) were in the third year of training, 215(55.4%) fourth, and 39(10.1%) in the final year. Highest positive response was found for learning Teamwork 216(55.7%) and the lowest for Situational Awareness 62(15.9%). Leadership had highest good practice responses (subscales range: 77.6% to 76.6%) and Communication had the lowest (subscales range: 16.5% to 74.2%). Agreement on Informal Learning mode was the highest 268(69.1%) and the lowest was for Simulator Learning 63(16.2%). Besides, 274(70.6%) and 281(72.4%) subjects agreed on the supportive role of supervisors and hospital administrations. The correlation of the studied variables with the year of training was significant only for Teamwork (p=0.02) and Medication Safety skills (p=0.01). Conclusion: Modified Hospital Survey on Patient Safety Culture could be used as a benchmark for evaluating patient safety teachings and practices. Significance of patient safety non-technical skills was established with limited evidence for the utility of organised teaching programmes.

Patient safety awareness and attitude among interns of a tertiary care hospital.

To assess the knowledge, behaviours and attitudes towards Patient Safety (PS) among interns of a tertiary care hospital, a cross sectional survey was conducted among 126 interns of Combined Military Hospital, Lahore (CMH Lhr), using Questionnaire (APSQ -4) in December 2019. Statistical analysis was done on SPSS 23. The interns exhibited good PS knowledge. The highest response was evident for "Attitude to Medical Error Reporting" domain (53.34±7.62) followed by "PS Knowledge" (50.88±6.85) with lowest response for "Attitude to PS Skills" domain (Mean = 16.34 ± 3.46). Independent Sample T Tests for comparison of mean responses of civilian and military interns revealed significant difference for PS Attitude to PS Training only, T Test (df)1.940 (124) p-value = 0.055. PS knowledge exists among the interns with limited training and practices. Medical educationists and supervisors should incorporate PS culture in junior doctors through rigorous training.

Spinal Tuberculosis: Clinicoradiological Findings in 274 Patients.

Background: Mycobacterium tuberculosis is a major cause of myelopathy and radiculopathy in settings with a high prevalence of tuberculosis/human immunodeficiency virus (HIV) coinfection. However, a paucity of publications exists on the spectrum of neurological and magnetic resonance (MR) imaging findings of spinal tuberculosis in these populations. Methods: We conducted a retrospective study of adults with spinal tuberculosis at a referral center in South Africa for patients with spinal disease without bony involvement seen at plain film radiography. We report the clinical, laboratory and spinal MR imaging findings, compare HIV-infected and HIV-uninfected patients, and correlate clinical and cerebrospinal fluid findings with those of MR imaging. Results: Of 274 patients, 209 (76%) were HIV infected and 49 (18%) were HIV uninfected. Radiculomyelitis occurred in 77% (n = 210), and spondylitis in 39% (n = 106). Subdural abscess (n = 42) and intramedullary tuberculoma (n = 33) were common. In 24% of HIV-infected and 14% of HIV-uninfected patients, spinal disease manifested as a paradoxical tuberculosis reaction, frequently following tuberculous meningitis. The triad of neurological deficit, fever, and back pain was similar in patients with spondylitis (24%), epi/subdural abscess without bony disease (14%), meningoradiculitis (17%), and isolated myelitis (17%) . Conclusions: Radiculomyelitis is a common manifestation of spinal tuberculosis in settings with high tuberculosis/HIV prevalence, often presenting as a paradoxical reaction. We describe a high frequency of rarely reported spinal tuberculosis manifestations, suggesting that these are more common than implied by the literature.

Posttubercular syringomyelia in HIV-infected patients: A report of 10 cases and literature review.

OBJECTIVES: To describe the clinical presentation, spinal magnetic resonance imaging (MRI) findings and outcome of HIV-infected patients with tuberculosis (TB)-associated syringomyelia and to compare these findings between all HIV-infected and -uninfected cases published in the literature. METHODS: A retrospective observational study conducted over a 12.5-year period at a public-sector referral hospital in South Africa. HIV-infected adults with neurological TB in whom MRI confirmed a syrinx were included. We searched PubMed to identify all published syringomyelia cases. RESULTS: Ten patients were enrolled. Syringomyelia complicated neurological TB within four years of initial diagnosis in all patients (median: 21 months, range: 0-39) after initial diagnosis. Six patients were treated conservatively (TB treatment = 5, no treatment = 1); four improved, but only one was ambulant during follow-up. Four patients underwent syringoperitoneal shunting; three improved and one died three months later. Our literature review identified 50 additional cases (HIV-infected = 2, HIV-uninfected = 9, HIV status not documented = 39 [presumed HIV-uninfected]). Clinical and imaging findings and outcomes were similar between HIV-infected and -uninfected cases, except for time of presentation following neurological TB diagnosis, which was delayed (>4 years) in 46% of HIV-uninfected cases, compared to 8% of HIV-infected cases. Conclusions Syringomyelia is a disabling complication of neurological TB that usually presents early after neurological TB diagnosis in HIV coinfected patients.

Diffusion-weighted magnetic resonance imaging of spinal infection and malignancy.

BACKGROUND AND PURPOSE: Pyogenic and tuberculous spondylitis can mimic malignancy. The purpose of this study was to deter mine the efficacy of diffusion-weighted magnetic resonance imaging in differentiating spinal infection and malignancy. METHODS: Fifty-one consecutive patients with suspected spinal infection or malignancy were enrolled in the study. Apparent diffusion coefficients (ADCs) of paraspinal soft tissue mass and normal and abnormal vertebral bone marrow were determined on the diffusion-weighted magnetic resonance images of the spine. The mean ADCs of normal and abnormal vertebral bodies in patients with confirmed infection or malignancy were compared using nonparametric tests. RESULTS: ADCs of 69 tuberculous, 9 pyogenic, and 50 malignant vertebral marrow lesions were significantly higher than ADCs of normal marrow. ADCs of malignant bone marrow and 5 paraspinal soft tissue lesions were significantly lower than tuberculosis and pyogenic infection. There was no significant difference between the ADCs of 44 adult and 25 pediatric tuberculous bone lesions or between tuberculosis and pyogenic infection. Using the cutoff ADC of 1.02x10(-3)mm2/s for bone marrow, the sensitivity, specificity, and accuracy were 60.26%, 66.00%, and 62.50%, respectively, for distinguishing infection from malignancy. The sensitivity, specificity, and accuracy increased to 94.12%, 82.35%, and 90.20%, respectively, when the ADCs of associated soft tissue lesions were higher than 1.17x10(-3)mm2/s. CONCLUSIONS: Diffusion-weighted magnetic resonance imaging has limited usefulness for differentiating spinal infection and malignancy.

Prognostic capabilities of coronary computed tomographic angiography before non-cardiac surgery: prospective cohort study.

OBJECTIVES: To determine if coronary computed tomographic angiography enhances prediction of perioperative risk in patients before non-cardiac surgery and to assess the preoperative coronary anatomy in patients who experience a myocardial infarction after non-cardiac surgery. DESIGN: Prospective cohort study. SETTING: 12 centers in eight countries. PARTICIPANTS: 955 patients with, or at risk of, atherosclerotic disease who underwent non-cardiac surgery. INTERVENTIONS: Coronary computed tomographic angiography was performed preoperatively; clinicians were blinded to the results unless left main disease was suspected. Results were classified as normal, non-obstructive (<50% stenosis), obstructive (one or two vessels with ≥ 50% stenosis), or extensive obstructive (≥ 50% stenosis in two vessels including the proximal left anterior descending artery, three vessels, or left main). MAIN OUTCOME MEASURE: Composite of cardiovascular death and non-fatal myocardial infarction within 30 days after surgery (primary outcome). This was the dependent variable in Cox regression. The independent variables were scores on the revised cardiac risk index and findings on coronary computed tomographic angiography. RESULTS: The primary outcome occurred in 74 patients (8%). The model that included both scores on the revised cardiac risk index and findings on coronary computed tomographic angiography showed that coronary computed tomographic angiography provided independent prognostic information (P=0.014; C index=0.66). The adjusted hazard ratios were 1.51 (95% confidence interval 0.45 to 5.10) for non-obstructive disease; 2.05 (0.62 to 6.74) for obstructive disease; and 3.76 (1.12 to 12.62) for extensive obstructive disease. For the model with coronary computed tomographic angiography compared with the model based on the revised cardiac risk index alone, with 30 day risk categories of <5%, 5-15%, and >15% for the primary outcome, the results of risk reclassification indicate that in a sample of 1000 patients that coronary computed tomographic angiography would have resulted appropriately in 17 net patients receiving a higher risk estimation among the 77 patients who would have experienced the primary outcome (P<0.001). Coronary computed tomographic angiography, however, would have resulted inappropriately in 98 net patients receiving a higher risk estimation, among the 923 patients who would not have experienced the primary outcome (P<0.001). Among patients who had a perioperative myocardial infarction, preoperative coronary anatomy showed extensive obstructive disease in 31% (22/71), obstructive disease in 41% (29/71), non-obstructive disease in 24% (17/71), and normal findings in 4% (3/71). CONCLUSIONS: Though findings on coronary computed tomographic angiography can improve estimation of risk for patients who will experience perioperative cardiovascular death or myocardial infarction, findings are more than five times as likely to lead to an inappropriate overestimation of risk among patients who will not experience these outcomes. Perioperative myocardial infarction occurs across the spectrum of coronary artery disease, suggesting that there could be several pathophysiologic mechanisms.

The coronary CT angiography vision protocol: a prospective observational imaging cohort study in patients undergoing non-cardiac surgery.

INTRODUCTION: At present, physicians have a limited ability to predict major cardiovascular complications after non-cardiac surgery and little is known about the anatomy of coronary arteries associated with perioperative myocardial infarction. We have initiated the Coronary CT Angiography (CTA) VISION Study to (1) establish the predictive value of coronary CTA for perioperative myocardial infarction and death and (2) describe the coronary anatomy of patients that have a perioperative myocardial infarction. METHODS AND ANALYSIS: The Coronary CTA VISION Study is prospective observational study. Preoperative coronary CTA will be performed in 1000-1500 patients with a history of vascular disease or at least three cardiovascular risk factors who are undergoing major elective non-cardiac surgery. Serial troponin will be measured 6-12 h after surgery and daily for the first 3 days after surgery. Major vascular outcomes at 30 days and 1 year after surgery will be independently adjudicated. ETHICS AND DISSEMINATION: Coronary CTA results in a measurable radiation exposure that is similar to a nuclear perfusion scan (10-12 mSV). Treating physicians will be blinded to the CTA results until 30 days after surgery in order to provide the most unbiased assessment of its prognostic capabilities. The only exception will be the presence of a left main stenosis >50%. This approach is supported by best available current evidence that, excluding left main disease, prophylatic revascularisation prior to non-cardiac surgery does not improve outcomes. An external safety and monitoring committee is overseeing the study and will review outcome data at regular intervals. Publications describing the results of the study will be submitted to major peer-reviewed journals and presented at international medical conferences.