Patient Blood Management Program Implementation: Comprehensive Recommendations and Practical Strategies.

INTRODUCTION: Blood transfusion is one of the most common medical practices worldwide. However, current scientific literature has shown that the immunomodulatory effects of blood transfusion are associated with an increased likelihood of infection, prolonged hospitalization, and morbimortality. Also, it means high costs for healthcare systems. METHODS: In this context, acknowledging that blood transfusions are essentially heterologous cell transplantations, the use of therapeutic options has gained strength and is collectively known as the patient blood management (PBM) program. PBM is an approach based on three main pillars: (1) treating anemias and coagulopathies in an optimized manner, especially in the preoperative period; (2) optimizing perioperative hemostasis and the use of blood recovery systems to avoid the loss of the patient's blood; (3) anemia tolerance, with improved oxygen delivery and reduced oxygen demand, particularly in the postoperative period. RESULTS: Current scientific evidence supports the effectiveness of PBM by reducing the need for blood transfusions, decreasing associated complications, and promoting more efficient and safer blood management. Thus, PBM not only improves clinical outcomes for patients but also contributes to the economic sustainability of healthcare systems. CONCLUSION: The aim of this review was to summarize PBM strategies in a comprehensive, evidence-based approach through a systematic and structured model for PBM implementation in tertiary hospitals. The recommendations proposed herein are from researchers and experts of a high-complexity university hospital in the network of the Sistema Único de Saúde, presenting itself as a strategy that can be followed as a guideline for PBM implementation in other settings.

Healthcare costs related to respiratory syncytial virus in paediatric intensive care units in the Netherlands: a nationwide prospective observational study (the BRICK study).

Background: The implementation of the approved respiratory syncytial virus (RSV) preventive interventions in immunisation programmes is advancing rapidly. Insight into healthcare costs of RSV-related paediatric intensive care unit (PICU) admissions is lacking, but of great importance to evaluate the impact of implementation. Therefore, this study aimed to determine the total annual RSV-related paediatric intensive care healthcare costs in the Netherlands. Methods: A nationwide prospective, observational, multicenter study was performed from September 2021 until June 2023. The total annual RSV-related healthcare costs on PICUs in the Netherlands were calculated using RSV-related costs (subgroup I) and consequential costs (subgroup II and III). Subgroup I comprised all PICU admitted infants ≤12 months of age with laboratory-confirmed RSV infection. Subgroup II and III consisted of postponed elective PICU admissions and refused acute PICU admissions due to RSV-related lack of PICU capacity. Findings: A total of 424 infants with RSV-related PICU admission were included. Median age at PICU admission was 46 days (IQR 25-89). The median length of PICU admission was 5 days (IQR 3-8). The total RSV-related PICU costs are € 3,826,386 in 2021-2022, and € 3,183,888 in 2022-2023. Potential costs averted by RSV preventive interventions is € 1.9 to € 2.6 million depending on season, and the duration of protection. Interpretation: RSV-related PICU admissions cost €3.1 to €3.8 million in the Netherlands during one season. The introduction of new RSV preventive interventions into the Dutch immunisation programme will generate significant cost-savings on PICUs and decreases the admission burden of PICUs. Funding: None.

A Study on Nature of Violence Against Doctors in Tertiary Care Centers in Karnataka, India: A Cross-Sectional Study.

Background: Over the previous decades, violence against physicians has risen. To comprehend the issue connected with it, we need to know the nature of violence and doctor's views on the current state of safety at their disposal. The purpose of the study was to assess the incidence and nature of violence against doctors in tertiary health care centers in Karnataka, India. Objectives: The objectives were to collect data from three tertiary care centers, evaluate the incidence of violence against doctors in tertiary care centers, and evaluate the nature of violence against doctors in tertiary care centers. Methods: From the list of all tertiary care centers in Dakshina Kannada, three tertiary care hospitals were randomly chosen. Approval of the Ethical Committee from the Institutional Ethics Committee (IEC) of KVG Dental College and permission from chosen hospitals were obtained. A pre-validated questionnaire was handed over to the available physicians and surgeons in these hospitals to be filled. The total number of participants in the study was 330. Results: Nearly half (48.02% of physicians) reported experiencing violence during working hours. The Department of Obstetrics and Gynaecology recorded 43.2% of instances, while surgery, medicine, and other departments reported 23.6%, 22.8%, and 10.4%, respectively. Conclusions: Violence against physicians continues to be a huge issue that must be addressed through decisive measures by the police and hospitals. This impacts the healthcare system in the nation and often cripples it owing to the loss of human resources and working hours.

Determinants of Outcomes in Convulsive Status Epilepticus: An Observational Study at a Tertiary Care Center in North India.

Objective Status epilepticus (SE) presents a critical neurological emergency associated with high morbidity and mortality rates worldwide. However, the determinants influencing outcomes in SE within specific regional contexts remain less explored, especially within North India. Understanding the factors influencing the prognosis of SE in this region is crucial for tailored therapeutic approaches and improved patient outcomes.  Materials and methods This observational study was conducted at Jawaharlal Nehru Medical College, Aligarh, India, from December 1, 2020, to November 31, 2022. Patients who presented with convulsive SE lasting more than five minutes or repetitive and discrete seizures with impaired consciousness between the interictal period for at least 30 minutes were included in the study. Their clinical and biochemical variables at presentation were assessed and correlated with the outcome. Results Out of the 110 patients included in the study, males represented 59.1% (n=65), outnumbering females, who comprised 40.9% (n=45). Favourable outcome was observed in 66.36% (n=73) of patients, and unfavourable outcome was observed in 33.63% (n=37). The mean time interval between seizure onset to the patient's arrival at the hospital was 5.30 ± 4.96 hours, and the mean time interval between seizure onset to the point of seizure control was 7.10 ± 6.38 hours. On analysing the factors associated with unfavourable outcome, the type of seizure at onset (p=0.021), Glasgow Coma Scale (GCS) of <=12 at presentation (p<0.001), presence of refractory seizure (p<0.001), presence of abnormal epileptiform discharges on electroencephalography (p=0.001), Status Epilepticus Severity Score (STESS) of >2 (p<0.001), serum lactate levels (p<0.001), duration of hospital stay (p=0.004), time interval between seizure onset to hospital arrival (p<0.001) and time interval between seizure onset to the point of seizure control (p<0.001) showed significant association. However, on analysing the independent risk factors of unfavourable outcome using multivariate logistic regression, only duration of hospital stay (p<0.001, odds ratio (OR): 1.205, 95% confidence interval (CI): 1.046-1.389), and GCS of less than or equal to 12 at presentation (p<0.001, OR: 12.354, 95% CI: 2.974-51.319) showed significant association. Conclusions Our study highlighted key clinical and time-related parameters influencing the outcome of convulsive SE. Understanding these factors is crucial for better treatment and improved patient outcomes. Further research is essential for refining interventions in this complex condition.

Five-Year Evaluation of the PROA-NEN Pediatric Antimicrobial Stewardship Program in a Spanish Tertiary Hospital.

Introduction: Actions to reduce and optimize antimicrobial use are crucial in the management of infectious diseases to counteract the emergence of short- and long-term resistance. This is particularly important for pediatric patients due to the increasing incidence of serious infections caused by resistant bacteria in this population. The aim of this study was to evaluate the impact of a pediatric antimicrobial stewardship program (PROA-NEN) implemented in a Spanish tertiary hospital by assessing the use of systemic antimicrobials, clinical indicators, antimicrobial resistance, and costs. Methods: In this quasi-experimental, single-center study, we included pediatric patients (0-18 years) admitted to specialized pediatric medical and surgical units, as well as pediatric and neonatal intensive care units, from January 2015 to December 2019. The impact of the PROA-NEN program was assessed using process (consumption trends and prescription quality) and outcome indicators (clinical and microbiological). Antibiotic prescription quality was determined using quarterly point prevalence cross-sectional analyses. Results: Total antimicrobial consumption decreased during the initial three years of the PROA-NEN program, followed by a slight rebound in 2019. This decrease was particularly evident in intensive care and surgical units. Antibiotic use, according to the WHO Access, Watch and Reserve (AWaRe) classification, remained stable during the study period. The overall rate of appropriate prescription was 83.2%, with a significant increase over the study period. Clinical indicators did not substantially change over the study period. Direct antimicrobial expenses decreased by 27.3% from 2015 to 2019. Conclusions: The PROA-NEN program was associated with reduced antimicrobial consumption, improved appropriate use, and decreased costs without compromising clinical and/or microbiological outcomes in patients.

Investigating the Prevalence and Predictors of Uncontrolled Hypertension: A Cross-Sectional Study in Gujarat, India.

BACKGROUND: Uncontrolled hypertension is a major public health concern that contributes significantly to cardiovascular morbidity and mortality. Treatment of hypertension prevents and reduces cardiovascular morbidity, notably a 40% reduction in risk of stroke and a 15% reduction in risk of myocardial infarction. Understanding the prevalence and predictors of uncontrolled hypertension is crucial for developing targeted interventions. OBJECTIVE: This study aimed to determine the prevalence of uncontrolled hypertension and identify potential predictors among patients attending the Non-Communicable Disease (NCD) clinic of a tertiary care center in Gujarat, India. METHODS: A cross-sectional study involving 732 adult patients with hypertension was conducted. Sociodemographic data, lifestyle factors, anthropometric measurements, and comorbidities were assessed. Blood pressure was measured using standardized protocols, and uncontrolled hypertension was defined as a systolic blood pressure ≥140 mmHg or diastolic blood pressure ≥90 mmHg. Univariate and multivariate logistic regression analyses were performed to identify predictors of uncontrolled hypertension. RESULTS: The prevalence of uncontrolled hypertension was 60.2% (95% CI: 56.7%-63.7%). In the multivariate analysis, increasing age (adjusted OR: 1.21, 95% CI: 1.05-1.39), increased body mass index (adjusted OR: 1.49, 95% CI: 1.27-1.75), diabetes (adjusted OR: 1.68, 95% CI: 1.20-2.35), chronic kidney disease (adjusted OR: 2.11, 95% CI: 1.22-3.65), and current smoking status (adjusted OR: 1.83, 95% CI: 1.14-2.93) were identified as independent predictors of uncontrolled hypertension. CONCLUSION: This study revealed a high prevalence of uncontrolled hypertension in this tertiary care setting. Age, obesity, diabetes, chronic kidney disease, and smoking were identified as significant predictors. Targeted interventions addressing these modifiable risk factors and comorbidities are crucial for improving blood pressure control and reducing the burden of hypertension-related complications.

Comparative study of job burnout in Shanghai-based nurses against Maslach norm and Hangzhou norm.

AIM: This study aimed to analyze the trend in job burnout among nurses in Shanghai, China. BACKGROUND: The nursing profession globally faces a significant challenge due to aging populations, causing a human resources crisis. Job burnout notably impacts nurses' enthusiasm for work and their overall well-being. Understanding the trends in job burnout among nurses is crucial for addressing this issue. METHODS: A cross-sectional study involving 799 nurses from a tertiary-care hospital and 11 community health service centers in Pudong New Area South, Shanghai, was conducted using convenience sampling. Data were collected through a general information questionnaire and the Maslach Burnout Inventory scale, to assess job burnout levels. These data were compared with the established Maslach and Hangzhou norms in China. RESULTS: 74.6% of the participants experienced job burnout. The emotional exhaustion dimension had an average score of 27.27 ± 13.93, indicating high levels of burnout; the depersonalization dimension had an average score of 7.83 ± 6.68, showing moderate levels of fatigue; and the personal achievement dimension had an average score of 26.75 ± 10.26, also indicating moderate fatigue. Notably, nurses aged 32-33 years with 11-12 years of professional experience were the most affected. The findings suggest that job burnout is a significant issue in Pudong New Area South, Shanghai, with a notable increase in severe burnout cases over the past decade. CONCLUSION: Nurses, particularly during the COVID-19 pandemic, face high rates of burnout, with emotional exhaustion being particularly prevalent. To support and retain the nursing workforce, hospital administrators must implement external reward mechanisms and develop policies that encourage personal growth, career development, and a humanistic approach to care. IMPLICATIONS FOR NURSING AND HEALTH POLICY: From our review of the literature, we identified instances where burnout standards are either not assessed or lack uniformity in their application. Therefore, it is imperative to adopt a standardized occupational burnout scale for a nationwide survey, encompassing nurse populations across various levels, including province, region, city, and institution. This approach will facilitate the establishment of a practical norm for occupational burnout within China. This norm would enable conducting regular assessments and comparisons to understand the evolving trends of job burnout among nurses, which could pave the way for the creation of targeted support interventions for the nursing profession.

Detection of Enteropathogens in Human Immunodeficiency Virus and Non-Human Immunodeficiency Virus-Infected Children with Acute Diarrhea in an Indonesian Tertiary Hospital Using Multiplex Real-Time Polymerase Chain Reaction.

Purpose: Diarrhea is one of the leading causes of mortality in children living in developing countries. The etiology of acute diarrhea in each healthcare center varies depending on place, time, and population. This study aimed to identify pathogen patterns in human immunodeficiency virus (HIV)-infected and non-HIV children suffering from acute diarrhea, using multiplex real time reverse transcriptase polymerase chain reaction (RT-PCR), in an Indonesian tertiary hospital. Methods: This cross-sectional study was conducted at Dr. Cipto Mangunkusumo National Hospital from March 2019 to April 2020. Results: The study showed that multiplex RT-PCR results were positive in 58.9% of the specimens, with more positive results in HIV-infected children than in non-HIV-infected children (70% vs. 54.7%). Altogether 72 enteropathogens were detected from all specimens. Enteropathogens in non-HIV children with acute diarrhea consisted of bacteria (70.6%) and viruses (29.4%) with a predominance of enteroaggregative Escherichia coli (25.4%), followed by Campylobacter spp. (11.8%), enteropathogenic E. coli (9.8%), Norovirus GII (7.8%), and Clostridium difficile (7.8%). Enteropathogens in HIV-infected children consisted of viruses (57.1%), bacteria (28.6%), and parasites (14.3%) comprising Norovirus GII (24%), Cryptosporidium spp. (14.3%), Campylobacter spp. (14.3%), Norovirus GI (14.3%), and Astrovirus (14.3%). Cryptosporidium spp. was the only parasite found in this study and was found only in HIV-infected children. In non-HIV children with acute diarrhea, most pathogens were invasive bacteria, while in HIV-infected children, more viral and parasite infections occurred, primarily caused by opportunistic pathogens. Conclusion: The pattern of enteropathogens can help clinicians determine further examinations and appropriate empirical antimicrobial therapy for the patient.

Maxillofacial trauma and its management presenting at a tertiary care hospital in Lahore during Covid-19 pandemic.

Objectives: The objective of this study was to assess the patterns of maxillofacial injuries, aetiology and their management during the pandemic of Covid-19 in a tertiary care hospital in Lahore, Pakistan. METHODS: This is a single center, prospective cross-sectional study. Patients from all age groups who presented at the Emergency room of Jinnah Hospital Lahore and managed by the Oral and Maxillofacial Surgery Department during 1st December 2020 till 31st January 2021 were included. Data were analyzed using IBM SPSS for Windows, Version 20.0. RESULTS: Total 202 patient were analyzed, 161 (79.7%) were male and 41 (20.3%) were females. Male to female ratio was 4:1. About fifty three percent of patients belonged to the age group 15-35 years. The most common cause was road traffic accidents (RTA), followed by fall. Eighty-three (41.1%) had only soft tissue injuries without any bony fracture and 119 (58.9%) had facial bones fractures. Zygomatic bone fracture was most common (53.8%) followed by mandible fracture (31.1%). Sixty-one out of 119 patients with fractures were treated with Open Reduction Internal Fixation (ORIF). Three patients had complete loss of vision because of facial trauma. Only 56 (28%) patients were managed under General Anaesthesia. CONCLUSIONS: During the initial pandemic era, a large majority of patients presenting with maxillofacial injuries were young male adults. The most common cause of maxillofacial trauma was RTAs. Soft tissue injuries were predominant followed by facial bone fractures and zygomatic bone was more frequent among the fracture cases. Covid-19 pandemic increased the difficulties faced in the management of maxillofacial trauma patients.

Retrospective analysis of 1,203 cases of referral to a quaternary vascular surgery outpatient clinic within the Unified Health System, São Paulo, Brazil

ABSTRACT Objective Consequently, in this study, we aimed to evaluate 1,203 cases of referral to a quaternary vascular surgical service, in São Paulo, Brazil, over a 6-year period, to assess the appropriate need for referral; in addition to the prevalence of surgical indications. Methods In this retrospective analysis, we reviewed the institutional records of participants referred from Basic Healthcare Units to a vascular surgical service inside the Brazilian Unified Health System, between May 2015 and December 2020. Demographic and clinical data were collected. The participants were stratified, as per the reason for referral to the vascular surgical service, previous imaging studies, and surgical treatment indications. Referral appropriateness and complementary examinations were evaluated for each disease cohort. Finally, the prevalence of cases requiring surgical treatment was defined as the outcome measure. Results Of the 1,203 referrals evaluated, venous disease was the main reason for referral (53%), followed by peripheral arterial disease (19.4%). A considerable proportion of participants had been referred without complementary imaging or after a long duration of undergoing an examination. Referrals were regarded as inappropriate in 517 (43%) cases. Of these, 32 cases (6.2%) had been referred to the vascular surgical service, as the incorrect specialty. The percentage of referred participants who ultimately underwent surgical treatment was 39.92%. Carotid (18%) and peripheral arterial diseases (18.4%) were correlated with a lower prevalence of surgical treatments. Conclusion The rate of referral appropriateness to specialized vascular care from primary care settings was low. This may represent a subutilization of quaternary surgical services, with low rates of surgical treatment.

Comparing outcomes following direct admission and early transfer to specialized trauma centers in open tibial fracture treatment: a systematic review and meta-analysis.

INTRODUCTION: Guidelines on the management of open tibia fractures recommend timely treatment in a limb reconstruction center which offer joint orthopedic-trauma and plastic surgery services. However, patient's transfer between centers remains inevitable. This review aims to evaluate the clinical outcomes and hospital factors for patients directly admitted and transferred patients to a limb-reconstruction center. METHODS: A research protocol adhering to PRISMA standards was established. The search included databases like MEDLINE, EMBASE, and the Cochrane library up until March 2023. Nine articles met the inclusion criteria, focusing on open tibia fractures. Exclusion criteria were experimental studies, animal studies, and case reports. Outcomes of interest were operation and infection rates, nonunion, limb salvage, and the Enneking limb score. RESULTS: The analysis involved data from 520 patients across nine studies published between 1990 and 2023, with the majority (83.8%) having Gustilo Anderson type III open tibia fractures. Directly admitted patients showed lower overall infection rates (RR 0.30; 95% CI 0.10-0.90; P = 0.03) and fewer deep infections (RR 0.39; 95% CI 0.22-0.68; P = 0.001) compared to transferred patients. Transferred patients experienced an average five-day delay in soft tissue closure and extended hospital stays by eight days. Patients transferred without initial surgical management underwent fewer total surgical procedures. The direct admission group displayed more favorable functional outcomes. CONCLUSION: Low- to moderate-quality evidence indicates worse clinical outcomes for transferred patients compared to directly admitted patients. Early treatment in specialized limb reconstruction units is essential for improved results in the management of open tibia fractures. LEVEL OF EVIDENCE: Therapeutic level IIa.

Preferred versus Actual Place of Care and Factors Associated with Home Discharge among Korean Patients with Advanced Cancer: A Retrospective Cohort Study.

Respecting the preference for a place of care is essential for advance care planning in patients with advanced cancer. This retrospective study included adult patients with cancer referred to an inpatient palliative care consultation team at a tertiary acute care hospital in South Korea between April 2019 and December 2020. Patients' preference for place of care and demographic and clinical factors were recorded, and the actual discharge locations were categorized as home or non-home. Patients discharged home but with unintended hospital visits within 2 months were also investigated. Of the 891 patients referred to the palliative care consultation team, 210 (23.6%) preferred to be discharged home. Among them, 113 (53.8%) were discharged home. No significant differences were found between patients who preferred home discharge and those who did not. Home discharge was higher among female patients (p = 0.04) and lower in those with poor oral intake (p < 0.001) or dyspnea (p = 0.02). Of the 113 patients discharged home, 37 (32.8%) had unintended hospital visits within 2 months. Approximately one-quarter of hospitalized patients with advanced cancer preferred to be discharged home, but only half of them received the home discharge. To meet patients' preferences for end-of-life care, individual care planning considering relevant factors is necessary.

Vaccine effectiveness and the epidemiological characteristics of a COVID-19 outbreak in a tertiary hospital in Republic of Korea.

BACKGROUND: Healthcare facilities are high-risk sites for infection. This study analyzed the epidemiological characteristics of a coronavirus disease 2019 (COVID-19) outbreak in a tertiary hospital after COVID-19 vaccination had been introduced in Republic of Korea. Vaccine effectiveness (VE) and shared anti-infection strategies are also assessed. METHODS: The risk levels for 4,074 contacts were evaluated. The epidemiological characteristics of confirmed cases were evaluated using the chi-square test. The "1 minus relative risk" method was used to determine VE in preventing infection, progression to severe disease, and death. In the largest affected area (the 8th floor), a separate relative risk analysis was conducted. A multivariate logistic regression analysis (with 95% confidence interval [CIs]) was used to identify transmission risk factors with a significance level <10% via the backward elimination method. RESULTS: In total, 181 cases of COVID-19 were confirmed, with an attack rate of 4.4%. Of those cases, 12.7% progressed to severe disease, and 8.3% died. In the cohort isolation area on the 8th floor, where 79.0% of the confirmed cases occurred, the adjusted odds ratio was 6.55 (95% CI, 2.99-14.33) and 2.19 (95% CI, 1.24-3.88) for caregivers and the unvaccinated group, respectively. VE analysis revealed that 85.8% of the cases that progressed to severe disease and 78.6% of the deaths could be prevented by administering a second vaccine. CONCLUSION: Caregiver training for infection prevention and control is necessary to reduce infection risk. Vaccination is an important intervention to reduce the risk of progression to severe disease and death.

Psychiatric Morbidity: A Retrospective Study From a Tertiary Care Center.

Background It is crucial to monitor the psychiatric morbidity patterns of patients to comprehend the burden and trends of mental illness, as well as to create targeted prevention and intervention strategies. Due to the significant regional differences in mental illness, the current study assessed the psychiatric morbidity pattern from a tertiary care center in Central India. Methods We conducted this retrospective record-based study using data from the outpatient department register of the Psychiatry Department of Government Bundelkhand Medical College, Sagar, Madhya Pradesh, India. All records from January to December 2022 were included, while duplicate and incomplete records were excluded. Data from 2005 cases were finalized for analysis after considering inclusion and exclusion criteria. Data abstraction was done for age, gender, marital status, family history of any psychiatric disorder, and diagnosis (according to ICD-10) from the records. Data analysis was conducted using SPSS Version 26.0 (IBM Corp., Armonk, NY). Quantitative data were presented as means ± standard deviation (SD), whereas qualitative data were presented as frequency and percentages. The chi-square test was applied to determine the association, and p-values <0.05 were considered significant. Results The mean age of the patients was 37.2±16.9 years, where the youngest patient was of four years of age and the eldest was 85 years of age. Most patients were males (50.6%), married (61.1%), and from rural areas (71.8%). Mood (affective) disorder (32.4%) was the most common, followed by schizophrenia, schizotypal and delusional disorders (20.0%), and neurotic, stress-related, and somatoform disorders (17.4%). Organic mental disorders and substance use disorders were more common in unmarried individuals and males. Females had higher rates of mood disorders and somatoform disorders, with varying age distributions. Adult personality disorder and mental retardation had equal frequencies among males and females, with different age distributions. Hyperkinetic disorder was more common in males, while headache syndrome was more common in females. Psychiatric disorders were more prevalent in the urban population, except for substance abuse and hyperkinetic disorder. Conclusion Our study highlights the types of psychiatric disorders among patients at a tertiary care center, aiding clinicians in improving care and emphasizing early detection and treatment of mental illnesses.

Frecuencia de referencias ambulatorias injustificadas, en base a diagnósticos no pertinentes, realizadas a un hospital peruano de tercer nivel / Frequency of unjustified ambulatory referrals bases on no pertinent diagnosis sent to a third level Peruvian hospital

Objetivo: Determinar la frecuencia y describir las características de referencias injustificadas, en base a diagnósticos no pertinentes, enviadas al servicio de consulta externa adultos de un hospital de tercer nivel. Material y métodos: Estudio transversal, observacional y descriptivo, realizado en el Hospital Cayetano Heredia (HCH) en el periodo abril a diciembre del 2019. Se utilizaron los datos del aplicativo "REFCON" con una población de 99 891 referencias. Para la variable "justificación de la referencia", se utilizó un listado de diagnósticos que no deberían derivarse a hospitales de la DIRIS Lima Norte. Adicionalmente, se estudiaron las variables de edad, sexo, grupo etario, especialidad de destino, categoría del EESS de origen, distrito de origen, y diagnóstico del grupo de referencias injustificadas. Se utilizó estadística descriptiva. Resultados: La frecuencia de referencias injustificadas fue de 8,4 %. El 34,2 % fue de pacientes adultos; el 65,8 %, de adultos mayores; y el 67 %, de pacientes mujeres Las especialidades con más referencias injustificadas fueron cardiología, geriatría, medicina interna, medicina familiar y neurología. Los diagnósticos injustificados más frecuentes fueron hipertensión esencial, lumbago no especificado y cefalea. Conclusiones: La frecuencia de referencias injustificadas al HCH por diagnósticos no pertinentes fue 8,4 %, tasa similar a otros dos estudios, pese a la emisión de una lista de diagnósticos que no deberían derivarse a hospitales de la DIRIS Lima Norte.

SUMMARY Objective: To determine the frequency and to describe the characteristics of unjustified ambulatory referrals bases on no pertinent diagnosis done at an adult outpatient clinic of a third level Peruvian hospital. Methods: A cross-sectional study was carried-out from April to December 2019 at Hospital Cayetano Heredia. Data were extracted from REFCON with a population of 99 891 referrals. To justify the reference, a list of diagnosis that does not require referral was used. In addition, variables such as age, sex, specialty of destination, category of EESS, district of origin and diagnosis of the unjustified referral. Descriptive statistics was used. Results: the frequency of unjustified referrals was 8.4%; 34.2% comprised the adult population; 65.8% were elder and 67% were female. Specialties with more unjustified referrals were geriatrics, internal medicine, family medicine and neurology. The most common unjustified diagnosis was essential hypertension, nonspecific low back pain and headache. Conclusions: Despite of socializing a list of unjustified referral diagnosis a frequency of 8,4% remain in this category, which is like results from two previous studies.

Telemedicine ready or not? A cross-sectional assessment of telemedicine maturity of federally funded tertiary health institutions in Nigeria.

Introduction and objective: Telemedicine has reinforced its position as a means for the continuity of healthcare services and a cost-effective approach to improving health equity as demonstrated during the COVID-19 pandemic. The preparedness of health systems for telemedicine is an indicator of the scalability of their services, especially during catastrophes. We aimed to assess the maturity and preparedness of federally funded tertiary health institutions in Nigeria, to deploy telemedicine as such data are currently lacking and are required to drive improvements in health services delivery. Methods: We conducted a cross-sectional survey of thirty randomly selected federally funded tertiary health institutions in Nigeria using the Pan American Health Organization's tool for assessing the maturity level of health institutions to implement telemedicine between 17 September 2020 and 1 September 2021. Descriptive statistics were used for overall maturity levels and non-parametric tests to compare scores for overall maturity and specific Pan American Health Organization domains per region. The level of significance was set at p-value <0.05. Results: The response rate was 77.4% (24 of 30 randomly polled federally funded tertiary health institutions responded). Overall, the median telemedicine maturity level was 2.0 (1.75) indicating a beginner level. No significant inter-zonal difference in the median overall maturity level (p = 0.87). The median maturity levels for telemedicine readiness in specific domains were organizational readiness - 2.0 (2.0), processes 1.0 (1.0), digital environment 2.0 (3.0), human resources 2.0 (1.0), regulatory issues - 1.5 (1.0) and expertise 2.0 (2.0); mostly at beginner level, with no inter-zonal differences. Most participating institutions had no initiatives in place for domains of processes and regulatory issues. Conclusions: The current telemedicine maturity level of federally funded tertiary health institutions in Nigeria is at the beginner level. This behoves policy-makers to advance the implementation and deployment of telemedicine nationwide as part of digital quality healthcare, to improve health equity and to ensure continuity of healthcare services in the event of another pandemic.

Pediatricians' perception of factors concerning the clinical application of blockchain technology to pediatric health care: a questionnaire survey.

BACKGROUND: Interest in digital medical information has increased because it allows doctors to easily access a patient's medical records and provide appropriate medical care. Blockchain technology ensures data safety, reliability, integrity, and transparency by distributing medical data to all users over a peer-to-peer network. This study attempted to assess pediatricians' thoughts and attitudes toward introducing blockchain technology into the medical field. METHODS: This study used a questionnaire survey to examine the thoughts and attitudes of 30- to 60-year-old pediatricians regarding the introduction of blockchain technology into the medical field. Responses to each item were recorded on a scale ranging from 1 (never agree) to 7 (completely agree). RESULTS: The scores for the intentions and expectations of using blockchain technology were 4.0 to 4.6. Pediatricians from tertiary hospitals responded more positively (4.5-4.9) to the idea of using blockchain technology for hospital work relative to the general population (4.3-4.7). However, pediatricians working in primary and secondary hospitals had a slightly negative view of the application of blockchain technology to hospital work (p=0.018). CONCLUSION: When introducing the medical records of related pediatric and adolescent patients using blockchain technology in the future, it would be better to conduct a pilot project that prioritizes pediatricians in tertiary hospitals. The cost, policy, and market participants' perceptions are essential factors to consider when introducing technology in the medical field.

Moderate and severe traumatic brain injury in general hospitals: a ten-year population-based retrospective cohort study in central Norway.

BACKGROUND: Patients with moderate and severe traumatic brain injury (TBI) are admitted to general hospitals (GHs) without neurosurgical services, but few studies have addressed the management of these patients. This study aimed to describe these patients, the rate of and reasons for managing patients entirely at the GH, and differences between patients managed entirely at the GH (GH group) and patients transferred to the regional trauma centre (RTC group). We specifically examined the characteristics of elderly patients. METHODS: Patients with moderate (Glasgow Coma Scale score 9-13) and severe (score ≤ 8) TBIs who were admitted to one of the seven GHs without neurosurgical services in central Norway between 01.10.2004 and 01.10.2014 were retrospectively identified. Demographic, injury-related and outcome data were collected from medical records. Head CT scans were reviewed. RESULTS: Among 274 patients admitted to GHs, 137 (50%) were in the GH group. The transferral rate was 58% for severe TBI and 40% for moderate TBI. Compared to the RTC group, patients in the GH group were older (median age: 78 years vs. 54 years, p < 0.001), more often had a preinjury disability (50% vs. 39%, p = 0.037), and more often had moderate TBI (52% vs. 35%, p = 0.005). The six-month case fatality rate was low (8%) in the GH group when transferral was considered unnecessary due to a low risk of further deterioration and high (90%, median age: 87 years) when neurosurgical intervention was considered nonbeneficial. Only 16% of patients ≥ 80 years old were transferred to the RTC. For this age group, the in-hospital case fatality rate was 67% in the GH group and 36% in the RTC group and 84% and 73%, respectively, at 6 months. CONCLUSIONS: Half of the patients were managed entirely at a GH, and these were mainly patients considered to have a low risk of further deterioration, patients with moderate TBI, and elderly patients. Less than two of ten patients ≥ 80 years old were transferred, and survival was poor regardless of the transferral status.

The Outcomes and Revision Rate of Total Hip Arthroplasty in a Single Tertiary Center: A Retrospective Study.

Introduction Total hip arthroplasty (THA) is a commonly performed and successful orthopedic practice procedure. However, failure of arthroplasty may require revision THA and pose substantial clinical challenges for orthopedic surgeons. Therefore, this retrospective study aimed to estimate the revision rate of THA and its risk factors at a tertiary care hospital. Methods A retrospective cohort study was conducted in 2021 of patients who had undergone THA during 2016-2020 in a tertiary care hospital. All patients above 18 years old who had a THA were included in the study. The data was collected from patients' medical charts/electronic databases. Results A total of 148 THAs were included in this study. In total, 77 (52%) were females, and 71 (48%) were males. The average age of our patients was 49±17 years old, and the mean recorded BMI was 29.6. A total of 62% (n=92/148) of our participants were shown to have at least one comorbid disease, with hypertension being the most common comorbidity. Our findings show that half of the patients, 74 (50%), had a THA due to both primary and secondary osteoarthritis, 37 (25%) patients had avascular necrosis of the hip, and 25 (17%) were due to trauma. The most performed surgical approach was Kocher-Langenbeck (posterior) approach on 128 (86%), followed by the Hardinge (lateral) approach on 20 (13.51%). The most observed complication in the patients was postoperative pain in 35 (23.65%), followed by UTIs in 5 (3.38%). Of the 148 patients, nine (6.08%) had revision surgery. Regarding the revision rate, male patients were associated with a significantly higher rate of revision (P=<0.001), and older patients had a significantly increased risk of revision (P=0.026). Patients who developed complications, such as UTI, were associated with a higher revision rate (P=0.035). Also, a posterior approach (Kocher-Langenbeck) of the procedure was significantly linked to an increased risk of revision (P=0.014). Conclusion All in all, there are multiple associated factors with an increased incidence of revision THA. For example, male patients, older patients, complication development during the hospital stay, and posterior surgical approach were all associated with a significantly higher rate of revision.

Implementation of early rehabilitation for critically ill children in China: A survey and narrative review of the literature.

Introduction: The focus of this survey was to understand the current status of implementation of early rehabilitation for critically ill children in China. We also reviewed the available literature on this topic for further insights to inform its future development. Materials and methods: We used a cross-sectional study design to survey tertiary hospitals nationwide. Questionnaires were distributed via the social media platform "WeChat Questionnaire Star" within the framework of the Rehabilitation Group of the Pediatrics Branch of the Chinese Medical Association. A narrative literature review on the implementation of the early rehabilitation for critically ill pediatric and/or adult patients was carried out. Results: A total of 202 valid questionnaires were received. About half (n = 105, 52.0%) of respondent hospitals reported that they implement early rehabilitation for critically ill children. Among these 105 hospitals, 28 implemented a continuous chain of early rehabilitation. A total of 24 hospitals had set up permanent specialized centralized early rehabilitation units for critically ill children. Implications and future directions: Early rehabilitation for critically ill children is not widely available in China and only a minority of hospitals implement a continuous chain of early rehabilitation. To improve this undesirable situation, we suggest creating a two-level integrated system comprising centralized early rehabilitation units and surrounding early rehabilitation networks within a region.