An Opportunity to Seize From Low Hanging Fruits: Capitalising on Incidentally Reported Coronary Artery Calcification.

AIM: We investigated the prevalence of incidental coronary artery calcifications (CAC) from non-electrocardiogram (ECG)-gated computed tomography (CT) chest (both contrast and non-contrast) for inpatients. We also assessed for downstream investigation and statin prescription from the inpatient teams. Incidental CAC are frequent findings on non-ECG-gated CT chest. It is associated with adverse prognosis in multiple patient cohorts. METHOD: All non-ECG-gated CT chest done as inpatients from a single centre referred from 1 January 2022 to 31 December 2022 with reported incidental CAC were reviewed for inclusion. Patients who had a history of known coronary artery disease, history of coronary stent or bypass, and presence of cardiac devices were excluded. RESULTS: Total of 123 patients were included, making the prevalence 6.2% (123/1,980). The median age is 76 years (interquartile range 69-85) and predominantly male at 54.5%. The majority of CT chest done were contrasted scans (91.1%). Only 26.8% of CAC were reported on severity with visual quantification, with 7.3% each reported for both moderate and severe CAC. Only 2.4% of CAC were reported in the conclusion of the CT report. Most of these patients were asymptomatic (34.1%). A total of 20.3% of patients had further tests done. Inpatient hospital mortality was 8.1%. About 23.6% and 34.1% of patients were on aspirin and statin therapy respectively at baseline. There was only 1 patient (1.2%) who was prescribed with new statin therapy on discharge. CONCLUSION: Incidental CAC is prevalent in inpatient settings and remains under-recognised by ordering clinicians, with low prescription rate of statin therapy. Practice-changing measures to standardise reporting of incidental CAC is needed to identify patients with subclinical coronary disease and initiate preventive interventions.

Resource implications following expansion of computed tomography coronary angiography: An Australian experience.

INTRODUCTION: To determine the downstream utilisation of Computed Tomography Coronary Angiography (CTCA) in a single Australian tertiary centre. METHODS: A single-centre retrospective study analysed 1460 patients undergoing CTCA between 1st January 2015 to 31st December 2018 at a tertiary hospital in Victoria, Australia, with a catchment area of 500,000 people. The coronary stenosis grading, plaque characteristics and coronary calcium score were identified. The downstream impact was assessed by measuring the number of stress echocardiograms, myocardial perfusion scans (MPS), invasive coronary angiograms and subsequent revascularisations. RESULTS: The number of CTCA's performed steadily increased from 59 in 2015 to 395, 461 and 545 in 2016, 2017 and 2018 respectively. Seven hundred and fifty-seven (52%) were females, and 703 (48%) males with 724 (50%) normal CTCA studies. The number of downstream stress echocardiogram performed each year was 2, 60, 46 and 16, respectively, accompanied by MPS numbers of 0, 21, 29, and 18. There were 9, 37, 57 and 64 invasive coronary angiograms with 1, 13, 19 and 22 corresponding revascularisations. Despite small increases in absolute numbers of patients presenting with chest pain (from 2678 in 2015 to 3660 in 2018), there was a significant increase in downstream further testing from 11 in 2015 to 98 in 2018. CONCLUSION: The use of CTCA expansion has resulted in an increase in downstream testing. Therefore, resource planning with regards to CTCA expansion will have to account for increased rates of functional testing, invasive angiography and revascularisation.

Displacement as a predictor of functional impairment in tsunami-exposed children.

Thirty months after the Indian Ocean tsunami of 26 December 2004, thousands of families in Aceh Province, Indonesia, remained in temporary barracks while sanitation conditions and non-governmental organisation support deteriorated. This study sought to determine the factors associated with functional impairment in a sample of 138 displaced and non-displaced Acehnese children. Using multivariate linear regression models, it was found that displacement distance was a consistent predictor of impairment using the Brief Impairment Scale. Exposure to tsunami-related trauma markers was not significantly linked with impairment in the model. Paternal employment was a consistent protective factor for child functioning. These findings suggest that post-disaster displacement and the subsequent familial economic disruption are significant predictors of impaired functioning in children's daily activities. Post-disaster interventions should consider the disruption of familiar environments for families and children when relocating vulnerable populations to avoid deleterious impacts on children's functioning.

The living environment and children's fears following the Indonesian tsunami.

The tsunami that struck South-east Asia on 26 December 2004 left more than 500,000 people in Aceh, Indonesia, homeless and displaced to temporary barracks and other communities. This study examines the associations between prolonged habitation in barracks and the nature of fears reported by school-age children and adolescents. In mid-2007, 30 months after the tsunami, the authors interviewed 155 child and parent dyads. Logistic regression analysis was used to compare the fears reported by children and adolescents living in barracks with those reported by their peers who were living in villages. After adjusting for demographic factors and tsunami exposure, the data reveals that children and adolescents living in barracks were three times more likely than those living in villages to report tsunami-related fears. The study demonstrates that continued residence in barracks 30 months after the tsunami is associated with higher rates of reporting tsunami-related fears, suggesting that barracks habitation has had a significant impact on the psychological experience of children and adolescents since the tsunami.

Improving health services to displaced persons in Aceh, Indonesia: a balanced scorecard.

PROBLEM: After the Indian Ocean tsunami in December 2004, the International Organization for Migration constructed temporary health clinics to provide medical services to survivors living in temporary accommodation centres throughout Aceh, Indonesia. Limited resources, inadequate supervision, staff turnover and lack of a health information system made it challenging to provide quality primary health services. APPROACH: A balanced scorecard was developed and implemented in collaboration with local health clinic staff and district health officials. Performance targets were identified. Staff collected data from clinics and accommodation centres to develop 30 simple performance measures. These measures were monitored periodically and discussed at meetings with stakeholders to guide the development of health interventions. LOCAL SETTING: Two years after the tsunami, 34 000 displaced persons continued to receive services from temporary health clinics in two districts of Aceh province. From March to December 2007, the scorecard was implemented in seven temporary health clinics. RELEVANT CHANGES: Interventions stimulated and tracked by the scorecard showed measurable improvements in preventive medicine, child health, capacity building of clinic staff and availability of essential drugs. By enhancing communication, the scorecard also led to qualitative benefits. LESSONS LEARNT: The balanced scorecard is a practical tool to focus attention and resources to facilitate improvement in disaster rehabilitation settings where health information infrastructure is poor. Introducing a mechanism for rapid improvement fostered communication between nongovernmental organizations, district health officials, clinic health workers and displaced persons.

Prospective surveillance for surgical site infection in St. Petersburg, Russian Federation.

OBJECTIVE: To assess the risk-adjusted incidence and predictors of surgical site infections (SSIs). DESIGN: Prospective, multicenter, observational cohort study. SETTING: Seven surgical departments at 3 urban academic hospitals in St. Petersburg, Russian Federation. PATIENTS: All patients had surgery performed between January 15 and May 12, 2000. A total of 1,453 surgical procedures were followed up. Medical records were unavailable for less than 3% of all patients; patients were not excluded for any other reason. The mean patient age was 49.3 years, 61% were female, and 34% had an American Society of Anesthesiologists physical status classification (hereafter, "ASA classification") of at least 3. Surgery for 45% of the patients was emergent. RESULTS: In all, 138 patients (9.5%) developed SSI, for a rate that was approximately 3.5 times the risk-stratified rates in the United States. Male sex (odds ratio [OR], 1.54), ASA classifications of 3 (OR, 3.7) or 4 (OR, 5.0), longer duration of surgery (OR, 2.2), and wound classes of 3 (OR, 5.5) or 4 (OR, 14.3) were associated with increased SSI risk in multivariate analysis. Endoscopic surgery was associated with a lower risk of SSI (OR, 0.23). Antibiotic prophylaxis was used in 0%-33% of operations, and 69% of uninfected patients received antibiotics after the operation. CONCLUSIONS: The SSI rates are significantly higher than previously reported. Although this finding may be attributable to inadequate antibiotic prophylaxis, local infection control and surgical practices may also be contributors. Use of antibiotic prophylaxis should be encouraged and the effect of local practices further investigated. Active SSI surveillance should be expanded to other parts of the Russian Federation.

Evaluation of the Clinical Assessment project: a computer-based multimedia tool to assess problem-solving ability in medical students.

OBJECTIVE: The purpose of this work was to describe Clinical Assessment, a computer-based multimedia patient simulation used to assess the problem-solving abilities of medical students and to evaluate its capacity to guide the assignment of course grade. METHODS: This was a multisite reviewer-blinded comparison of course grades, National Board of Medical Examiners pediatric examination score, and Clinical Assessment scores at 3 pediatric clerkship sites of the Harvard Medical School. Participants included 470 students completing their pediatric clerkships. Each student's performance on < or = 4 Clinical Assessment patient case simulations was compared with National Board of Medical Examiners pediatric examination scores and course grades assigned by clerkship directors based on overall ward performance. RESULTS: Data from both the National Board of Medical Examiners pediatric "shelf" examination and the course grade were available for 411 students who completed > or = 1 Clinical Assessment case. There was a strong correlation between Clinical Assessment score and course grade when comparing students receiving honors versus satisfactory category course grades. Students who ordered more expensive or greater numbers of laboratory tests did not achieve greater diagnostic accuracy on Clinical Assessment. Clinical Assessment had a high positive predictive value for course grade: 95% of students scoring > or = 90% on Clinical Assessment achieved an honors category course grade. CONCLUSIONS: Because nearly all of the students who scored very well on Clinical Assessment received honors category course grades, future high scorers on this examination merit consideration for assigning a high course grade. A computer-based multimedia patient simulation assessment tool provides objective information that can complement a student's National Board of Medical Examiners score and course grade and may assist in evaluating clinical problem-solving ability.

Panel 2.9: repair and recovery of health systems.

This is a summary of the presentations and discussion of Panel 2.9, Repair and Recovery of Health Systems of the Conference, Health Aspects of the Tsunami Disaster in Asia, convened by the World Health Organization (WHO) in Phuket, Thailand, 04-06 May 2005. The topics discussed included issues related to the repair and recovery of health systems as pertain to the damage created by the Tsunami. It is presented in the following major sections: (1) needs assessment; (2) coordination; (3) filling gaps; (4) capacity building; (5) what was done well, and what should have been done better; (6) lessons learned; and (7) recommendations. Recommendations included: (1) how to make health systems better prepared for coping with disasters; and (2) how to support preparedness in local communities.

An outbreak of Pseudomonas aeruginosa pneumonia and bloodstream infection associated with intermittent otitis externa in a healthcare worker.

OBJECTIVES: To investigate an outbreak of Pseudomonas aeruginosa pneumonia and bloodstream infection among four neonates, determine risk factors for infection, and implement preventive strategies. DESIGN: Retrospective case finding; prospective surveillance cultures of patients, personnel, and environmental sites; molecular typing by pulsed-field gel electrophoresis; and a matched case-control study. PATIENTS AND SETTING: Neonates in the level-III neonatal intensive care unit of a tertiary-care pediatric institution. INTERVENTIONS: Cohorting of patients with positive results for P. aeruginosa, work restrictions for staff with positive results, implementation of an alcohol-based hand product, review of infection control policies and procedures, and closure of the unit until completion of the investigation. RESULTS: Seven (4%) of 190 environmental cultures and 5 (3%) of 178 cultures of individual healthcare workers' hands grew P. aeruginosa. All four outbreak isolates and one previous bloodstream isolate were genotypically identical, as were the P. aeruginosa isolates from the hands and external auditory canal of a healthcare worker with intermittent otitis externa. Four of 5 case-patients versus 5 of 15 matched control-patients had been cared for by this healthcare worker (P = .05). The healthcare worker was treated and no further cases occurred. CONCLUSIONS: These findings suggest that a healthcare worker with intermittent otitis externa may have caused this cluster of fatal P. aeruginosa infections, adding the external ear to the list of colonized body sites that may serve as a source of potentially pathogenic organisms.

Once-daily gentamicin dosing for the preterm and term newborn: proposal for a simple regimen that achieves target levels.

OBJECTIVE: Based on recent safety and efficacy data, combined with the known pharmacokinetic parameters of aminoglycosides in the newborn, once-daily gentamicin should be preferable to the many other dosing regimens currently in use. Although there are growing data to support its use in term newborns, experience with preterm infants is more limited. In our Neonatal Intensive Care Unit, we experienced difficulties regarding complicated dosing regimens, actual dosing errors, and the tendency to check trough and peak levels around the third dose for infants receiving only a 48 hour course. Therefore, we conducted a quality improvement initiative in which we developed and tested a clinical practice guideline for the use of once-daily gentamicin for preterm and term infants that we hoped would yield trough and peak levels in our target range. METHODS: We combined a review of the published English language literature with pharmacokinetic analysis of our own data prior to initiation of this new regimen to design the following dosing regimen: <35 weeks gestation: 3 mg/kg q 24 hours, > or =35 weeks gestation: 4 mg/kg q 24 hours. Our goal serum levels were a trough < or =2 microg/ml and a peak between 6 and 12 microg/ml. We collected and analyzed trough and peak levels from all infants receiving this dosing regimen in the first week of life for at least 72 hours between 3/1/99 and 12/31/00. RESULTS: In total, 214 babies met our inclusion criteria, 75 of whom were <35 weeks gestation. 100% of babies of all gestational ages had a nontoxic trough level. For infants <35 weeks gestation, 79% had a therapeutic peak level, with a mean value of 6.8 microg/ml. For infants of at least 35 weeks gestation, 93% had a therapeutic peak level, with a mean value of 8.4 microg/ml. 92% of nontherapeutic peaks were too low. CONCLUSION: This study of once-daily gentamicin represents the largest sample size of pre-term infants published to date. The proposed regimen is simple and yields a high proportion of desirable levels. We recommend it for use in preterm and term newborns.

Use of an alcohol-based hand rub and quality improvement interventions to improve hand hygiene in a Russian neonatal intensive care unit.

BACKGROUND: Hand hygiene (HH) is critical to infection control, but compliance is low. Alcohol-based antiseptics may improve HH. HH practices in Russia are not well described, and facilities are often inadequate. SETTING: Four 6-bed units in a neonatal intensive care unit in St. Petersburg, Russia. METHODS: Prospective surveillance of HH compliance, nosocomial colonization, and antibiotic administration was performed from January until June 2000. In February 2000, alcohol-based hand rub was provided for routine HH use. Eight weeks later, a quality improvement intervention was implemented, consisting of review of interim data, identification of opinion leaders, posting of colonization incidence rates, and regular feedback. Means of compliance, colonization, and antibiotic use were compared for periods before and after each intervention. RESULTS: A total of 1,027 events requiring HH were observed. Compliance was 44.2% before the first intervention, 42.3% between interventions, and 48% after the second intervention. Use of alcohol rose from 15.2% of HH indications to 25.2% between interventions and 41.5% after the second intervention. The incidence of nosocomial colonization (per 1,000 patient-days) with Klebsiella pneumoniae was initially 21.5, decreased to 4.7, and then was 3.2 in the final period. Rates of antibiotic and device use also decreased. CONCLUSIONS: HH may have increased slightly, but the largest effect was a switch from soap and water to alcohol which may have been associated with decreased cross-transmission of Klebsiella, although this may have been confounded by lower device use. Alcohol-based antiseptic may be an improvement over current practices, but further research is required.