Increasing venous thromboembolism risk assessment through a whole hospital-based intervention: a pre-post service evaluation to demonstrate quality improvement.

Venous thromboembolism (VTE) is a primary cause of morbidity and mortality in hospitalized patients. VTE risk assessment is a crucial part of the VTE prevention guideline. However, VTE risk assessment was not consistently undertaken for admitted patients. The aim of this study was to identify whether a quality improvement project implemented to change documentation of VTE risk assessment for hospitalized patients impacted patient safety by decreasing the rate of VTE incidences. The study was set in a 600+ bed acute hospital that provides medical and surgical services for adult patients during the period October 2018-September 2020. The hospital adopted the American College of Chest Physicians (ACCP) 9th edition VTE prevention guidelines and followed the Modified Caprini risk assessment tool. Following the FOCUS-Plan-Do-Check-Act (FOCUS PDCA) improvement methodology, the improvement team implemented multicomponent interventions over a 3-month period, including conducting educational sessions, sharing VTE documentation compliance results, giving reminders during rounds, assigning a VTE liaison physician within each clinical specialty, and updating and communicating the hospital adopted VTE guidelines. A total of 17 612 patients were included, respectively, 8971 in pre-intervention and 8641 post-intervention period. Documentation of VTE risk assessment upon admission increased significantly in the post quality improvement intervention period (60% vs. 42%, relative increase of 30%, χ2 = 1.43, P < 0.001). The run chart trend analysis demonstrated significant improvement shift and improvement trend after quality improvement project implementation, and it was sustained for 15 months. There was no impact on patient safety with a slight not statistically significant decrease in the VTE incidences rate post intervention period (0.4% vs. 0.5%, relative decrease of 1%, χ2 = 0.82, P < 0.397). The quality improvement project intervention significantly increased the percentage of patients assessed for VTE risk in a hospital setting.

Duration and aetiology of extended hospitalization among COVID-19 patients in United Arab Emirates.

Background: A retrospective review of the early stages of the COVID-19 pandemic in 2020 and the challenges faced by hospitals is essential in the post-pandemic era of 2022. Aim: To identify the reasons for prolonged hospitalization after recovery for COVID-19 patients in the United Arab Emirates. Methods: This was a retrospective observational study of 150 (18.75%) patients with prolonged hospitalization in a tertiary hospital in Dubai from 1 April to 1 July 2020. Data was obtained from the electronic medical records of the hospital. Continuous variables are reported as mean and standard deviation, and categorical variables are reported as numbers and percentages. Results: The mean duration of hospitalization was 48.5 (9-272) days, with an interquartile range (IQR) of 22 days. The mean duration of extended stay was 27.5 (2-231) days, with an IQR of 17 days. The common reasons for prolonged hospitalization were mandatory isolation 28% (n = 62), hospital-acquired infections 17% (n = 37), acute respiratory distress syndrome 15% (n = 32), myopathy/neuropathy 14% (n = 31), pulmonary fibrosis requiring oxygen supplementation 14% (n = 31), and completion of COVID-19 treatment 12% (n = 25). Conclusion: To make optimal use of available hospital resources, reasons that directly or indirectly contributed to the prolonged hospitalization of patients should be considered and addressed during future pandemics or disease outbreaks.

Physicians' perceptions and preferences for implementing venous thromboembolism (VTE) clinical practice guidelines: a qualitative study using the Theoretical Domains Framework (TDF).

BACKGROUND: Venous thromboembolism is a primary cause of morbidity and mortality in hospitalised patients. Clinical practice guidelines were developed to prevent venous thromboembolism events. This study adopted the Theoretical Domains Framework to explore the beliefs and perceptions of physicians adoption of clinical practice guidelines for the uptake of venous thromboembolism prevention guidelines. METHODS: Semi-structured interviews were conducted with a stratified purposive sample of internal medicine physicians in an acute hospital. The interview topic guide was developed using the Theoretical Domains Framework to identify the factors perceived to influence the practice. Two researchers coded the interview transcripts using thematic content analysis. Emerging relevant themes were mapped to TDF domains. RESULTS: A total of sixteen medical physicians were interviewed over a six-month period. Nine theoretical domains derived from thirty-three belief statements were identified as relevant to the target behaviour; knowledge (education about the importance of VTE guidelines); beliefs about capabilities (with practice VTE tool easier to implement); beliefs about consequences (positive consequences in reducing the development of VTE, length of stay, financial burden and support physician decision) and (negative consequence risk of bleeding); reinforcement (recognition and continuous reminders); goals (patient safety goal); environmental context and resources (workload and availability of medications were barriers, VTE coordinator and electronic medical record were enablers); social influences (senior physicians and patient/family influence the VTE practice); behavioural regulation (monitoring and mandatory hospital policy); and nature of the behaviour. CONCLUSIONS: Using the Theoretical Domains Framework, factors thought to influence the implementation of VTE clinical practice guidelines were identified which can be used to design theoretically based interventions by targeting specific psychological constructs and linking them to behaviour change techniques to change the clinical practice of physicians.

Complement-mediated autoimmune haemolytic anaemia as an initial presentation of Legionnaires' disease.

A 42-year-old diabetic man presented to the hospital with severe sepsis and multiorgan dysfunction. A probable respiratory source of sepsis was suspected because of suggestive clinical and radiological findings. He was critically ill and was therefore admitted to intensive care for further management including ventilatory support and renal replacement therapy. He was also found to have marked anaemia requiring multiple blood transfusions with clinical and laboratory evidence pointing towards severe haemolysis. Further workup for the aetiology of pneumonia established a diagnosis of Legionella by confirmatory tests namely legionella antigen in the urine and exponentially rising serum antibody titres. The cause for the severe haemolysis was found to be complement-mediated autoimmune haemolysis as determined by direct antiglobulin test positive for complement components C3 and negative for IgG. Such clinically significant autoimmune haemolysis as a presenting feature, rather than a late complication, has never before been reported in the literature.

Blood pressure control measured as "time in range" during initial 24 h for inpatients with spontaneous nontraumatic intracerebral haemorrhage.

BACKGROUND AND PURPOSE: Blood pressure (BP) control is an integral part in the management of spontaneous nontraumatic intracerebral haemorrhage. The aim of this study is to propose a novel concept of blood pressure control measured as 'Time in Range'(TiR) and assess its relationship to neurological deterioration. METHOD: Retrospective study of 120 patients with Intracerebral haemorrhage who were admitted within 6 h of the symptom onset. The hourly BP readings for initial 24 h were studied in the form of time in range (TiR). TiR was defined as the percentage of readings with 'in range' systolic BP (SBP 110-140mmHG) during a unit time period. TiR was correlated with mean SBP at 6,12,18 and 24 h. It was categorized dichotomously as controlled (more than 50%) or not controlled (equal to or less than 50%) and analyzed with the change in Glasgow coma scale (drop of ≥2 units) at 24 h. RESULTS: Correlation of TiR with mean SBP at 6 and 24 h showed significant negative correlation [r = -0.71 (at 6 h); r = -0.88 (at 24 h); p < 0.001]. The association of TiR with neurological deterioration(ND) was measured by change in GCS; with lower TiR associated with higher chances of neurological deterioration at 12 h interval [OR 4.5(1.2-16.8); p = 0.025], but not at 24 h interval [OR 1.4 (0.34-5.44); p = 0.670]. CONCLUSION: Our novel concept of 'Time in Range'(TiR) was found to be relevant in our study. Its association with mean SBP reflect its potential to be a modality of expressing control of SBP in Spontaneous Nontraumatic Intracerebral Haemorrhage.

Rapidly worsening pneumonia in a middle-aged woman: a rare diagnosis and a crucial management decision.

A 54-year-old Indian female presented to the hospital with a 4-day history of fever, shortness of breath and blood-streaked sputum. Chest radiograph showed consolidation and she was admitted as a case of bilateral bronchopneumonia. She was started on broad-spectrum antibiotics and antivirals but she continued to deteriorate clinically with increasing oxygen requirement and worsening lung infiltrates. Since lab investigations also revealed significant anaemia and renal impairment, vasculitic workup for pulmonary renal haemorrhagic syndrome was ordered even though she had no haemoptysis in the hospital and haemoglobin was stable after initial blood transfusion. High-resolution computed tomography scan was done on day 5 to assess progression and for any clue to diagnosis. It showed extensive bilateral air space consolidation and ground-glass opacities with suggested radiological differential diagnosis of cryptogenic organising pneumonia or pulmonary haemorrhage. Pulmonology team did not recommend bronchoscopy at the time.In view of the clinical features of rapidly progressing pneumonia despite standard treatment, history of haemoptysis, anaemia, renal impairment and CT scan findings suggestive of pulmonary haemorrhage, pulse intravenous Methylprednisolone was initiated. The patient showed marked clinical and radiological improvement. The vasculitic workup later revealed positive myeloperoxidase antibody and a definitive diagnosis of microscopic polyangiitis was made. She was discharged in a stable condition and advised to follow-up in rheumatology where she continues to follow-up 2 years after her initial diagnosis.This is the first case reported in literature, where treatment was initiated for this rare disease entity within a week of presentation based on highly suggestive clinical, laboratory and radiological evidence without waiting for a confirmatory diagnosis. Delay in this rapidly deteriorating patient could have been fatal and our prompt action was crucial in securing a favourable outcome.

COVID-19-associated leukocytoclastic vasculitis leading to gangrene and amputation.

A 41-year-old male with type 2 diabetes mellitus (T2DM) presented with complaints of recent onset limb weakness, diffuse body rash and fever. Computerized Tomography (CT) scan of the brain did not reveal a stroke but laboratory investigations of the patient portrayed multi-systemic involvement. Naso-pharyngeal swab for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was taken which resulted as positive. Soon after, a biopsy of the skin lesions revealed histo-pathological features of leukocytoclastic vasculitis. The patient was further investigated for connective tissue disease and vasculitis only to yield a negative result for all relevant antibodies, with the exception of the anti-phospholipid antibody which was positive. The patient suffered through a complex and prolonged hospital stay that required the input of multiple sub-speciality teams. Although initially presenting with a normal chest X-ray the patient went on to have severe bilateral pneumonia and a progression of initial skin rash leading to severe necrosis of the left foot with dry gangrene of the left big toe. Due to these issues, coronavirus-disease-2019 (COVID-19) aimed therapy was started along with multiple skin debridements, antibiotics and eventual amputation of the patient's affected large toe. The following case-study details all the before-mentioned events with discussion of the possible reasons behind the patient's presentation and eventual outcome.

Prediction of risk of adverse events related to percutaneous endoscopic gastrostomy: a retrospective study.

BACKGROUND: Percutaneous endoscopic gastrostomy (PEG) is a popular method for long-term enteral feeding. Our aim was to determine potential risk factors for adverse events related to PEG, as well as consequent prolonged hospitalization. METHODS: Data were retrospectively collected from the admission records of a tertiary center between July 2015 and June 2018. Possible predictors of the 3 following outcomes were evaluated: minor PEG-related adverse events, major PEG-related adverse events, and length of hospital stay. Data were tested for correlation using the Spearman coefficient and for association using Kruskal-Wallis tests for significance. RESULTS: A total of 362 admissions involving 146 patients were included in the study. Of the admissions, 221 (61.0%) had only minor adverse events, 100 (27.6%) had only major adverse events, and 41 (11.3%) had both. Eighty (22.1%) had PEG-site infection and 128 (35%) had aspiration pneumonia. Serum albumin levels at presentation were negatively correlated with the length of hospitalization (P<0.001), which also differed between patients presenting with major and minor adverse events (P<0.001 and P=0.026). The Charlson comorbidity index was positively correlated with the duration of hospitalization (P<0.001). Higher index scores were found more among patients presenting with aspiration pneumonia (P=0.004) and lower scores were found among patients presenting with PEG site infection and inadvertent PEG removal compared with those presenting with a major complication (P<0.001). CONCLUSION: The patient's general medical condition and nutritional status are the greatest risk predictors for developing adverse events related to their PEG feeding, as well as a consequent extended hospital stay.

Rhabdomyolysis: a rare adverse effect of levetiracetam.

A 62-year-old previously healthy male was admitted with new onset generalised tonic-clonic seizures. Treatment was initiated with the antiepileptic levetiracetam and he had no further episodes of seizures. Creatine kinase (CPK) level was 1812 IU/L 12-hour postadmission. Despite good hydration, his CPK levels continued to rise dramatically and reached a level of 19 000 IU/L on day 5. This rise was unexplained as he did not have any further seizures and had a normal renal function. In the absence of other risk factors, the rare possibility of levetiracetam being responsible for the disproportionately high CPK was considered. Within 12 hours of withdrawal of levetiracetam, there was a downward trend in the CPK levels, with a 10-fold decrease in CPK levels over the next 4 days. This is only the ninth case reported in literature regarding this rare and potentially serious adverse effect of levetiracetam.

An extraordinary case of recurrent stroke, disseminated thrombosis and endocarditis.

A 43-year-old woman with no known cardiovascular risk factors was admitted with a second episode of ischaemic stroke. She was not a known case of connective tissue disease like systemic lupus erythematosus or antiphospholipid syndrome (APS). During the current episode, she was found to have markedly deranged coagulation parameters and laboratory evidence of microangiopathic haemolysis, but no evidence of sepsis or active bleeding. Further investigation revealed multiple organ infarcts. A diagnosis of probable catastrophic APS was made and she improved dramatically with a combination of plasmapheresis, corticosteroids and therapeutic anticoagulation. Serological markers of APS were negative. Her hospital course was complicated by Libman Sacks endocarditis with significant aortic regurgitation that improved markedly with anticoagulation obviating the need for high-risk cardiac surgery. At discharge, she was stable and well and was advised long-term anticoagulation and rheumatology follow-up.

Ackerman syndrome: a rare cause of arthritis with dermatitis.

We present a case of a middle-aged woman who presented with acute onset of non-erosive oligoarthritis and cutaneous lesions. Her laboratory work up revealed mild anaemia with positive antinuclear antibody. Her skin biopsy confirmed the presence of interstitial granulomatous dermatitis. She was treated with a successful trial of non-steroidal anti-inflammatory agents. Interstitial granulomatous dermatitis with arthritis (IGDA), or Ackerman syndrome, is an under-recognised cause of arthritis with dermatitis. This is primarily due to the varied clinical presentation of the skin lesions and the non-specific laboratory findings. Our aim is to highlight the pivotal role of skin biopsy as part of the diagnostic assessment of patients who present with arthritis and concomitant skin lesions.

A young patient with recurrent respiratory tract infection and anasarca.

A young man with a history of recurrent respiratory tract infections for the past 8 years presented with generalised anasarca. He was found to have advanced renal disease (stage 4) and a profound proteinuria of 82.9 g/day. Further workup revealed the presence of advanced bronchiectatic changes in the lungs. Rectal biopsy showed the characteristic pattern of amyloid deposition. A diagnosis of systemic amyloidosis secondary to bronchiectasis was made. To the best of our knowledge no other cases of bronchiectasis-associated renal amyloid disease with such marked proteinuria have been reported in the literature. Our patient had a relatively short duration between the onset of his symptoms related to underlying bronchiectasis and his clinical presentation of renal amyloidosis. He had an aggressive course of disease and unfortunately died at a very young age.

Frequency, characteristics and risk factors of carotid artery stenosis in ischaemic stroke patients at Civil Hospital Karachi.

OBJECTIVE: To determine the frequency and characteristics of carotid artery stenosis in acute ischaemic stroke patients and to assess the significance of common risk factors for carotid stenosis in these patients. METHOD: One hundred consecutive patients admitted with acute ischaemic stroke were included in the study. The relevant history, physical examination and laboratory investigations were done as per the Performa. Doppler ultrasound was performed during the hospitalization to find out carotid artery stenosis. Statistics analysis was done with SPSS v 14. RESULTS: Out of one hundred (100) patients, sixty one (61%) were males and thirty nine (39%) were females. Thirty nine patients (39%) were found to have carotid artery stenosis, all of them on the ipsilateral side corresponding to the ischaemic lesion. Eleven (11) of these patients had stenosis on the contra lateral side as well. The presence of stenosis was significantly correlated with older age and the presence of multiple risk factors. Majority (52%) of the lesions were severe to critical as determined by Doppler peak systolic velocity. Fifty nine (59%) were non calcified. CONCLUSION: Carotid artery stenosis is strongly associated with ischaemic stroke. Doppler studies are recommended for the high risk patients for the primary as well as secondary prevention of ischaemic stroke.

Vitamin D deficiency in fibromyalgia.

OBJECTIVE: To check the Vitamin D levels in patients diagnosed as fibromyagia in our population. METHODS: Study was done at Medical OPD of Civil Hospital Karachi, from January to March 2009. Female patients diagnosed as Fibromyalgia according to American College of Rheumatology (ACR) criteria and exclusion of systemic illness on examination, and normal reports of blood CP, ESR, serum calcium, phosphate and Alkaline Phosphatase, were asked to get Vitamin D levels in their serum. Vitamin D deficiency is defined as <20 ng/ml, Vitamin D insufficiency 21-29 ng/ml and Vitamin D sufficiency equal or >30 ng/ml. RESULT: Forty female patients were included in the study. The mean age was 37.65 +/- 11.5 years. Mean Vitamin D level was 17.41 +/- 5.497 ng/ml. Thirty two (80%) of patients had Vitamin D deficiency, mean levels of 15.855 +/- 4.918 ng/ml and 8(20%) had Vitamin D insufficiency, mean levels of 23.64 +/- 2.39 ng/ml. Patients with vitamin D deficiency and age less than 45 years were 22 (68.75%), had mean vitamin D level 16.87 +/- 4.48 ng/ml whereas in age ranging from 46-75 years were 10 (31.25%) had mean vitamin D level 16.09 +/- 6.45 ng/ml. CONCLUSION: Vitamin D deficiency is frequently seen in patients diagnosed as fibromyalgia and nonspecific musculoskeletal pain in our population. Although the sample size of the study is small, but the figures are so alarming that it is an eye opener towards the need of a population based study, including normal population as well as those presenting with musculoskeletal pain.

Acute acalculous cholecystitis in dengue fever.

OBJECTIVE: To investigate the frequency, clinical features, management and outcome of acute acalculous cholecystitis in dengue fever patients. METHODS: Forty patients were admitted with the diagnosis of dengue fever, according to the clinical manifestations and laboratory investigations. The diagnosis of dengue fever was confirmed by a positive IgM antibody test result for a late or convalescent phase blood specimen. The diagnosis of acute acalculous cholecystitis was made according to clinical features and sonographic findings. Liver function tests, complete blood counts were determined. Abdominal ultrasound was performed with a real time scanner in patients with abdominal pain and abnormal results on liver function tests. RESULTS: Eleven out of 40 patients of dengue fever (27.5%) had complication of acute acalculous cholecystitis. There were 8 males and 3 females. The mean and standard deviation from the onset of fever to hospital visit was 3.3 +/- 0.8 days (range 2-5 days). The mean white cell counts was 4154 +/- 1577.5 cmm. The mean platelet counts were 26,727 +/- 10460.3 cmm on presentation in hospital. The mean SGPT level was 148.5 +/- 190.17 mg/dl. Mean alkaline phosphatase was 398 +/- 214.8 mg/dl. On sonography all had thickened gall bladder. The mean gall bladder wall thickness was 5.2 +/- 1.3 mm. Three patients had ascites and one patient had pleural effusion. CONCLUSION: Acute acalculous cholecystitis was seen in a significant proportion of patients with dengue fever. All patients improved with good hydration and correction of thrombocytopenia. Based on these observations it is suggested that close observation and initial treatment of thrombocytopenia is mandatory.

Three consecutive audits to achieve acceptable colonoscopy completion rates.

OBJECTIVE: To compare the acceptable colonoscopy completion rates in three successive audits, identifying the reasons for failure of completion and rectifying them to improve the performance at our endoscopy unit. METHODS: Study was conducted at Endoscopy unit of Medical Unit One Civil Hospital Karachi. The first audit was conducted retrospectively on the colonoscopy results, done from November 2004 to November 2005. As the information was incomplete, a performa was designed for the next prospective audit from December 2005 to November 2006. The shortcomings found in the results of this audit were improved in the third audit done prospectively from December 2006 to November 2007. RESULTS: In the first audit 164 patients (111 male) underwent colonoscopy. The mean age was 40 +/- 10.08 years. The overall caecal intubation rate was 55%, but adjusted caecal intubation was not calculated because of inadequate documentation. In the second audit, 119 patients (66 male) underwent colonoscopy. The mean age was 45 +/- 10.17 years. After implementing changes the overall crude caecal intubation rate was 54.8% and the adjusted caecal intubation rate was 75% with exclusion of strictures and poor preparation. In the third audit, 122 patients (58 males) underwent colonoscopy. The mean age was 38 +/- 11.07 years. With further improvement in methodology the overall crude caecal intubation rate was (80.3%) and the adjusted caecal intubation rate was (98%). CONCLUSION: These audits allowed us to evaluate our endoscopy services and to detect the short comings and deviation from standard techniques and hence improving the performance in the subsequent year for the benefit of patients.

Liver histology in hepatitis C virus positive patients with normal and elevated alanine amino transferase levels.

OBJECTIVE: To compare liver histology in HCV RNA positive patients with normal and elevated Alanine Aminotransferase Level (AST). METHODS: This Cohort (prospective) study was conducted at Civil Hospital Karachi from Jan 2007 to July 2007. Forty patients with positive HCV RNA were included. Their liver function tests were followed for three months. Those having normal ALT on three occasions were taken as controls and those having elevated ALT were taken as cases. Liver biopsy was performed, Specimens were reviewed by single pathologist. Scheuer's scoring for grading of inflammation and staging of fibrosis of chronic hepatitis was used. RESULTS: Out of Forty patients having positive HCV RNA, 14 (35%) were male and 26 (65%) were female. Mean ALT in control group was 27.3 +/- 6.1 u/l, mean ALT in cases was 91.7 +/- 39.95 u/l. Mean age in controls was 34.2 +/- 10.75 years and in cases was 33.6 +/- 9.40 years. On histopathology, the mean grade of inflammation in controls was 1.40 +/- 0.681 while in cases was 1.20 +/- 0.834, which was not statistically significantly different in the two groups (p = 0.411). Similarly mean staging of fibrosis in controls was 1.20 +/- 0.768 and in cases was 1.35 +/- 1.348 which was also not statistically different in the two groups (p = 0.668). Stage 3 and 4 fibrosis was seen only in raised ALT group and not in the controls. CONCLUSION: Patients with persistently normal ALT and elevated ALT, although had similar grading of inflammation but the fibrosis score was more in elevated ALT group. None of the patients with normal ALT had normal histology, so decision for antiviral treatment should be individualized in this group also.

Platelet count/splenic size ratio: a parameter to predict the presence of esophageal varices in cirrhotics.

OBJECTIVE: To evaluate platelet count/ splenic size ratio as a non-invasive parameter to predict the presence and absence of esophageal varices in patients with cirrhosis of liver. DESIGN: An observational, cross- sectional study. PLACE AND DURATION OF STUDY: The medical units of the Civil Hospital, Karachi, between October 2003 and October 2004. PATIENTS AND METHODS: During one year of study, one hundred and thirteen (113) patients with cirrhosis of liver were studied. These patients were evaluated for the cause of chronic liver disease, ascites and splenic size by abdominal ultrasound, serum proteins and albumin, prothrombin time, complete blood count including platelet count and liver functions test. All the patients had upper GI endoscopy to determine if they had esophageal varices and were classified according to Child s-Pugh classification. It was determined if the platelet count/ splenic size ratio between the two groups was different and its relation to the presence or absence of esophageal varices was noted. RESULTS: Of the one hundred and thirteen (113) patients included in the study, 35(31%) were female and 78(69%) male. The mean age of these patients was 37.1(+/- 14.85) years. Thirty-eight patients had HBsAg, 59 had anti-HCV antibodies, 8 patients had both HbsAg and anti-HCV antibodies and the cause of cirrhosis in 8 patients was indeterminate. Fifty patients had ascites. Of 113 patients, 15(13.27%) were classified as Child s Pugh class A, 68(60.18%) in class B and 30(26.55%) in class C. Sixty-six (58.4%) patients had esophageal varices on upper GI endoscopy while 47(41.6%) had no endoscopic evidence of esophageal varices. The ratio between platelet count/ splenic size was found to be significantly (p < 0.001) different between patients who had esophageal varices and those who did not. CONCLUSION: Platelet count/splenic size ratio is an important and an independent parameter associated with the presence of esophageal varices.