Technological Challenges set up by Continuous Wireless Monitoring designed to Improve Management of Critically Ill Patients in an Internal Medicine Unit (LIMS study): Study Design and Preliminary Results
Background: Wireless vital parameter continuous monitoring (WVPCM) is compared to regular nurse monitoring in order to provide data on the clinical and economic impact of critically ill patients (CIPs) in Internal Medicine Units (IMU). Study Design: Pilot prospective randomized controlled open-label multi-center study with WIN@Hospital wearable wireless system creating alerts on portable devices (ipad). Experimental Arm: CIPs with MEWS (Modified Early Warning Score) ≥ 3 and/or NEWS (National Early Warning Score) ≥ 5 at admission underwent WCPCM over the first 72 h. Active Comparator: CIPs with MEWS ≥ 3 and/or NEWS ≥ 5 at admission undergoing regular nurse monitoring. Primary outcomes: Reduction of major complications (MC) from 15% to 5%.
Disorganized Diseases: Are they a Simple Explosion of Random Energy and there...asclepiuspdfs
Objective: The study has two objectives: (1) To determine the prevailing characteristics of a given set of patients with “disorganized disease” and (2) to determinate the prevailing outcomes for these patients in family medicine to assess their implications for decision-making. Participants and Methods: A qualitative, longitudinal, and retrospective cases series study based on a single cohort was carried out. Analyses based on a retrospective study of case records from June to October 2017, in a family medicine office in the Health Center Santa Maria de Benquerencia, Toledo, Spain. A convenience sample was selected consisting of patients who consulted during that period and who met the criteria for entering the study. These cases were considered in the epidemiological term as index cases, which means that beyond these the study should be expanded. Hence, in addition, using a technique of snowball “mental” or “astute clinical observation” others patients attended previously were included until the saturation of the data. The cases were described in short case reports. An analysis of the content of these reports was carried out, defining categories of qualitative data. The results were interpreted, and a generalization was drawn from these cases.
Are Primary Care Clinicians Serving Low-Income Patients More Likely to Screen...asclepiuspdfs
Background: Women of all income levels experience domestic violence (DV). Primary health-care providers are able to screen women early and provide services or referrals; however, regular DV screening rarely occurs in the US. We investigated whether implicit bias based on patient population income level could be influencing provider practices in California. Methods: Data for this study were drawn from a self-administered survey conducted from October 2013 to March 2014. Providers (n = 152) were included if they worked in primary care and provided information on the predominant income of their patients. The survey included questions on provider demographics, screening practices, and number of female victims identified. Results: Providers serving low-income patient populations (LIPPs) or higher-income patient populations had equivalent training and knowledge about DV. However, DV screening practices (e.g., screening more often, at a younger age, and giving a screening question for DV) and outcomes (DV victims identified) varied significantly by patient population income level (P < 0.01). Working with low-income patients and engaging in universal screening practices both predicted more victim identification (P < 0.01). Conclusions: Implicit bias appears to influence clinicians’ screening practices, with those serving LIPPs being more likely to screen regardless of training or knowledge. If DV screening in primary care occurred more regularly, it would yield more detection of victims at all income levels. Training and self-reflection could combat implicit bias, as well as written policies and standardized procedures to encourage universal screening practices by clinicians irrespective of the income level of their patient populations.
Factors associated to adherence to DR-TB treatment in Georgia, Policy Brief (...Ina Charkviani
Tuberculosis (TB) is a widely spread disease globally that causes millions of people’s death worldwide. Treatment for TB is complex and usually involves taking several antibiotics at once for a long time (sometimes up to two years). Considering the severity of the treatment regimen, it becomes hard for the patients to adhere and complete proposed treatment and particularly for those who are infected with drug-resistant strain of TB. Poor adherence to treatment remains significant problem that prevents countries from obtaining high treatment success rates that is essential for health systems to control the epidemic and decrease spread of the disease. A new study from Georgia looks at adherence to treatment factors among drug resistant TB (DR-TB) patients and provides evidence that may help policy-makers develop effective strategies for improving treatment outcomes among DR-TB patients. The study findings might be helpful for other countries in the region where TB burden is also high.
Disorganized Diseases: Are they a Simple Explosion of Random Energy and there...asclepiuspdfs
Objective: The study has two objectives: (1) To determine the prevailing characteristics of a given set of patients with “disorganized disease” and (2) to determinate the prevailing outcomes for these patients in family medicine to assess their implications for decision-making. Participants and Methods: A qualitative, longitudinal, and retrospective cases series study based on a single cohort was carried out. Analyses based on a retrospective study of case records from June to October 2017, in a family medicine office in the Health Center Santa Maria de Benquerencia, Toledo, Spain. A convenience sample was selected consisting of patients who consulted during that period and who met the criteria for entering the study. These cases were considered in the epidemiological term as index cases, which means that beyond these the study should be expanded. Hence, in addition, using a technique of snowball “mental” or “astute clinical observation” others patients attended previously were included until the saturation of the data. The cases were described in short case reports. An analysis of the content of these reports was carried out, defining categories of qualitative data. The results were interpreted, and a generalization was drawn from these cases.
Are Primary Care Clinicians Serving Low-Income Patients More Likely to Screen...asclepiuspdfs
Background: Women of all income levels experience domestic violence (DV). Primary health-care providers are able to screen women early and provide services or referrals; however, regular DV screening rarely occurs in the US. We investigated whether implicit bias based on patient population income level could be influencing provider practices in California. Methods: Data for this study were drawn from a self-administered survey conducted from October 2013 to March 2014. Providers (n = 152) were included if they worked in primary care and provided information on the predominant income of their patients. The survey included questions on provider demographics, screening practices, and number of female victims identified. Results: Providers serving low-income patient populations (LIPPs) or higher-income patient populations had equivalent training and knowledge about DV. However, DV screening practices (e.g., screening more often, at a younger age, and giving a screening question for DV) and outcomes (DV victims identified) varied significantly by patient population income level (P < 0.01). Working with low-income patients and engaging in universal screening practices both predicted more victim identification (P < 0.01). Conclusions: Implicit bias appears to influence clinicians’ screening practices, with those serving LIPPs being more likely to screen regardless of training or knowledge. If DV screening in primary care occurred more regularly, it would yield more detection of victims at all income levels. Training and self-reflection could combat implicit bias, as well as written policies and standardized procedures to encourage universal screening practices by clinicians irrespective of the income level of their patient populations.
Factors associated to adherence to DR-TB treatment in Georgia, Policy Brief (...Ina Charkviani
Tuberculosis (TB) is a widely spread disease globally that causes millions of people’s death worldwide. Treatment for TB is complex and usually involves taking several antibiotics at once for a long time (sometimes up to two years). Considering the severity of the treatment regimen, it becomes hard for the patients to adhere and complete proposed treatment and particularly for those who are infected with drug-resistant strain of TB. Poor adherence to treatment remains significant problem that prevents countries from obtaining high treatment success rates that is essential for health systems to control the epidemic and decrease spread of the disease. A new study from Georgia looks at adherence to treatment factors among drug resistant TB (DR-TB) patients and provides evidence that may help policy-makers develop effective strategies for improving treatment outcomes among DR-TB patients. The study findings might be helpful for other countries in the region where TB burden is also high.
Low Functional health literacy is a problem affecting 90 million residents of the United States. Among the 90 million, 36% are adults who have “below basic” health literacy skills. Assessing health literacy is important in improving health behaviors, health outcomes, and perceived communication barriers related to health. The Patient Protection and Affordable Care Act enacted in 2010 brought about changes that demand a more coordinated approach to manage health care services. This research focused on the efforts being made to promote health literacy at Medicaid health homes such as Greater Buffalo United Accountable Healthcare Network (GBUAHN). This research consisted of observation of Patient Health Navigator interactions with patients in order to identify best practices of health literacy initiatives within GBUAHN. Results suggest best practices include promoting and establishing relationship to effectively enhance patients understanding of all their healthcare needs. This study suggests that GBUAHN should continue making use of recommendations related health literacy promotion while exploring areas of improvement as noted on scorecard. Patient Health Navigators are engaging patient in manner that will establish adherence within patients.
Multiple Chemical Sensitivities - A Proposed Care Model v2zq
Multiple Chemical Sensitivities - A Proposed Care Model - Resources for Healthy Children www.scribd.com/doc/254613619 - For more information, Please see Organic Edible Schoolyards & Gardening with Children www.scribd.com/doc/254613963 - Gardening with Volcanic Rock Dust www.scribd.com/doc/254613846 - Double Food Production from your School Garden with Organic Tech www.scribd.com/doc/254613765 - Free School Gardening Art Posters www.scribd.com/doc/254613694 - Increase Food Production with Companion Planting in your School Garden www.scribd.com/doc/254609890 - Healthy Foods Dramatically Improves Student Academic Success www.scribd.com/doc/254613619 - City Chickens for your Organic School Garden www.scribd.com/doc/254613553 - Huerto Ecológico, Tecnologías Sostenibles, Agricultura Organica www.scribd.com/doc/254613494 - Simple Square Foot Gardening for Schools - Teacher Guide www.scribd.com/doc/254613410 - Free Organic Gardening Publications www.scribd.com/doc/254609890 ~
Evaluations of and Interventions for Non Adherence to Oral Medications as a P...NiyotiKhilare
The focus of this presentation will be medical non-adherence as a psychosocial issue in diabetes. The presentation will also focus elaborately on empowerment as an intervention amongst other interventions.
Natural History of Disease & Levels of preventionsourav goswami
I have tried to explain the National History of Disease taking the example of a disease condition. Similarly, the different prevention levels are also explained in a similar manner. The presentation also includes few newer concepts of screening like lead time and length time bias.
N.B: Please download to see all the animations.
The unusual occurrence in a community or region of disease, specific health related behaviour (eg. Smoking) or other health related events (eg. Traffic accidents) clearly in excess of “expected occurrence.
Remote Patient Monitoring (RPM) is becoming an essential part of future healthcare. Read this guide, to learn more about remote patient monitoring. Click here :https://bluestartelehealth.com/
A Mobile-Phone Tele-Medicine System That Promotes Self-Management of Blood Pr...IJERA Editor
The current practice adopted by hypertensive patients in managing hypertension is making frequent visits to a health center as recommended by medical specialists. However, very few patients adhere to this practice as it is time consuming and tiresome especially if they have to travel for long distances to have their BP checked. This practice is also not practical for critically-ill patients. Consequently, most patients neglect BP check-ups and therefore focus on medication alone. This puts the patients’ at risk as uncontrolled BP can lead to fatal complications. The overall objective of this research was to design, develop and pilot-test a mobile telemedicine system that helps patients’ to self-manage their BP condition from the comfort of their homes. Participatory action research design was used in this study. Testing for performance, usability and utilityof the tele-medicine system was conducted.
Low Functional health literacy is a problem affecting 90 million residents of the United States. Among the 90 million, 36% are adults who have “below basic” health literacy skills. Assessing health literacy is important in improving health behaviors, health outcomes, and perceived communication barriers related to health. The Patient Protection and Affordable Care Act enacted in 2010 brought about changes that demand a more coordinated approach to manage health care services. This research focused on the efforts being made to promote health literacy at Medicaid health homes such as Greater Buffalo United Accountable Healthcare Network (GBUAHN). This research consisted of observation of Patient Health Navigator interactions with patients in order to identify best practices of health literacy initiatives within GBUAHN. Results suggest best practices include promoting and establishing relationship to effectively enhance patients understanding of all their healthcare needs. This study suggests that GBUAHN should continue making use of recommendations related health literacy promotion while exploring areas of improvement as noted on scorecard. Patient Health Navigators are engaging patient in manner that will establish adherence within patients.
Multiple Chemical Sensitivities - A Proposed Care Model v2zq
Multiple Chemical Sensitivities - A Proposed Care Model - Resources for Healthy Children www.scribd.com/doc/254613619 - For more information, Please see Organic Edible Schoolyards & Gardening with Children www.scribd.com/doc/254613963 - Gardening with Volcanic Rock Dust www.scribd.com/doc/254613846 - Double Food Production from your School Garden with Organic Tech www.scribd.com/doc/254613765 - Free School Gardening Art Posters www.scribd.com/doc/254613694 - Increase Food Production with Companion Planting in your School Garden www.scribd.com/doc/254609890 - Healthy Foods Dramatically Improves Student Academic Success www.scribd.com/doc/254613619 - City Chickens for your Organic School Garden www.scribd.com/doc/254613553 - Huerto Ecológico, Tecnologías Sostenibles, Agricultura Organica www.scribd.com/doc/254613494 - Simple Square Foot Gardening for Schools - Teacher Guide www.scribd.com/doc/254613410 - Free Organic Gardening Publications www.scribd.com/doc/254609890 ~
Evaluations of and Interventions for Non Adherence to Oral Medications as a P...NiyotiKhilare
The focus of this presentation will be medical non-adherence as a psychosocial issue in diabetes. The presentation will also focus elaborately on empowerment as an intervention amongst other interventions.
Natural History of Disease & Levels of preventionsourav goswami
I have tried to explain the National History of Disease taking the example of a disease condition. Similarly, the different prevention levels are also explained in a similar manner. The presentation also includes few newer concepts of screening like lead time and length time bias.
N.B: Please download to see all the animations.
The unusual occurrence in a community or region of disease, specific health related behaviour (eg. Smoking) or other health related events (eg. Traffic accidents) clearly in excess of “expected occurrence.
Similar to Technological Challenges set up by Continuous Wireless Monitoring designed to Improve Management of Critically Ill Patients in an Internal Medicine Unit (LIMS study): Study Design and Preliminary Results
Remote Patient Monitoring (RPM) is becoming an essential part of future healthcare. Read this guide, to learn more about remote patient monitoring. Click here :https://bluestartelehealth.com/
A Mobile-Phone Tele-Medicine System That Promotes Self-Management of Blood Pr...IJERA Editor
The current practice adopted by hypertensive patients in managing hypertension is making frequent visits to a health center as recommended by medical specialists. However, very few patients adhere to this practice as it is time consuming and tiresome especially if they have to travel for long distances to have their BP checked. This practice is also not practical for critically-ill patients. Consequently, most patients neglect BP check-ups and therefore focus on medication alone. This puts the patients’ at risk as uncontrolled BP can lead to fatal complications. The overall objective of this research was to design, develop and pilot-test a mobile telemedicine system that helps patients’ to self-manage their BP condition from the comfort of their homes. Participatory action research design was used in this study. Testing for performance, usability and utilityof the tele-medicine system was conducted.
This presentation has the measures to be taken for the safety of patients. It covers the 6 goals
Goal 1: Identify patients correctly
Goal 2: Improve effective communication
Goal 3: Improve the safety of high-alert medications
Goal 4: Ensure safe surgery
Goal 5: Reduce the risk of health care-associated infections
Goal 6: Reduce the risk of patient harm resulting from falls
Adverse Events among HIV/MDR-TB Co-Infected Patients Receiving Antiretroviral...Dr.Samsuddin Khan
Abstract
Background
Significant adverse events (AE) have been reported in patients receiving medications for multidrug- and extensively-drug-resistant tuberculosis (MDR-TB & XDR-TB). However, there is little prospective data on AE in MDR- or XDR-TB/HIV co-infected patients on antituberculosis and antiretroviral therapy (ART) in programmatic settings.
Methods
Médecins Sans Frontières (MSF) is supporting a community-based treatment program for drug-resistant tuberculosis in HIV-infected patients in a slum setting in Mumbai, India since 2007. Patients are being treated for both diseases and the management of AE is done on an outpatient basis whenever possible. Prospective data were analysed to determine the occurrence and nature of AE.
Results
Between May 2007 and September 2011, 67 HIV/MDR-TB co-infected patients were being treated with anti-TB treatment and ART; 43.3% were female, median age was 35.5 years (Interquartile Range: 30.5–42) and the median duration of anti-TB treatment was 10 months (range 0.5–30). Overall, AE were common in this cohort: 71%, 63% and 40% of patients experienced one or more mild, moderate or severe AE, respectively. However, they were rarely life-threatening or debilitating. AE occurring most frequently included gastrointestinal symptoms (45% of patients), peripheral neuropathy (38%), hypothyroidism (32%), psychiatric symptoms (29%) and hypokalaemia (23%). Eleven patients were hospitalized for AE and one or more suspect drugs had to be permanently discontinued in 27 (40%). No AE led to indefinite suspension of an entire MDR-TB or ART regimen.
Conclusions
AE occurred frequently in this Mumbai HIV/MDR-TB cohort but not more frequently than in non-HIV patients on similar anti-TB treatment. Most AE can be successfully managed on an outpatient basis through a community-based treatment program, even in a resource-limited setting. Concerns about severe AE in the management of co-infected patients are justified, however, they should not cause delays in the urgently needed rapid scale-up of antiretroviral therapy and second-line anti-TB treatment
DASHBOARD BENCHMARK
Miatta Teasley
Capella University
Running Head: DASHBOARD BENCHMARK
DASHBOARD BENCHMARK
April 19,2022
DASHBOARD BENCHMARK
Second Quarter Hypertension Intervention Compliance at Med for adults presenting with Diabetes
Intervention
Needed
Completed
Compliance Percentage
Initial Lactate within 3 hours
30
30
100%
Blood cultures were drawn before antibiotics
22
17
77%
Antibiotics administered within 3 hours
22
20
91%
Fluid resuscitation if in septic shock within 2hours
19
12
63%
Vasopressors if hypertension persists after fluid or lactate >4mmoL/L within 6 hours
12
7
58%
Overall
105
86
82%
Second Quarter Dialysis Intervention
Compliance and Inpatient Mortality
Patient ID
Number of Interventions needed
Number of Interventions completed
Inpatient Mortality
2000
4
2
0
2014
3
3
1
2098
2
1
0
2134
5
4
0
2156
3
4
1
2245
4
2
0
2345
3
3
1
2567
5
4
1
2676
4
1
1
2935
3
2
0
Note: The Staffing benchmark for the nurse staffing unit is 3 patients per nurse. The average monthly staffing for the unit is 3 nurse workloads. The average number of patients in the unit per month in the third quarter was 5.75.
The data above is a review regarding the compliance of Dialysis measures and interventions compliance and the sample of the second quarter inpatient mortality. The information below entails evaluating the data, which indicates that various departments need to be improved, and a proposal for a specific area and target for improvement.
Evaluation of Dashboard Metrics
There are several inefficiencies in regards to dialysis measures at Med. From the dashboard concerning the compliance of executing the arranged measures and procedures, the two stand out at the 77% compliance rate on drawing blood cultures before running antibiotics and 58% compliance rate on administering vasopressors for those patients that require them. As per Medicare.Gov (n.d), the national average for meeting dialysis guidelines is 72%, and the state of Minnesota is 60% which indicates that Med is performing at 82% overall testing. Higher percentages are required to ensure the advanced quality of life for residents of the healthcare institution (Morfín et al., 2018).
Failure to complete blood draws for cultures before running broad-spectrum antibiotics; there will be an incapability to authorize contamination and the responsible pathogen. This can result in an inefficient or ineffective intervention for aiding a patient. Moreover, by failing to confirm infection from the start, unnecessary and wasteful care interventions could be performed or ordered for patients (Morfín et al., 2018). As per the failure to administer vasopressors, the institution is gambling with the patient's life. As the reinforcement for the dialysis unit states, vasopressor therapy is needed to sustain and uphold perfusion in the wake of life-threatening hypertension. The needed nature of compliance concerning administering this intervention can be seen in the samp.
Whilst breast cancer is a fatal disease affecting millions worldwide, identification and management of these patients did not initially attract critical attention to minimize the impact of lockdown, post-lockdown, and other measures. Breast cancer patients' conditions may not remain stable without proper care, worsening their prognosis. Proper care includes the timely instigation of surgery, systemic therapy, and psychological support. This includes low-and middle-income countries where there are already concerns with available personnel and medicines to adequately identify and treat these patients. Consequently, there was a need to summarize the current scenario regarding managing breast cancer care during COVID-19 across all countries, including any guidelines developed. We systematically searched three scientific databases and found 76 eligible articles covering the medical strategies of high-income countries versus LMICs. Typically, diagnostic facilities in hospitals were affected at the beginning of the pandemic following the lockdown and other measures. This resulted in more advanced-stage cancers being detected at initial presentation across countries, negatively impacting patient outcomes. Other than increased telemedicine, instigating neo-adjuvant endocrine therapy more often, reducing non-essential visits, and increasing the application of neo-adjuvant chemotherapy to meet the challenges, encouragingly, there was no other significant difference among patients in high-income versus LMICs. Numerous guidelines regarding patient management evolved during the pandemic to address the challenges posed by lockdowns and other measures, which were subsequently adopted by various high-income countries and LMICs to improve patient care. The psychological impact of COVID-19 and associated lockdown measures, especially during the peak of COVID-19 waves, and the subsequent effect on the patient's mental health must also be considered in this high-priority group. We will continue to monitor the situation to provide direction in future pandemics.
Community Based Treatment Support Services: The Treatment Support Arm of the ...jehill3
Community Based Treatment Support Services: The Treatment Support Arm of the AIDSRelief Program
Martine Etienne, UMSOM-IHV/AIDSRelief
HIV/AIDS Working Group Showcase
CORE Group Spring Meeting, April 29, 2010
Research the requirements to sit for the PMP Exam (both paper and .docxronak56
Research the requirements to sit for the PMP Exam (both paper and online methods).
Write a 2 page paper. In your paper include a discussion on the following:
· The amount of experience you must have to sit for the exam
· The amount of hours of project management training you must take before you sit for the exam
· The fees required to take the exam
· Download and fill out the "PMP Credential Application - submit it with your 2 page paper in the Appendix
Include a cover sheet and 2-3 references. References should be obtained through the Grantham University online library. You may use online resources for this assignment (not Wikipedia). Please adhere to the Publication Manual of the American Psychological Association (APA), 6th ed., 2nd printing when writing and submitting assignments and papers
S224 • CID 2010:51 (Suppl 2) • Eron
S U P P L E M E N T A R T I C L E
Telemedicine: The Future of Outpatient Therapy?
Lawrence Eron
John A. Burns School of Medicine, University of Hawaii, Kaiser Moanalua Medical Center, Honolulu
Early hospital discharge of acutely infected patients to received outpatient parenteral antimicrobial therapy
has been shown to be safe and effective. However, concerns over safety, potential litigation, and anxieties of
the patient and family about not receiving professional care have limited the use of this approach. Telemedicine
may overcome these barriers by allowing health care providers to monitor and communicate with acutely
infected patients from a remote medical center via a home computer station transmitting audio, video, and
vital signs data. Potential benefits of telemedicine include significant cost savings and faster convalescence,
because patients at home may feel more comfortable and actively involved in their treatment than patients
in the hospital. Clinical studies have shown that telemedicine is safe and cost-effective, compared with hospital
treatment, in chronically ill and acutely infected patients. More studies are needed to further establish the
widespread and increasing practice of telemedicine, which may represent the future of medicine.
Early hospital discharge to use of outpatient parenteral
antimicrobial therapy (OPAT) has been shown to be
both safe and effective for the treatment of acutely in-
fected patients [1–5]. Conditions frequently treated in
this manner include community-acquired pneumonia
(CAP), skin and soft-tissue infection, urinary tract in-
fection, and bacterial endocarditis. However, OPAT
alone is not recommended for some patients with severe
illness or complications, including those who must be
monitored several times per day because of comorbid-
ities and/or low performance scores [6]. Furthermore,
the decision to discharge a patient to OPAT or to dis-
charge a patient who has been switched to oral anti-
biotics may be delayed because of persistent fever or
simply for a day of observation [4, 7, 8]. Routine in-
hospital observation after the or ...
Epidemiological factors associated with catheter-associated urinary tract infection (CAUTI) in acute care hospitals and long-term care settings.
Similar to Technological Challenges set up by Continuous Wireless Monitoring designed to Improve Management of Critically Ill Patients in an Internal Medicine Unit (LIMS study): Study Design and Preliminary Results (20)
Convalescent Plasma and COVID-19: Ancient Therapy Re-emergedasclepiuspdfs
Convalescent plasma has again re-emerged as a therapy during coronavirus disease (COVID-19) outbreaks currently use as a prophylactic or an interventional treatment in infected patients. Convalescent plasma has been used in the 20th century confronting different infectious diseases where there was no other therapy available. Conceivably, this convalescent plasma therapy tends to be proving a game-changing treatment in some COVID-19 patients and could support treatment, in addition to the current interventions before other developed therapies are available for the population.
The Negative Clinical Consequences Due to the Lack of the Elaboration of a Sc...asclepiuspdfs
Until a few years ago, the immune system was considered as responsible for the only defense against microbial infections and other external agents. On the contrary, the immune cells have been proven to be linked not only through cell-cell contact but also by releasing proteins capable of influencing the immune-inflammatory response, the so-called cytokines or interleukins. Moreover, the cytokines have appeared to play not only immune activities but also metabolic and systemic effects influencing the overall biological systems, including the nervous, the endocrine, and the cardiovascular systems, by representing the main endogenous molecules responsible for the maintenance of the unity of the biological life. Therefore, only the systematic clinical consideration of cytokine effects may allow the generation of real future holistic medicine.
The great benefit of blood/blood constitutes therapy is the ability to provide transfusion support for patients with many unique hematologic conditions. For some patients, such as patients with sickle cell disease, thalassemia major, immune hemolytic anemia, anemia of kidney disease, and aplastic anemia may need for this consolidation extends throughout their life. By knowing the alteration mechanisms of these conditions, we can appreciate the stationary, urgency, and the value of the transfused red blood cell (RBC).
Decreasing or Increasing Role of Autologous Stem Cell Transplantation in Mult...asclepiuspdfs
During the past four decades, autologous stem cell transplantation (ASCT) has been the first choice and the standard option for the treatment of newly diagnosed patients with multiple myeloma. The introduction of new agents such as thalidomide, lenalidomide, and bortezomib has led to a clear improvement in basic approach and those agents became the standard of care in the induction phase; however, they were not able to play the role of ASCT in term of progression-free survival and overall survival. Debate continues about the best induction, consolidation, and maintenance taking into account the toxicities of these new agents. The new monoclonal antibody (anti CD38) starts to take its place in the induction setting and it seems to be a promising agent in the high-risk group. Until recently, ASCT is the standard treatment for newly diagnosed patients.
Comparison of the Hypocalcemic Effects of Erythropoietin and U-74389Gasclepiuspdfs
Aim: This study calculated the effects on serum calcium (Ca) levels, after treatment with either of two drugs: The erythropoietin (Epo) and the antioxidant lazaroid (L) drug U-74389G. The calculation was based on the results of two preliminary studies, each one of which estimated the certain influence, after the respective drug usage in an induced ischemia-reperfusion animal experiment. Materials and Methods: The two main experimental endpoints at which the serum Ca levels were evaluated were the 60th reperfusion min (for the Groups A, C, and E) and the 120th reperfusion min (for the Groups B, D, and F). Especially, the Groups A and B were processed without drugs, Groups C and D after Epo administration, whereas Groups E and F after the L administration. Results: The first preliminary study of Epo presented a non-significant hypocalcemic effect by 0.34% ± 0.68% (P = 0.6095). However, the second preliminary study of U-74389G presented a non-significant hypercalcemic effect by 0.14% ± 0.66% (P = 0.8245). These two studies were coevaluated since they came from the same experimental setting. The outcome of the coevaluation was that L is 2.3623042-fold (2.3482723–2.3764196) more hypercalcemic than Epo (P = 0.0000). Conclusions: The antioxidant capacities of U-74389G ascribe 2.3623042-fold more hypercalcemic effects than Epo (P = 0.0000).
The term refractory anemia (RA) may be confusing to those who are not hematologists. RA should be well defined because it means more than what it says. RA is defined as anemia that is not responsive to therapy except transfusion.[1] The term RA is used to rule out those types of anemia with a known cause such as anemia of systemic diseases (liver and kidney) and anemia of inflammation even though they are considered refractory to therapy.[2] RA with cellular or hypercellular bone marrow was formerly used to exclude aplastic anemia.
Management of Immunogenic Heparin-induced Thrombocytopeniaasclepiuspdfs
Immunogenic heparin-induced thrombocytopenia (HIT) is an immune response to heparin associated with significant morbidity and mortality in hospitalized patients if unidentified as soon as possible, due to thromboembolic complications involving both arterial and venous systems. Early diagnoses based on a comprehensive interpretation of clinical and laboratory information improve clinical outcomes. Management principles of strongly suspected HIT should not be delayed for laboratory result confirmation. Treatment strategies have been introduced including new, safe, and effective agents. This review summarizes the clinical therapeutic options for HIT addressing the use of parenteral direct thrombin inhibitors and indirect factor Xa inhibitors as well as the potential non-Vitamin K antagonist oral anticoagulants.
73-year-old woman without any pertinent history was admitted to the hospital due to remittent fever with erythema. She showed itching and linearly arranged erythema on the chest, back, and abdomen [Figure 1a and b]. As she had been taking daily cefditoren pivoxil for the 4 days before her admission, she was diagnosed as having drug-related scratch dermatitis, and the antibiotic treatment was stopped. Her fever remained. Laboratory data showed elevated levels of white blood cells (14,800/μl, normal range 4000–7000) and liver enzymes such as aspartate aminotransferase (AST) 138 IU/L (normal range 5–40), alanine aminotransferase 97 IU/L (normal range 5–35), and ferritin (17469.5 ng/mL, normal range 5–152).
Bone Marrow Histology is a Pathognomonic Clue to Each of the JAK2V617F, MPL,5...asclepiuspdfs
According to the World Health Organization and Clinical Laboratory Molecular and Pathological criteria bone marrow pathology in JAK2V617F mutated trilinear myeloproliferative neoplasm (MPN) patients essential thrombocythemia (ET) and polycythemia vera are indistinguishably featured by clustered medium to large pleomorphic megakaryocytes and increased cellularity (60–90%) due to increased erythropoiesis and megakaryopoiesis. MPL515 mutated ET is the second distinct clonal MPN characterized by thrombocythemia in a normocellular bone marrow showing clustered increased large to giant mature megakaryocytes with staghorn-like hyperlobulated nuclei. Calreticulin (CALR) mutated hypercellular thrombocythemia associated with prefibrotic megakaryocytic, granulocytic myeloproliferation (MGM) recently became the third distinct MPN featured by dense clusters of immature megakaryocytes with cloud-like nuclei. Bone marrow pathology in newly diagnosed MPN patients appears to be a pathognomonic clue for diagnostic differentiation between JAK2V617F mutated trilinear MPN, MPL515 normocellular thrombocythemia, and CALR thrombocythemia with MGM characteristics followed by secondary reticulin fibrosis. Their natural histories clearly differ featured by an increase of erythro/granulopoiesis and cellularity in JAK2V617F, decrease of erythropoiesis and cellularity in MPL515 and increase of dual megakaryo/granulopoiesis and cellularity in CALR mutated MPN.
Helicobacter pylori Frequency in Polycythemia Vera Patients without Dyspeptic...asclepiuspdfs
Introduction: In polycythemia vera (PV) patients, peptic ulcer and gastroduodenal erosions are more common than the general population, but there are insufficient data on the frequency of Helicobacter pylori (HP) and its role in etiopathogenesis. In this study, we aimed to compare the prevalence of HP infection in PV patients without dyspeptic complaints with a healthy control group without dyspeptic complaints. Materials and Methods: Fifty patients with PV without dyspeptic complaints and 50 controls without dyspeptic complaints were enrolled in this study after informed consent obtained. Stool samples of selected patients were analyzed using HP stool antigen test (True Line®). Results: There was surprisingly striking difference between HP prevalence in PV patients without dyspeptic complaints and asymptomatic healthy controls (64% vs. 2%) (P < 0.05). There was no significant relationship found between HP presence and age, gender, treatment modalities, complete blood count, positivity of JAK2 V617F, serum erythropoietin level, and splenomegaly in PV patients (P > 0.05). Conclusion: As the susceptibility of HP infections in PV patients are higher, it is recommended to have close surveillance of these patients by screening HP presence. In addition, when HP positivity is determined, the eradication of HP is essential to prevent possible future gastrointestinal lesions in patients with PV.
Lymphoma of the Tonsil in a Developing Communityasclepiuspdfs
The lymphoma of the tonsil is a rarity. Single case reports have appeared in countries as disparate as China, Greece, India, Japan, and Turkey. Therefore, this paper presents cases found in Nigeria among the Ibo ethnic group. The epidemiological comparisons are deemed to be worthy of documentation such as age ranges and sides of involvement.
Should Metformin Be Continued after Hospital Admission in Patients with Coron...asclepiuspdfs
Background: In most patients with diabetes, guidelines recommend discontinuation of oral anti-diabetic agents. Preliminary data suggest that pre-admission metformin use may have a mortality benefit in patients with coronavirus disease (COVID)-19 admitted to the hospital. Objective: The objective of the study was to review the impact of metformin on morbidity and mortality among hospitalized patients with COVID-19. Methods: Review of English literature by PUBMED search until November 10, 2020. Search terms included diabetes, COVID-19, metformin, retrospective studies, meta-analyses, pertinent reviews, pre-print articles, and consensus guidelines are reviewed.
Clinical Significance of Hypocalcemia in COVID-19asclepiuspdfs
Background: Preliminary data suggest that hypocalcemia is common among patients with COVID-19 admitted to the hospital. Objective: The objective of the study was to examine the clinical significance of hypocalcemia in the setting of COVID-19. Methods: Literature search (PubMed) until August 5, 2020. Search terms include hypocalcemia, COVID-19, mortality, and complications. Retrospective studies are reviewed due to a lack of randomized trials. Results: Prevalence of hypocalcemia among hospitalized patients with COVID-19 ranges from 62% to 78%, depending on the definition of hypocalcemia and patients’ characteristics. In most cases, hypocalcemia is mild to moderate biochemically. Hypocalcemia is a risk factor for hospitalization of patients with COVID-19. In already hospitalized patients, hypocalcemia is significantly associated with increase severity of COVID-19 and its complications, including multiorgan failure, acute respiratory distress syndrome, and death. Hypocalcemia is significantly correlated with inflammatory markers of COVID-19. Causes of hypocalcemia in COVID-19 patients are unclear, but Vitamin D deficiency may be a contributing factor. Conclusion: Hypocalcemia is common in hospitalized patients with COVID-19 and carries unfavorable outcomes. Further studies are needed to examine the causes of hypocalcemia in COVID-19 and to see whether normalization of circulating calcium levels improves prognosis.
Excess of Maternal Transmission of Type 2 Diabetes: Is there a Role of Bioche...asclepiuspdfs
Objective: An excess of maternal transmission of Type 2 diabetes (T2D) has been reported in some populations but not confirmed in other studies. Mitochondrial inheritance has been proposed to explain such excess. In the present paper, we have considered the presence of T2D in the mother and/or in the father in relation to the risk of T2D and to age at onset of the disease in the offspring. The distribution of two genetic polymorphisms involved in glucose metabolism in relation to the presence of T2D in the mother has been also considered. Materials and Methods: Two hundred and seventy-nine participants with T2D were studied in the population of Penne, a small rural town in the eastern side of central Italy. Adenosine deaminase locus 1 (ADA1) and phosphoglucomutase locus 1 (PGM1) phenotypes were determined by starch gel electrophoresis. Statistical analyses were carried out using commercial software (SPSS). Results: The proportion of patients from T2D mothers is much greater as compared to the proportion of the patients from T2D fathers (P < 0.0001). Age at onset of the disease in patients in whom one or both parents are T2D is lower as compared to other patients. The distribution of ADA1 and PGM1 phenotypes in participants with T2D depends on the presence of diabetes in the mother. Conclusions: About the transmission of T2D, our data confirm the high proportion of maternal T2D and show the role of two common biochemical polymorphisms involved in glucose metabolism.
The Effect of Demographic Data and Hemoglobin A 1c on Treatment Outcomes in P...asclepiuspdfs
Objective: Diabetes mellitus, the most common cause of non-traumatic foot amputations, is a life-threatening condition due to its high mortality and morbidity. In our study, we retrospectively evaluated our patients with diabetic foot syndrome in our clinic. Materials and Methods: The demographic data, duration of diabetes, Wagner classification, haemoglobin A 1c (HbA1c) levels, white blood cell, C-reactive protein sedimentation levels, hospital stay, and treatment results were evaluated retrospectively in 14 patients with diabetic foot between January 2017 and December 2018. Results: The mean age of the patients was 62.43 ± 7.7 years. Of the 14 patients, 3 were females and 11 were males. All 14 patients were type 2 diabetes mellitus. When diabetic foot Wagner classification was performed, 6 patients were evaluated as Wagner 2, five patients were Wagner 3, and three patients were evaluated as Wagner 4. Nine patients had complete amputation and 3 had vascular surgery. Conclusion: Although the level of HbA1c is below the target level, the risk of diabetic foot is increased when there is no adequate diabetes mellitus foot training. Inadequate diabetic patient education and hospitalization of patients after infection progress the amputation rate.
Self-efficacy Impact Adherence in Diabetes Mellitusasclepiuspdfs
The aim of the paper is to explore how self-efficacy (SE) is associated with adherence among adults with diabetes mellitus (DM). Methods: The search of electronic databases identified 564 records from 2007 to 2017 on SE and adherence from different perspectives and its effect on adults with DM. Discussions: SE increases the confidence in adults in their self-care behaviors. Non-adherence continues to be a significant barrier to SE. SE and adherence should be informed by an understanding of theoretical frameworks and the individual characteristics. Conclusion: Adherence is likely among adults with better SE to empower them to make valid decisions about their health. Interventions to improve SE should be tailored based on different types of non-adherence such as intentional and unintentional non-adherence. Implications: An intercollaborative professional practice approach is crucial to improve SE and adherence for sound judgment and valid decision-making.
Uncoiling the Tightening Obesity Spiralasclepiuspdfs
While an underweight prevalence was once more than twice that of obesity, now more people are obese than underweight. Obesity is one of the leading causes of preventable death in the world. There are an estimated 2,100,000,000 obese people worldwide and that number is forecast to grow to 51% of the world’s population by 2030. Escalating obesity-related disease costs threaten to bankrupt the world’s health-care systems.
Prevalence of Chronic Kidney disease in Patients with Metabolic Syndrome in S...asclepiuspdfs
Background and Objective: Chronic kidney disease (CKD) which is an increasingly important clinical and public health issue is associated with cardiovascular disease. Epidemiologic studies have also linked metabolic syndrome (MetS) with an increased risk of incident CKD. Therefore, the present study was designed retrospectively to find the prevalence and potential risk factors of CKD in patients with MetS in Saudi Arabia.
Management Of Hypoglycemia In Patients With Type 2 Diabetesasclepiuspdfs
Hypoglycemia is the rate-limiting step of intensive management in patients with diabetes. Lowering one’s A1C to a prescribed target is expected to mitigate one’s risk of developing long- and short-term diabetes-related complications. Several of the less expensive and commonly prescribed glucose lowering agents favored by practitioners result in weight gain, hypoglycemia, and even an increased risk of cardiovascular (CV) mortality. Although achieving a targeted A1C of <7 % is the standard of care, clinicians often fail to evaluate patients for glycemic variability which can increase oxidative stress driving long-term diabetes-related complications including CV death. The use of concentrated insulins and glucagon-like peptide-1 receptor agonists separately or in combination with each other reduces glycemic variability and one’s risk of hypoglycemia. Pharmaceutical agents which allow patients to safely achieve their targeted A1C without weight gain and hypoglycemia should be preferred in patients with type 2 diabetes.
Predictive and Preventive Care: Metabolic Diseasesasclepiuspdfs
South Asians have a very high incidence of ischemic heart disease and stroke. In addition, they also have a very high incidence of metabolic diseases such as prehypertension, hypertension, visceral obesity, metabolic syndrome, prediabetes, type-2 diabetes, and its clinical complications. Currently, there are over 75 million diabetic subjects in India and an equal number of prediabetics. Republic of China has taken over India as the diabetes capital of the world, with over 115 million diabetics. Modern medicine is disease focused and has failed to address the prevention of these chronic diseases. According to the reports from the United Nations (Millennium Development Goals [MDGs], the World Health Organization, Global Health Initiatives, and the non-communicable disease risk task force), obesity has increased by 2-fold and type-2 diabetes by 4-fold worldwide. Experts in this field predict that chances of meeting the MDGs set by the UN members of reducing the incidence of these diseases at 2025 to the level of 2020 are very little. Western medicine has failed to reduce or reverse the trend in the incidence of these diseases. We feel that an integrated approach to health care may be a better option, to reduce the disease burden in developing and resource-poor countries. Having said that, one cannot prevent something that one is not aware of, as such it is the need of the hour for us, to develop a robust predictive and preventive health-care platform. In an earlier article, we presented our views on reducing or reversing cardiometabolic diseases. There is great enthusiasm among the health-care providers and professional bodies that integration of emerging technologies will help develop personalized, precision medicine, as well as reduce the cost of health-care worldwide.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
Technological Challenges set up by Continuous Wireless Monitoring designed to Improve Management of Critically Ill Patients in an Internal Medicine Unit (LIMS study): Study Design and Preliminary Results
2. Pietrantonio, et al.: LIght Monitor Study (LIMS): study design and preliminary results
28 Journal of Community and Preventive Medicine • Vol 2 • Issue 1 • 2019
Continuous monitoring of ASST-Garda’s activity data
has shown an increasing trend, regardless of the season,
in Emergency Room (ER) presentation and subsequent
hospitalization of patients over 65 years with exacerbation
of chronic diseases. Access data to ER in the first quarter of
2017 compared with the same period of 2016, showed that a
1% increase in ER presentations resulted in a 10% increase
in Internal Medicine admissions, causing overcrowding both
of the ER and IM ward. A recent retrospective study in the
IM Department of the Manerbio Hospital demonstrated that
27% of patients admitted to the IM ward are critical (needing
continuous monitoring and advanced medical technology),
10% of which fulfilled criteria for intensive care transfer:
MEWS≥ 5) presenting 5-6 active pathologies. Furthermore,
25% of hospitalized patients had social difficulties requiring
activation of integrated hospital-territory pathways.[2]
Toensureappropriatecare,itisthereforeessentialtostratifypatients
based on clinical intensity and care complexity and to define end-
stage disease in order to provide adequate nursing settings, staff
standards and the necessary technological equipment.
In order to provide data on the clinical impact of acute and
critically ill patients in an Internal Medicine Unit, as well
as economic data regarding the relative cost of acute patient
management during ordinary hospitalization, and to asses
whether continuous monitoring of vital parameters improves
quality of care, an interventional study was proposed by the
Internal Medicine Unit of Manerbio Hospital (ASST-Garda)
in collaboration with the University of Modena and Reggio
Emilia (Medical Statistics Unit). The study aims at assessing
the efficacy of a wireless continuous monitoring system in
reducing major complications and improving outcome and the
quality of care in acute selected patients, while reducing costs,
as compared to traditional monitoring performed at regular
intervals by the nursing staff. Continuous monitoring of vital
signs may permit detection of deterioration of acute patients in
a non-intensive care setting (such as those hospitalized in the
Internal Medicine Unit), allowing staff to promptly respond
urgently to variations in the patient’s condition and initiate
appropriate care. In order to respond to an apparent lack of
specific studies comparing the use of wireless monitoring
systems and traditional vital sign monitoring in critical acute
patients, the study was designed to highlight the benefits of
continuous monitoring of vital signs in the first 72 hours of
hospitalization. The study also indirectly aims to assess the
reduction in hospitalization costs by using the decrease in
average length of stay as a proxy parameter.
Study design [Figure 2]
The LIght Monitor Study (LIMS) is a pilot prospective
randomized controlled open-label multi-center study aimed
at evaluating the management of critically ill hospitalized
patients using wireless monitoring of vital signs as compared
to conventional monitoring in the first 72 h of hospitalization,
with the option to extend monitoring to 5 days if the MEWS
after 72 h is greater than or equal to 3 and/or the NEWS is
greater than or equal to 5.
PRESENTATION OF DESIGN
Wireless monitoring versus conventional monitoring in the
first 72 h of hospitalization, for unstable CIPs with MEWS
≥3 and/or NEWS ≥5.
Experimental group
All patients with MEWS greater than or equal to 3 and/or
NEWS greater than or equal to 5 at admission, regardless of
the reason for hospitalization together with all patients with
poor glycemic control and/or severe fluid and electrolyte
imbalance, regardless of MEWS/NEWS, are deemed eligible
for continuous wireless monitoring using the WIN@Hospital
system.
Control group
All patients with MEWS greater than or equal to 3 and/or
NEWS greater than or equal to 5, at admission, regardless of
Figure 1: Trend of complexity indicators in Internal Medicine
hospitalized patients[3-5]
Figure 2: Study design. Moher et al. mod[6]
3. Pietrantonio, et al.: LIght Monitor Study (LIMS): study design and preliminary results
Journal of Community and Preventive Medicine • Vol 2 • Issue 1 • 2019 29
the reason for admission and all patients with poor glycemic
control and/or severe fluid and electrolyte imbalance,
regardless of MEWS/NEWS will continue to undergo
traditional monitoring performed at regular intervals (at least
4 times a day) by the nursing staff.
Study population
All critical patients (with the need for continuous monitoring
and high technology) without a pacemaker, with MEWS
≥3 and/or NEWS ≥5 at admission and all patients with
glycemic decompensation and/or severe fluid and electrolyte
imbalance, regardless of MEWS/NEWS.
Identification of the monitoring tool used SYSTEM
WIN@
Hospital
The WIN@Hospital system is a portable wireless system
(Medical Class IIA) that allows continuous, real-time vital
sign monitoring, automatic calculation of the NEWS score
and creation of a personalized alert system for each patient
via a portable device (ipad), reducing the need for nursing
staff to be constantly present.
SAFETY ASSESSMENT
The wireless monitoring system WIN@Hospital is a Medical
Class II light monitoring system trade registered with the
code A CE0434 in accordance with Directive 93/42/EEC.
WIN@Medical monitoring systems allow real-time data
display, but do not require the continuous presence of nursing
staff monitoring data, because, as a class IIA device, it is not
designated as an intensive monitoring tool nor life-saving
(class II B), but a simple support tool aimed at tracking
clinical parameters (to improve diagnosis, for the automation
of detection procedures and for the reduction of clinical risk).
Time frame
The time frame is 24 months.
Primary outcomes
Reduction in occurrence of major complications from 15% to
5% in critically ill patients undergoing continuous monitoring
using the wireless system.
Secondary outcomes
Reduction in hospitalization costs: reduction by one day in
patient’s average length of hospital stay; reduction in time
dedicated to monitoring vital parameters by nursing staff per
24 hours, stratification of hospitalized patients in Internal
Medicine according to level of care intensity (using MEWS
and NEWS score) and identification of end stage patients.
Statistical methodology
The detection and treatment of early signs of deterioration
in the patient’s clinical condition reduce the incidence
of major complications and improve patient outcomes.
The preliminary study carried out at the Medical Unit of
Manerbio Hospital demonstrated that 25% of hospitalized
patients can be defined as critical (MEWS≥3) and as such
require monitoring. At least 15% of these patients have major
complications. Assuming a rate of major complications in
the control arm of 15%, we consider a relative reduction
by two thirds of this percentage as clinically significant,
which translates to decrease in risk from 15% to 5% in the
experimental arm. By setting the error α and β equal to 5%
and 20%, or 80% power, recruitment of 141 patients per
arm would be necessary to detect a statistically significant
difference of at least 10%, that is 15% - 5%. In anticipation of
a 5% drop-out rate, 148 patients per arm (296 patients in total)
should be recruited. As regards to data analysis, descriptive
statistics (mean, median and related distribution parameters)
will be reported for continuous variables while the absolute
frequencies, relative and percentage (n,%) will be calculated
for the different categorical variables. The comparison
between groups regarding binary outcomes will be assessed
using measures of association such as the difference
between risk and the relative risk, while for continuous
variables the difference between averages and medians.
Each point estimate will be reported with the corresponding
95% confidence interval. Using the 2016 figures from the
Internal Medicine Unit of Manerbio Hospital (Source: DRG
Office Manerbio, January 2017) which reported an average
hospital stay of 9.21 days (standard deviation: 6.7 days) in
traditionally monitored critically ill patients, we estimate that
continuous monitoring of the patient will decrease the length
of stay to 8.21 days, a total reduction of one day.
Statistical analysis
This trial was designed as a randomized multi-center study [7]
.
Univariate comparisons of data were performed using the
studentttestforcontinuousvariablesandtheYatesChi-Square
for categorical variables. Adjusted means were calculated as
well as mean differences, with corresponding confidence
intervals, between the two arms. The covariates included
in the model were age, gender, body mass index, MEWS,
NEWS, CIRS, BRASS, IIA indexes, end stage disease, and
patients’origin. All analyses were conducted using SAS v.9.2
(SAS Institute Inc., Cary, NC).
PRELIMINARY RESULTS
During the first 12 months, out of a total of 95 patients enrolled,
89 were evaluable (35M/54F), with a mean age 80.5 years.
Mean CIRS-CI was 4, and CIRS SI was 1.8. Main DRGs
(Diagnosis Related Groups): 127 (heart failure), 87 (respiratory
failure), 576 (sepsis). End-stage disease so far represents more
than 30% of the sample. Of the 89 patients, 38% had a BRASS
score of ≥20 indicating cases where discharge may present
difficulties and planning of step-down care is required. More
than 50% of patients presented with an IIAindex 3 indicating
4. Pietrantonio, et al.: LIght Monitor Study (LIMS): study design and preliminary results
30 Journal of Community and Preventive Medicine • Vol 2 • Issue 1 • 2019
high dependence on nursing assistance. Nurses saved a
minimum of 49,6 minutes to a maximum of 58,1 minutes on
time spent monitoring each patient per day, which may translate
to increased time spent on other activities which contribute to
patient wellbeing. Of a total 1998 patients admitted in one year
(2017 activity data of Manerbio Internal Medicine, source:
ASST-Garda Statistics Office), only 5% were recruited out of
the 27% deemed eligible, due to conditions such as dementia,
coma or end stage disease which rendered signing of the
informed consent impossible.
As regards to the primary end-point, the preliminary results
are encouraging in that a trend towards reduction of major
complications in the experimental group appears to be seen
(31% in experimental arm versus 45% in the control arm).
Moreover, on analysis of the secondary end-points, a decrease
in re-admissions (7% versus 11%) and, impressively, mortality
(7.3% versus 23.9%) has been observed.
More than 30% of the patients meet the criteria defining end
stage disease (positive answer to “surprise question”: “Would I
be surprised if this patient died in the next 12 months?”); 42.5%
in the experimental arm and 33.3% in the control arm.
Preliminary results have failed to confirm the hypothesis
regarding reduction in hospital stay, showing, on the contrary,
increased LOS in the experimental arm (11.5 days versus
10.6 days).
This result is probably due to the evidence that in the
experimental arm the BRASS20 (need for discharge
planning) is higher (33.3% versus 22.2%).
Preliminary findings of the LIMS Study are summarized in
Table 1 and 2.
DISCUSSION
Contrary to current beliefs, upheld nonetheless by scientific
studies,[8]
the hospital internist regularly faces complex,
unstable patients with difficult diagnoses and multiple
comorbidities, who pass into their care once relatively
stabilized. Management of this phase requires the specific
competencies of the internist in diagnosis and management
of the unstable, acutely unwell patient. However, the burden
of management of clinical complexity, comorbidities, frailty,
disability and social problems is appropriately shared with
other disciplines (e.g. geriatricians, physiatrists) and may
occur in the setting of assisted-care residential facilities,
long-term care, home healthcare, or in collaboration with
General Practitioners etc.[9]
The increasing role of Internal Medicine units in the
management of urgent admissions can be partially explained
by the fact that an IM ward is generally present in all hospitals
and usually boasts a higher number of beds compared to
specialized wards (Geriatrics, Neurology, Pediatrics, etc.),
which are less well represented and have a lower number of
beds. According to the Literature [10]
, Internal Medicine units
admit mainly complex DRGs with neurological or cardiac
issues as well as many patients fitting criteria for Geriatric
Unit admission. Older age, together with polypharmacy,
absence of formal and/or informal home-help services,
history of falls, temporal disorientation, type of residence and
use of psychoactive drugs significantly increase likelihood of
hospital admission through the ER.
Considering that 55% of hospital admissions in Italy are urgent,
and that the IM unit receives 27% of the total emergency
admissions, not to mention that 83% of the IM admissions
come from the ER, the prevalent activity in IM units is
characterized by management of the acute complex patient[11]
.
ACUTE COMPLEX CARE MODEL
(ACCM)[12]
According to these data, theACCM seems to be an interesting
proposal for the appropriate management of the acute patients
presenting at ER and admitted in the IM Wards. ACCM
represents the hospital counterpart of the chronic care model
and is similarly aimed to ensure the efficacious and effective
care of complex and poly-pathological patients when they
are hospitalized for acute diseases. The target population
are acutely ill complex and poly-pathological patients
(CIPs), admitted to hospital and requiring high technological
resources. The mission is to improve the management of
medical admissions through pre-defined intra-hospital tracks
and a global, multidisciplinary, patient-centered approach.
The ACCM strengths are represented by (a) in-hospital care
pathways, based on patients’ needs and tailored for CIPs, (b)
ability to balance risk and benefits of specialist treatments in
any single patient, and (c) managerial competencies applied
to CIPs and multi-professional integration.
The acute poly-pathological patient should be identified
immediately on arrival at the hospital, and the need for
hospitalization should be carefully evaluated while looking
for alternative outpatients pathways. The selection of
patients for admission to the hospital is essential to avoid
overcrowding of emergency and medical wards, to reduce
clinical risk, and to allow appropriate and timely care.
A patient with a single-organ acute disease, but with multiple
chronic comorbidities in labile compensation, should be
taken in charge immediately by an internist who, thanks to his
training and knowledge, can ensure a global care, coordinate
organ specialists in a functional way, and administer poly-
pharmacy, synergistically to the patient’s health status. The
clinical summary and the list of priorities should be written
5. Pietrantonio, et al.: LIght Monitor Study (LIMS): study design and preliminary results
Journal of Community and Preventive Medicine • Vol 2 • Issue 1 • 2019 31
down immediately after admission, and the composition
of the multidisciplinary team, required by patient’s health
conditions, should be clearly reported in the medical records.
According to validated criteria, for example the MEWS[13]
and the NEWS scores, vital parameters should be monitored
continuously[14]
or at regular intervals, and wireless systems
may permit creation of an adequate care setting[15]
for
the patient without having to move them to a different
department.
Continuous monitoring of vital parameters may allow early
detection of deterioration in acute patients not admitted in
intensive care such as those hospitalized in IMU, allowing
the staff to immediately address the patient’s needs achieving
promptly the most appropriate care. As there are no studies
Table 1: LIMS preliminary results: Patients’ characteristics
Variable Experimental arm (n=43) Control arm (n=46)
Age
Years Mean, SD 77.4 12.4 79.2 11.6
80 n, % 24 55.8% 27 58.7%
Gender
Female n, % 28 65.1% 26 56.5%
Male n, % 15 34.9% 20 43.5%
MEWS score
0–14 Mean, SD 3.1 1.2 2.9 1.2
3 n, % 15 34.9% 12 26.1%
NEWS score
0–20 Mean, SD 7.2 2.2 6.8 2.2
5 n, % 34 79.1% 30 65.2%
Weight
kg Mean, SD 74.6 18.7 71.4 13.3
Height
cm Mean, SD 163.5 8.1 164.8 8.3
BMI
kg/m2
Mean, SD 28 7.5 26.4 5
Coming from
ER n, % 24 55.8% 21 45.7%
Without admission request n, % 15 34.9% 17 37.0%
Other n, % 4 9.3% 8 17.4%
End stage disease
No n, % 23 57.5% 30 66.7%
Yes n, % 17 42.5% 15 33.3%
CIRS score
1–5 Mean, SD 1.7 0.3 1.8 0.3
0–13 Mean, SD 3.3 1.5 3.7 1.6
≥4 n, % 19 45.2% 25 55.6%
BRASS score
0–36 Mean, SD 14.8 8.7 14.0 8.2
20 n, % 14 33.3% 10 22.2%
IIA score
1–4 Mean, SD 2.5 1.1 2.4 0.9
≥3 n, % 22 53.7% 23 50.0%
SD: Standard deviation. ER: Emergency room, BMI: Body mass index
6. Pietrantonio, et al.: LIght Monitor Study (LIMS): study design and preliminary results
32 Journal of Community and Preventive Medicine • Vol 2 • Issue 1 • 2019
comparing the use of wireless monitoring systems and
traditional vital signs monitoring in critical acute patients, the
study was designed to highlight the benefits of continuous
monitoring of vital signs in the first 72 h hospitalization to
reduce the MC and improving outcome.
The preliminary results are encouraging as they appear
to highlight a trend favouring continuous monitoring
over traditional monitoring in terms of reduction in major
complications.
Of note, of the secondary end-points studied a promising trend
towards decrease in re-admissions reduction in mortality has
been observed.
Moreover, between 33.3% and 42.5% of the patients are in
the end stage of their disease according to the answer of the
“surprise question”: this may explain the difficulty often
found in stabilizing the clinical condition of more than a
quarter of the patients admitted to the Internal Medicine Unit.
More data are needed to confirm the hypothesis of LOS
reduction.
Limitation of the study
The aim of this article is to present the study design and the
preliminary results. The number of patients recruited at this
stage represent less than a third of the total required sample,
and as such only apparent trends extrapolated from initial
analysis of the data have been reported herein.
CONCLUSIONS
Continuous wireless monitoring of vital parameters may
permit early detection of deterioration in critically ill
patients allowing prompt intervention, increasing safety and
reducing costs. Extending the wireless monitoring system to
low intensity facilities and indeed to the home setting may
guarantee expert assistance following hospital discharge,
reducing overcrowding in the ER and IM units.
Doing the right thing to the right patient at the right time
represents the core mantra guiding quality diagnostic-
therapeutic pathways that, accompanied by appropriate and
efficient clinical reasoning, is the only way to reduce costs
and length of hospital stay while at the same time delivering
care at a level of excellence.
An important role of the Internal Medicine Unit is improving
clinical conditions of patients otherwise in the terminal phase
of their illness, such that life expectancy is indeed prolonged.
Therefore the IMU also contributes to the active management
of end-stage patients, as need for palliative care is effectively
deferred as a this newfound clinical stability actually allows
discharge after the acute phase.
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