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Background: The COVID-19 pandemic has led to the implementation of restrictive policies on theatre procedures, with profound impacts on service delivery and theatre output., Objectives: To quantify these effects at a tertiary hospital in KwaZulu-Natal Province, South Africa., Methods: A retrospective review of morbidity and mortality data was conducted. The effects on emergency and elective caseload, intensive care unit (ICU) admissions from theatre, theatre cancellations and regional techniques were noted., Results: Theatre caseload decreased by 30% from January to April 2020 (p=0.02), ICU admissions remained constant, and theatre cancellations were proportionally reduced, as were the absolute number of regional techniques., Conclusions: The resulting theatre case deficit was 1 260 cases. It will take 315 days to clear this deficit if four additional surgeries are performed per day.

Objectives: This mixed-method feasibility study conducted in New South Wales (NSW), Australia, aimed to explore clinical practices around the identification of patients with refractory epilepsy and referral from primary care to Tertiary Epilepsy Centers. The perceptions of general practitioners, neurologists, and adults living with refractory epilepsy were considered., Methods: Fifty-two data collection events were achieved through 22 semi-structured interviews with six neurologists and 12 adults who currently have, or have had refractory epilepsy, and four family members, 10 clinical observations of patient consultations and 20 surveys with general practitioners. A thematic analysis was conducted on the qualitative data alongside assessment of observational fieldnotes and survey data., Findings: Two main themes emerged: 1) Patient healthcare pathways and care experiences highlighted the complex and deeply contextualized experiences of both patients and healthcare professionals, from first identification of people's seizures, in primary and community care settings, to referral to Tertiary Epilepsy Centers, shedding light on a fragmented, nonstandardized referral process, influenced by both individual and shared-care practices. 2) Factors impacting referrals and patient pathways indicated that onward referral to a Tertiary Epilepsy Center is affected by the knowledge, or the lack thereof, of healthcare professionals regarding treatment options. Barriers include limited person-centered care, shared decision-making, and refractory epilepsy education for healthcare professionals, which can delay patients' disease identification and can hinder speedy referral pathways and processes, in Australia for up to 17 years. In addition, person-centered communication around care pathways is affected by relationships between clinicians, patients, and family members., Conclusion: This study has identified a noticeable lack of standardized care across epilepsy-related healthcare sectors, which recognizes a need for developing and implementing clearer epilepsy-related guidelines and Continuing Professional Development in the primary and community care settings. This, however, requires greater collaboration and commitment in the primary, community, and tertiary care sectors to address the ongoing misconceptions around professional roles and responsibilities to optimize shared-care practices. Ultimately, prioritizing person-centered care on both patients' and professionals' agendas, in order to improve satisfaction with care experiences of people living with complex epilepsy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 The Author(s). Published by Elsevier Inc. All rights reserved.)

Background: The long-term outcomes of patients discharged from the hospital after successful care in intensive care unit (ICU) are not briskly evaluated in Korea. The aim of this study was to assess long-term mortality of patients treated in the ICU and discharged alive from the hospital and to identify predictive factors of mortality., Methods: In 3,679 adult patients discharged alive from the hospital after ICU care between 2006 and 2011, the 1-year mortality rate (primary outcome measure) was investigated. Various factors were entered into multivariate analysis to identify independent factors of 1-year mortality, including sex, age, severity of illness (APACHE II score), mechanical ventilation, malignancy, readmission, type of admission (emergency, elective surgery, and medical), and diagnostic category (trauma and non-trauma)., Results: The 1-year mortality rate was 13.4%. Risk factors that were associated with 1-year mortality included age (hazard ratio: 1.03 [95% CI, 1.02-1.04], P < 0.001), APACHE II score (1.03 [1.01-1.04], P < 0.001), mechanical ventilation (1.96 [1.60-2.41], P < 0.001), malignancy (2.31 [1.82-2.94], P < 0.001), readmission (1.65 [1.31-2.07], P < 0.001), emergency surgery (1.66 [1.18-2.34], P = 0.003), ICU admission due to medical causes (4.66 [3.68-5.91], P < 0.001), and non-traumatic diagnostic category (6.04 [1.50-24.38], P = 0.012)., Conclusions: The 1-year mortality rate was 13.4%. Old age, high APACHE II score, mechanical ventilation, malignancy, readmission, emergency surgery, ICU admission due to medical causes, and non-traumatic diagnostic category except metabolic/endocrinologic category were associated with 1-year mortality.

Background: Accurate prediction of reference ranges of renal lengths facilitates clinical decision making. Currently a single renal-length-reference chart is used for both kidneys, which is solely based on the age of the child without adjusting for anthropometrics. Objective of the study is to assess the length of morphologically-normal kidneys ultrasonically and to build models to predict the renal lengths of children presenting at the Radiology Department of Lady Ridgeway Hospital for Children., Methods: A descriptive cross sectional study was done among 424 children with 233 males and 191 females at the study setting. Study population included children undergoing abdominal ultrasound scans for indications not related to renal disease. Children with a family history of renal diseases or with morphologically-abnormal kidneys were excluded. Bipolar-lengths of kidneys, gender and anthropometrics were documented. Having tested for assumptions, Wilcoxon-signed rank test, Mann-Whitney U test and multiple linear regression were used., Results: The mean (SD) bipor-length of right and left kidneys were 6.83 (1.43) and 7.05 (1.36) respectively (p < 0.001). Age, height and weight were significantly correlated with the renal lengths (p < 0.05). Until 16 months, there was a significant difference between the renal lengths between males and females (P < 0.05). Yet the association with gender was not significant from 17 months and in overall. Until 16 months, the best linear-regression equation (p < 0.001) for the left kidney was; 3.827 +  0.019(length in centimeters) +  0.141(weight in kilograms) - 0.023(age in months) - 0.347(for male sex). For the right kidney, it was; 3.888 + 0.020(length or height) + 0.121(weight) - 0.037(age) - 0.372 (for male sex). The respective R squares were 59.2 and 53.5% with VIF (Variance-Inflation-Factor) ranging from 1.06 to 2.08. From 17 months, best equation for left kidney (p < 0.001) was; 5.651+ 0.022(age) + 0.01(BMI). For right kidney it was; 5.336 + 0.022(age) + 0.012(BMI). The R squares were 62.5 and 66.1% with VIF being 1., Conclusions: The established models explain more variability for children above 17 months. Both renal lengths are affected significant by the body's' anthropometric parameters. For each kidney, separate normograms of renal lengths which are local-context-specific must be prepared. Further research must be promoted.

The objectives were to evaluate the workplace violence and risk for psychiatric morbidity, as well as their correlates, among health workers in a tertiary healthcare setting in Nigeria. A stratified random sampling technique was used to recruit the health workers. Each participant was administered a socio-demographic questionnaire, the ILO/ICN/WHO/PSI Workplace Violence Questionnaire and the 12- item General Health Questionnaire. A total of 380 health workers were recruited, with a mean age of 36.4 (±7.64) years. The prevalence rates of workplace violence and risk of psychiatric morbidity were 39.9% and 38.5%. Factors with independent associations with workplace violence included young age, female sex and worry about workplace violence while a widowed, separated or divorced marital status and being victim of workplace violence independently increased risk for developing psychiatric morbidity. This study therefore showed that workplace violence is common in the health care setting, and significant proportion of workers are at risk for developing psychiatric morbidity. These observations suggest need for the regular mental health screening of health workers, as well as the need for programmes aimed at preventing workplace violence in this setting., (Copyright © 2019. Published by Elsevier B.V.)

Background: Illness perception is significantly related to several outcome measures in different medical conditions. However, little is known about headache-related causal attributions and cognitive and emotional representations in patients with migraine., Objective: To examine perceived causes of headache and demographic, clinical, and psychological correlates and predictors of illness perception in patients with migraine attending a tertiary care headache centre., Methods: A sample of 143 patients with migraine (85.3% women, mean age 44.0 ± 12.1 years) completed the Brief Illness Perception Questionnaire (Brief IPQ), the Symptom Questionnaire (SQ), and the Migraine Disability Assessment (MIDAS) Questionnaire. A set of demographic and clinical characteristics was also collected., Results: Stress, heredity, and nervousness were the most frequent perceived causes of headache. Female gender was significantly related to higher Brief IPQ "consequences" and "emotional response" scores. Increased psychological distress and a poorer clinical course were significantly associated with more negative illness representations. In multiple regression analysis, a longer illness duration, increased depressive symptoms, and higher levels of headache-related disability and painfulness of headache attacks independently predicted a worse illness perception., Conclusions: In patients with migraine, depressive symptoms and a worse disease status, characterized by a longer history of suffering, higher disability and more painful headache attacks, may negatively affect illness perception. It could also be that dysfunctional illness representations lead to depressive symptoms and decrease patients' motivation to adhere to treatments, resulting in a worse outcome. Future studies should examine whether the improvement of illness perception through specific psychological interventions may promote a better adaptation to migraine., (Copyright © 2018 Elsevier Inc. All rights reserved.)

Objectives: To examine the effects of a 6-month nurse case manager (NCM) intervention compared to standard care (SC) on glycemic control and diabetes distress in a Canadian tertiary-care setting., Methods: We recruited 140 adults with type 2 diabetes and glycated hemoglobin (A1C) levels >8% (64 mmol/mol) from 2 tertiary care facilities and randomized them to: 1) a 6-month NCM intervention in addition to SC or 2) SC by the primary endocrinologists. Assessments were conducted at baseline and at 6 months. Primary outcomes included A1C levels and diabetes distress scores (DDS). Secondary outcomes included body mass index, blood pressure, diabetes-related behaviour measures, depressive symptoms, self-motivation and perception of support., Results: At the 6-month follow up, the NCM group experienced larger reductions in A1C levels of -0.73% compared to the SC group (p=0.027; n=134). The NCM group also showed an additional reduction of -0.40 (26% reduction) in DDS compared to those in the SC group (p=0.001; n=134). The NCM group had lower blood pressure, ate more fruit and vegetables, exercised more, checked their feet more frequently, were more motivated, were less depressed and perceived more support. There were no changes and no group differences in terms of body mass index, medication compliance or frequency of testing., Conclusions: Compared to SC, NCM intervention was more effective in improving glycemic control and reducing diabetes distress. It is, therefore, a viable adjunct to standard diabetes care in the tertiary care setting, particularly for patients at high risk and with poor control., (Copyright © 2017 Diabetes Canada. Published by Elsevier Inc. All rights reserved.)

Myasthenia gravis (MG) requires lifelong treatment. The cost of management MG is very high in developed countries but there is no information on the cost of management of MG in the developing countries. This study reports the direct and indirect cost and predictors of cost of MG in a tertiary care teaching hospital in India. In a prospective hospital based study, from a tertiary hospital in India 66 consecutive patient during 2014-2015 were included. The age of the patients ranged between 6 and 75years. The severity of MG was assessed by myasthenia gravis foundation association (MGFA) class (MGFA) I-V. The patient data was collected s and their direct cost was calculated from the computerized Hospital information system. The indirect cost was calculated from patient's memory, checking the bills of transportation and wages loss by the patient or the care giver. Total annual cost of MG ranged between INR (4560-532227) with median INR 61390.5 (US$911.64). The median cost of outpatient department (OPD) consultation of 16 patients was INR 20439.9 (US$303.53), of 50 admitted patients was INR 44311.8 (US$658.03) and 21 intensive care unit (ICU) patients was INR 59574.3 (US$ 884.6) and the direct cost of thymectomy was INR 45000 (US$ 668.25). Direct cost was related to indirect cost (r=0.55; p=0.0001). Predictors of patient outcome were severity of MG, ICU admission, and thymectomy. The total median cost for management of myasthenia gravis was INR 61390.5 (4560-532227, US$911.64) per year, and the cost was mainly determined by the severity of MG., (Copyright © 2016 Elsevier Ltd. All rights reserved.)

Objective: Patients with vascular disease often have multisystem atherosclerosis and multiple comorbidities requiring comprehensive interdisciplinary specialty care. Consultation is a critical component of a tertiary vascular surgery practice, but analysis of this service is under-reported in the literature. After-hours inpatient consultations and interhospital transfers are associated with urgent patient care., Methods: A retrospective analysis of vascular surgery consultations was carried out from January 1, 2013, to December 31, 2013. Consultations included inpatient services, the emergency department, surgical and medical intensive care unit, and interhospital transfers. Data analysis included number of consults, time of consultation (during hours, 0700-1859; after hours, 1900-0659), referring service, nature, and outcome of consultation. Consultations were then classified as urgent if vascular surgical intervention was required as an intraoperative consultation, within 24 hours, or during the same hospitalization. Patients without a same-hospital vascular surgical intervention were classified as nonurgent., Results: During a 1-year period, 823 independent consult requests of 749 patients were analyzed. It was found that 57.8% of after-hours consults resulted in urgent patient care (P = .003); 29.7% of medicine, 33.3% of medical intensive care unit, 41.9% of trauma surgery, and 60% of emergency department after-hours consultations were urgent; 73% of surgery and 79.2% of interhospital after-hours consults required urgent vascular surgical intervention. Extremity ischemia, aortic disease, and iatrogenic consults accounted for 44.8%, 20.4%, and 11.1% of after-hours consults, with 57.9%, 56.4%, and 70% requiring urgent vascular surgical intervention, respectively., Conclusions: After-hours consultations are not always associated with an urgent vascular surgical intervention. Nonurgent after-hours consultations are requested more frequently from some services and may present an opportunity for education that could improve workflow of the vascular workforce., (Published by Elsevier Inc.)

Purpose: To examine the use of peripherally inserted central catheters (PICCs) in a tertiary care pediatric setting., Materials and Methods: An observational study of use and referral practices for PICCs in a tertiary care pediatric setting was performed with three distinct approaches: (i) in an institutional overview of trends, data from 2001 to 2012 were initially analyzed to identify high-level trends; (ii) an in-depth analysis of PICC referrals during 1 year was performed to determine details of referral patterns and clinical practices; and (iii) an electronic survey of the perception and understanding of referring clinical staff was conducted., Results: During the past decade, there has been a steady increase in the number of PICC insertions and a decrease in median PICC dwell times. Discrepancies were identified between the anticipated versus actual dwell times. A large proportion of patients was found to have multiple PICC insertions, short dwell times, and premature PICC removals, potentially resulting in increasing risks of short- and long-term complications. Large percentages of the staff respondents valued the role of PICCs and had a good understanding of short-term complications, but underestimated the scale of the PICC service (numbers placed, resources involved) and several long-term complications associated with PICCs., Conclusions: The number of PICCs inserted in children is increasing while PICC dwell times are decreasing. Better postprocedure care is important to minimize premature removals and avoid repeat insertions. Associated complications are not fully appreciated by the referring pediatricians. Further education and guidelines are needed., (Copyright © 2013 SIR. Published by Elsevier Inc. All rights reserved.)

Background: Worldwide the proportion of elderly people in the population is increasing. Currently in Pakistan 7.3 million people (5.6% of total population) are more than 60 years old. This age shift has emerged as an important health issue and is associated with an increased utilization of emergency services by the elderly. We carried out this study to assess the pattern of elderly patients (>60 years) who visit emergency departments in comparison to young adults (18-60 years)., Methods: Data was collected retrospectively of patients aged 18 years or more who visited the Emergency Department (ED) of Aga Khan University Hospital, Karachi (AKUH) during September, 2009 to September, 2011. The data collection sheet included patient's demographic information, triage category, reason for visit, clinical presentation, ED length of stay, day and time of presentation and their disposition. Data was entered and analyzed using SPSS version 19.0. Descriptive statistics were used to describe patient's demographics. Chi-square (χ²) test was used as a test of significance to compare differences between groups for categorical data and t-test for continuous data. Multiple logistic regression analysis was done to find out the association between the patient characteristics and outcomes (admission and expiry)., Results: Almost 24% (n = 13014) of all adults (n = 54588) presenting to the ED were over the age of 60 years. More than 57% of elderly patients belonged to the high priority triage category compared to 35% in younger patients. Most of the elderly patients ( 27%) presented with nonspecific complaints followed by shortness of breath (13%) and fever (9%). The median length of stay (LOS) in the ED for elderly was 379 minutes (252 min in under-60 yrs patients) and they were more likely to get admitted to in-patient departments compared to younger patients (OR 1.7 95% CI 1.6-1.8). A high proportion of those admitted (20%) required intensive or special care. Mortality in elderly patients was 2.3% as compared to 0.7% in young adults. This was accompanied by a higher mortality risk in the elderly with an odds ratio of 2.3 (CI 2-2.5)., Conclusion: Elderly ED users differ significantly from younger adults in terms of criticality on presentation, ED LOS and final disposition.

Introduction: We set a goal to reduce the incidence rate of catheter-related bloodstream infections to rate of <1 per 1,000 central line days in a two-year period., Methods: This is an observational cohort study with historical controls in a 25-bed intensive care unit at a tertiary academic hospital. All patients admitted to the unit from January 2008 to December 2011 (31,931 patient days) were included. A multidisciplinary team consisting of hospital epidemiologist/infectious diseases physician, infection preventionist, unit physician and nursing leadership was convened. Interventions included: central line insertion checklist, demonstration of competencies for line maintenance and access, daily line necessity checklist, and quality rounds by nursing leadership, heightened staff accountability, follow-up surveillance by epidemiology with timely unit feedback and case reviews, and identification of noncompliance with evidence-based guidelines. Molecular epidemiologic investigation of a cluster of vancomycin-resistant Enterococcus faecium (VRE) was undertaken resulting in staff education for proper acquisition of blood cultures, environmental decontamination and daily chlorhexidine gluconate (CHG) bathing for patients., Results: Center for Disease Control/National Health Safety Network (CDC/NHSN) definition was used to measure central line-associated bloodstream infection (CLA-BSI) rates during the following time periods: baseline (January 2008 to December 2009), intervention year (IY) 1 (January to December 2010), and IY 2 (January to December 2011). Infection rates were as follows: baseline: 2.65 infections per 1,000 catheter days; IY1: 1.97 per 1,000 catheter days; the incidence rate ratio (IRR) was 0.74 (95% CI=0.37 to 1.65, P=0.398); residual seven CLA-BSIs during IY1 were VRE faecium blood cultures positive from central line alone in the setting of findings explicable by noninfectious conditions. Following staff education, environmental decontamination and CHG bathing (IY2): 0.53 per 1,000 catheter days; the IRR was 0.20 (95% CI=0.06 to 0.65, P=0.008) with 80% reduction compared to the baseline. Over the two-year intervention period, the overall rate decreased by 53% to 1.24 per 1,000 catheter-days (IRR of 0.47 (95% CI=0.25 to 0.88, P=0.019) with zero CLA-BSI for a total of 15 months., Conclusions: Residual CLA-BSIs, despite strict adherence to central line bundle, may be related to blood culture contamination categorized as CLA-BSIs per CDC/NHSN definition. Efforts to reduce residual CLA-BSIs require a strategic multidisciplinary team approach focused on epidemiologic investigations of practitioner- or unit-specific etiologies.

Health reform worldwide is required due to the largely aging population, increase in chronic diseases, and rising costs. To meet these needs, nurses are being encouraged to practice to the full extent of their skills and take significant leadership roles in health policy, planning, and provision. This can involve entrepreneurial or intrapreneurial roles. Although nurses form the largest group of health professionals, they are frequently restricted in their scope of practice. Nurses can help to improve health services in a cost effective way, but to do so, they must be seen as equal partners in health service provision. This article provides a global perspective on evolving nursing roles for innovation in health care. A historical overview of entrepreneurship and intrapreneurship is offered. Included also is discussion of a social entrepreneurship approach for nursing, settings for nurse entre/intrapreneurship, and implications for research and practice.

Background: Coronary artery disease is fast emerging as the major concern for afflicting people across the globe. The Indian subcontinent is highly predisposed to this condition due to distinctive risk factor profile of this population. This fact has led to a condition where the current preventative and management protocols that have worked well in the non-Asian Indian Caucasian populations, have failed to bring about the anticipated control over the incidence and progression of CAD in Asian Indians. Metabolic syndrome has been identified as a major determinant of CAD in this population., Materials and Methods: The prevalence of metabolic syndrome was determined in 431 patients undergoing coronary angiography through various diagnostic algorithms. The Asian modified diagnostic criteria were also implemented to estimate the metabolic syndrome prevalence in patients with different levels of stenosis., Results: We observed a high incidence of metabolic syndrome in the patients with coronary artery disease. The prevalence of MS increased with increase in severity of coronary artery involvement. The IDF guideline with Asian modification was the most successful diagnostic algorithm., Conclusions: It is now imperative to acknowledge the unique pattern of CAD and risk factor profile prevalent among South Asians. This will facilitate more focused and individualized management protocols directed to this population. Metabolic syndrome is a major syndrome prevalent in this population. Hence, effective control of MS may help in reducing the morbidity and mortality due to CAD in a great way., (Copyright © 2010 Diabetes India. All rights reserved.)