The effect of regional transmural agreements on the information transfer of frail older patients

INTRODUCTION

Frail older patients are at risk for many complications when admitted to the hospital. Multidisciplinary regional transmural agreements (RTA) in which guidelines were set concerning the information transfer of frail older patients might improve outcomes. We aim to investigate the effect of implementation of the RTA on the completeness of the information transfer of frail older patients when admitted to and discharged from the hospital.

METHODS

This is a retrospective cohort study in which we collected data from 400 randomly selected hospitalized frail older patients (70+) before the implementation of the RTA, January through March 2021, and after, October through December 2021. The cohort was split up into four groups, which determined what correspondence would be checked (referral letter by General Practitioner (GP) and three groups of 'hospital letters': ED letter upon admittance, clinical discharge letter to the elderly care physician and clinical discharge letter to the GP. We assessed for mention of frailty, a medication list and mention of resuscitation orders.

RESULTS

In the period before implementation the mean age of patients was 82.6 years (SD 7.4) and 101 were female (50.5%), after implementation mean age was 82.3 (SD 6.9) and 112 were female (56.0%). Frailty was mentioned in hospital letters in 12.7% before and 15.3% after implementation (p = 0.09). More GP referral letters were present after implementation (32.0% vs. 54.0%, p = 0.03), however frailty was mentioned only in 12.5% before and 7.4% after (p = 0.58). There was a good handover of medication lists from the hospital (89.3% before, 94% after, p = 0.20) and even better from the GP (93.8% before, 100% after, p = 0.19). Resuscitation orders were mentioned in 59.3% of letters from the hospital before implementation and 57.3% after (p = 0.77), which is higher than in the referral letters (18.8% before and 22.2% after (p = 0.91).

DISCUSSION

The implementation of RTA improved the number of GP referral letters present; however, it did not lead to other significant improvements in communication between the hospital and the GP's. Frailty and resuscitation orders are still frequently not mentioned in the reports. After a successful reimplementation, the improvements of outcomes could be investigated.

Advances in haemostatic sponges: Characteristics and the underlying mechanisms for rapid haemostasis

In traumatized patients, the primary cause of mortality is uncontrollable continuous bleeding and unexpected intraoperative bleeding which is likely to increase the risk of complications and surgical failure. High expansion sponges are effective clinical practice for the treatment of wound bleeding (irregular/deep/narrow) that are caused by capillaries, veins and even arterioles as they possess a high liquid absorption ratio so can absorb blood platelets easily in comparison with traditional haemostasis treatments, which involve compression, ligation, or electrical coagulation etc. When in contact with blood, haemostatic sponges can cause platelet adhesion, aggregation, and thrombosis, preventing blood from flowing out from wounds, triggering the release of coagulation factors, causing the blood to form a stable polymerized fibre protein, forming blood clots, and achieving the goal of wound bleeding control. Haemostatic sponges are found in a variety of shapes and sizes. The aim of this review is to facilitate an overview of recent research around haemostatic sponge materials, products, and technology. This paper reviews the synthesis, properties, and characteristics of haemostatic sponges, together with the haemostasis mechanisms of haemostatic sponges (composite materials), such as chitosan, cellulose, gelatin, starch, graphene oxide, hyaluronic acid, alginate, polyethylene glycol, silk fibroin, synthetic polymers silver nanoparticles, zinc oxide nanoparticles, mesoporous silica nanoparticles, and silica nanoparticles. Also, this paper reviews commercial sponges and their properties. In addition to this, we discuss various in-vitro/in-vivo approaches for the evaluation of the effect of sponges on haemostasis.

Post-tonsillectomy Hemorrhage in Patients Receiving Ketorolac Analgesic

Background Ketorolac, the non-steroidal anti-inflammatory drug, is thought to have less sedation as well as postoperative nausea and vomiting in comparison to opioids, but with higher risk of post-tonsillectomy hemorrhage as reported in some of the literatures. There is no consensus till date in the use of ketorolac in the management of pain following tonsil and adenoid related surgeries. Objective To find out the incidence of hemorrhage following tonsil and adenoid related surgeries in patients receiving ketorolac in postoperative period. Method This is a retrospective chart review of patients undergoing tonsil and adenoid related surgeries who had received ketorolac during April, 2013 to May, 2019 at department of ENT-HNS, Patan Academy of Health Sciences (PAHS), Lalitpur, Nepal. Post-tonsillectomy hemorrhage rate was calculated in pediatric and adult patients. Result During the study period, 103 patients (male - 50 and female - 53) received ketorolac in postoperative period. Tonsillectomy and adenotonsillectomy were performed in 71and 32 patients respectively. Forty-five patients were < 18 years whereas 58 were ≥ 18 years. Most common indication for surgery was recurrent tonsillitis (66/103) followed by adenotonsillar hypertrophy (31/103). Post-tonsillectomy hemorrhage was observed in 15 patients; among them, four out 45 were < 18 years and 11 out of 58 ≥ 18 years. All five patients out of 15, who required surgical intervention for post-tonsillectomy hemorrhage, were ≥ 18 years and were operated for recurrent tonsillitis. Rest of the patients (10/15) were managed conservatively. None of the patients required blood transfusion. Conclusion Ketorolac is not associated with increased risk of post-tonsillectomy hemorrhage in children and can safely be administered. Whereas in adults, recurrent tonsillitis being the most common indication for tonsillectomy, it should be used cautiously.

Caffeic Acid Phenethyl Ester Effects: In Silico Study of its Osteoimmunological Mechanisms

Background:

Biological system complexity impedes the drug target identification by biological experiments. Thus drugs, rather than acting on target site only, can interact with the entire biological system. Study of this phenomenon, known as network pharmacology, provides grounds for biological target identification of new drugs or acts as a foundation for the discovery of new targets of present drugs. No publication is available on the interaction network of CAPE.

Aim:

This study was aimed at the investigation of the candidate targets and possible interactions of caffeic acid phenethyl ester (CAPE) involved in its osteoimmunological effects.

Methods:

This study encompasses the investigation of candidate targets and possible interactions of CAPE by analyzing through PASS Prediction and constructing a biological network of CAPE.

Results:

In response to input (CAPE), PASS Prediction generated a network of 1723 targets. While selecting the probability to be active (Pa) value greater than 0.7 brought forth only 27 targets for CAPE. Most of these targets predicted the therapeutic role of CAPE as an osteoimmunological agent. Apart from this, this network pharmacology also identified 10 potential anti-cancer targets for CAPE, out of which 7 targets have been used efficiently in developing potent osteoimmunological drugs.

Conclusion:

This study provides scientific prediction of the mechanisms involved in osteoimmunological effects of CAPE, presenting its promising use in the development of a natural therapeutic agent for the pharmaceutical industry. CAPE targets identified by web-based online databases and network pharmacology need additional in silico assessment such as docking and MD simulation studies and experimental verification to authenticate these results.

Graphene supported plasmonic photocatalyst for hydrogen evolution in photocatalytic water splitting

It is well known that the noble metal nanoparticles show active absorption in the visible region because of the existence of the unique feature known as surface plasmon resonance (SPR). Here we report the effect of plasmonic Au nanoparticles on the enhancement of the renewable hydrogen (H2) evolution through photocatalytic water splitting. The plasmonic Au/graphene/TiO2 photocatalyst was synthesized in two steps: first the graphene/TiO2 nanocomposites were developed by the hydrothermal decomposition process; then the Au was loaded by photodeposition. The plasmonic Au and the graphene as co-catalyst effectively prolong the recombination of the photogenerated charges. This plasmonic photocatalyst displayed enhanced photocatalytic H2 evolution for water splitting in the presence of methanol as a sacrificial reagent. The H2 evolution rate from the Au/graphene co-catalyst was about 9 times higher than that of a pure graphene catalyst. The optimal graphene content was found to be 1.0 wt %, giving a H2 evolution of 1.34 mmol (i.e., 26 μmolh(-1)), which exceeded the value of 0.56 mmol (i.e., 112 μmolh(-1)) observed in pure TiO2. This high photocatalytic H2 evolution activity results from the deposition of TiO2 on graphene sheets, which act as an electron acceptors to efficiently separate the photogenerated charge carriers. However, the Au loading enhanced the H2 evolution dramatically and achieved a maximum value of 12 mmol (i.e., 2.4 mmolh(-1)) with optimal loading of 2.0 wt% Au on graphene/TiO2 composites. The enhancement of H2 evolution in the presence of Au results from the SPR effect induced by visible light irradiation, which boosts the energy intensity of the trapped electron as well as active sites for photocatalytic activity.

Benign sinonasal masses: a clinicopathological and radiological profile

BACKGROUND

Benign nasal and paranasal sinus masses are commonly encountered in clinical practice. Though benign, certain nasal polyps, fungal sinusitis, hemangiomas and fibro-osseous tumors can present with locally destructive features and deformities, mimicking malignancies at once.

OBJECTIVE

This study was carried out to recognize the great variety of benign nasal lesions and their frequency in our region.

METHODS

A retrospective chart analysis of cases presenting as mass in nose and paranasal sinus that underwent surgery over three years duration at our institute was done. A provisional diagnosis was made after clinical assessment and radiological investigations, but the final diagnosis was established after histopathological examination.

RESULTS

A total 331 cases presented as masses in nose and paranasal sinus presented during the period. The clinicopathological examination aided by endoscopic and imaging studies revealed the non neoplastic benign masses in 293 and neoplastic masses in 38. Polyps were the commonest lesions constituting 70% cases followed by rhinosporidiosis in 10%. Fungal sinusitis, squamous papillomas, hemangiomas and inverted papillomas were found to be in order of 4.5%, 4%, 3.5% and 3% respectively. Rare cases like "rhinooto- cereberal" form of mucormycosis, angiomyoma, and psammomatoid ossifying fibroma were also observed in the study.

CONCLUSION

Most of the nasal polyps/fungal sinusitis can be diagnosed clinically. However many a times Computer tomography (CT) scan and biopsy are necessary to differentiate them from each other and treatment plan. Certain benign tumors have high potential for malignant transformation while others can present with locally destructive features and deformities.

A single blind controlled study comparing bipolar elecrocautery tonsillectomy to cold dissection method in pediatric age groups

Background: Tonsillectomy is one of the most commonly performed operations in otolaryngology. There are many proven methods of tonsillectomy, including cold dissection and bipolar electrocautery. Objective: To compare bipolar elecrocautery tonsillectomy with cold dissection method in pediatric age groups. Methods: Single blind controlled study to compare bipolar technique against the conventional dissection/snare technique. Results: The average amount of bleeding on electrocautery side was 4.07ml and on the cold dissection side was 14.58 ml. The mean time of operation for electrocautery and cold dissection was 12.04 and 16.57 minutes respectively. On the second post operative day, 35% of the patients complained of pain on the cauterized side, 30% complained of more pain on the dissection side while 35 % experienced equal pain on both sides. Post-operative complication such as hemorrhage was not seen in both the techniques employed. Conclusion: In the present study, bipolar diathermy tonsillectomy had advantages in having less post-operative time and blood loss intraoperatively but patients experience slightly more pain than cold dissection. DOI: http://dx.doi.org/10.3126/hren.v11i3.9651 Health Renaissance 2013;11(3):270-272

Pattern of head and neck malignancies in eastern part of Nepal

The term head and neck refers to the upper aerodigestive tract, the salivary glands, the thyroid, parathyroid glands, the sino-nasal tract and the skin of the head and neck region. Malignancies at these sites are important due to the divergence in their behaviors and prognosis. A retrospective, cross sectional, series of cases were studied to determine the pattern of head and neck malignancies in our department from January, 2005 to July, 2006. A total of 90 cases of head and neck malignancies proven on histopathology were studied. Pharynx 25 (27.78%) was the commonest site involved by cancer. In the pharynx, malignancies at the nasopharyngeal region contributed to the bulk of the tumor constituting 12 (48.00%). Histopathologically, squamous cell carcinoma was seen in 61, (67.77%) subjects. Most of the patients presented in IIIrd or IVth stage of disease. The commonest treatment strategy adopted was surgery with post operative radiotherapy. Nasopharyngeal carcinoma is a major concern in this part of the region.

Identification of Leptosphaeria maculans Pathogenicity Group 4 Causing Blackleg on Winter Canola in Oklahoma

Winter canola (Brassica napus L.) is a relatively new crop to Oklahoma and other southern U.S. states where it is considered a desirable rotation crop with wheat. In 2009, approximately 15,000 ha of winter canola were harvested in Oklahoma (3); that area is expected to almost double in 2010. Blackleg, a potentially devastating canola disease, was detected in Oklahoma in 2009. Blackleg is caused by Leptosphaeria maculans (Desmaz.) Ces. & de Not (anamorph = Phoma lingam (Tode:Fr.) Desmaz.). In early 2010, leaf samples showing typical symptoms of blackleg were collected from four canola fields near the town of Enid in Garfield County, OK. Small portions of infected tissues were surface disinfested in an aqueous solution of NaOCl (0.5% a.i.) for 1 min, rinsed twice in sterile distilled water, and plated on V8 medium. Seven colonies were isolated and when grown in pure culture, all produced 2 × 4.5 μm guttulate, unicellular, hyaline spores in pycnidia that ranged from 200 to 480 μm in diameter. These morphological characteristics correspond with those of P. lingam (1). To verify the pathogenic nature of the isolates and establish the pathogenicity group (PG) to which they belong, a standard inoculation protocol was followed on a set of three differential cultivars, Quinta, Glacier, and Westar (2). Briefly, for each isolate, tiny puncture wounds were made with sterile needles on the cotyledons of six 10-day-old plants of each differential and a 10-μl aliquot of a pycnidiospore suspension (1 × 10⁷ spores ml^-1) was deposited on the wounds. Also, a set of differentials were inoculated with distilled water (mock inoculation). Inoculated plants were incubated overnight in a misting chamber at 21°C in the dark and returned the next day to the greenhouse. Disease severity was recorded 10 days after inoculation using a 0 to 9 scale in which 0 to 2 = resistant, 3 to 6 = intermediate, and 7 to 9 = susceptible. This process was repeated three times. Two of the seven isolates evaluated were highly virulent on all three differentials, an indication they belong to pathogenicity group 4 (2). The other five isolates produced small lesions on Westar (resistant reaction) but failed to develop symptoms on the other two differentials. This phenotypic reaction has been associated with strains of PG-1. Mock-inoculated plants did not develop lesions. To our knowledge, this is the first time blackleg isolates from Oklahoma have been identified to the PG level. While this information will assist breeders in the development of both spring and winter canola lines with resistance to blackleg, additional studies are necessary to determine the relative prevalence and diversity of the various PG in Oklahoma. References: (1) G. H. Boerema. Trans. Br. Mycol. Soc. 67:289, 1976. (2) A. Mengistu et al. Plant Dis. 75:1279, 1991. (3) USDA. National Agricultural Statistics Service. Retrieved from http://www.nass.usda.gov/Statistics_by_State/Ag_Overview/ AgOverview_OK.pdf , September 20, 2010.

Primary salivary gland tumors in eastern Nepal tertiary care hospital

BACKGROUND

The knowledge of the distribution and pattern of salivary gland tumors in the tertiary care center can provide overview of the disease pattern in the region. It also helps in planning the strategies to treat the disease and launch the awareness program in the community to this largely curable disease.

METHODS

A retrospective observational study of all the salivary gland tumors treated in the department of Otolaryngology, B. P. Koirala Institute of Health Sciences during April 2004 to March 2009 was done. Age, sex, presenting features, radiological findings, histopathological type of the tumor and type of surgery were recorded and descriptive analysis was done to calculate frequencies, percentage and their relations.

RESULTS

Out of total 51 cases, 81% (n=41) were benign and 19% (n=10) malignant tumors. Male to female ratio was 1:2.1. Mean age for benign and malignant tumors were 32.3 and 46.5 years respectively. Parotid tumor outnumbered all other sites comprising 69%, followed by submandiibular 18% and minor glands 13%. Pleomorphic adenoma was the commonest tumor (76%) of all primary salivary gland tumors. Benign to malignant tumor ratio of parotid, submandibular and minor glands were 6:1, 3.5:1 and 1.3:1 respectively. Adenoid cystic carcinoma (40%) and mucoepidermoid carcinoma (30%) were commonest malignant tumors.

CONCLUSIONS

The principal site for salivary gland tumors in eastern Nepal population was the parotid and the pleomorphic adenoma outnumbered all other tumors. Most of the cases in both benign and malignant group presented with painless lump often misleading the gravity of disease.

Penetrating neck injury by an arrow: a paradigm of age old assault

Penetrating neck injuries by traditional weapons are rare entity in the modern era of sophisticated weapons. We report an unusual case of penetrating neck injury by a metallic arrow entering anterior neck in zone II and its tip coming out of neck posteriorly causing difficulty for patient to lie down as well as posing challenge to intubate. Arrows are low velocity projectile and from a close proximity they can cause penetrating trauma similar to a low powered handgun. Management of the case was discussed.

Eccrine poroma in neck of a child--a rare presentation

An eccrine poroma is a common benign tumour arising from the eccrine sweat gland duct epithelium in the dermo-epidermal region. Its occurrence in the neck region in pediatric age group is a rare entity. Here we report a case of an eccrine poroma in the retro-auricular area just below and behind the lobule of the left pinna in a nine years old child.

The morphology of central tympanic membrane perforations

The objective of this study was to assess the extent of conductive hearing loss in relation to different sizes and sites of simple central tympanic membrane perforations. Total 100 cases attending ENT OPD, BPKIHS during period of April 2003 to Mar 2004 without any discrimination of sex, race and religion were taken for the cross sectional prospective study. Dry, clean central tympanic membrane perforations due to various causes like chronic suppurative otitis media-tubotympanic, post acute suppurative otitis media residual perforations or simple traumatic perforations with conductive hearing loss and without preexisting hearing loss were clinicoaudiologically evaluated and analyzed. Hearing loss was found to be directly proportional to the size of perforation irrespective of their cause, which was statistically significant. Hearing loss in the study was found to range from negligible to 53dB. Overall, perforations involving posterioinferior quadrant were found to have maximum hearing loss.