Appropriateness of troponin testing in emergency department at a tertiary care hospital in Saudi Arabia

Objectives:To assess the appropriateness of troponin testing in the Emergency Department (ED) at King Saud Medical City, Riyadh, Saudi Arabia.Methods:This record-based cross-sectional study examined the electronic records of adult patients who underwent a troponin test following admission to hospital’s ED from January to March 2020.Results:A total of 367 troponin tests were ordered for 233 patients. Majority of these orders were appropriate (55%) while the remaining (45%) were adjudged as inappropriate. Among the inappropriate orders, majority were single (61%) compared to serial ones (39%). Overall, there were 166 inappropriate orders and the estimated direct monthly cost for inappropriate testing was 49,800 Saudi Riyals in the emergency department alone.Conclusion:Approximately half of the troponin tests ordered in the ED were inappropriate. The overall financial burden of inappropriate testing greatly impacts patient management and resource utilization. These findings emphasize the pressing need for institutional clinical guidelines to guide appropriate use of troponin testing.     

Childhood autoimmune hepatitis in a paediatric unit of a tertiary care hospital

INTRODUCTION

Although childhood autoimmune hepatitis (AIH) has been extensively investigated in the West, data on AIH in the East is lacking. We aimed to investigate AIH’s clinical, biochemical and histological features, as well as its outcomes, in one of Singapore’s two major paediatric units.

METHODS

This was a retrospective study of children diagnosed with AIH in the paediatric unit of National University Hospital, Singapore, over the last 12 years. Children with de novo AIH after liver transplantation were excluded. The demographic and clinical features of the patients, and their laboratory, treatment and clinical outcomes were reviewed.

RESULTS

This study comprised ten patients (six females, four males), with a median age of 5.1 (range 2.1–13.8) years at diagnosis. Five patients had inflammatory bowel disease (IBD). Seven patients had type 1 AIH, and three had autoimmune sclerosing cholangitis (ASC) and IBD; none had type 2 AIH. The median level of aspartate aminotransferase at diagnosis was 183 (range 45–2,649) U/L. Prednisolone 1 mg/kg/day was prescribed at diagnosis for eight patients. Two patients were lost to follow-up and were treated symptomatically when they re-presented with end-stage liver disease. Azathioprine or mycophenolate mofetil was prescribed after 3–7 months of treatment. Normalisation of aminotransferase levels took an average of 5.3 (range 1–39) months.

CONCLUSION

AIH is a rare but important cause of liver pathology. Children in this region with elevated aminotransferases or unexplained hepatomegaly should be screened for AIH.     

Analysis of blood tests in the emergency department of a tertiary care hospital

There is ample evidence that many investigations sent from the accident and emergency department are inappropriate, thus affecting the quality of patient care. A study was designed to address this issue in the emergency department of a tertiary care hospital of a large city. A prospective cross-sectional study was carried out during the 3-month period 1 December 1996 to 28 February 1997. A set of guidelines was used to assess the appropriateness of different blood tests for the initial assessment of the patients presenting with common clinical conditions, although any investigation could be done if considered important for patient management. All other blood tests were considered inappropriate. A total of 6401 patients were seen in the emergency department and 14,300 blood tests were done on 3529 patients with diagnoses covered by the guidelines. Of these 62.2% were found to be inappropriate. Of the total 22,655 investigations done on all the 6401 patients seen, only 3.8% influenced the diagnosis, 3.0% influenced patient care in the emergency department, and 4.0% influenced the decision to admit or not. Amylase and arterial blood gases were found to be the most appropriate investigations. Analysis of reasons for unnecessary use of emergency tests suggested that improving supervision, decreasing the utilization of the emergency department as a phlebotomy service for the hospital, and abolition of routine blood tests would help to improve patient care.     

三级医院急诊医生胜任素质模型研究

以急诊医生为研究对象,基于胜任素质理论,运用德尔菲法、行为事件访谈法及问卷调查等研究方法,通过规范的建模步骤开发三级医院急诊医生胜任素质模型。指出该模型包括13项基准胜任素质和7项鉴别胜任素质,并从基于该模型的急诊医生的甄选、培训与开发、绩效管理等方面探讨了其在人力资源管理中的可能运用。     

A preliminary study on neonatal septicaemia in a tertiary referral hospital paediatric unit

OBJECTIVE: To estimate the incidence of neonatal septicaemia, and to identify risk factors, clinical presentations and causal organisms. DESIGN: A cross-sectional study. SETTING: Neonatal Care Unit, University Paediatric Unit, Colombo North Teaching Hospital. SUBJECTS: Neonates admitted from January to December 1996 with clinical evidence of septicaemia. METHOD: Gestational age, birth weight and mode of delivery were evaluated as risk factors for septicaemia. Although diagnosis of septicaemia was made on clinical grounds, blood cultures were performed in all babies. Data was analysed by using Epi Info version 6. RESULTS: 98 babies had septicaemia. Incidence of septicaemia was 24.4 per 1000 live births and case fatality rate was 11.2%. Incidence was significantly higher in preterm babies, babies with low birth weight (LBW) and those born following instrumental delivery. 21.4% developed septicaemia on the first day of life, 74.5% between 2 and 7 days and 4.1% after the first week. Common presenting features were fever 61.2%, jaundice 52%, lethargy 37.8% refusal of feeds 25.5%, coffee grounds vomiting 22.4%, and fits 12.2%. Common bacteria identified were Klebsiella 26.5%, Staphylococcus aureus 15.3%, coliform bacilli 9.2% and spore forming bacilli 9.2%. Common sensitive antibiotics were amikacin 88.9%, amoxycillin + clavulanic acid 83%, ceftriaxone 78.1% and netilmicin 63.9%. CONCLUSIONS: Septicaemia is an important cause of morbidity, particularly in preterm babies, in babies with LBW and those with instrumentation at birth. The high incidence of late onset septicaemia together with the findings of Klebsiella and Staphylococcus aureus as common and resistant pathogens for septicaemia indicate that the majority were nosocomial infections.     

单中心10年急诊死亡患儿临床研究

目的 分析急诊死亡患儿的流行病学特点,了解引起儿童急诊死亡的主要疾病谱及其变化趋势.方法 回顾性分析2005-2014年重庆医科大学附属儿童医院1 115例急诊死亡病例资料,在城乡分布、年龄、性别、入院死亡时间、死亡地点、季节及原发疾病等方面进行统计分析.结果 急诊死亡患儿男女比例为157:100,农村患儿明显多于城市患儿(城乡比例为1:2.64).到院前死亡(death on arrival,DOA)占8.07％.新生儿死亡占37.49％,婴儿占26.10％,≤1岁死亡患儿高达63.59％,是急诊死亡患儿的主要年龄层.急诊死亡患儿以每年1月为高发季节(占13.63％).急诊死亡前5位疾病分别为肺炎(14.71％)、先天性心脏病(10.40％)、呼吸窘迫综合征(9.24％)、意外伤害(8.70％)和窒息(误吸)(5.11％).因此呼吸系统疾病占急诊死亡病例的23.95％.近年因意外伤害、手足口病死亡的患儿呈上升趋势.结论 1岁以内患儿是小儿急诊死亡的高危人群,呼吸系统疾病是患儿急诊死亡的主要病因.     

三级综合医院门急诊开展岗位培训实践探讨

首都医科大学宣武医院将岗位培训列入日常管理工作,每年定期组织岗位培训,通过模拟演练和督导检查反馈培训效果。实践证明,岗位培训在门急诊管理中发挥着重要作用,严格依法依规执业,保障患者安全,优化服务流程,及时应对门急诊突发事件,有效防控重大传染病疫情,不断提高服务水平。岗位培训是门急诊管理的重要手段,是患者安全的重要保障,是提高专业技能和服务水平的重要措施。     

Utility of multiplex real-time PCR for diagnosing paediatric acute respiratory tract infection in a tertiary care hospital

BackgroundAcute respiratory infections (ARIs) are responsible for considerable morbidity and mortality among children all over the world. Many of the etiologic agents of the infections especially viral go undiagnosed for lack of requisite facility and the cost factors. We have used a commercially available platform for diagnosis of ARIs in children receiving inpatient and outpatient services in a tertiary care centre.MethodsThe framework of the study was prospective and observational. In this study, clinical samples of children suffering from ARIs were subjected to real-time multiplex PCR targeting both viral and bacterial pathogens.ResultsOf 94 samples received at our centre (49 male and 45 female), the positivity for respiratory pathogens was detected in 50 (53.19%) samples. Clinical symptoms of patients and age distribution have been elaborated in text. A single pathogen (n = 29/50), two pathogens (15/50) and three pathogens (n = 6/50) were detected by multiplex RT-PCR. Of 77 isolates detected, maximum numbers were of human rhinovirus (HRV) (n = 14) (18.18%) Streptococcus pneumoniae (n = 14) (18.18%) followed by Staphylococcus aureus (n = 10) (12.98%).ConclusionThe epidemiology of ARIs considering viral etiologies is poorly understood due to less number of studies especially in Indian subcontinent. The advent of latest advanced molecular methods has made it possible to identify common respiratory pathogens and has contributed to cover the gap in existing knowledge.     

Acute kidney injury in the pediatric intensive care unit at a tertiary care hospital of the Armed Forces: a cross-sectional observational study

BackgroundAcute kidney injury (AKI) is shown to be the commonest complication in critically ill children admitted to the pediatric intensive care unit (PICU). Kidney Disease: Improving Global Outcomes (KDIGO) classification and definition are now used universally. We undertook prospective observational study to study the etiology and maximum stage of AKI as defined by KDIGO and its complications and outcomes.MethodsAll children admitted to the PICU were included in the study. The diagnosis of sepsis and multiorgan dysfunction syndrome (MODS) was made according to the standard international guidelines. The patients were followed up till discharge/death. All children were screened for AKI at admission and subsequently using serum creatinine measured by modified Jaffe's method and urine output measurement.ResultsA total of 197 children were admitted to the PICU. 38 (19.28%) developed AKI, and 6 (15.78%) developed stage III AKI. Malignancies, serious neurological and renal disorders, and postsurgery complications accounted for most of the cases with AKI. Six were admitted with primary renal condition. Sepsis with or without MODS was seen in 12 patients with AKI and in 8 without AKI. Twenty-one children with AKI and 3 children without AKI were exposed to nephrotoxic drugs. Twenty-three children with AKI required inotropic support. The average length of stay (ALOS) of children with AKI in the PICU was 9.86 days, whereas ALOS of children without AKI was 6.23 days. Eighteen children with AKI (47.36%) and 36 (21.38%) with no AKI died.ConclusionsAKI in children in the PICUs of referral hospitals in the armed forces have varied etiologies and presentations. These children require early identification and management with close monitoring to prevent long-term renal morbidity and mortality.     

急诊抢救室患者滞留时间影响因素的回归分析

目的：探讨急诊抢救室患者滞留时间的影响因素,为加快急诊患者分流,提高急诊服务质量提供科学依据。方法回顾性分析急诊抢救室患者4870例的信息,通过二分类Logistic单因素和多因素回归分析滞留时间的影响因素。结果影响急诊抢救室患者滞留时间＞6h的因素有就诊时间段、涉及多科室、治疗依从性、病情、费用支付方式、节假日就诊、年龄、就诊月份。而患者的性别、主诊科室、离抢去向、涉及交通事故、诊断个数、救护车送入、陪人不是影响患者滞留时间＞6h的因素。结论该家医院急诊抢救室部分患者滞留时间偏长,主要受就诊时间段、涉及多科室、治疗依从性、病情、费用支付方式等因素影响,值得重视。     

Second malignant neoplasms in childhood cancer survivors in a tertiary paediatric oncology centre in Hong Kong, China

Background  Childhood cancer survivors were at risk of development of second malignant neoplasms. The aim of this study is to evaluate the incidence, risk factors and outcome of second malignant neoplasms in childhood cancer survivors in a tertiary paediatric oncology centre in Hong Kong, China.

Methods  We performed a retrospective review of patients with childhood cancer treated in Children’s Cancer Centre in Prince of Wales Hospital, Hong Kong, China between May 1984 and June 2009. Case records of patients who developed second malignant neoplasms were reviewed. 

Results  Totally 1374 new cases aged less than 21-year old were treated in our centre in this 25-year study period.  Twelve cases developed second malignant neoplasms with 10-year and 20-year cumulative incidence of 1.3% (95% confidence interval 0.3%–2.3%) and 2.9% (95% confidence interval 1.1%–4.7%) respectively. Another 4 cases were referred to us from other centres for the management of second malignant neoplasms. In this cohort of 16 children with second malignant neoplasms, the most frequent second malignant neoplasms were acute leukemia or myelodysplastic syndrome (n=6) and central nervous system tumor (n=4). Median interval between diagnosis of primary and second malignant neoplasms was 7.4 years (range 2.1–13.3 years). Eight patients developed second solid tumor within the previous irradiated field. Radiotherapy significantly increased the risk of development of second solid tumor in patients with acute lymphoblastic leukemia (P=0.027). Seven out of 16 patients who developed second malignant neoplasms had a family history of cancer among the first or second-degree relatives. Nine patients died of progression of second malignant neoplasms, mainly resulted from second central nervous system tumor and osteosarcoma. 

Conclusions  Cumulative incidence of second cancer in our centre was comparable to western countries. Radiotherapy was associated with second solid tumour among patients with acute lymphoblastic leukemia. Patients who developed second brain tumor and osteosarcoma had a poor outcome.  

     

A retrospective review of trampoline-related injuries presenting to a paediatric emergency department in Singapore

INTRODUCTIONTrampolining is a popular activity. However, to our knowledge, no studies on paediatric trampoline-related injuries (TRIs) have been conducted in Asia. We aimed to provide an Asian perspective on paediatric TRIs and evaluate current safety measures.METHODSPatients aged under 16 years who presented to the emergency department at KK Women’s and Children’s Hospital, Singapore, from March 2012 to June 2016 with a TRI were identified from the National Trauma Registry. Data was collated retrospectively focusing on age, location of the trampoline, mechanism and location of injury, treatment, disposition, and follow-up treatment.RESULTS137 children were seen for a TRI during this period. There was even representation across age groups (< 6 years, 6–11 years and 11–16 years). 60.6% of these injuries occurred in a public trampoline park, and a smaller proportion involved home and school trampolines. 61.3% of injuries occurred on the trampoline and 25.5% involved a fall off it, while the remaining were incurred by hitting the trampoline frame. The most common injury was soft tissue injury, followed by fractures and dislocations, of which 16.7% required surgical intervention. Most patients were discharged to an outpatient clinic. 14.6% of all patients required admission and 9.5% eventually required surgical intervention. There were three stable head injuries and no cervical spine injuries or deaths.CONCLUSIONThe existence of trampoline parks has contributed to a rise in TRIs. We recommend measures such as general education, changes in the setup around the trampoline, increasing the age limit for trampolining, adult supervision and discouraging double bouncing.     

2012年和2016年北京儿童医院儿科急诊死亡病例临床特点分析

目的 分析2012年和2016年急诊抢救无效死亡的儿童病例的临床特点.方法 回顾性分析北京儿童医院急诊科2012年和2016年收治并经抢救无效死亡的241例患儿的临床资料及病例特点,比较患儿的性别、年龄、死亡原因.结果 2012年和2016年死亡的患儿分别为122例和119例.2012年死亡病例中,男71例(58.2％),女51例(41.8％);其中0～28 d的新生儿20例(16.4％),29 d至1岁70例(57.4％),＞1～3岁13例(10.7％),＞3～6岁10例(8.2％),＞6岁9例(7.4％);死亡原因以先天性疾病(53/122,43.4％)最多,感染性疾病(38/122,31.1％)次之,意外伤害(17/122,13.9％)居第3,血液病和肿瘤(14/122,11.5％)居第4.2016年死亡病例中,男70例(58.8％),女49例(41.2％);其中0～28 d的新生儿24例(20.2％),29 d至1岁60例(50.4％),＞1～3岁20例(16.8％),＞3～6岁8例(6.7％),＞6岁7例(5.9％);死亡原因以先天性疾病(55/119,46.2％)最多,血液病和肿瘤(47/119,39.5％)次之,感染性疾病(11/119,9.2％)和意外伤害(6/119,5.0％)居第3和第4.2012年因血液病和肿瘤死亡的总人数为14例,其中,0～1岁、＞1～3岁、＞3～6岁、＞6岁分别为1例(7.1％)、2例(14.3％)、4例(28.6％)、7例(50.0％);2016年因血液病和肿瘤死亡的总人数为47例,其中0～1岁、＞1～3岁、＞3～6岁、＞6岁分别为29例(61.7％)、10例(21.3％)、4例(8.5％)、4例(8.5％).与2012年比较,2016年感染性疾病和意外伤害显著减少,血液病和肿瘤显著升高,差异均有统计学意义(P＜0.05).结论 与2012年相比,2016年感染性疾病及意外伤害所致死亡比例明显下降;血液病和肿瘤占比显著升高,且年龄有降低趋势.     

Depression in chronic respiratory disorders in a tertiary rural hospital of Central India

Objective： To determine prevalence of depression in chronic respiratory disorders in a tertiary rural hospital of Central India. Various studies done in past have shown that prevalence of depression in diabetes and hypertension is around 40% -57%. Few studies have been done to screen depression in chronic respiratory disorders. This study was conducted in a tertiary rural hospital of Central india to find out prevalence of depression in indoor patients suffering from chronic respiratory disorders. Methods： Total 68 patients were evaluated for depression. Patients suffering from chronic respiratory disorders （ total duration of illness 〉 3 months） were evaluated using Prime MD Questionnaire. Patients suffering from diabetes, heart diseases, stroke, having past history of psychiatric illness, drug abusers, having lack of social support and suffering from chronic upper respiratory tract infections were excluded from this study. Questionnaire was asked when treatment for acute phase of illness is over. Results： Out of 68 patients evaluated, 36 （53%） were found out to be suffering from depression. Female gender （80%） was more prone to depression, inspite of the fact that all alcoholics were male. 39% of all chronic obstructive pulmonary disease （COPD） patients were suffering from depression in comparison to 65% for pulmonary tuberculosis and 44% for other chronic respiratory illness. 54% of patients suffering from depression are 〈 30 yrs of age, 53% are between 30-60 yrs of age and 52% are 〉 60 yrs of age, suggesting that age has no relation with depression. No association was seen between alcoholism and depression. Conclusion： Prevalence of depression in patients of chronic respiratory illness is very high, like in cases of diabetes and hypertension. Further community and hospital based studies are needed to find out exact prevalence of depression in chronic respiratory illnesses.     

Upper gastrointestinal endoscopy in children - an experience at a paediatric gastroenterology unit

Upper gastrointestinal endoscopy has changed the management of upper gastrointestinal problems in children. The aim of this communication is to share our experience with 153 cases on whom upper gastrointestinal endoscopy was done over a period of 24 months at a paediatric gastroenterology unit of a tertiary care hospital of Dhaka, Bangladesh. Children who attended the department with various gastrointestinal problems are the subjects of this paper. Intravenous midazolam and 10% pharyngeal xylocain were used in majority of cases for sedating the children. The ages of the children were between 15 months to 15 years (9.41+/- 3.22 years). The positive diagnostic yield was 92 out of 153 cases (60.1%). The major indication for doing endoscopy in the present series was recurrent abdominal pain (51.6%), followed by upper gastrointestinal bleeding (28.8%). Combining histopathological findings and CLO/rapid urease tests the overall positive yield of recurrent abdominal pain was 45 out of 79 (57%). The sources of upper gastrointestinal bleeding could be identified in 79.5% cases. Esophageal varices indicating portal hypertension were found in 62.5% children who were endoscoped for unexplained splenomegaly with or without ascitis. Endoscopy has become a safe and valuable procedure in the management of upper gastrointestinal problems in children and gastric antral biopsy has increased the positive diagnostic yield of recurrent abdominal pain in the studied children.     

急诊重症监护病房医院感染病原菌分布及耐药性分析

目的:分析南京医科大学第一附属医院急诊重症监护病房(emergency intensive care unit,EICU)医院感染病原菌分布及其耐药现状,为临床合理用药和控制医院感染提供依据.方法:对2006年1月-2007年6月该院EICU医院感染患者的各类标本中分离出的病原菌,采用K-B纸片扩散法进行敏感试验,对致病菌耐药率进行分析.结果:EICU医院感染病原菌多为耐药菌,病原菌以革兰阴性杆菌(G-)为主占65.33%、革兰阳性球菌(G )第二占18.29%、真菌第三占16.38%;革兰阴性杆菌中以铜绿假单胞菌、鲍氏不动杆菌、肺炎克雷伯菌及大肠埃希菌为主;革兰阳性菌主要以葡萄球菌属为主;真菌以白假丝酵母、光滑假丝酵母菌为主.大肠埃希菌和肺炎克雷伯菌的产超广谱耐β-内酰胺酶(ESBLs)菌检出率分别为58.06%和30.00%;耐甲氧西林葡萄球菌(MRS)检出率为71.87%.结论:加强对EICU病原菌分布及耐药率监测,同时依据细菌病原学及抗菌药物敏感性结果,选择抗菌药物.以减少新的耐药株的出现,降低医院感染率.     

三甲医院急诊护士离职原因的质性研究

目的:了解急诊护士离职原因,为医院管理者降低在职护士离职率提供依据.方法:采用质性研究的现象学方法,对12名急诊离职护士进行半结构访谈,对访谈结果整理分析.结果:通过录音、分析、对照、确认提炼主题,急诊护士离职原因主要为工作环境、工作性质特殊及不成熟的管理系统、社会家庭支持、组织承诺低、对急诊护士胜任能力要求高等.结论:护理管理者应为急诊护士创造和谐的工作环境,提供情感支持,减少离职率.