Metaparadigm of Nursing: The Art and Science of the Nursing Dimension

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Metaparadigm of Nursing: The Art and Science of the Nursing Dimension

The Metaparadigm of Nursing: The Art and Science of the Nursing Dimension Name Reg. No: Unit Code: Assessment Item No: Word Count: 1060 Words. Part One The metaparadigm of nursing identifies four key dimensions that guide the care giving practices in nursing; health, person, environment, and nursing (Fulton & Lyon, 2010, p.30). Of the four concepts, I single out nursing as the most central dimension for the nursing profession. In the healthcare setting, nursing is viewed as an art and science. The two concepts encompass the use personal skills, intuition and creativity, as well as theory and evidence-based approaches in providing care to patients (Tayray, 2009, p. 416). As a nursing professional, I value the two-dimensional concept of nursing because it reflects a holistic understanding of nursing (Jones, 2010, p. 186). The concept of nursing emphasizes the importance of knowledge, research, evidence-based practices and excellence in service provision

What are the short-term and long-term effects of poor communication with the physicians or employees in general?

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What are the short-term and long-term effects of poor communication with the physicians or employees in general?

You are the administrator of a 200-bed acute-care facility located in a medium-sized city somewhere in the Midwest. Your hospital provides the normal array of services and you think your management team does a good job. Acting on a suggestion from a staff member, you decide to ask your marketing department to undertake some research. You ask the staff to form two focus groups: one comprised of a dozen physicians randomly chosen from the active medical staff, who have handled at least 10 admissions apiece during the past year, and one comprised of a dozen citizens. The citizens will be recruited by posting a sign in a large neighborhood supermarket seeking paid volunteers. Questions for both groups will be open-ended and elicit responses as to how the hospital is perceived by each group.
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After a couple of months, the marketing department prepares the following report:

Summary: Physician Group

The physician focus group met during lunch with an experienced moderator. They were asked to provide information about the hospital, specifically their chief likes and dislikes. While nearly all voiced the opinion that the facility was up-to-date, had modern technology, and employed well-trained staff, their chief complaint was that they were never informed of what the hospital was about to undertake, they were always in the dark, and they always felt left out of decision making. To be specific, one physician commented, “I have been on staff for 3 years and wondered what the construction at the rear of the hospital was all about. I just found out it is a new outpatient dialysis unit.”

Another Physician spoke up and complained, “The new CT scanner that was ordered is a Philips. If I had known that, I might have persuaded the hospital to switch to Hitachi; it does better spin-echo imaging. It seems that no one ever tells us anything, and we are the ones charged with taking care of the patients.”

The responses from the remaining physicians were similar.

Summary: Consumer Group

This group of 12 was comprised of five men and seven women of varying ages. All lived less than 5 miles from the hospital, and eight had used the hospital within the last 12 months. The focus group session was conducted during lunch, the volunteers were paid $50 for their participation, and the group was asked open-ended questions regarding their perceptions of the hospital.

While everyone thought the hospital had the best reputation of any hospital in the city, they all voiced the opinion that they knew little about the hospital. When asked, “What new service provided by the hospital do you feel is the most important?” only one commented on the cardiac catheter unit. Most could not name any new service, and the only other service that was named at all was the emergency department.

You feel disappointed by the perceptions of the two groups, but you also believe this is an opportunity to launch new and better communication efforts, both internally and externally.
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Questions

You decide that improvement is needed in communication with physicians/employees and the public.

(a) What are the short-term and long-term effects of poor communication with the physicians or employees in general?

(b) What are the short-term and long-term effects of poor communication with the public?

(c) What do you plan to do to improve communication with each group? Set out a strategy for each group:

• What decision making model would you apply, why?

• Who should participate in the efforts, why?

• What are the budget implications?

• Set out the timetable

• How would you measure success?

The mystery of the blue death

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This report will look at the history of cholera and the similarities between the first outbreaks and now, and will also look at why there are still cholera outbreaks today. Other topics looked at include how climate change can make a difference and what the implications are of having so much more traffic of people coming and going by air travel now.

The Blue Death, also known as Cholera, is a contagious bacterial intestinal infection which is caused by drinking contaminated water. The bacterium which causes this is called vibrio cholerae and affects the small intestine with symptoms of severe diarrhoea, vomiting and dehydration. Most affected are small children and the elderly, with most cases resulting in death due to the amount of body water lost. Up until a hundred years ago, cholera was a public health issue in Europe but with improved sanitation and treatments of drinking water, the disease has pretty much been eliminated in developed countries. Cholera pandemics have usually occurred in developing countries where there is poor sanitation and water treatment; however there have been outbreaks in Europe and the US, the most recent one being in Haiti.

Image of vibrio cholerae bacterium

Let’s take a brief look at the history of cholera. John Snow (1813-1856) was a British physician and surgeon-apothecary and is considered one the founders of epidemiology for his research into finding the source of the cholera outbreak in the 19th century.. Scientists at that time had identified the humoral model of disease and later the miasma model as the cause for outbreaks of cholera. However, John Snow had different opinions and started his own research to find what he thought was the cause of cholera. It was through his research that he was able to determine the cause, and he used models to help him in his findings. Models are analogies that help clarify hypotheses – proposed explanations of relationships between causes and effects, and play a very important and significant role in testing hypotheses. They allow scientists to investigate their findings and often in a variety of different ways. As well as putting practise into action, it allows scientists to observe their hypotheses at work. However, using animal models does not accurately relate to humans but still gives an insight into what the expected results may be. Only after successfully testing on animals would scientists then look for human volunteers, and this is due to ethics. In this instance, Snow’s use of animal models led him to question findings that he had learned about toxic gas and as such gave way to a new hypothesis.

The humoral model of disease proposed that cholera was caused by an imbalance in one of more of the following fluids; blood, phlegm and black and yellow bile. These four were termed the ‘humors’ and treatment was applied by the physicians own interpretation of the humoral imbalance so was very varied. Often purgatives and emetics were prescribed to balance the system. Some treatments even included the use of leeches to get rid of the bad blood in the body. However, scientists later developed the miasma model of disease which proposed that cholera was an epidemic disease which could be the cause of exposure to some sort of toxic gas or miasma and the medical orthodoxy at that time believed that the toxic gas was a result of the fermentation of organic material such as human waste. This resulted in early promoters of public health focusing on the removal of cesspools and piles of composting faeces, with the main aim being to build a network of sewer pipes that would carry waste material into the River Thames.

After the first cholera outbreak in 1831, John Snow went on to do further medical studies and then practised surgery in a hospital in London. Anaesthesia was not used in surgery at that time and Snow had read about it being used and actually got to see one of the first demonstrations of it being employed. This led to Snow recognising that there was a lack of control over the precise dosage of anaesthesia required so he started to experiment and develop devices that would accurately measure precise doses, eventually designing gauges and masks as well as using a variety of animal models to test on. It was a result of this experimentation that led him to question the miasma model of disease for the cause of cholera, as what he had learned about toxic gas did not seem consistent with epidemics.

Snow’s research on anaesthesia was experimental, unlike his work on cholera, so firstly the basic skills of experimenting were necessary coupled with deep curiosity to find out the way things work and how they have certain effects on certain things, in other words; careful, systematic observations. A scientific background would be highly advantageous and you have to be prepared to accept the fact that things may not turn out properly. For planning effective experiments to test dosage measurements a scientist had to have the necessary equipment or improvise if necessary, and be able to do so with some degree of accuracy and also be able to record the results in an accurate way so that they could easily be interpreted. The ability to record results in a variety of different ways, like graphs, charts and tables, was also essential. The scientist had to have a general knowledge and interest in what they wished to experiment and all results had to be carefully and meticulously recorded so a great deal of patience was also required. Designing contrasting observations could also be a good way to test hypotheses as well as using different types of models to record the effects and properties of certain drugs. The use of models would also be beneficial in monitoring accurate delivery systems for anaesthesia.

Therefore, experiments are considered strong tests of hypotheses because they ultimately test them and can either support them or come up with alternative ones. Sometimes several experiments could be conducted and that could exclude one or more of the hypotheses. They also allow results to be analysed and conclusions to be reached and often scientists could form some sort of theory based on the results of an experiment which can then be put into research papers to be discussed thus publicising the findings of experiments. It is imperative that experiment results are recorded accurately. An important fact to remember is that experiments only support hypotheses; they can never prove it right or wrong. A control experiment would be set up so that any change could be monitored and this control would be neutral.

As mentioned before, it was Snow’s experiments with anaesthesiology and working with gases that led him to recognise that the patterns of cholera outbreaks were inconsistent with the patterns that would be expected from poising by toxic gas, and because he couldn’t induce cholera in animal models, he realised he would have to try a different approach. He also found the symptoms of cholera to be inconsistent with symptoms that would be shown if exposed to toxic gas. Cholera was often called the ‘blue death’ as it would cause a person’s skin to turn blue due to respiratory failure resulting in death and is caused by the bacterium vibro cholerae, causing severe diarrhoea and dehydration with death occurring due to such a extreme loss of body fluid. It is mainly transmitted through contaminated water, but can also be spread through food such as fish and shellfish from contaminated water, and produces toxins which cause the symptoms.

John Snow believed that cholera was caused by either eating or drinking something that was contaminated because the gastrointestinal symptoms seemed to be more consistent with this rather than toxic gas poisoning. He tried to convince his fellow scientists that cholera was transmitted through contaminated water but his ideas were not accepted at this early date due to the fact that scientists rarely agree on things. They all had different explanations and formulated their own experiments and collected data and did not want to know that their theory could be flawed or there could be another explanation. Due to the fact that there was lack of evidence to support Snow’s ideas, they were dismissed and generally ignored as people accepted the miasma model of disease as the cause of cholera.

Symptoms of cholera

Cholera outbreaks are more consistent with contamination of water than air due to the fact that in 1854 London there was no running water in homes so people had to use a communal water pump that served particular neighbourhoods. This meant everyone was sharing the same water supply. John Snow had mapped locations of the pumps where cholera outbreaks occurred and collected evidence that everyone who got sick all took water from the same pump. It was his belief that cholera was spread by contaminated water and therefore was confined to a particular area, whereas if it were due to contaminated air, then there would be more widespread cases in London at the time and the outbreak would have spread quicker. Also, none of the doctor’s treating patients had contracted cholera themselves so this suggests that it could not have been air contamination. However, the miasma model persisted because medical theory at the time believed the disease was cause by contaminated air, usually derived from decaying organic matter. This meant that people were more worried about atmosphere pollution rather than water, and the fact that there was little evidence to support Snow’s theories at the time. The general medical opinion was that because the air can be corrupted by perspiration, dirt and faeces, the squalid living conditions were blamed for cholera outbreaks. As a result of this, John Snow realised that he would have to find a different way to test his hypothesis.

While Snow did not have a background in epidemiology, his past research on anaesthesia helped him design a new model for the cause of cholera because he already had experience of using experimental techniques. His approach to the research on cholera was similar to the research he did on anaesthesia, and started with clinical observations, followed by forming a hypothesis which then resulted in a theory being formed. His observations were not only based on his experiences in dealing with patients of the firs cholera outbreak, but also on the experiences of others plus extensive examination of medical literature available at the time. He realised that there was no possible way to do an experimental test of his hypothesis so he had to look for other ways to do these tests. So he did extensive research of all available records and tried to find some sort of pattern. He also noticed that there was severe lack of personal hygiene and overcrowding at the time which he associated with cholera and concluded that it was spread by contaminated water.

After Snow published a research paper in 1849 regarding cholera, it was suggested by a journalist that an experiment should be conducted of people living side by side with similar lifestyles but only the water source should be varied. This would provide critical evidence as it would basically be testing Snow’s hypothesis about cholera being transmitted through contaminated water. If one side was given water from a contaminated source and the other side given sterile, boiled water, then the outcome would result in only one side displaying cholera symptoms. It would show that cholera was spread by drinking contaminated water.

Between 1860 and 1865, Louis Pasteur (1822-1895) proposed the germ theory of disease which proved that most infectious diseases were caused by micro-organisms. He worked with French wine growers and helped with the fermentation process to develop pasteurisation, which is a method that killed germs. Initially he did his research with wine and beers, and demonstrated that bacteria were responsible for beer and wine going sour, later on applying the same principle to milk. He found that harmful bacteria could be removed by boiling a liquid and then letting it cool down, and this is known as pasteurisation. It was this discovery that supported Snow’s hypothesis about cholera being transmitted through contaminated drinking water.

This led to Snow questioning public health and did more research into the topic, doing door to door interviews of families affected by cholera and interviewing doctors that had treated cholera patients. Working alongside Snow was William Farr (1807-1883), who was keeping records of births and deaths on London and they were looking for some sort of pattern. Snow started looking at the geographic distribution of cholera outbreaks compared to the sources of drinking water available and mapped where the cholera deaths occurred. He was trying to verify the source of the water as it would help him trace where the outbreak may be stemming from. Snow found that by comparing a neighbourhood by their source of water supplier would give him a better idea of where the contamination may be and he could basically use it as an experiment using one side as a control and then recording the results. If he looked at two neighbourhoods with their own water source then it would be more difficult to pinpoint where the contamination could be since there were two separate sources, whereas with just the one neighbourhood, it would be easier to see and record the results. The variables that were included in a casual web for cholera are living conditions, public health, water sources and illness at the time. Snow saw his conclusions about cholera to be inferences based on his observations whereas the medical journal reviewer considered these to be conjectures. An inference is a conclusion drawn from background knowledge and facts, whereas a conjecture is based on speculation which has not been proved.

In 1854, there was another cholera outbreak near the Broad Street pump. Snow believed that the outbreak was caused there by the lack of proper sanitation and the general squalor of living conditions. His hypothesis was that contaminated water from nearby cesspools was somehow leaking into the water supply, causing this outbreak of cholera. He had to do some non-experimental tests so resorted to going door to door asking specific questions and trying to identify a pattern again. He took his findings to the Parish Board and presented his findings, asking them to remove the handle on the Broad Street pump. This was regarded with scepticism at first but the handle was removed and eventually the number of cholera cases dropped.

Cholera outbreaks in Broad Street, London 1854

Snow focused on households that were affected by the cholera outbreak and conducted his interviews in those neighbourhoods to gather his evidence. However, a minister of St James Church, Reverend Henry Whitehead, who was sceptical of Snow’s explanations, started conducting his own interviews but he focused on households which were not affected by cholera and found that households using the pump at Broad Street were nine times more likely to contract cholera than those who didn’t use it. In this way, he improved on Snow’s test of his hypothesis and actually identified where the first incident of cholera started – it was an infant living just a few feet from the pump that had died from diarrhoea a couple of days before the outbreak. The two ended up working together, eventually asking the Board of Public Health to dig up the area around the pump to try and identify the cause. When the area had been excavated, they found that water had been leaking from a cesspool under the building where the infant had died and this was seeping into the water supply at the pump. After making further inquiries, they found out that the infant’s mother had actually washed the soiled diapers of the sick child in the basement of her building and then dumped the water into the cesspool near the pump. The main difference between correlation and causation is that correlation describes the relationship between two things or variables whereas causation is causing something to happen. In this case, Snow and Whitehead looked at the correlation aspect of why there were still cholera outbreaks. After the excavation of the area around the pump revealed the contaminated water of cesspools leaking into the drinking water supply and after a drought the following summer, Members of Parliament voted to start a project that would improve the sewer system and move the sewer pipes further downstream of the Thames in order to prevent further outbreaks of cholera.

After the construction of new sewer systems in England, there were no further outbreaks but some have still occurred mostly in developing countries around the world, for example the outbreak in Peru in 1991, which caused a lot of deaths. The most recent outbreak has been in Haiti.

The main difference between public health in the 19th century and now is that there is a lot more awareness now and things have been greatly improved, especially with the invention of the water closet and the sewer systems being improved. However, as mentioned, there has been a recent cholera outbreak in Haiti, which was confirmed on October 21st 2010. This is thought to have been caused by breaches in the water supply, sanitation and hygiene infrastructure used by large groups of people causing exposure to contaminated water or food and in order for it to occur in the first place, it’s thought that it had to be present among the population but how this could happen is still unknown.

Climate change could play a big part in the spread of cholera, as the bacteria can lie dormant for long periods of time, and due to global warming and rising water temperatures the bacteria is given the opportunity to come active and start multiplying. In extreme heat conditions, the bacterium would multiply quickly in stagnant pools of water and in extreme wet conditions the bacterium can spread by overflowing rivers. Also, animals in the water can end up eating the bacterium and these animals are then eaten by humans, causing the spread of cholera.

These days, travel has become a lot more commonplace and this greatly increases the chances of cholera spreading from one country to another, especially overseas. To combat this, awareness has been raised about these concerns and if travelling to a different country, the general advice is to boil any water before drinking to make sure that any harmful bacteria are killed, thus reducing the chances of becoming ill or contracting something. However, this is not guaranteed to stop the spread of cholera as the bacterium can lay dormant and could basically be in most creatures in the sea that are consumed as delicacies, especially the ones that are eaten raw.

In conclusion, due to the improved public health and sanitation in developed countries, cholera is no longer a problem. However, it is still a problem in developing countries, where the public health and living conditions are not as good as the developed countries and there seems to be a general lack of education when it comes to personal hygiene and cleanliness. The outbreaks of cholera generally tend to be focused around areas that have no running water and have to chare a communal water supply. This greatly increases the risk of the bacterium spreading.

One can only hope that with continued dedication and education, awareness can be raised with regards to sanitation and public health, but sadly the conditions in some countries lead to outbreaks, as often there is not enough money for proper sewer systems or education for the people. Crowded living conditions coupled with natural disasters also increase the risk of cholera outbreaks. To sum it all up, hopefully one day cholera will be wiped out, but as it stands just now, this is something that will most likely keep occurring due to the fact that some countries are better off than others. After all, everyone prays for the day where disease and death will no longer be the main issue of day to day life.

Integrating PACS- CR and DR into Radiology Department

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ABSTRACT

This research paper gives a thorough description of the Picture Archival and Communication System (PACS), Computed Radiography (CR) and Digital Radiography (DR). Various advantages of integrating these technologies in the Radiology Department are highlighted. The method of analysis includes taking into consideration the pros and cons of having these systems and it provides reputed information from various medical journals published within the recent years. The disadvantages of these systems are also explored also using excerpts. Recommendations to standardize exposure technique charts were suggested, as well as suggestions to provide individual training. To conclude, this paper clearly states that the advantages outweigh the disadvantages, and the integration of these three systems in any institution would be very beneficial.


INTRODUCTION

X-ray imaging involves the generation of x-radiation by utilizing the ability of high frequency of electromagnetic waves, and the capture of these x-rays after they have passed through the patient. With the use of conventional radiography, images are captured on film, whereas Digital Radiography (DR) is a filmless procedure where the images are displayed on a computer monitor. DR can be divided into cassette-based (Computed Radiography-CR) or cassette-less image capture. A Picture Archiving and Communication System (PACS) is a computerized means of replacing the role of conventional radiographic film. The use of CR/DR alongside PACS allows us to acquire, store, transmit and display radiographic images digitally. The transition of the Radiology Department from conventional radiography to these technologies comes with many benefits. The introduction of PACS, CR and DR has brought many positive changes in the Radiology Department such as improved patient care, efficiency in the workflow and improved image quality when compared to conventional radiography.


OBJECTIVES

The aim of this paper includes discussing these technologies in detail and how their integration into the Radiology Department has brought about positive changes. The intention of this paper is to discuss the advantages of each of these technologies (CR/DR and PACS) as compared to conventional radiography.


APPROACH

For this paper, various online medical journals as well as reputed medical websites were used. Focus was made on the most recent journals such as “PACS: Taking Radiology into the 21st Century.” This is a research journal of the Radiological Society of Pakistan and was published by the Pakistan Journal of Radiology in 2016. This journal discusses the impact upon patient care due to the transitioning of a full PACS system with digital images as opposed to film-based images. Another recent journal in which this paper is based on is “Transitioning to Digital Radiography,” by W. T. Drost. This journal was published by the Journal of Veterinary Emergency and Critical Care, San Antonio in 2011. This paper explores the different forms of DR and compares the workflow for each of these technologies. Finally, a publication entitled “Buyer’s Guide to Digital Radiography” discusses the issues that healthcare providers need to evaluate, such as digital technology costs, maintenance fees, and potential impact of this technology on staff.


FINDINGS AND DISCUSSION

X-ray imaging involves the generation of X-rays and the capture of these X-rays after they have passed through the patient. With the use of conventional radiography, images are captured on film. With this film-based radiography, cassettes contain the film and the image that is produced on this film is known as the latent image. These cassettes, with exposed film, are transported to the darkroom. In the darkroom, the film is taken out of the cassette. It is then developed and fixed to transform the latent image into a radiograph, and the cassette is then reloaded with an unexposed film. This manual processing takes a long time, as opposed to the automatic processing of a digital system that takes 60-90 seconds. One downside to these film-based radiographs is that it can only be at one location at a time and they are generally stored in a dark film room when not in use.

Computed radiography (CR) is one form of Digital Radiography (DR), which employs the use of CR cassettes. An imaging plate that is coated with photostimulable phosphors is contained within these cassettes, and when exposed to x-rays, their electrons become excited to a higher energy state. The electrons become trapped in the phosphor. These trapped phosphors form a latent image, similar to that on an x-ray film in conventional radiography. The imaging plate must be processed rapidly because the electrons forming the latent image may only be stable or stored on the plate for minutes. The cassette containing the latent image is processed in the CR plate reader by removing the imaging plate from within the cassette, where it is then scanned by a laser which frees the trapped electrons, returning them to a lower level energy state. This laser scanning causes the material to emit light, and this light is captured and amplified using photomultiplier tubes, and then sent to an analog-to-digital (AD) converter.

Drost (2015), in the article entitled “Transitioning to Digital”, stated that “The digital image is formed based on the location (x and y coordinates) and the intensity (z coordinate) of the light emitted during the laser scanning. The brightness of each pixel in the image relates to the amount of x-ray attenuation of the structure imaged.” After it is sent to the AD converter, the imaging plate is exposed to a high intensity fluorescent light, which eliminates any remaining electrons, allowing it to be reused. It is then put back into the cassette and ejected from the reader. CR cassettes are the same size as conventional X-ray cassettes and are also used in similar manner. One similarity is that a separate cassette must be used for each radiographic projection and a couple advantages of CR over conventional radiography is that a CR plate reader does not have to be located in a darkroom and processing of imaging plates takes 60–90 seconds. However, we can immediately see that conventional radiography, which uses darkroom, is more expensive from the constant purchases of film developer and fixer solutions, film holders, and the film itself. There are also costs associated with disposal of the chemical waste generated by processing the film. The elimination of these chemicals that are associated with conventional radiography, as well as the reduction in the use of radiation, are cost savings which can be reaped from DR.

Digital Radiography (DR) involves cassette-less imaging and comes in two forms; one that directly converts x-rays to an electrical signal (direct DR) and another that converts x-rays to light, and then to an electrical signal (indirect DR). Instead using a cassette, a piece of equipment called a flat panel detector is used. Direct DR detectors have a photoconductive layer that converts x-rays into an electric signal. This photoconductive layer is linked to a thin film transistor array that is spread across the detector, creating a matrix that maps the x and y coordinates of the signal. The intensity of the signal (z coordinate) is related to the x-ray attenuation of the patient, and is displayed as brightness. For indirect DR, the photoconductive layer is replaced by a scintillator, which is usually made of cesium iodide crystals. The scintillator converts x-rays to light, and a diode layer converts the light to an electrical signal that is linked to the thin film transistor. In both systems, the flat panel fits into the existing x-ray table and is connected to a computer via a cable.

The workflow associated with DR is faster than that off analog radiography and CR. The computer in the DR is used to input patient data and to preview the images. The patient is placed on the x-ray table and the density of the body part being radiographed is measured. The settings for the x-ray machine are based on the technique chart. However, the technique chart varies from the one used for conventional radiography. Once an exposure is made, the radiograph is displayed on the computer within seconds (DentsiryIQ, 2015).

One of the essential differences between conventional and CR/DR radiography is that film-based images cannot be altered once they are processed. The exposure conditions and the developing procedure for conventional radiography determines the final result; that is, the density and contrast are fixed (Drost, 2011). Whereas, digital images can be altered after they have been produced. The radiographer can apply different mathematical operations to alter the pixel values, which can change certain characteristics of the image. This operation is called “image processing” and can be used to correct overexposure or underexposure, amongst many other things. Once the study is complete, images are sent to a workstation or an image server.

For conventional radiography, view boxes are required. Digital images however, are viewed on a monitor at one or multiple workstations. If clients request a copy of their digital images, CDs or DVDs should be able to burn at least at one workstation. A DR is a rectangular pixel matrix and each pixel contains information about x-ray attenuation of the structure in the x-ray beam. Film-based radiographs have a narrow range of exposure techniques that produce a diagnostic quality radiograph. DR systems have a wide dynamic range and are more ‘forgiving’ to the errors of radiographic technique (Strickland, 2000). A better contrast resolution is produced with a wide dynamic range than film-based radiographs. Detective quantum efficiency (DQE) describes the performance of an imaging system as a function of the system’s ability to process signal and noise. In general, digital systems with a high DQE have higher spatial and contrast resolution and therefore higher image quality. DR systems achieve a high DQE using lower radiographic techniques. This should mean fewer repeated radiographs based on the radiographic technique compared to conventional radiography. We can again see the benefits of CR/DR as compared to conventional radiography and transitioning our Radiology Department to include these technologies will cause it to benefit greatly.

A Picture Archiving and Communication System (PACS) is a “computerized means of replacing the roles of conventional radiological film; images are acquired, stored, transmitted and displayed digitally,” (Strickland, 2000). PACS can be a single desktop personal computer which receives, stores and retrieves the images or it can be a country wide system with hundreds of health care facilities linked to each other by a high bandwidth network, having many servers and data centers. The kind of hardware required broadly consists of computers to store the images, workstations to review and retrieve them and a network to connect all the components (uz Zaman, 2016). When such a system is installed throughout the hospital, a filmless clinical environment becomes the result.

The journal published by the Radiological Society of Pakistan (RSP) entitled “PACS: Taking over the 21 st Century,” discusses how PACS has revolutionized how images are stored, reported and distributed. The journal also states that PACS has forever changed the workflow in the Radiology Department as well as patient care. The efficiency resulting from handling data electronically is one of the main advantages of a PACS. That is, it cannot be stolen, lost or misfiled as compared to film-based images. Patients care is improved because it eliminates the physical need for the patient to carry the film wherever a consultation needs to be made, whether it is a private doctor or a public institute. They are also burdened with caring for their image records.

Another advantage of PACS digital images over film-based images is the simultaneous viewing of the same image at multiple locations. Conventional film can only physically exist in one place at any one time. By introducing PACS in the Radiology Department, images are available at a fast rate for reviewing and reporting at various workstations, and there are no longer any delays due to the non-availability of images (Drost, 2011). Copying of film-based images, which would have been needed in such a case, were associated not only with additional cost but also lost in image quality. Furthermore, there is no loss of image quality over time with PACS images as compared to film-based images. The introduction of a PACS has undoubtedly brought about many positive changes in the Radiology Department.

Although the introduction of PACS, CR and DR in our Radiology Department has many benefits, the cost factor in switching from conventional radiography to these technologies must be weighed, such as the cost of the digital equipment itself. In general, CR is the least expensive, followed by DR (uz Zaman, 2016). If the practice uses 2 or more x-ray tables simultaneously, CR cassettes can be used on either table, whereas for a DR system, a flat panel detector must be purchased for each x-ray table. Service contracts for the DR systems are recommended and the cost of these contracts is usually a percentage of the purchase price. Computer equipment, including monitors, is needed when the system is installed and the amount of computer equipment can be expanded at a later date if so desired. Regardless, factors that include maintenance and computer equipment, such as software upgrades, should be planned for. However, some benefits of DR may not be obvious initially. With the use of DR, the darkroom, x-ray film, processing chemicals and storage of recovered silver becomes obsolete (Van der Stelt, 2008). As DR becomes more popular in all phases of medicine, the demand for X-ray film will decrease, likely driving the price of film higher.


RECOMMENDATIONS

With the various advantages listed above, the overall upgrading of radiology departments worldwide to a digital system is strongly recommended and crucial. Digital systems can produce an increased radiation dose to patients, which has been noted, and as such, standardization of exposure values is very important. This can be done by developing exposure technique charts, identifying acceptable exposure ranges and also by ensuring that the technologist/radiographer receive proper training and integration with the use of a digital radiography system specifically.


CONCLUSION

The introduction of PACS, CR or DR into the Radiology Department has, without a doubt, generated numerous benefits. Some of the advantages that have been gathered from the literatures studied include improved workflow, better patient care, enhanced image quality, ease of use, faster completion of a study, fewer repeat radiographs, less physical storage space and the ability to easily send an image to another location. The various journals made particular note that even though there are a few disadvantages of switching to Digital Radiography, the advantages that exist with the use of DR are vast and overwhelms any disadvantages that exist. However, I believe that there should be some evidence to prove these claims, such as a case study within a named hospital. We can better appreciate the long-term investment in Digital Radiography if such a case study outlined initial cost of implementing and maintaining a conventional radiography system, then comparing these figures with the cost of transitioning to Digital Radiography.


REFERENCES

Turner Syndrome: Diagnosis- Development and Management

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Turner Syndrome


Abstract

Turner syndrome is defined as the loss or partial loss of an X chromosome (XO) in a female. Signs and symptoms typically include short stature, gonadal dysgenesis and various somatic abnormalities. Approximately 99% of conceptions with Turner syndrome miscarry, while the remaining frequency of livebirths is 1 in 1,500 to 1 in 2,500. Turner syndrome may be suspected prenatally (in approximately two-thirds of affected fetuses) through ultrasound. Common findings include nuchal cystic hygroma, increased nuchal translucency, nonimmune hydrops, and cardiac and/or renal abnormalities. A low or elevated maternal serum α-fetoprotein may be noticed in fetuses with Turner syndrome. However, many fetuses have normal sonographic features and are detected inadvertently through karyotyping as a routine part of CVS or amniocentesis, most commonly performed for advanced maternal age.

Different sex chromosome complements have been associated with Turner syndrome. The Turner phenotype is thought to be due to the presence of one active copy of a “Turner gene” or “Turner genes” on the X chromosome. It is more than likely that these genes normally escape X inactivation and have functional Y chromosome homologs. Ernest B. Hook and Dorothy Warburton, famous geneticists, have proposed that all viable 45, X cases are cryptic mosaics with a rescue cell line (possibly in the placenta) and result from mitotic loss. Below is the karyotype of an individual with Turner syndrome.


Background and Significance

Born in 1892 in Harrisburg, Illinois, Henry Hubert Turner is noted for discovering Turner syndrome in 1938. He graduated from medical school at the University of Louisville School of Medicine in 1921 and practiced as an endocrinologist. Turner recognized common signs and symptoms such as a webbed neck, short stature, lack of secondary sex characteristics and fertility complications.  In June 1938, Dr. Turner read before the annual meeting of the Association for the Study of Internal Secretions in San Francisco his paper entitled “A Syndrome of Infantilism, Congenital Webbed Neck, and Cubitus Valgus.” He described 7 patients-6 adolescents and 1 adult. The following is an excerpt from Turner during the meeting in an interview, “I had seen a few young girls who had not matured, and they were short in stature and they had short necks with a low hair line and increased carrying angle at the elbow. And I became intrigued with them and I was wondering what in the world could do this to them. And finally, I had seen patients who on x-raying neck they did not show any absence of the cervical vertebra or any fusion of it like you find in Klippel-Feil Syndrome. They all followed a definite pattern. They were all, as I say, short in stature and had no breast development and no internal organs that we could find except perhaps with an endoscope. We could see a little nipple that might have been a cervix less than one cm. in size, and…” The classification of these symptoms led to the discovery of Turner syndrome.


Diagnosis and Management

Diagnosis and management of Turner syndrome requires an initial comprehensive and detailed evaluation followed by annual evaluations for life. Recent advances in science and technology have significantly improved the prognosis and quality of life for individuals with Turner syndrome. The diagnosis of Turner syndrome is made through chromosome analysis. Single nucleotide polymorphism (SNP) microarray genotyping has shown to be effective in the diagnosis of Turner syndrome but will not detect balanced X-autosome translocations. For any individual with 45, X cell line plus a marker or fragment, molecular SRY (sex-determining region Y) and TSPY (testes-specific protein Y-encoded) probe analysis should also be performed to rule out the presence of Y chromosomal material. A common association or hallmark of Turner syndrome is short stature. Normally, there is mild intrauterine growth restriction (IUGR), decreased growth rate in childhood, and no adolescent growth spurt. Final adult height averages about 56 inches. Growth-hormone therapy is commonly offered for this condition, usually started between 2 and 5 years of age if height is below the 5

th

percentile on standard curves. The injections continued until appropriate bone age or satisfactory height has been reached, which is typically around mid-adolescence.

Gonadal dysgenesis is usually present at birth. The ovaries appear normal during the first 12 weeks of gestation. This is followed by a decline in the number of follicles with very few, if any, remaining at birth. The ovaries that are present do not produce estrogen and most females will require hormone replacement therapy. Supplemental estrogen is usually started around 14-15 years of age and is coordinated to minimize compromising growth while corresponding puberty with that of peers. Estrogen supplementation promotes the development of secondary sex characteristics and combined with progesterone, establishes and maintains menses throughout adulthood. Pregnancy is possible for adult women with Turner syndrome using donor eggs, and their pregnancy rate is equal to that of women with other causes of premature ovarian failure. A complete cardiac evaluation with imaging before pregnancy in women with Turner syndrome is recommended due to the increased risk of aortic aneurysm. Fertility among women with the 45, X karyotype and without recognized mosaicism is not common. There is a high risk of miscarriage and an increased likelihood of chromosomal errors and anatomic defects in the offspring of fertile 45, X women, making a prenatal diagnosis highly recommended. Autoimmune diseases are more common in individuals with Turner syndrome. These include gastrointestinal disorders such as ulcerative colitis, Crohn disease, and celiac disease. Glucose intolerance with insulin resistance is common and there is an elevated risk of diabetes.


Cognitive/Psychologic Development

The intellectual and psychosocial characteristics of Turner syndrome can vary greatly, however, patterns of development and adaptation have been noted. The early childhood of some 45, X females may have delays in walking and other motor skills. This decreased coordination can occur into childhood and may interfere with success in sports and athletics. Most females with Turner syndrome do not exhibit signs of language impairment and early language development is often unaffected.

Early research associated individuals with Turner syndrome to have intellectual disability however, this is no longer accurate. A vast review of studies of IQ in females with Turner syndrome indicated that the mean verbal IQ was not significantly different from females who do not have Turner syndrome. The impairment of perceptual and spatial thinking has been associated with several related cognitive impairments, such as difficulty mentally rotating geometric shapes, orienting to left-right directions, drawing human figures, and solving arithmetic problems. Brain MRI studies have shown decreases in parietal gray and occipital white matter in Turner syndrome. Neuropsychologic profiles have acknowledged strengths in verbal processing. Approximately 50 percent of girls diagnosed with Turner syndrome need some type of special education during the school years. Specifically, mathematics and penmanship are areas in which the affected struggle with. However, learning difficulties are not limited to any single academic area. When any learning difficulties are identified, early and intensive intervention is highly recommended. It is found that these cognitive deficits have lasted until adulthood in women with Turner syndrome, with or without estrogen replacement therapy.

Behavioral characteristics of Turner syndrome appear to vary with the developmental level. Preadolescent girls have been shown to have increased incidence if ADHD and difficulty concentrating. Adolescents have been observed to be more anxious, depressed, and socially withdrawn and to have fewer friends. Girls with Turner syndrome will develop a stronger sense of self-esteem if they experience success and are encouraged to develop their own special abilities. Turner syndrome support groups can help counter the sense of isolation sometimes experienced by those individuals affected and their families. Sharing experiences and information often provide great benefits and resources.


Karyotype variations

Half of all individuals with Turner syndrome have a 45, X karyotype. Many chromosomal variants can also produce a Turner syndrome phenotype. The three most common forms are 45,X,  46,X,i(Xq),  and 45,X/46,XY, with an incidence rate of 50%, 17% and 4%, respectively. The chart titled Figure 1 lists the karyotype and incidence percentage various females with Turner syndrome. It is estimated that less than 1% of individuals with 45, X survive to birth with this karyotype of Turner syndrome. Monosomy X accounts for approximately 15% of all spontaneous miscarriages. The mechanism of chromosome loss is probably mitotic in origin. The parental origin of the missing X seems to influence Turner syndrome stigmata, including those related to the kidney, eye, body weight and lipid profile. Advanced maternal age is not associated with an increased incidence of Turner syndrome. The 45, X karyotype is normally noted in individuals with Turner syndrome who are the most severely affected, but the clinical features can vary greatly. Intellectual disability is not typically associated with the 45, X karyotype.

In the 46,X,i(Xq) karyotype, the isochromosome Xq is the most common structural rearrangement of the X chromosome and is present in approximately 15-20 percent of individuals with Turner syndrome. The isochromosome usually consists of two q arms joined at the centromere, with no short arm present. In all cases, females have a Turner phenotype with short stature, but their remaining somatic features may be less pronounced. Many individuals with 46,X,i(Xq) will have ovarian dysgenesis and some may be fertile. These individuals are also more likely to have a higher incidence of autoimmune disorders, including Hashimoto thyroiditis, inflammatory bowel disease and diabetes mellitus. Isochromosome Xq is rarely found in spontaneous abortions, or miscarriages, but is frequent in postnatal diagnoses of Turner syndrome.

The 45,X/46,XY karyotype can produce phenotypes from females with Turner syndrome with or without intellectual disability, to males with ambiguous genitalia and/or gonadal dysgenesis, to almost normal males. Prenatal counseling should be offered to discuss gonadal surveillance.


Figure 1


Karyotype


Incidence (%)

45, X

50%

46, X,i(Xq)

17%

45, X/46, XX

15%

45, X/46, X,r(X)

7%

46, XXq2,  46, XXp2,  46, X,i(Xp)

7%

45, X/46, XY

4%


Prenatal counseling

Genetic counseling of parents with an intrauterine diagnosis of Turner syndrome normally includes discussion of short stature, which will involve the use of human growth therapy. Gonadal dysgenesis in the fetus resulting in infertility will be likely and hormonal therapy can enable females to experience normal pubertal development and pregnancy via egg donation may be an option. The parents should also expect other physical abnormalities such as cardiac malformations, webbed neck and renal anomalies may be present. High-resolution ultrasounds approximately 20 weeks gestation can help differentiate fetuses who are seriously affected and those that have mild manifestations. The ultrasound can also visualize the genitals to identify any discrepancies between karyotype and phenotype. The genetic counselor should express that intellectual disability is not a characteristic of Turner syndrome, but may be noticed with individuals who express the karyotype 45,X/46,XY. There is a risk of difficulty in motor or learning skills. Early intervention is extremely beneficial, and management is no different from children with normal chromosomes and similar developmental problems. Variability among girls with Turner syndrome is substantial and prediction about any child’s prognosis is not possible.


Overall Prognosis

Individuals affected with Turner syndrome typically can expect to live a relatively normal life. Although life expectancy is slightly shorter than individuals who are unaffected, life expectancy can be improved by managing symptoms such as obesity, diabetes mellitus and hypertension. Medications and other therapies and can also help females experience puberty and menarche along with their peers. Women who choose to have children can do so via a donor egg and can have a normal pregnancy. Major technologies have greatly increased life expectancy and will increase in the years to come with new medications and scientific breakthroughs.


References:

  • Baena N, De Vigan C, Cariatie E, et al. Turner syndrome: evaluation of prenatal diagnosis in 19 European registries, Am J Med Genet A 2004; 129:16.
  • Brooker, R. J. (2017). Genetics: Analysis & Principles (6th ed.). McGraw-Hill Education.
  • Hook EB, Warburton D. Turner syndrome revisited: review of new data supports the hypothesis that all viable 45, X cases are cryptic mosaics with a rescue cell line, implying an origin by mitotic loss. Hum Genet 2014; 133:417.
  • Jones, Richard E., and Kristin H. Lopez. Human Reproductive Biology. 4th ed., Elsevier, 2014.
  • Schaefer, MD, Bradley, and Harris D Riley. “A Tribute to Henry H. Turner, MD (1892-1970).”

    The Endocrinologist

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  • Stockholm K, Juul S, Juel K, et al. Prevalence, incidence, diagnostic delay, and mortality in Turner syndrome. J Clin Endocrinol Metab 2006; 91:3897

Effects of HIV and AIDS in Children and Adolescents

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Introduction

The purpose of this paper is to provide researched information on the multifaceted effects of adolescents living with HIV and Aids A lot of people talk more about HIV and AIDS in adults than children. At the end of 2015, 2.6 million children throughout the world among the ages of 15 and younger were living with HIV.  This paper will discuss some of the most recent issues plaguing this demographic and new research, treatment options, and leading efforts to impact the stigma around them.

Unfortunately, one-third of them were getting treatment. Most of these cases have been spotted in sub-Saharan Africa. It is the leading cause of death among teens. Diagnosis of the virus comes with having a weak immune system. Therefore, people with the virus cannot fight infections and some cancers very well.

Many children who have HIV, contracted it through their mother. Either during the birthing process, or though breastfeeding. Women who get tested positive, and stick to the treatment given by physicians, lower the chances of passing on the virus to the babies. Children can also get infected through sexual abuse or rape. In some countries, child marriages are culturally accepted. Young girls could get HIV from their older husbands if he is infected and could be pass it on to their babies. The younger the child is when they first have sex, the higher the risk of them contracting HIV. There is also the issue of children or adolescents, who are sexually active and are not using protection. Adolescents do not always know how to use a barrier method, or they may use them incorrectly. Not using a barrier method such as, birth control or condoms can raise the risk.


Article Review #1 – Status of HIV epidemic control among adolescent girls and young women aged 15–24 years in seven African countries

In 2016, an expected 1.5 million females matured 15–24 years were living with human immunodeficiency infection (HIV) contamination in Eastern and Southern Africa, where the pervasiveness of HIV disease among pre-adult young ladies and young ladies (3.4%) is more than double that for guys in a similar age go (1.6%). Progress was evaluated toward the Joint United Nations Program on HIV/AIDS (UNAIDS) 2020 focuses for juvenile young ladies and young ladies in sub-Saharan Africa. About 90% of those with HIV disease mindful of their status, 90% of the HIV-infected people mindful of their status on antiretroviral treatment (ART), and 90% of those on treatment virally stifled. Utilizing information from late Population-based HIV Impact Assessment (PHIA) reviews in seven nations. The national commonness of HIV contamination in pre-adult young ladies and young ladies matured 15–24 years, the rate who knew about their status, and among those people who knew, the rate who had accomplished viral concealment were determined. The objective for viral concealment among all people with HIV disease is 73%, which was the result of 90% x 90% x 90%. Among every one of the seven nations, the predominance of HIV contamination among juvenile young ladies and young ladies was 3.6%; among those right now, announced monitoring their HIV-positive status, and 45.0% were virally smothered. Continued endeavors by national HIV and general wellbeing projects to analyze HIV contamination in immature young ladies and young ladies as ahead of schedule as conceivable to guarantee fast inception of ART should help accomplish plague control among pre-adult young ladies and young ladies. The number of inhabitants in youthful people matured 15–24 years in Africa is the quickest developing youth segment bunch universally. By 2055, the present population of 226 million youths and youthful people is relied upon to twofold. A quick and significant decrease in HIV rate right now basic to accomplish scourge control by 2030. The PHIA overviews give the primary population level evaluations of viral burden concealment for juvenile young ladies and young ladies in the seven nations reviewed. Although it is empowering that among juvenile young ladies and young ladies who knew that they were HIV-positive, 86% detailed that they were getting ART and 82% of those had accomplished viral concealment, more stays to be finished. Not exactly half (46.3%) of HIV-positive pre-adult young ladies and young ladies knew about their HIV-positive status, which is simply over most of the way to the 90% UNAIDS target, and dependent on revealed current utilization of ART, inclusion at the populace level among pre-adult young ladies and young ladies with analyzed HIV disease extended from 78% to 90%. In Lesotho, Uganda, and Tanzania, self-detailed ART use among pre-adult young ladies and young ladies mindful of their HIV-positive status is moving toward the 90% objective. Despite the fact that the pace of viral burden concealment (45.0%) among all HIV-constructive youthful young ladies and young ladies was well underneath the UNAIDS 73% objective, the high pace of viral burden concealment among HIV-constructive immature young ladies and young ladies who revealed current ART use (82%) is especially promising, proposing that once these people get a determination, national ART programs are fruitful in starting and keeping up them on successful ART. – Progress There has been striking advancement toward generally speaking HIV pandemic control in nations right now, reported by PHIA overview results (2015–2016) from Malawi, Zambia, and Zimbabwe, which found that 62.0% of all HIV-positive grown-ups matured 15–59 years were virally stifled. In Swaziland, the pervasiveness of viral burden concealment among HIV-positive grown-ups matured 18–49 years dramatically increased from 34.8% in 2011 to 71.3% in 2017, and a 44% decrease in HIV rate was seen over a similar period. Rather than these achievements in the general grown-up populace, the 45% predominance for viral burden concealment among pre-adult young ladies and young ladies is well underneath the 73% objective, proposing the methodologies that have been all the more comprehensively fruitful in starting and keeping grown-ups with HIV on ART are less effective right now. Indeed, even as huge advancement has been made toward accomplishing the 90/90/90 focuses in these nations, extra, directed systems are expected to arrive at certain gatherings, especially pre-adult young ladies and young ladies.


Article Review #2 – Mental health challenges among adolescents living with HIV

Emotional well-being issue, including mental disarranges, general mental misery, enthusiastic, and social issues, are a main source of health‐related incapacity, influencing 10–20% of youngsters overall, and are prescient of psychological wellness issue and different morbidities in adulthood. Most investigations of emotional well-being difficulties among teenagers living with HIV in low‐ and middle‐income nations are cross‐sectional and do exclude examination gatherings; notwithstanding, they do demonstrate the need to address psychological wellness inside consideration frameworks tending to HIV or essential consideration. In an investigation of 162 HIV‐infected youngsters and teenagers in Kenya, 49% were accounted for to have in any event one mental analysis or suicidality, with uneasiness issue generally normal (32.3%), trailed by significant burdensome issue (17.8%). A cross‐sectional investigation of 562 HIV‐infected young people from Malawi found a downturn predominance of 18.9%. Inside another investigation in Rwanda inspecting 100 HIV‐infected kids ages 7–14 years, the pervasiveness of sorrow announced was 25%. A cross‐sectional investigation of 82 HIV‐infected young people ages 10–18‐years old in Kampala, Uganda found that 51.2% had scores showing huge mental trouble, 17.1% had endeavored suicide in the previous year, 19.5% had ever endeavored suicide, and 30.5% had encountered crazy side effects in the past. HIV‐related shame is a key issue that impacts teenagers living with HIV across country‐income settings by influencing personal satisfaction, medicinal services access, and wellbeing results. Disgrace and separation experienced by HIV‐infected youth through the more extensive network, just as in clinical experiences, are noteworthy hindrances to HIV treatment, frequently prompting negative results and unexpected frailty results. Moreover, HIV‐related disgrace is frequently entwined with different wellsprings of shame, incorporating those related with psychological wellness and additionally substance use issue. Research that explores these effects upon general wellbeing can control the advancement of administration conveyance and arrangement of ideal social insurance proper for the asset setting. Such mediations to battle obstructions because of shame are particularly important for young people changing their clinical consideration to grown-up care settings, as the weight and exchange of physical, passionate, and social stressors during this powerless, formative period increment.


Article #3 – A call to improve HIV testing and linkage to treatment

Regardless of the holes in proof, the significance of improving HIV testing and linkage to mind has been perceived by the worldwide wellbeing network. For instance, a WHO esteems and inclinations study uncovered that key obstructions to HIV testing and advising included unpleasant administrations and young people’s interests about classification. Thusly, WHO discharged its ‘Direction for HIV Testing and Counseling and Care for ALHIV’ and a reciprocal online device (http://apps.who.int/juvenile/hiv-testing-treatment/) to manage nations as they alter existing projects and grow new ones. A key arrangement boundary that numerous nations must deliver to improve access and inclusion is young people’s capacity to give lawful educated agree to HIV administrations, including testing and care. This AIDS supplement was dispatched with the objective of giving new proof and bits of knowledge to program organizers, specialists, strategy producers, and financing organizations who are trying to improve or create HIV testing, conclusion, linkage to mind and treatment projects, approaches, and systems for young people and youth. Seven of the nine articles center around Sub-Saharan Africa, mirroring the landmass’ weight of the worldwide HIV pandemic; two articles feature difficulties in the United States tending to juvenile key populaces, who have explicit hindrances to getting to administrations. Together, these investigations not just distinguish key holes in access and worthiness of administrations yet feature a scope of promising automatic reactions. With an emphasis on in danger young people getting to HIV benefits, the Metropolitan Atlanta people group pre-adult quick testing activity study by Camacho-Gonzalez et al. distinguished an intercession that gave scene-based testing, persuasive talking and case the executives to teenagers and youth. Wilson et al. feature that young people esteem parental figure backing and constructive communications with human services laborers, and that they want settling on self-ruling choices in regard to HIV finding and exposure. Denison et al. detail the procedure and significance of drawing in youth in projects and research intended to address their issues.


Article #4 –


Adherence to antiretroviral therapy and retention in care for adolescents living with HIV from 10 districts in Uganda

Foundation – Young people have increased expanded consideration since they are the main age bunch where HIV related mortality is going up. We set out to portray the level and factors related with adherence to antiretroviral treatment (ART) just as the 1-year maintenance in care among young people in 10 delegate areas in Uganda. Also, we investigated the obstructions and facilitators of adherence to ART among teenagers. Techniques -The examination included 30 wellbeing offices from 10 agent locale in Uganda. We utilized both subjective and quantitative information assortment strategies in joined structure. The previous included Focus bunch conversations with young people living with HIV, Key witness interviews with different partners and top to bottom meetings with teenagers. The quantitative included utilizing review records survey to separate the last recorded adherence level from all young people who were dynamic in HIV care. Components related with adherence were removed from the ART cards. For the 1-year maintenance in care, we looked through the emergency clinic records of all young people in the 30 offices who had begun ART 1 year before the examination to discover what number of were still in care. Out of 1824 teenagers who were active on ART, 90 % had less than 95 % adherence recorded on their ART record at their last center visit. Just area in rustic wellbeing offices was autonomously connected with poor adherence to ART. Of the 156 teenagers who began ART, were yet dynamic in care 1 year later. Shame, separation and divulgence issues were the most exceptional of all obstructions to adherence. Different obstructions included destitution, weakness, symptoms, pill trouble, discouragement among others. Facilitators of adherence for the most part included companion bolster gatherings, directing, steady social insurance laborers, short holding up time and arrangement of nourishment and transport. End – Adherence to ART was acceptable among young people. Being in country territories was related with poor adherence to ART and 1-year maintenance in care was awesome among teenagers who were recently begun on ART. Shame and divulgence issues keep on being the fundamental boundaries to adherence among young people. Inspecting system – To choose 10 locales out of 112 areas in Uganda, one region was purposively chosen from each sub district. These sub districts included in the regions of Arua, Gulu, Serere, Mbale, and others. Of the 10 areas, 30 % were arbitrarily chosen from locale which recorded great administrations (levels of Cotrimoxazole prophylaxis over 80 %, a half year CD4 access of 80 % and linkage to think about ALHIV of 70 %). Another 30 % were chosen from those without the great administrations and the rest were regions with novel circumstances as indicated by the pattern quantitative pre-adult study by the Uganda Ministry of Health (MOH) [30]. In each region, just wellbeing offices offering ART administrations for young people were chosen. Of these, one must be an emergency clinic, one a Health Center (HC) IV and a HC III with the goal that diverse office levels were secured. Because of coordination, it was foreordained that we study just 30 wellbeing offices. We purposively chose 10 medical clinics of which 5 were Regional Referral Hospitals. To make 10 HC III and 10 HC IVs, we purposively chose one HC III and HC IV, from every one of the 10 locale. By stratified testing, choice of offices was made in an approach to catch the individuals who had great administrations for ALHIV as indicated by the pattern quantitative review as prior portrayed, and the individuals who don’t. The choice was additionally made so that open and private, different usage accomplices were included with the goal that we show signs of improvement comprehension of the different settings.


Article #5 –


Transitioning HIV-infected adolescents to adult care at 14 clinics across the United States

HCT-centered research essentially addresses singular level issues, yet auxiliary obstructions might be progressively basic to fruitful HCT as they decide factors identified with protection qualification, transportation get to, and even young people’s ability to go to mind (e.g., HIV-related shame). Discontinuity across clinical frameworks is especially significant for young people without help to arrange commitment over various consideration systems (Mugavero, Norton and Saag, 2011). The American Academy of Pediatrics (2013) as of late accentuated the requirement for HCT-related protocols (AAP, 2014), and this paper diagrams HCT-related obstructions and members’ potential answers for help advise coordinated assistance conveyance, direct proper assets, and address needs at juvenile and grown-up facilities. Questioners utilized a semi-organized meeting manual for address themes including progress procedures and conventions; HCT facilitators, hindrances, and arrangements; and between center connections. Aides were educated by HIV care linkage and commitment and HCT for other interminable ailments inquire about. Members got $25 Amazon gift vouchers for their time. Institutional Review Boards at the University of North Carolina Greensboro and taking an interest ATN destinations affirmed the examination. All interviewees gave verbal assent and all information were put away on secret word ensured PCs or in a bolted stockpiling bureau. Information were breaking down utilizing the consistent relative method (Buetow, 2010; Glaser and Strauss, 1967) to look at how suppliers portrayed HCT, with center around HCT facilitators and boundaries. Colleagues freely read and physically coded every transcript to make a codebook. Topical codes dependent on existing writing were in this way added to guarantee that hypothesis based and emanant ideas were incorporated. This codebook was explored and altered by other group members (MacQueen, McLellan, and Kay, 1998). Codes were outlined and refined inside an information table (Glaser and Strauss, 1967), and consolidated into a grid to think about centers’ depictions of HCT forms. The coders freely applied the concluded codes to all transcripts utilizing Atlas.ti rendition 7 with 90% between rater understanding. Coders at that point scanned transcripts and field notes for negative cases with respect to boundaries and arrangements related subjects, altering the coding grid varying, and came back to the transcripts for extra correlations (Glaser and Strauss, 1967). Coding differences were settled through accord of the whole research group.


Article #6 –


Opportunities for action and impact to address HIV and AIDS in adolescents

Frequently, the absence of clearness around what makes up a powerful HIV program for teenagers and how to actualize compelling intercessions so they can be open to young people turns into a significant hindrance to tending to the difficulties featured all through this article. The articles right now to give answers to these inquiries and further clearness on the best way to address these difficulties. Among these, a methodical survey by Mavedzenge et al takes note of that various intercessions structured principally for grown-ups have top notch proof showing their potential viability in lessening HIV transmission, dreariness, and mortality. The survey prescribes that these intercessions be organized in juvenile HIV programming. The audit additionally affirms the viability of in-school intercessions and some focused-on mediations in geologically characterized networks at changing announced high-chance practices identified with HIV. In view of this audit, the creators suggest that projects organize the development of chances for young people to get to HIV testing and guiding, just as mediations demonstrated to diminish HIV transmission, AIDS-related dismalness and mortality. These incorporate condoms, arrangement of antiretroviral drugs for the avoidance of mother-to-kid transmission of HIV, antiretroviral treatment, arrangement of clean infusing gear to individuals who infuse medications, and deliberate clinical male circumcision in high HIV commonness and low circumcision pervasiveness settings.

The audit takes note of the proof of potential adequacy for oral pre-introduction prophylaxis among hetero couples and men who have intercourse with men, and conduct change intercessions among individuals who infuse medications and men who have intercourse with men, and suggests that these 2 mediations be scaled up in teenagers. The survey additionally takes note of the significance of basic hindrances, for example, laws, approaches, standards and perspectives, neediness and pay disparity, which influence the conveyance and take-up of these successful HIV-explicit intercessions. This orderly survey didn’t yield any indisputable proof on how viable intercessions can be conveyed to teenagers to yield ideal effect on HIV results. To address this hole in information, a few extra articles were authorized to report the experience and exercises gained from the scale up and usage of key mediations arriving at young people. The surveys present exercises from encounters in the presentation and scale up of willful clinical male circumcision,13 prophylactic services,14 human papilloma infection vaccination,15 and sexual and close accomplice savagery prevention. They feature various significant program components to control successful usage for young people: 1. Agreement on clear national focuses for youths matured 10–19 years to control arranging and observing of progress. 2. Government commitment and authority in execution. 3. Strengthening frameworks and limit, including both assistance conveyance and coordination including numerous divisions, to guarantee effective scale up, proficiency, and maintainability. 4. A clear and steady strategy and rules system, engaging on-screen characters with the power to address usage needs for teenagers and to empower suppliers to all the more likely location the exceptional needs of this more youthful populace. 5. Bundling of the mediation with other wellbeing and social advancement intercessions applicable to the network and the teenagers to boost sway. 6. The significance of anticipating request creation and administration conveyance, improving stages (especially schools), and network moves toward that offer the best open door for wide and supported reach of youths. 7. Strengthening information for promotion, dynamic, and program improvement, including suitable age disaggregated observing and assessment and research including young people matured 10–19 years. 8. Engagement of network structures and youthful informal communities to help powerful assembly and manufacture new, even more tolerating standards around the intercessions and results of intrigue.


References:

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A. the unrestrained market economy leads to too few or too many resources going to a specific economic activity.

/in /by

A. the unrestrained market economy leads to too few or too many resources going to a specific economic activity.

B. the market system fails to allocate resources to each individual according to their abilities.

C. the market system fails to allocate an equal share of resources to all individuals.

D. the market system fails to allocate resources to each individual according to their needs.

Market failure occurs because

A. the market system does not make individuals responsible for the social costs/benefits of their actions.

B. the market system does not make individuals responsible for the private costs/benefits of their actions.

C. the market system forces individuals to consider the social consequences of their actions.

D. the market system forces individuals to consider the social and private consequences of their actions.

Suppose the government adopts a policy that forces pesticide producers to bear the social costs of groundwater contamination associated with the use of their product. This policy will _________ the price of pesticides. (Graph, S.S.)

Since orange growers regard the pesticide as a key input in the production of oranges, the market for oranges will obviously be affected.

The government policy on pesticides causes the market price of oranges to ______

The government policy on pesticides causes the equilibrium quantity of oranges to ______

Suppose that repeated application of a pesticide used on orange trees causes harmful contamination of groundwater. The pesticide is applied annually in virtually all of the orange groves throughout the world. Most orange growers regard the pesticide as a key input in their production of oranges. (Graph, S.S.)

In what sense do consumers of oranges now “pay” for dealing with the spillover costs of pesticide production?

A. The price of oranges to consumers is higher.

B. Because of regulation, oranges are of a lower quality.

C. Consumers do not pay since the taxes and/or regulations are imposed on the growers.

D. Orange consumption is higher.

Which of the following government policies might be effective in achieving the amount of orange production that fully reflects all social costs?

A. A tax on growers commensurate with the cost to third parties.

B. Government financing or production of oranges.

C. Regulations that limit the use of pesticides.

D. Both A and C are viable policies.

E. Both A and B are viable policies.

Many people who do not smoke cigars are bothered by the odor of cigar smoke. Use the accompanying diagram of the market for cigars to illustrate the implications of a failure of the market cigar supply curve to reflect the social or spillover costs of cigar smoking. (Graph, S.S.)?

In the absence of any government involvement in the market for cigars, will too many or too few cigars be produced and consumed?

From society’s point of view, will the market price of cigars be too high or too low?

A nation’s government has determined that mass transit, such as bus lines, helps alleviate traffic congestion, thereby benefiting both individual auto commuters and companies that desire to move products and factors of production speedily along streets and highways.

Nevertheless, even though several private bus lines are in service, commuters in the city are failing to take the social benefits of the use of mass transit into account.

The socially efficient use of bus services may be achieved by which of the following government policies?

A. Regulations.

B. Subsidies.

C. Government financing and/or production.

D. Any of the above?

E. None of the above

Consider a nation with a government that does not provide people with property rights for a number of items and that fails to enforce the property rights it does assign for remaining items.

Externalities would be _______ common in this nation than in a country such as the United States.

A careful study has determined that bus transit has an external benefit for society valued at $2 per bus ride as a result of the reductions in urban congestion and air emissions that result.

Consider the current demand for and supply of bus transit, which in this locale is provided by a number of firms in a competitive marketplace and which currently do not account for the$2 per-ride external benefit.

To reach the optimal level of production shown in your graph, the government should

A. pay a subsidy to either the producers or riders

B. start to produce the good

C. tax those receiving the extra benefit

D. do nothing

A cost or benefit of an economic activity that has an impact on an individual’s well-being, even though the individual was not directly involved in the activity, is known as a(n)

A. externality.

B. free-rider.

C. capital loss.

D. public good.

In the figure, P and Q locate the socially optimal price and quantity of a good. In the case of a good that generates positive externalities, the market price would be _____P and the market quantity would be ______ Q, while in the case of a good that generates negative externalities, the market price would be ________ P and the market quantity would be ____________ Q.

A. equal to; lower than; higher than; equal to

B. lower than; equal to; higher than; equal to

C. lower than; lower than; higher than; higher than

D. lower than; lower than; lower than; higher than

Pollution produced by a factory is being dumped into a local river. The community uses local funds to clean the river. This is an example of

A. an effluent fee because it is as if the factory is taxing the community.

B. an external benefit since it creates jobs in environmental science.

C. an external cost as the community, not the factory, is paying for the clean up.

D. a public good.

Which one of the following is a primary difference between a public good and a private good?

A. Private goods are purchased by money transfers while public goods are purchased by in-kind transfers.

B. A private good is subject to the free-rider problem while a public good is not.

C. Private goods are manufactured because of the workings of the price system while public goods come about through antitrust legislation.

D. Private goods are subject to the principle of rival consumption while public goods are not.

A true public good must be provided by the government. Which of the following goods provided by the government is a true public good?

A. Highways where tolls are collected.

B. Postal service.

C. Tax collection.

D. Flood control.

Suppose Canada spends less per capita on national defense than many other countries of similar size and income. A reasonable economic explanation would be that

A. Canadians perceive national defense as generating external costs rather than as a public good.

B. Canada’s tax system is less efficient than other industrial nations.

C. Canada is able to free-ride on the defense spending of the United States.

D. national defense is not a public good in Canada.

Other than correcting externalities, other economic functions of government include

A. providing a legal system, allocating public goods, promoting competition, and stabilizing the economy.

B. income redistribution and the regulation and provision of merit and demerit goods.

C. deciding what to produce, how to produce it and for whom to produce for all sectors of the economy.

D. deciding which states may or may not impose income taxes, charge fees and enforce contracts.

Which of the following is not a political function of the government that leads to involvement in the economy?

A. Merit and demerit goods.

Patient Presented To A Podiatry Clinic

/in /by

This case study discusses podiatric management of a patient presented to a podiatry clinic with heel pain, upon referral from a General Practitioner. A brief description of the patient’s condition, the aetiology of heel pain, patient assessment leading to possible diagnosis and deferential diagnosis will be outlined. This is followed by discussion on the short, medium and long term podiatry management. Patients’ education and the psychosocial factors influencing the management as well as the outcome measures of intervention will also be discussed.

The patient in this case study is referred to as Emily blunt (Emily). Emily is 36 years old and works as a woman police constable (WPC). Emily complains of a sore foot which started a few weeks ago. Emily explains that the pains appear worse in the evening, but there is a pain of stiffness which is very hard to manage first thing in the morning. She manages the pain with Solpadine which she buys over the counter. Emily recently joined the local gym in an effort to help regulate her weight and to improve her fitness. Emily looks after her mother’s dog which she takes for a walk. Emily asserts that palpation of the heel around both lateral and medial ankle area elicits pain as well as pressing of a thumb around the anteromedial aspect of the calcaneal.

Heel pain is a very common foot problem usually encountered by podiatrist (Navrvaez et al., 2000). According to Bergmann (1980) the origin of heel pain is multi-factorial. It is usually not caused by a single injury, such as a twist or fall, but rather the result of repetitive stress and pounding of the heel ( Woelffer et al, 2000 ) which usually presents in the form of pain either under the heel or just behind the heel, where the Achilles tendon connects to the heel bone (Brown, 1996). In most cases the pain is under the foot towards the front of the heel (Schuberth, 1990)

Current literature regarding heel pain, suggest Plantar Fasciitis (PF), inflammation of the plantar fascia as the main cause. Most cases of plantar fasciitis are the result of a biomechanical defect that causes abnormal pronation (Martin et al, 2001). For example, a patient with a flexible rearfoot varus may at first appear to have a normal foot structure but, on weight-bearing, may display significant pronation. The talus will plantar flex and adduct as the patient stands, while the calcaneus everts. This pronation significantly increases tension on the plantar fascia. Ankle equinus, rearfoot varus, forefoot varus, and limb length variation, can also lead to an abnormal pronation and cause additional stress on the origin of the plantar fascia (De Garceau et al, 2003).

As in the case of Emily, many people who experience PF describe it as pain in the heel with their first steps in the morning, after getting out of bed. It feels like a sharp stabbing pain at the bottom or front of the heel bone (Balint, 2003). According to Kosinski and Lilja (1999), the pain, in most cases is more severe following periods of inactivity, like early in the morning or after sitting for a long period. After walking around for a while the sharp pain subsides and it is replaced by a dull ache (Kosinski and Lilja (1999). However, the symptoms may become worse again getting to the end of the day (Balint, 2003) as seen in Emily’s case. Other common causes of heel pain include Calcaneal Stress Fracture which has symptoms that closely resemble those usually associated with PF, Nerve Entrapment, Siastica, Heel bursitis, Tarsal Tunnel Syndrome, and some systemic condition such as Systemic lupus erythematosus (Lemont, Ammirati and Usen, 2003).

The podiatrist may diagnose planter fasciitis based on the patient’s detailed medical history and the clinical presentation. In Emily’s case, the podiatrist will undertake a thorough physical examination which will include musculoskeletal and biomechanical assessment and ask pertinent questions about the pain. The podiatrist may ask the patient whether their daily activities involve walking and standing excessively; which Emily does. Emily’s physical examination should include inspection of both feet at closed and open chain to look for any abnormal pronation or other biomechanical irregularities. The podiatrist may palpate bony prominences especially over the medial calcaneal tubicle, noting any tenderness or palpable defects. This will elicit pain which is generally local at the origin of the anatomical central band of the planter fascia, with no significant pain on compression of the calcaneus from the medial to lateral direction. Palpating the medial band of the planter fascia while passively dorsiflexing the toes and thereby activating the windlass mechanism can also cause discomfort. It is important to note patient’s foot type as well as quality of footwear. Gait analysis can be done by the podiatrist observing the foot while Emily is walking, this may help identify gait abnormalities. Passive range of motion of the foot and ankle should be assessed for indications of restricted movement. Any discrepancies in limb length should also be noted. During the physical examination, it is also important to assess for any neurological changes and check for any nerve irritations (Tinel or valleix sign) .While imaging is not often used in the diagnosis of plantar fasciitis; they may be requested in order to narrow down differential diagnosis like calcaneal stress fracture.

After diagnosing a patient with plantar fasciitis, the treatment is a two-step process (Landorf et al, 2004). The first step outcome is to decrease the patient’s pain level by at least 90 percent. Conservative treatment are icing, stretching exercises, rest and activity modification, shoe inset and non-steroidal anti-inflammatory drugs (NSAIDs) (Thomas et al, 2010).

Emily is quite young, active and has recently got herself into more activities such as going to the gym and walking her mother’s dog. She also plans to support her partner in the marathon. Therefore Podiatry treatment goal for Emily will be reduction of pain and inflammation.

Ice can be applied via ice massage or ice pack onto the facia. Crushed ice can be placed in a plastic bag wrapped in a towel, then applied for 15-20 minutes (Young, Rutherford and Niedfeldt, 2001); the use of crushed ice allows the pack to be moulded to the foot, thereby increasing the contact area. (Alfredson and Lorentzon, 2000).

Rest and activity modification (Reid, 1992) is vital to the treatment of plantar fasciitis. Complete rest may not be practical for more active individuals like Emily considering the nature of her job. Alternatively, Emily must alter activities that can exacerbate the pain. A dieticians help will also be invaluable if Emily is to check her weight.

Research has shown manual stretching to be ineffective, because patients do not stretch correctly and consistently (Kleisinger, 2003). Since equinus and tight gastrocnemus and soleous is often one of the aetiologies of PF, it is important to address this issue for pain reduction and prevention of recurrence. Wall stretching for at least 15 to 30 minutes daily (REF) will be effective for Emily, under the supervision of a physiotherapist.

Emily may be given an insole with a valgus filler padding. The padding could be manufactured from a semi-compressed foam. The thickness will depend on the severity of the pronation and the patient’s foot wear. The edges should be bevelled for comfort and to guard against any secondary problem.

Several classes of drugs have a role to play in musculoskeletal injury management. But their use should be closely monitored because of the risk of dependence and abuse (Gill and Kiebzak, 1996). Non-steroidal anti-inflammatory drugs (NSAIDs) like short-acting indomethacin or diclofenac taken orally could be prescribed by Emily’s GP. These provide a combination of analgesic and anti-inflammatory effects and are particularly useful in conditions with ongoing inflammation (BNF, 2007) as in Emily’s case.

Many patients attempt self remedies before seeking medical advice. Emily is concerned because she has been on a self medicated Solpadine. Solpadine contains codeine, caffeine and paracetamol; paracetamol overdose may cause irreversible liver damage and bleeding. Caffeine causes nervousness and gastro intestinal disturbances and codeine, drowsiness. Prolonged use as in the case of Emily may lead to addiction and result in withdrawal symptoms once the drug is stopped (BNF, 2007) and Emily may need counselling in other to cope.

PF is a self-limited condition. Studies have shown that it lasts for approximately 6 to 12 months. The podiatrist will expect to see Emily in 6 months time with an improvement in pain, acceptable weight and a considerable level of exercise tolerance.

If Emily’s symptoms are not improving, then the medium term management plan would be steroid injection. Steroid injections are well documented for the treatment of PF, but must be used with caution in other not to cause other damages to the fascia (Tsai, Wang and Tang, 2003). The long term goal for Emily will be to correct any biomechanical defect and to prevent reoccurrence. This can be achieved by using customized orthoses and a more invasive surgical treatment. (Lee, McKeon and Hertel, 2009).

Patients may respond to an injury and pain with mood disturbances, including depression, lowered self esteem, anxiety, anger and maladaptive behaviour (Braddeley, 1990). Although Emily appears strong and motivated, accepting the change in lifestyle will be with difficulty. Her inability to train as she would have wanted, in order to achieve her plan to support her partner and the difficulty she has to endure when it comes to walking the dog will make her worry. In this case, patient education to address psychosocial issues that may militate against Emily’s progress is very vital for better treatment outcomes (Lazarus and Folkman, 1984). Calm explanation, reassurance and involving her in deciding the management plan can help work against these psychological disturbances. Education and supportive counselling; giving literature explaining the condition are also good (Kaplan, 1986). Also, structures within her work place should allow her to take a break or work minimal hours while she recuperates. If there is the need, a referral to a psychologist for counselling would also be helpful. Understanding the stresses in Emily’s life and finding ways to help her cope could lead to better patient engagement for treatment success.

Study on the Outcome of Damage Control Surgery

/in /by


A RETROSPECTIVE STUDY ON THE OUTCOME OF DAMAGE CONTROL SURGERY IN SPMC FROM YEAR 2005 TO 2010. A RETROSPECTIVE STUDY

Submitted by:

Chris George C. Pales, MD

Co-Author:

Benedict Edward P. Valdez, MD


INTRODUCTION:



WHAT IS THE TOPIC ALL ABOUT?

The traditional approach to combat injury care is surgical exploration with definitive repair of all injuries. This approach is successful when there is limited number of injuries. These are usually performed in patients with unstable conditions such as profound hemorrhagic shock which known to affect the over-all survival of the patient. Prolonged operative times and persistent bleeding lead to the lethal triad of coagulopathy, acidosis, and hypothermia, resulting in a mortality of about 90%.

The Three stages of damage control are as follows:


  1. Control of hemorrhage and contamination.

    Also known as bail-out surgery is the first stage. It is a life-saving procedures and is rapidly performed by the surgeon. The main goal this time is to control blood loss and minimizing contamination. It includes control of hemorrhage from bleeding major vessels and solid organs through packing of abdomen, deviation from intestinal anastomosis and temporary closure of abdomen.

  2. Resuscitation:

    Once control of hemorrhage is achieved, patient is now transferred to ICU for correction of any derangement. Rewarming of the patient to avoid hypothermia, correction of blood loss, hydration and stabilization of BP, and avoiding coagulopathy.

  3. Reoperation.

    One patient has been stabilized, especially within 24-48 hours, definite procedure will be done at operating room.



WHAT IS ALREADY KNOWN ABOUT THE TOPIC?

Damage control surgery is relatively new technique, about 20 years old. It is well recognized that trauma patients especially those with profound shock has a higher chance to die secondary to intra-operative metabolic failure than from the trauma itself.

The analogy of damage control surgery is to stop all haemorrhage and gastrointestinal spillage as quickly as possible while patient is having unstable vital signs at the operating room. It is coined from a U.S. Navy technique which is “the capacity of a ship to absorb damage and maintain mission integrity.”

Speed of decision and surgery in severely injured trauma patients is the key to avoid death to patient. The well recognized consequence of hypovolemic, hypothermic patient is what we call the “lethal triad.” It comprises the vicious cycle of hypothermia, acidosis, and coagulopathy. It is a viscous cycle that is very lethal if not recognized and controlled immediately.

Patient who is stable with acceptable laboratory results, good ventilator response, non-hypothermic, are then returned to the operating for the “definitive operation.” (figure 1). Bowel anastomoses and colostomy maturation, definitive vascular repair, removal of hemostatic packing, and closure of abdominal fascia where is done.

Figure 1.

Cover

The documented mortality for the damage control approximately 50% with a documented morbidity of approximately 40% as summarized in the following table.

Cover



WHAT IS NOT YET KNOWN ABOUT THE TOPIC?

With the advent of modern technology and numerous studies, what is the outcome of patients undergoing Damage control surgery in SPMC from January 1, 2005 to December 31, 2010.



WHAT IS THE SIGNIFICANCE OF THE STUDY?

This study will give us data on the effectiveness of Damage Control Surgery done at SPMC from January 1, 2005 – December 31, 2010. It will give the surgeons the data of factors that determine the outcome of damage control surgery, thus giving ways of improving healthcare management to patients.



WHAT WILL THIS STUDY DO?


General Objective:

The study aims to determine the outcome of damage control surgery done in SPMC from January 1, 2005 to December 31, 2010


Specific Objective:

  1. To describe the demographic and clinical profile of patients who underwent damage control surgery
  1. To determine the number of patients who underwent definitive surgical

procedure after damage control surgery

3. To determine the mortality rate of patients who underwent undergoing damage control surgery in SPMC from January 1, 2005 to December 2010.

4. To determine the factors that affects the outcome of patients undergoing damage control surgery in SPMC from January 1, 2005 to December 2010 in terms of nature of injury, time of operation from injury and pre-operative vital signs.


Patient’s Demographic Profile

Describe the trauma patients according to the following variables:

  1. Sociodemographic characteristics
  • Age
  • Sex
  1. Clinical characteristics:
  • Pre-operative vital signs
  • Associated Injuries
  • GCS score
  • Organs Involved
  1. Co-morbidities
  2. Determine the interventions and clinical outcome of patients
  • Duration of Operation
  • Operations performed
  • Mortality rate
  • Re-operation performed
  • Disposition

Figure 1. Conceptual Framework














METHODOLOGY


General Design

The study employed is a retrospective, descriptive study design. Chart review of all patients who underwent damage control surgery during January 1, 2005 to 2010 will be done by the author with the permission of the medical records section and the hospital research committee.


Setting

The study will be will be conducted at Southern Philippines Medical Center, a tertiary hospital in Davao City in June 2013.


PARTICIPANTS:


INCLUSION CRITERIA:

This study will include all patients admitted and underwent Damage control surgery at Southern Philippines Medical center in 2005-2010. Damage control surgery includes resection of major injuries to the gastrointestinal tract without re-anastomosis; control of hemorrhage through peri-hepatic packing and temporary closure of abdomen and use of an alternate closure of a cervical incision, thoracotomy, laparotomy, or site of exploration of an extremity.


EXLCLUSION CRITERIA:

None


SAMPLING PROCEDURES:

The study subjects (target population) of this research are the patients admitted and underwent Damage control surgery at Southern Philippines Medical Center in 2005-2010.


Randomization:

None


DATA GATHERING


Dependent Variable:

Number of Damage Control Surgery from 2005-2010


Main outcome measures and other dependent variables:

Number of patients who expired and number of patients survived.


Independent Variables

Age and Sex

Nature of injury

Time of intervention from time of injury

Pre-Operative vital signs

Glasgow coma scale

Organs involved

Duration of Operation

Availability of Blood


Interventions:

None


Data Handling and Analysis:

All data will be computed as to the mortality rate by computing the number of patients who expired to the total number of patients who underwent Damage control surgery.

Furthermore, determination of mortality will be computed by computing the ratio of mortality as of Age and Sex, Nature of injury, Time of operation from injury and Pre-op vital signs, Duration of Operation, Availability of blood, Organs involved.


ETHICAL CONSIDERATIONS


Ethics Review

The proponent of the study will secure an approval from the Cluster Ethics Research Committee of The Southern Philippines Medical Center prior to doing the research. A similar approval is also secured from the Department of Surgery of the same institution with the approval of a consultant in-charge.

Privacy

No phone calls or home visits as follow up to participants.

Confidentiality

The researchers will not disclose the identities of the patients at any time. The data obtained during the study will be under the Department of Surgery of Southern Philippines Medical Center and will be kept in confidentiality.

Extent of Use of Study Data

The data collected by the researcher will only be used to answer the objectives of stated in the protocol. Data will be available to others as a finished paper.

Authorship and Contributorship

The main proponent of the study is the main author and researcher of the study. Consultant guidance and support will be provided Dr. Benedict Valdez, head of Section of Trauma, Department of Surgery, SPMC. He is the co-author who will aide in the study design. A professional statistician will help in the study write-up and data analysis. The author and co-author gives consent to use the data collected for further research.

Conflicts of Interest

The main proponent and the co-authors declare no conflict of interest.

Publication

The research will be submitted for national and international publication groups and may be chosen for publication. In all portions in the paper, the author and co-authors will be duly acknowledged.

Funding

The main proponent of the study is using personal funds to conduct the study. Funding of the braces will depend on the patients and their guardians

.


REFERRENCES

  1. Schwartz book of Surgery 8

    th

    Edition by F. Charles Brunicardi
  2. Trauma, Fifth Edition by David Feliciano, MD
  3. A logical approach to trauma – Damage control surgery Shibajyoti Ghosh, Gargi Banerjee, Susma Banerjee, D. K. Chakrabarti

Department of Surgery, R. G. Kar Medical college, West Bengal, India.

  1. Townsend: Sabiston Textbook of Surgery, 17th ed., Copyright © 2004 Elsevier


  2. Combat Damage Control Resuscitation: Today and Tomorrow ;Colonel Lorne H. Blackbourne, MDUS Army Institute of Surgical Research, 3400 Rawley E. Chambers Ave. Fort Sam Houston, TX 78234USA
  3. Damage Control: Beyond the Limits of the Abdominal Cavity. A Review

Maeyane S. Moeng, MB, BCh, FCS(SA),1 Jerome A. Loveland, MB, BCh, FCS(SA),2 and Kenneth D. Boffard, BSc(Hons), MB, BCh, FRCS, FRCS(Edin), FRCPS(Glas), FCS(SA), FACS, FCS(SA)

  1. Feasibility of Damage Control Surgery in the Management of Military Combat Casualties

Ben Eiseman, MD, Ernest Moore, MD, Daniel Meldrum, MD, Christopher Raeburn MD

DUMMY TABLES

TABLE 1: Demographics and Clinical Characteristics.

CHARACTERISTICS

Nature of Injury

Stab wound

62

Gunshot wound

98

Blunt Trauma

54

Penetrating Injuries

53

Initial Vital signs

Normotensive

96

Hypotensive

157

Tachycardic (>100cpm)

105

Non-tachycardic (<100cpm)

148

Mean GCS score

11

Time of Operation from time of Injury

1hr

Mean Age

34

Sex Distribution

M

TABLE 2: OUTCOME


Expired

Mean Duration of Operation

45mins

Organs Involved

liver

Units of blood transfused

2 units


Underwent Definitive Procedure

Mean Duration of Operation

1hr

Organs Involved

liver

Units of blood transfused

4

TABLE 3: BUDGET

PROBABLE EXPENDITURE

PROPOSED BUDGET

PRINTING COST

300php

STATISTICIAN

3,300php

SUPPLIES

1,500

TOTAL

5,100php

TABLE 4: TIMETABLE

MONTH 2014

PROPOSED ACTIVITY

JANUARY

SUBMISSION OF PROPOSAL

MARCH

DATA GATHERING

JUNE

DATA PROCESSING

JULY

1

ST

DRAFT

AUGUST

2nD DRAFT

SEPTEMBER

FINAL PAPER


CURRICULUM VITAE

Name: Chris George C. Pales

Address: Unit 303, Palmetto Place, Maa road, Davao City

Telephone
Cell: 09238060856

Phone
Email:

docpales@gmail.com

/

colicaab@yahoo.com


Personal Information




Date of Birth: April 9, 1983


Place of Birth: Koronadal City, South Cotabato


Citizenship: Filipino


Status: Married


Gender: Male


Education

:

Elementary: Kipalbig Elementary School, Kipalbig, Tampakan, South Cotabato (SY 1990-1996)

High School: Notre Dame of Marbel University, Koronadal, South Cotabato (SY 1996-2000)

Colllege: West Visayas State University, Iloilo City (SY 2000-2004)

Medicine: West Visayas State University, Iloilo City (SY 2004-2008)

DATA COLLECTION SHEET

A RETROSPECTIVE STUDY ON THE OUTCOME OF DAMAGE CONTROL SURGERY IN SPMC FROM YEAR 2005 TO 2010. A RETROSPECTIVE STUDY

Chris George C. Pales, MD/Benedict Edward P. Valdez, MD

Hospital #:

Age:

Sex:

NATURE OF INJURY

Stab wound______

Gunshot wound______

Blunt Trauma______

Penetrating Injuries______

VITAL SIGNS ON ADMISSION

BP:

HR:

RR:

TEMP:

GCS score:

TIME OF ARRIVAL SINCE INJURY

_______ Minutes

_______ Hours

_______ Days

DURATION OF OPERATION:

UNITS OF BLOOD TRANSFUSED:

INTRA-OP VITAL SIGNS:

BP:

CR:

ORGANS INVOLVED:

RE-OPERATION DONE FOR DEFINITIVE PROCEDURE?

____Yes

____No

NUMBER OF HOSPITAL STAY:

DISPOSITION:

______DISCHARGED IMPROVED

______DIED

CAUSE OF DEATH:

Describe legal and ethical implications of the issue using the ANA Code of Ethics (2001) as framework.

/in /by

Describe legal and ethical implications of the issue using the ANA Code of Ethics (2001) as framework.

Please use the grading rubric to create an outline of your assignment. Each section of the rubric should be a section of your final paper and could become the headings. Your assignment will be graded based on each element of the rubric. Compare each section of your paper with the rubric to ensure all elements are covered. Then, include an introduction and conclusion to tie the paper together. If you have any questions regarding the assignment please contact your instructor using the Course Help forum.
Do you have additional questions about this assignment or would you like more guidance?   Professor IQTM may be able to help you.  Type in any questions you may have about the assignment or select the questions that are present.  Keep in mind that if Mary doesn’t know the answer she will become smarter with each question she is asked and your instructor will be able to help you if Mary cannot.
Analyze the position statement from the International Council of Nurses chosen in week 1. This position statement is the foundation for this final project.
In a 12 to 15 slide PowerPoint presentation, not including the title slide and reference slide, address the following:
Present the Position Statement.
Describe why this issue is important to professional nursing practice.
Analyze at least three scholarly nursing articles related to this subject, including what the articles add to the understanding of this issue.
Describe legal and ethical implications of the issue using the ANA Code of Ethics (2001) as framework.
Summarize how this position statement can be utilized to improve the health of the population.
Use bullet points on the content slides and include speaker’s notes to discuss the content.  Remember to use APA 6th edition formatting for slide references and review the link on How to make an APA formatted PPT slide presentation.
The standard of performance required for undergraduate nursing programs is C+ (77%) or higher in all nursing courses. Students who earn a grade of less than C+ in any nursing course must repeat the course and earn at least a C+ in order to complete the program of study. If a student’s GPA falls below 2.0 he or she may be placed on academic probation.
Final Project Rubric
Competency
18 Points
12 Points
6 Points
0 Points
Total
Present the Position Statement
Presents the Position Statement
Presents the title of the Position Statement but does not include any additional information
Does not present the Position Statement
No paper submitted or content missing
/18
Describe why this issue is important to professional nursing practice
Describes why this issue is important to professional nursing practice
Superficially describes why this issue is important to professional nursing practice
Does not describe why this issue is important to professional nursing practice
No paper submitted or content missing
/18
Analyze at least three scholarly nursing articles related to this subject, including what the articles add to the understanding of this issue
Analyzes at least three scholarly nursing articles related to this subject, including what the articles add to the understanding of this issue
Analyzes at two scholarly nursing articles related to this subject, including what the articles add to the understanding of this issue
Analyzes at one scholarly nursing articles related to this subject, including what the articles add to the understanding of this issue
No paper submitted or content missing
/18
Describe legal and ethical implications of the issue using the ANA Code of Ethics (2001) as framework
Describes legal and ethical implications of the issue using the ANA Code of Ethics (2001) as framework
Describes legal or ethical implications of the issue using the ANA Code of Ethics (2001) as framework
Describes legal and ethical implications of the issue but does not use the ANA Code of Ethics (2001) as framework
No paper submitted or content missing
/18
Summarize how this position statement can be utilized to improve the health of the population
Summarizes how this position statement can be utilized to improve the health of the population
Superficially  summarizes how this position statement can be utilized to improve the health of the population
Does not summarize how this position statement can be utilized to improve the health of the population
No paper submitted or content missing
/18
Competency
2.5 Points
2 Points
1 Point
0 Points
Total
Organization
Organization excellent, ideas clear and arranged logically, transitions smooth, no flaws in logic.
Organization good; ideas usually clear and arranged in acceptable sequence; transitions usually smooth, good support
Organization minimally effective; problems in approach, sequence, support and transitions
Organization does not meet requirements
/2.5
Grammar
Grammar, punctuation, mechanics, and usage correct and idiomatic, consistent with Standard American English
Grammar, punctuation, mechanics, and usage good mostly consistent with Standard American English; errors do not interfere with meaning or understanding
Grammar, punctuation, mechanics and usage distracting  and often interfere with meaning or understanding
Grammar, punctuation, mechanics, and usage interfere with understanding
/2.5
APA Format
Demonstrates competent use of mechanics and APA
Minimal APA errors
Many APA errors
Complete lack of understanding
/2.5
References
References are relevant, authoritative and contemporary
Adequate references
Minimal use of appropriate references
Poor use and/or selection of references not relevant
/2.5
TOTAL
/100
Academic integrity: Sources not cited and/or word-for-word (verbatim) content used from another source without the use of quotation marks earns a 0 for the paper.