Evaluation of Morning Report Sessions in Emergency Departments of Teaching Hospitals Affiliated With Shahid Beheshti University of Medical Sciences

مقدمه: معاونت آموزشی و امور دانشجویی وزارت بهداشت و درمان و آموزش پزشکی کشور پروژه ملی تحت عنوان "پروژه تعیین معیارها و شاخص های آموزش بالینی در مراکز و بیمارستانهای آموزشی" با هدف ارائه مجموعه استانداردهای آموزش بالینی طراحی و اجرا نمود که حاصل آن استخراج و معرفی استانداردهای آموزش بالینی پزشکی در مورد کلینیک سرپایی، راندهای آموزشی، گراند راند، گزارش صبحگاهی و ژورنال کلاب بود که پائیز سال 1388 ابلاغ گردید. در این مجموعه 96 استاندارد با قید "باید" و 139 استاندارد با قید "بهتر است" به عنوان استانداردهای مناسب کشور ایران پیشنهاد شده است. مطالعه حاضر با هدف ارزشیابی جلسات گزارش صبحگاهی گروه طب اورژانس بیمارستانهای آموزشی تحت پوشش دانشگاه علوم پزشکی شهید بهشتی بر اساس استانداردهای اعلام شده از سوی معاونت آموزشی وزارت بهداشت درمان و آموزش پزشکی انجام گرفت. روش کار: مطالعه مقطعی حاضر جهت ارزشیابی استانداردهای آموزش بالینی در حیطه گزارش صبحگاهی با استفاده از 3 فهرست وارسی و یک لیست مستندات جمع آوری اطلاعات صورت گرفت که در مجموع 54 استاندارد گزارش صبحگاهی را پوشش می داد. فهرست وارسی اول بصورت حضوری و با مشاهده مستقیم در گزارش صبحگاهی تکمیل شد و شامل 37 سوال بود. فهرست وارسی دوم که شامل 26 سوال بود، ضمن مصاحبه با معاون آموزشی یا رئیس بخش های اورژانس تکمیل شد. فهرست وارسی سوم شامل 10 سوال بود که با پرسش از دستیار ارشد بخش تکمیل گردید. سپس نمره نهایی مطلق و درصد آن در استانداردهای اجباری و ترجیحی تعیین و رتبه بندی شد. برای آنالیز داده ها از نرم افزار 21  SPSS و سطح معنی داری 05/0 استفاده شد. يافته ها: یافته های حاصل از 50 مورد گزارش صبحگاهی در در بخش اورژانس بیمارستان امام حسین و 94 مورد گزارش صبحگاهی در بخش اورژانس بیمارستان شهدا تجریش مورد تجزیه و تحلیل قرار گرفت. در بخش اورژانس بیمارستان امام حسین میانگین امتیاز در استانداردهای اجباری 5/89 درصد و استانداردهای ترجیحی 7/45 درصد بود. در بخش اورژانس بیمارستان شهدا تجریش میانگین امتیاز در استانداردهای اجباری 6/73 درصد و استانداردهای ترجیحی 60 درصد بود. میانگین امتیاز کسب شده در استانداردهای اجباری در بخش اورژانس بیمارستان امام حسین بطور معنی داری بیشتر از اورژانس شهدا تجریش بود (025/0=p). وضعیت اجرای استانداردهای ترجیحی اگرچه در بیمارستان شهدا تجریش بهتر از بیمارستان امام حسین بود، ولی این اختلاف از نظر آماری معنی دار نبود (1/0=p). در مجموع میانگین کل امتیاز کسب شده در مورد تمام استانداردهای گزارش صبحگاهی در بخش اورژانس بیمارستان شهدا تجریش 8/66 درصد و بخش اورژانس بیمارستان امام حسین 6/67 درصد بود که اختلاف معنی دار نداشتند (92/0=p). نتيجه گيری: بر اساس یافته های مطالعه حاضر میانگین کل امتیاز کسب شده در مورد تمام استانداردهای گزارش صبحگاهی در بخش اورژانس بیمارستان های شهدا تجریش و امام حسین در سطح متوسطی قرار داشتند. میانگین امتیاز کسب شده در استانداردهای اجباری در بخش اورژانس بیمارستان امام حسین بطور معنی داری بیشتر از اورژانس شهدا تجریش بود. وضعیت اجرای استانداردهای ترجیحی اگرچه در بیمارستان شهدا تجریش بهتر از بیمارستان امام حسین بود، ولی اختلاف از نظر آماری معنی دار نبود.Introduction: The present cross-sectional study was done to evaluate the standards of clinical training regarding morning report and data gathering was done using 3 assessment lists and a list of evidence, which covered 54 standards of morning report in total. The first assessment list, which included 37 questions, was filled in person by direct observation during morning report. The second assessment list included 26 questions and was filled by interviewing either education chief executive or department head of the emergency department (ED). The third assessment list consisted of 10 questions and was filled by questioning the chief resident of the department. Then the final absolute score and its percentage were determined and ranked based on obligatory and preferred standards. SPSS version 21 was used for data analysis and 0.05 was considered as significance level. Methods: The present cross-sectional study was done to evaluate the standards of clinical training regarding morning report and data gathering was done using 3 assessment lists and a list of evidence, which covered 54 standards of morning report in total. The first assessment list, which included 37 questions, was filled in person by direct observation during morning report. The second assessment list included 26 questions and was filled by interviewing either education chief executive or department head of the emergency department (ED). The third assessment list consisted of 10 questions and was filled by questioning the chief resident of the department. Then the final absolute score and its percentage were determined and ranked based on obligatory and preferred standards. SPSS version 21 was used for data analysis and 0.05 was considered as significance level. Results: Findings resulting from 50 morning reports in ED of Imam Hossein Hospital and 94 morning reports in ED of Shohadaye Tajrish Hospital were analyzed. In ED of Imam Hossein Hospital, mean score was 89.5% regarding obligatory standards and 45.7% in preferred standards. In ED of Shohadaye Tajrish Hospital, mean score was 73.6% for obligatory standards and 60% for preferred standards. Mean score of Imam Hossein Hospital was significantly higher than Shohadaye Tajrish Hospital regarding obligatory standards (p = 0.025). Although preferred standards were carried out better in Shohadaye Tajrish Hospital, compared to Imam Hossein Hospital, this difference was not statistically significant (p = 0.1). In total, mean score of the hospitals considering all standards of morning report, was 66.8% in Shohadaye Tajrish Hospital and 67.6% in Imam Hossein Hospital, which were not significantly different (p = 0.92). Conclusion: Based on the findings of the present study, mean total score of all the standards regarding morning report in EDs of Shohadaye Tajrish and Imam Hossein Hospitals was average. Mean score of obligatory standards was significantly higher in ED of Imam Hossein Hospital, compared to ED of Shohadaye Tajrish Hospital. Although the score regarding preferred standards was higher in Shohadaye Tajrish Hospital, compared to Imam Hossein Hospital, this difference was not statistically significant.

Predictive Factors of Poor Outcome in Road Traffic Injures; a Retrospective Cohort Study

Introduction: Road traffic injuries (RTI) are among the most important health problems worldwide as they cause more than 1.2 million deaths and 50 million injuries each year. Therefore, the present study aims to evaluate the outcome and aftermath of RTI in those who were injured and hospitalized due to a traffic accident.Methods: In the present retrospective cohort study with a one-year follow-up, data were extracted from the profiles of the RTI hospitalized patients. Outcome of the patients was evaluated at the time of discharge and 1-year later including their living state, presence of a disability or complete recovery.Results: 1471 patients were studied (mean age of 32.8±17.0; 80.3% male). 571 (38.8%) had mild disability, 684 (46.5%) moderate disability, and 85 (5.8%) had severe disability at the time of discharge. In the end, 53 (3.6%) died. In the 1-year follow-up, 194 (13.2%) had mild disability, 43 (2.9%) had moderate disability, 9 (0.6%) had severe disability, and 7 (0.5%) were in a vegetative state. Presence of an underlying disease (p=0.03), loss of consciousness for more than 24 hours (p=0.04), spinal injury (p=0.002), presence of multiple trauma (p=0.01), increased ISS (p<0.001), need for ventilator (p<0.001), and organ injuries during hospitalization (p<0.001) are independent factors that increase the risk of poor outcome in RTI patients.Conclusion: Based on the results of the present study, underlying illnesses, loss of consciousness for more than 24 hours, spinal injury, multiple trauma, increased ISS, need for ventilator, and organ injuries during hospitalization were independent factors that increased the probability of poor outcome in RTI injuries

Mesenchymal stromal cells’ therapy for polyglutamine disorders: where do we stand and where should we go?

Polyglutamine (polyQ) diseases are a group of inherited neurodegenerative disorders caused by the expansion of the cytosine-adenine-guanine (CAG) repeat. This mutation encodes extended glutamine (Q) tract in the disease protein, resulting in the alteration of its conformation/physiological role and in the formation of toxic fragments/aggregates of the protein. This group of heterogeneous disorders shares common molecular mechanisms, which opens the possibility to develop a pan therapeutic approach. Vast efforts have been made to develop strategies to alleviate disease symptoms. Nonetheless, there is still no therapy that can cure or effectively delay disease progression of any of these disorders. Mesenchymal stromal cells (MSC) are promising tools for the treatment of polyQ disorders, promoting protection, tissue regeneration, and/or modulation of the immune system in animal models. Accordingly, data collected from clinical trials have so far demonstrated that transplantation of MSC is safe and delays the progression of some polyQ disorders for some time. However, to achieve sustained phenotypic amelioration in clinics, several treatments may be necessary. Therefore, efforts to develop new strategies to improve MSC's therapeutic outcomes have been emerging. In this review article, we discuss the current treatments and strategies used to reduce polyQ symptoms and major pre-clinical and clinical achievements obtained with MSC transplantation as well as remaining flaws that need to be overcome. The requirement to cross the blood-brain-barrier (BBB), together with a short rate of cell engraftment in the lesioned area and low survival of MSC in a pathophysiological context upon transplantation may contribute to the transient therapeutic effects. We also review methods like pre-conditioning or genetic engineering of MSC that can be used to increase MSC survival in vivo, cellular-free approaches-i.e., MSC-conditioned medium (CM) or MSC-derived extracellular vesicles (EVs) as a way of possibly replacing the use of MSC and methods required to standardize the potential of MSC/MSC-derived products. These are fundamental questions that need to be addressed to obtain maximum MSC performance in polyQ diseases and therefore increase clinical benefits.Portuguese Foundation for Science and Technology: SFRH/BD/148877/2019; CENTRO01-0145-FEDER-000008 CENTRO-01-0145FEDER-022095 POCI-01-0145-FEDER-016719 POCI-01-0145-FEDER-029716 POCI01-0145-FEDER-016807 POCI-01-0145-FEDER016390 UID4950/2020 CENTRO-01-0145-FEDER-022118info:eu-repo/semantics/publishedVersio

Mesenchymal stem cell-derived extracellular vesicles for kidney repair: current status and looming challenges

Abstract Novel therapies are urgently needed to address the rising incidence and prevalence of acute kidney injury (AKI) and chronic kidney disease (CKD). Mesenchymal stem/stromal cells (MSCs) have shown promising results in experimental AKI and CKD, and have been used in the clinic for more than a decade with an excellent safety profile. The regenerative effects of MSCs do not rely on their differentiation and ability to replace damaged tissues, but are primarily mediated by the paracrine release of factors, including extracellular vesicles (EVs), composed of microvesicles and exosomes. MSC-derived EVs contain genetic and protein material that upon transferring to recipient cells can activate several repair mechanisms to ameliorate renal injury. Recent studies have shown that MSC-derived EV therapy improved renal outcomes in several animal models of AKI and CKD, including ischemia-reperfusion injury, drug/toxin-induced nephropathy, renovascular disease, ureteral obstruction, and subtotal nephrectomy. However, data about the renoprotective effects of EV therapy in patients with renal failure are scarce. This review summarizes current knowledge of MSC-derived EV therapy in experimental AKI and CKD, and discusses the challenges that need to be addressed in order to consider MSC-derived EVs as a realistic clinical tool to treat patients with these conditions

Contemporary National Patterns of Eligibility and Use of Novel Lipid‐Lowering Therapies in the United States

Background The emergence of PCSK9i (proprotein convertase subtilisin kexin type 9 inhibitor) and icosapent ethyl (IPE) has expanded the role of lipid‐lowering therapies beyond statins. Despite recommendations by clinical practice guidelines, their national eligibility and use rates remain unclear. Methods and Results In the National Health and Nutrition Examination Survey data from 2017 to 2020, we assessed eligibility and the use of statins, PCSK9i, and IPE among US adults according to American College of Cardiology/American Heart Association guideline recommendations. Eligibility for PCSK9i and IPE were determined in the following 2 scenarios: (1) assuming existing lipid‐lowering therapy as the maximum tolerated before assessing eligibility for novel therapies and (2) assessing eligibility after assuming initiation and maximal escalation of preexisting lipid‐lowering therapies and accounting for expected lipid improvements. Of 2729 sampled individuals, representing 149.3 million adults, 1376 had indications for statins, representing 65.8 million or 44.0% (95% CI, 40.9%–47.2%) of adults. Current statin use was 45% of those eligible and was low across demographic groups. A total of 9.7 and 11.6 million adults would benefit from PCSK9i and IPE, respectively, based on lipid profiles and existing therapies. Assuming maximal escalation of statins and addition of ezetimibe, 4.1% (95% CI, 2.8%–5.4%) of adults or 6.1 million would benefit from PCSK9i and 6.8% (95% CI, 5.4%–8.3%) or 10.2 million from IPE. Conclusions Six and 10 million individuals have clinical profiles whereby PCSK9i and IPE, respectively, would be expected to improve cardiovascular outcomes even after maximum escalation of statins and ezetimibe use, but remain undertreated with lipid‐lowering therapies. Optimal use of lipid‐targeted agents that include these novel agents is needed to improve population health outcomes

Changes in Leukocyte Subpopulations with Decline in Glomerular Filtration Rate in Patients with Type 2 Diabetes

Recent studies suggested the role of white blood cells (WBCs) in the pathogenesis and complications of type 2 diabetes. Increased WBC counts predict mortality in patients with chronic kidney disease (CKD). In this study alterations in WBC subpopulations in diabetic patients with non-dialysis dependent CKD are investigated. This was a cross-sectional study  on 376 participants, including   272 diabetic  patients  and  104  healthy  controls.  Total  and  differential  WBC  counts  were  compared  among diabetics with CKD, diabetics without CKD and controls. Among patients with type 2 diabetes, there was no significant difference in total WBC count between those with and without CKD. Diabetic patients with CKD had higher neutrophil, monocyte and eosinophil and lower lymphocyte count compared with both diabetic patients without CKD and healthy controls. Except for monocytes, a significant association was observed between GFR and differential WBC counts, which persisted after adjustment for conventional diabetes riskfactors (R2=0.272, P < 0.001 for regression model). Neutrophil/lymphocyte ratio was the best predictor ofGFR in total study population (beta= -1.995 ± 0.45,

Fasting hyperinsulinaemia and 2-h glycaemia predict coronary heart disease in patients with type 2 diabetes

International audienceAim: Patients with diabetes are at greater risk of cardiovascular events. Insulin resistance (IR) and hyperinsulinaemia are both related to an increased cardiovascular risk, but whether IR predicts coronary heart disease (CHD) independently of other risk factors in patients with type 2 diabetes (T2D) is a topic of considerable controversy. The aim of the present study was to evaluate the prospective relationship of fasting insulin, HOMA-IR, fasting plasma glucose (FPG) and 2-h post-load glucose (2hPG) load with CHD incidence among such patients. Methods A total of 2607 patients with T2D were enrolled in a community-dwelling cohort and followed for an average of 7.2 years. Conventional CHD risk factors, FPG, 2hPG, fasting insulin levels and HOMA-IR index were measured at baseline. Cox regression hazard ratios (HRs) were used to assess CHD risk. Results A total of 299 ‘hard’ CHD events were registered (in 114 women and 185 men). Increasing levels of fasting insulinaemia were positively associated with CHD incidence. This correlation persisted after controlling for gender, body mass index, blood pressure, lipid profile, medication use and HbA1c [HR for each increase in quartile (fully adjusted model): 1.18 (95% CI: 1.06–1.32); P &lt; 0.01]. 2hPG showed a non-linear association with incident CHD [HR of highest vs lowest quartile: 1.64 (95% CI: 1.03–2.61)]. Fasting glycaemia was not associated with CHD risk, whereas HOMA-IR had a direct and independent correlation with CHD risk [HR for each one-quartile increase: 1.19 (95% CI: 1.07–1.34); P &lt; 0.01]. Conclusion Fasting insulin levels are positively associated with incidence of CHD in T2D. Furthermore, 2hPG appears to be a significant predictor of incident CHD independently of other risk factors, including HbA1c. These findings suggest that strategies targeting the reduction of insulinaemia and post-load glycaemia may be useful for preventing cardiovascular complication

Renal Artery Stenosis Alters Gene Expression in Swine Scattered Tubular-Like Cells

Background: Scattered tubular-like cells (STCs) proliferate and differentiate to support neighboring injured renal tubular cells during recovery from insults. Renal artery stenosis (RAS) induces renal ischemia and hypertension and leads to loss of kidney function, but whether RAS alters renal endogenous repair mechanisms, such as STCs, remains unknown. We hypothesize that RAS in swine modifies the messenger RNA (mRNA) profile of STCs, blunting their in vitro reparative capacity. Methods: CD24+/CD133+ STCs were isolated from pig kidneys after 10-weeks of RAS or sham (n = 3 each) and their gene cargo analyzed using high-throughput mRNAseq. Expression profiles for upregulated and downregulated mRNAs in RAS-STCs were functionally interpreted by gene ontology analysis. STC activation was assessed by counting the total number of STCs in pig kidney sections using flow cytometry, whereas cell proliferation was assessed in vitro. Results: Of all expressed genes, 1430 genes were upregulated and 315 downregulated in RAS- versus Normal-STCs. Expression of selected candidate genes followed the same fold change directions as the mRNAseq findings. Genes upregulated in RAS-STCs were involved in cell adhesion, extracellular matrix remodeling, and kidney development, whereas those downregulated in RAS-STCs are related to cell cycle and cytoskeleton. The percentage of STCs from dissociated kidney cells was higher in RAS versus Normal pigs, but their proliferation rate was blunted. Conclusions: Renal ischemia and hypertension in swine induce changes in the mRNA profile of STCs, associated with increased STC activation and impaired proliferation. These observations suggest that RAS may alter the reparative capacity of STCs

Absence of a positive correlation between CRP and leptin in rheumatoid arthritis

Aims: Rheumatoid Arthritis (RA) is a model of chronic inflammatory disease. In this study we evaluated the correlation of leptin and CRP in patients with RA and normal controls. Main methods: A total of 75 patients with RA and 40 healthy adults were recruited in this case-control study. RA patients were categorized into high (DAS–28 > 3.2) and low activity (DAS ≤ 3.2) group according to their DAS-28 score. Key findings: Leptin level was significantly correlated with CRP in healthy controls (r = 0.365; p < 0.05), but this correlation was lost in RA patients (r = 0.095, p = 0.41). Patients with RA had higher serum leptin levels compared to healthy controls (P < 0.01). No difference in serum leptin level was observed between patients with high and low activity disease. Also leptin was correlated with BMI in healthy controls (r = 0.326, p = 0.037). This correlation was not present in RA patients (r = 0.039, p = 0.756). Significance: We observed that the physiologic correlation between leptin and CRP and BMI and CRP was not present RA patients. This is a new study reporting the lost correlation between leptin and CRP in RA patients