Pleural effusion as a manifestation of multiple myeloma

Multiple myeloma is a clonal B-cell malignancy, characterised by proliferation of plasma cells and secretion of paraproteins. These plasma cells accumulate predominantly in the bone marrow; rarely, they invade other areas, especially the thorax. Myeloma presenting with a pleural effusion is rare and reported in only 6% of patients with myeloma. Such patients generally present late and have a poor prognosis. Here, we describe a patient presenting with a lung mass, renal failure and a massive unilateral pleural effusion due to multiple myeloma who was treated successfully

683 Cost effectiveness of reducing CLABSI in the limited resource setting of developing countries

Introduction: A recent meta-analysis by the World Health Organization estimated that the rate of central-line associated blood stream infections (CLABSIs) among adult ICU patients in developing countries was 12.2 per 1000 central line days which is 2-3 fold higher than in developed countries, and account for a crude unadjusted excess mortality of 15% to 24%. This burden is not only unacceptably high, but for the most part remains unaddressed. Excellent evidence exists for CLABSI rate reduction, like the bundled initiative by Pronovost et al. that utilized five steps to significantly reduce the incidence of CLABSIs. We will evaluate the cost effectiveness of implementing the bundled care approach published by Pronovost et al for CLABSI prevention, and compare it to the scenario of not utilizing it at baseline.Methods: We performed a cost-effectiveness evaluation using a decision tree analysis with the TreeAge software. The intervention was considered to be the implementation of a bundled intervention to reduce CLABSI, and was compared to the baseline of not applying it. A probabilistic sensitivity analysis was performed using a Monte Carlo simulation of 10,000 patients. Distributions were created for several parameters including total costs, total effects and probability of developing a CLABSI with and without the bundle intervention.Results: Patients in the baseline group who expire from a CLABSI were found to incur costs of $3531, while those who survive cost$4136 per patient. By comparison at baseline, ICU patients without CLABSI who are discharged cost $1502 and those who expire in the ICU cost$1199. With bundle implementation, patients who die from CLABSI were found to cost $3609 while those that survive having a CLABSI$4214. With the bundled intervention, average patients discharged from the ICU cost $1579 and those who die cost$1277. As a group, regardless of intervention, patient who died from a CLABSI lost 21.89 DALYS, while patients who survived a CLABSI lost 6.8 DALYs. By contrast, the average ICU survivor who did not experience a CLABSI lost 1.38 DALYs, while those who died lost 21.91 DALYs. The baseline cost-effectiveness analysis results show that implementing the bundled intervention as modeled was more expensive by $43.65 for the overall ICU stay of the average patient, but saved 0.14 DALY per patient with a central line. For these estimates, the incremental cost-effectiveness ratio come out to$301.57 per DALY averted, well under the cost-effectiveness acceptability threshold of twice the capital gross national income of most low- and middle-income countries.Conclusions: This analysis provides evidence that implementation of a bundled approach to reduction of CLABSI can be both effective and cost-effective across limited resource settings such as those found in developing countries

Implementing work place based assessment: the modified direct observation of procedural skills (DOPS) across medical specialties. An experience from a developing country

Objective: To assess the skill level of residents regarding central venous catheterisation insertion, and to assess the reliability of scores in a simulated situation. Methods: The quasi-experimental study with pre- and post-test design was conducted from February to June 2013 at the Aga Khan University, Karachi, and comprised four workshops attended by residents. The workshops were video-recorded for feedback and self-assessment. At the end of the workshops, knowledge and procedural skills were assessed using a self-generated 38-item, task-specific instrument after ensuring its content validity. Data was analysed using SPSS 19. Results: There were 40 residents in the sample. The self-generated instrument was reliable with Cronbach’s alpha value 0.83 and inter-rater coefficient 0.79. There was significant improvement in the skills level post-intervention compared to the baselines mean values (p=0.001). The subjects were satisfied with the workshops, as indicated by a mean score of 8.83+/-1.367. Conclusions: The workshops appeared to improve the central venous catheterisation insertion skills of the residents. Key Words: Direct observation of procedural skills, Workplace-based assessment, Postgraduate medical education, Resident, Central venous catheterisation. Continue.