Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study

Background: In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient’s autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown.Aim: To determine the barriers and perceptions in discussion of code status by physicians.Design: Questionnaire-based cross-sectional study.Setting and participants: This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included.Results: A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal discomfort in discussing death (29.8%), and fear of legal consequences (28.5%) were the top most barriers. In hospital-related barriers, time constraint (57.1%), lack of hospital administration support (48.0%), and suboptimal nursing care after do not resuscitate (48.0%) were the most frequent. There were significant differences among opinions of trainees when compared to those of attending physicians.Conclusion: Family-related barriers are the most frequent roadblocks in the end-of-life care discussions for physicians in Pakistan. Strengthening communication skills of physicians and family education are the potential strategies to improve end-of-life care. Large multi-center studies are needed to better understand the barriers of code status discussion in developing countries

Applying a mixed-method approach to improve on-the-job learning and job satisfaction in a cohort of interns at a university hospital

Introduction: Job satisfaction is vital for the optimal functioning of medical practitioners. Herein, we report our experience of restructuring the internship program by identifying the gaps, developing, implementing strategies to overcome gaps and sharing the results of the pre-implementation and post-implementation audit, as an example for establishing a system for improving intern\u27s work-based learning and satisfaction in a university hospital setting.Methods: Using Kern\u27s six-step instructional model, a prospective mixed-method study was conducted at Aga Khan University Hospital. In phase 1 (2013) gaps were identified by evaluating various aspects of the internship program. Strategies were developed and implemented to overcome the identified gaps. In phase 2 (2014-2016) the impact of these developmental strategies was assessed.Results: A total of 65 interns, 30 residents, and 22 faculty members participated in phase I, while 71 interns participated in phase II. The reformation of orientation sessions, including practical exposure and content of sessions, opportunities to enhance hands-on experience and supervision in inpatient areas, operating rooms, supervision by fellows, supervision for hands-on procedures, career counseling, and mentorship, led to significant improvement in satisfaction. It was identified that the lack of hands-on opportunities can be overcome by surgical skills-based workshops. These reforms led to an overall rise in intern satisfaction (50% vs 75.4%, p=0.02).Conclusion: Periodic restructuring of an existing program helps to improve the work-based learning experience and overall satisfaction among interns. This not only maximizes learning but also eases interns into their postgraduate life and workload subsequently enabling them to become more competent and well-rounded health practitioners

HUNGER AND DEATH OF HUMANS: A SEMIOTIC ANALYSIS OF ICONIC GENOCIDES IMAGES OF THE WORLD

The intentional destruction of a particular race, ethnicity, religious groups or nationality is referred by Genocide. Genocides have occurred (and continue to occur) in every corner of the globe, in societies ancient and modern, as in Iraq and some other Arab and Islamic countries, for reasons as diverse as the acquisition of land and resources, to the demented hatred of a single man. Images work hand in hand with written records and books to document the cruelty of those historical incidents. The present study analyses ten images of the most heinous genocides in human history on semiotic bases in order to reach the meanings that an image conveys. The study concludes that images connote meanings beyond the mere presentation of a person. Children appear as signs of innocence and freedom, but sometimes they represent lost childhood and aging. Positive connotations characterize the appearance of women, such as passions, wisdom and protection while in other images, they signify hunger, distraction and their inability to provide shelter for their children and food to satisfy their hunger. In some images, men signify power and control while in others they signify hopelessness and humility. It is also noticeable that black people as well as white ones are equally the victims of those genocides. This may deliver the message that violence does not exclude anyone.   &nbsp

Is endoscopic third ventriculostomy a viable treatment option for normal pressure hydrocephalus? A systematic review

Background: Endoscopic third ventriculostomy (ETV) is considered an alternative treatment for hydrocephalus and has become a standard of care for obstructive hydrocephalus. Recent studies have also explored its role in normal pressure hydrocephalus (NPH). We conducted a systematic review aiming to assess the outcomes of this minimally invasive endoscopic technique as a viable treatment option for NPH.Methods: A systematic literature search was performed using PubMed and Scopus databases, using iterations of search terms Endoscopic third ventriculostomy, Idiopathic normal pressure hydrocephalus, and Normal pressure hydrocephalus. To be eligible for inclusion in the review, articles had to report the usage of ETV as a primary treatment modality for NPH, report its outcomes, and be published in the English language.Results: Out of the 13 studies selected for qualitative synthesis, nine supported the use of ETV for NPH as an effective treatment option with improvement in the preoperative symptoms. Two studies favored shunt over ETV, stating that quality of life is better with VP shunt insertion. One study reported that ETV has higher perioperative mortality rates that outweigh its benefits. One study reported it to be an ineffective surgical option.Conclusion: The current review of evidence does not support the use of ETV for the treatment of NPH, except perhaps in a small subset of patients. These patients have a shorter duration of symptoms and a better preoperative neurological status. The lumbar infusion test and ventricular infusion test are modalities useful for selecting these candidates

Marine collagen as a source of bioactive molecules. A review.

Skins, scales and bones are the major by-products of the fish-processing industry. These by-products are not regarded as ordinary saleable products and are usually discarded causing a heavy environmental impact. However, marine by-products are a good source of collagen that could be extracted and further enzymatically hydrolyzed to liberate interesting bioactive peptides. Collagen-derived peptides may exhibit interesting antioxidant activity, potent antihypertensive activity, antimicrobial activity against different strains of bacteria, protective effect on cartilage, capacity to stimulate bone formation, and also other interesting activities (e.g., satiety, calciotropic, or opioid). The bioactive properties of collagen-derived peptides, and also their resistance to protein digestion, make them potential ingredients of health promoting foods.Peer Reviewe

Impact of sequential capacity building on emergency department organisational flow during COVID-19 pandemic: a quasi-experimental study in a low-resource, tertiary care centre

Introduction A quasi-experimental study was conducted to estimate the impact of sequential emergency department (ED) capacity building interventions on key performance indicators such as patients’ length of stay (LOS) and wait time (WT) during the COVID-19 pandemic. This was achieved through augmenting personnel education and head count, space restructuring and workflow reorganisation.Setting and participants This study included 268 352 patients presenting from January 2019 to December 2020 at Indus Hospital and Health network Karachi, a philanthropic tertiary healthcare facility in a city of 20 million residents. A follow-up study was undertaken from January to December 2021 with 123 938 participants.Primary and secondary outcome measures These included mean and median ED-LOS and WT for participants presenting in different cohorts. The results of the pre-COVID-19 year 2019 (phase 0) were compared with that of the COVID-19 year, 2020 (phases 1–3 corresponding to peaks, and phase 4 corresponding to reduction in caseloads). The follow-up was conducted in 2021 to see the sustainability of the sequential capacity building.Results Phases 1, 2 and 3 had a lower mean adjusted LOS (4.42, 3.92 and 4.40 hours) compared with phase 0 (4.78 hours, p<0.05) with the lowest numbers seen in phase 2. The same held true for WT with 45.1, 23.8 and 30.4 min in phases 1–3 compared with 49.9 in phase 0. However, phase 4 had a higher LOS but a lower WT when compared with phase 0 with a p<0.05.Conclusion Sequential capacity building and improving the operational flow through stage appropriate interventions can be used to off-load ED patients and improve process flow metrics. This shows that models created during COVID-19 can be used to develop sustainable solutions and investment is needed in ideas such as ED-based telehealth to improve patient satisfaction and outcomes

Interfacial Reactions of Tetraphenylporphyrin with Cobalt-Oxide Thin Films

We have studied the adsorption and interfacial reactions of 2H-tetraphenylporphyrin (2HTPP) with cobalt-terminated Co3O4(111) and oxygen-terminated CoO(111) thin films using synchrotron-radiation X-ray photoelectron spectroscopy. Already at 275 K, we find evidence for the formation of a metalated species, most likely CoTPP, on both surfaces. The degree of self-metalation increases with temperature on both surfaces until 475 K, where the metalation is almost complete. At 575 K the porphyrin coverage decreases drastically on the reducible cobalt-terminated Co3O4(111) surface, while higher temperatures are needed on the non-reducible oxygen-terminated CoO(111). The low temperature self-metalation is similar to that observed on MgO(100) surfaces, but drastically different from that observed on TiO2(110), where no self-metalation is observed at room temperature.Fil: Wechsler, Daniel. Universitat Erlangen-Nuremberg; AlemaniaFil: Fernández, Cynthia Carolina. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Química, Física de los Materiales, Medioambiente y Energía. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Química, Física de los Materiales, Medioambiente y Energía; ArgentinaFil: Tariq, Quratulain. Universitat Erlangen-Nuremberg; AlemaniaFil: Tsud, Nataliya. Elettra - Synchrotron Ligght Laboratory; ItaliaFil: Prince, Kevin C.. Consiglio Nazionale delle Ricerche; Italia. Istituto Officina dei Materiali; Italia. Elettra - Synchrotron Ligght Laboratory; ItaliaFil: Williams, Federico José. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Química, Física de los Materiales, Medioambiente y Energía. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Química, Física de los Materiales, Medioambiente y Energía; Argentina. Universitat Erlangen-Nuremberg; AlemaniaFil: Steinrück, Hans Peter. Universitat Erlangen-Nuremberg; AlemaniaFil: Lytken, Ole. Universitat Erlangen-Nuremberg; Alemani

Temperature-Dependent Reactions of Phthalic Acid on Ag(100)

We have investigated the adsorption and temperature-dependent reactions of phthalic acid on Ag(100), in the temperature range 110-700 K, by synchrotron radiation X-ray photoelectron spectrocopy (SR-XPS), temperature-programmed desorption (TPD) and near-edge X-ray absorption fine structure (NEXAFS). Phthalic acid adsorbs intact at 110 K, but decomposes to phthalic anhydride and polyanhdride at 150 K. When heated further, phthalic anhydride desorbs at 250 K, leaving only polyanhydride on the surface, which at 350 K decomposes into a carboxylate, through desorption of phthalic anhydride and water. The carboxylate is stable until 500 K, after which it decomposes, through desorption of CO2 and benzene, into carbon; the latter diffuses into the bulk, leaving only a little carbon on the Ag(100) surface at 600 K.Fil: Franke, Matthias. Universitat Erlangen-Nuremberg; AlemaniaFil: Marchini, Florencia. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Química, Física de los Materiales, Medioambiente y Energía. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Química, Física de los Materiales, Medioambiente y Energía; ArgentinaFil: Zhang, Liang. Universitat Erlangen-Nuremberg; AlemaniaFil: Tariq, Quratulain. Universitat Erlangen-Nuremberg; AlemaniaFil: Tsud, Nataliya. Charles University; República ChecaFil: Vorokhta, Mykhailo. Charles University; República ChecaFil: Vondraćek, Martin. Academy of Sciences of the Czech Republic; República ChecaFil: Prince, Kevin. Elettra - Synchrotron Ligght Laboratory; ItaliaFil: Röckert, Michael. Universitat Erlangen-Nuremberg; AlemaniaFil: Williams, Federico José. Consejo Nacional de Investigaciones Científicas y Técnicas. Oficina de Coordinación Administrativa Ciudad Universitaria. Instituto de Química, Física de los Materiales, Medioambiente y Energía. Universidad de Buenos Aires. Facultad de Ciencias Exactas y Naturales. Instituto de Química, Física de los Materiales, Medioambiente y Energía; ArgentinaFil: Steinrück, Hans-Peter. Universitat Erlangen-Nuremberg; AlemaniaFil: Lytken, Ole. Universitat Erlangen-Nuremberg; Alemani