implementation

Medical postgraduate trainees are given increasing levels of responsibility during training in the apprenticeship-model of training [1-3]. Responsibility is said to be a key driver of deep learning and understanding [4-7]. Trainees with greater levels of responsibility for decision making have higher levels of motivation to learn compared with trainees who self-assess as having less autonomy [5]. The Royal College of Pathologists (RCPath) indicate that ‘graded responsibility’ is part of training histopathologists and provided a framework for implementation with increasingly complex specimens suitable for reporting by more senior trainees [8,9]. 

Context: Perioperative management of morbidly obese patients undergoing bariatric surgery is challenging. Lacking standardized perioperative protocols, complication rates may be high. This retrospective study aims to quantify the incidence of significant blood pressure decreases on induction of anesthesia and intraoperative hypoxemia, before implementation of a standardized protocol designed for bariatric surgery. Design: Retrospective, observational study. Setting: A 250-bed county hospital in northern Sweden. Subjects: 219 morbidly obese patients (body mass index > 35 kg/m2) who underwent bariatric surgery between 2003 and 2008. Main outcome measures: Incidence of systolic blood pressure (SAP) falls to less than 70% of the preoperative baseline during induction of anesthesia and incidence of perioperative hypoxemia. Results: The incidence of confirmed SAP falls to below 70% of baseline at induction of anesthesia was 56.2% (n = 123/219). This incidence rose with increasing age (p < 0.001) but not with body mass index (BMI). 3.7% (n = 8/219) of cases were marked as difficult intubations. A transient period of hypoxemia was observed in 6.8% (n = 15/219) and was more common with increasing BMI (p = 0.005). Fourteen different drug combinations were used in the study population. Of those administered an induction anesthetic drug, 72.6% (n = 159/193) were given an overdose when calculated by lean body weight, but this did not correlate significantly to SAP falls (p = 0.468). Conclusion: The incidence of a significant blood pressure fall upon induction of anesthesia was common. The incidence of airway and ventilation problems were low. Overdosing of anesthetics and excessive variation in applied anesthesia methods were found.

Objective: To determine the prevalence of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in labor and delivery units in one of the epicentres of the West Coast. Study Design: This was a retrospective chart review of patients admitted to labor and delivery from April 15, 2020-May 15, 2020 after implementation of a universal testing policy on Labor and Delivery. Results: The prevalence of patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in the admitted labor and delivery population was 2.5%, of whom 87.5% were asymptomatic. Conclusion: We present additional data on the prevalence of asymptomatic SARS-CoV-2 in pregnant patients on the West Coast, which is much lower compared to other locales, possibly as a result of aggressive ‘shelter in place’ policy. Universal screening is insufficient to detect asymptomatic SARS-CoV-2 and thus rapid, universal testing should be prioritized for labor and delivery units for the protection of patients and staff, and to better allocate appropriate resources.  Key points: 1. 2.5% of 320 patients tested positive for SARS-CoV-2. 2. 87.5% of positive patients were asymptomatic. 3. Universal testing on labor and delivery is necessary. 4. ‘Shelter-in-place’ policies reduced SARS-CoV-2. 

Chest compression is the fundamental technique in cardiopulmonary resuscitation (CPR) in patients with cardiac arrest [1]. The quality and the early implementation of CPR are essential to improve the prognosis and the chances of restoring spontaneous circulation. In the literature, there are some articles about the poor quality of chest compression [2-4]. Therefore chest compression is as crucial as alerting the emergency services or early defibrillation in the survival chain. In accordance with the guidelines, chest compressions have to be performed continuously to improve the outcome [5]. However, the efficacy of manual chest compression diminishes over time with the fatigue of the provider (which appears within minutes of starting the procedure), and is impaired during transportation manoeuvres, which expose patients to unforeseen interruptions and a deterioration in the quality du massage in terms of power and rhythm. The efficacy of manual chest compression has been reported to fall by 20% per minute [6,7]. Mechanical chest compression overcome this problem of operator fatigue by ensuring constant efficacy in terms of both quality and quantity. Even though current data show no difference between manual chest compression and automated systems in terms of survival, haemodynamic studies in animal models have shown that mechanical techniques are more effective [8].

The question raised in the title of this letter is a natural consequence of the findings and conclusions that have been growing steadily in recent years regarding the results of treatment for acute pneumonia (АР). If you look at the publications of recent years in this field of medicine, it turns out that one of the main obstacles to progress in improving the results of treatment of this disease is the lack of appropriate methods for determining the pathogen. Thus, the lack of timely diagnostic information about the etiology of the disease excludes the possibility of targeted antibiotic therapy. In recent years, such regrets have become more and more relevant, playing the role of the main explanation for treatment failures .Continuing to narrow the unidirectional view of the problem and to pay attention only to the microbial factor as the main cause of the disease, such views are in fact another illusion, which, even in the case of its hypothetical implementation, will not make significant changes in the overall trend. This statement is easy to verify if you rely on well-known facts, and not use as arguments assumptions and guesses.

Among eye diseases, cataract is the most commonly encountered lens disease and the leading cause of reduced vision. Cataract caused by radiation develops due to neck & head, central nervous system tumors, eye localized tumors and total body irradiation. Today, the only treatment of cataract is surgery. Beta radiation is seen to have an important place both in the etiology and treatment of cataract. Beta-radiation creates cataract in the lens as an adverse effect. However, beta radiation implementation is used for delay or prevention of cataract in glaucoma surgery. Effects of beta-radiation on the etiology and treatment should be supported by further prospective clinical studies.

Today, there is a considerable increase in localizing adrenal bulks with the bringing radiologic diagnosis methods having high technology into use and improvement in diagnostic tests. Adrenal glands are vital tissues for the organism due to the hormones they secrete. Death is a natural result in the absence of adrenal cortex. Adrenal bulks can be seen with different clinical, laboratory and radiological data. These bulks are often benign and rarely malign. They can be functional or non-functional. Major treatment methods used fort he treatment of adrenal gland primary tumors or metastases are surgery, arterial embolisation, chemical ablation, radiofrequency ablation and radiotherapy [1-4]. Adrenal glands are one of the metastatic fields. In wide autopsy series, adrenal metastasis has been determined between the rates of 13-17% [5]. While unilateral metastasis is common, bilateral metastasis’ rate of incidence is between 4-20%. It has been stated that lung (35%), gastric (14%), esophageal (12%) and hepatobiliary (10%) primary carcinomas adrenal metastasis are prevalent most frequently [2]. Curative treatments are tested on patients having cancer with oligo metastasis limited with adrenal gland and primary source is under control because of the expectation of long-term survival, and the surgery is the first choice. These bulks can be treated with open and laparoscopic surrenalectomy in a curative way. It was reported in studies that overall survival was longer in resection of clinically isolated adrenal metastases when compared with nonsurgical therapy (including RFA, external beam radiotherapy, arterial embolization, radioembolization, chemical ablation, and cryoablation) [1,2,5,7]. Lo et al., found one-year survival as 73% and two-year survival as 40% in their study conducted on 52 patients having curative resection for solitary adrenal metastasis [3]. Tanvetyanon et al., demonstrated 5-year survival rates of 25% following resection of isolated synchronous adrenal metastases and reported 26% after resection of metachronous adrenal metastases in their study conducted on NSCLC patients developing solitary adrenal metastasis [4]. Conducted studies revealed that the rate of complication was 9-20% in patients having adrenalectomy for solitary adrenal metastasis [2-4,7]. In recent years, the use of radiotherapy, which is a treatment modality as effective as surgical resection, has become prevalent for the management of oligometastases. Today, three different modalities have been tested in the radiotherapy treatment of adrenal gland metastases. In the first one, total 50 Gy treatment dose with 3D-CRT as daily 2 Gy fraction dose is given [8]. The second one is IMRT implementations for adrenal gland metastases but it isn’t thought as suitable according to Practice Guidelines for Neuroendocrine Tumors published by NCCN in 2010. The third radiotherapy modality is stereotactic body radiotherapy (SBRT). SBRT implementations have started to be preferred today since they are completed in a few fractions in addition to that they show close results to surgery for primary tumors and metastases. Holy et al., implemented SBRT to patients having 13 solitary adrenal metastases with NSCLC at 5 fractions and between 20 and 40 Gy total doses. They found disease-free survival as median 12 months, overall survival as median 23 months and local control rate as 77% [9]. In SBRT implementations for different cancer types determined 30 adrenal metastases, Chawla et al., reported the rates of one-year survival, local control and distant metastasis as 44%, 55% and 13% respectively [10]. In Casamassima et al.,’s study on this issue, the rate of two-year local control was found as 90% [11]. Second degree toxicity was seen in none of the above mentioned studies according to the RTOG toxicity classification. Wardak et al., reported that the patient having lung cancer that they implemented SBRT for bilateral adrenal metastases developed adrenal insufficiency depending on SBRT [6]. Ippolito et al., Reported that adrenal insuffiency may be due to both the tumor and the local treatment [12]. Incidence of symptomatic adrenal insufficiency were reported 4% [2,13]. Casamassima et al and Onishi et al studies, two grade 2 adrenal insuffiencies were reported [11,14]. Consequently, when all these data were evaluated, it is seen that SBRT use has gradually become prevalent for patients not suitable for surgery because of comorbid disease, for patients having oligometastatic cancer that are not suitable for surgery since it has vital risk to resect or that refuse surgery. However, it hasn’t been clear yet that local control will be provided with how many total doses and which fraction schema. There is no agreement on the examination of the adrenal hormone axes because of the short length of life. Besides, it should be kept in mind that adrenal insufficiency can develop in patients implemented SBRT because of bilateral adrenal metastasis developing as synchronous or metachronous. The hormone levels of these patients need to be followed. More researches should be done to lighten this matter.  

Introduction: Most police officers work long hours in day and night shifts and this exposure can harm your health. Objective: Know the Body Mass Index (BMI) of a group of policemen of both sexes chosen at random to calculate the degree of overweight / obesity of the observed population. Material and Method: An cross-sectional study was carried out on 75 elements of the municipal police of sexes, obtaining age, height, and weight with which the corresponding Body Mass Index was obtained. Descriptive statistics were used. Results: Measurements were taken at 75 (100%) policemen of both of them sexes, 60 (80%) male and 15 (20%) female. And the following results were obtained: ideal weight 5 (6.6%), overweight 21 (28.0%) elements and obesity 49 (65.3%). Discussion: Obese workers are prone to getting sick, missing work, disability and early retirement when compared to non-obese workers. Obesity can be a predictor of early mortality; therefore, with a BMI of 30-35, life expectancy decreases from 2 to 4 years and with a BMI of 40-45 it decreases from 8 to 10 years. In our study we found 70 (93.3%) policemen were overweight and obese BMI> 25). Conclusions: Our findings recommend the implementation of diverse programs for the improvement of the health of this labor group with a multidisciplinary team as well as the adequate physical spaces for the practice of the corresponding activities.

Objectives: Natural disasters confront individuals, communities and governments with the challenge of rebuilding and addressing psychosocial sequelae. With the increasing number of natural disasters it is timely to evaluate the efficacy of interventions and strategies to address the mental health needs of individuals and the community. Method: An evaluation of literature related to the psychological impact of natural disasters, treatment efficacy and government strategies to confront the social and psychological impact of natural disasters for the period 1983-2016 was undertaken. Results: Epidemiological studies following natural disasters despite the use of differing psychological measures demonstrate significant psychological morbidity - anxiety (7-42%), complicated grief (28-41%), depression (6.5-38%), post-traumatic stress disorder (11-89%) and substance misuse (1.3-24%). Intervention studies post-disaster demonstrate efficacy variability. Conclusions: The increase in the number and impact of meteorological and hydrological events since the 1980s and the psychological, social and economic consequences of these events has resulted in the development and implementation of government policies to confront the immediate and long-term adverse outcomes. The focus is typically on resources and infrastructure redevelopment with less focus on social and mental health interventions with long-term evaluation of interventions uncommon. The consequence of natural disasters emphasizes the importance developing strategies to ensure effective evaluated psychosocial interventions are available across at-risk communities.

Levels of electrically evoked stapedial reflex thresholds (eESRTs) are frequently used as most comfortable levels (MCL) in cochlear implant fitting. The problem of routine one-channel-technique of reflexometry is long duration of this procedure. In order to “compress the time” we suggest method of consecutive stimulation of all electrodes of implant with simultaneous registration of stapedial reflexes-SWEEP-session. Practical implementation of the SWEEP-session is described here. This method has been successfully used in several hundred CI patients. Registration of evoked electrical stapedial reflex thresholds (eESRTs) during CI fitting is long procedure. In order to “compress the time” we suggest our SWEEP-session method. Practical implementation of this SWEEP-session is described here in accordance with the patent of Russian Federation.

The National Programme for Prevention and Control of Deafness (NPCD) was launched in 2006 by Government of India, but despite its phase wise implementation, the community oriented ear care has not been properly realized in view of existing IPHS Standards 2012 at PHC Level. So understanding of its real impact after implementation is desired. Therefore the Impact of Implementation status of community oriented ear care at the primary health system level on NPCD in India needs exploration.

Background: The measures are being put in place for the management of Hepatitis B virus (HBV) infection in Hargeisa, Somaliland among pregnant women remain the most vulnerable to develop chronic hepatitis. Routine screening in pregnant women is therefore necessary for effective control. However, the performance of the commonly used the HBsAg sero test strips has been available. Also, identifying the risk factors of transmission in pregnant women is importance for the implementation of preventive measures. Hence, the goal of this study was to determining seroprevalence and associated risk factors with HBV infection among pregnant women. Material & Methods: The study area was carried out at Hargeisa group hospital in Somaliland from May 2018 up to December 2018. The researcher was collected research pregnancy woman data through questionnaire & used diagnostics methods such as Hepatitis B surface antigen (HBsAg) test, antibodies test (HBsAb) by used anti-card test and ELIZA system. In order to find specific full information’s about patients & relationship the associated risk factors with hepatitis B in pregnancy. Data processed and analyzed by used both words and SPSS package. The sample size investigated was 80 patients. Of these, 28 were excluded; among the reasons for exclusion were prior HBV vaccination and known HBsAg sero-positive status. Aims of Study: The study was designed & aimed to determine seroprevalence and associated factors of HBV infection among pregnant women. To assess and establish if there is significant relationship between blood transfusion and hepatitis B virus at Hargeisa group hospital (HGH). Results and Discussion: The results in the current study shown that the pregnancy with hepatitis BV and it relation with appeared some symptoms in our study was 24(46.15%) of patients appeared they have cirrhosis symptom, 12(23.08%) of patients answered they have liver failure, while 9(17.31%) of patients appeared yellowish of eyes & skin and 5(9.62%) showed hepatic cancer. Overall, HBV prevalence: HBsAg was detected in fifteen 15(31.3%) of the participants while all fifteen (100%) had total HBcAb (both IgM and IgG). Of the HBsAg sero-positive women, 26(42.7%) were positive for HBeAg; eight (13.3%) were positive for HBeAb and four 4(9%) were negative for both HBeAg and HBeAb which was close similar with other previous studies. On the other hand, We found identify statistically significant p-values < 0.05 and high relationship between HBV and some demographic and clinical risk factors such as blood transfusions, levels of knowledge about HBV infection in addition to age and marital status. Conclusion: The results of this study showed that the seroprevalence of HBV infections in pregnant women and it relationship with blood transfusion in Hargeisa Group Hospital, Hargeisa, Somaliland is high. However, further studies are needed to assess the role of other demographic and clinical risk. Urgent action is required to improve hepatitis B infection control measures to reduce dependence on blood transfusions and make new policies for treatment of anemia in HGH

Acute gastroenteritis (AGE) is a common presenting complaint in paediatrics. Most often, the reason for admission into hospital is to initiate intravenous rehydration in patients with severe dehydration and inability to tolerate oral intake. We found that Ondansetron acts as a potent antiemetic to support an increased number of children receiving oral hydration, and subsequently leading to decreased rates of admission. This study aims to audit the use of Ondansetron to Oral Rehydration Therapy (ORT) on children with acute gastroenteritis, and its effect on admission rates from the emergency department in University Hospital, Limerick (UHL). Data collected over a 3-month period from June to August 2017 in which Ondansetron was not used was compared to another 3-month period when Ondansetron was used. Several outcomes were measured including admission to hospital. The rate of admission decreased by 15% [26/74 (35%) in 2017 to 16/81 (20%) in 2019 p = 0.22]. 81 patients received Ondansetron, of which 79% were successfully rehydrated orally. The administration of Ondansetron reduced the need for intravenous fluids and hospital admission overall in these children with AGE. This reduction ultimately accounted for lower costs incurred by the Health Services Executive per patient, and also suggested the anti-emetic use as a cost effective measure for managing and treating patients with AGE.

Despite critical care advances, robust antibiotic therapy and improved strategies in early detection and prevention of infection, the incidence of morbidity and mortality from neonatal sepsis worldwide in preterm and low birth weight neonates remains overwhelmingly high. Neonatal sepsis is characterised by a clinical syndrome of systemic signs of infection and bloodstream bacteraemia in newborns within the first months of life. The risk of sepsis in neonates is inversely proportional to gestational age and birth weight due to deficiency in humoral immunity and the need for more invasive supportive neonatal intensive care unit interventions. Adverse effects such as necrotising enterocolitis associated with antimicrobial therapy are serious enough to warrant exploration of alternative therapeutic strategies. Immunoglobulin replacement therapy offers hope of enhancing immune competence and reducing infection rates in vulnerable populations. It is evident from the relevant studies to date that the benefits offered by intravenous immunoglobulin prophylaxis may not be significant enough for routine hospital implementation. Further research to better understand the mechanisms underlying immunodeficiency will lead to the realisation of alternative therapeutic and prophylactic interventions.

Objective: This study discusses strategies to overcome hypertension patient compliance to manage self-care. The purpose of the study is to provide a summary of the importance of attention to managing hypertension. Method: a review of literature relevant to hypertension, policies, and management, both pharmacological and non-pharmacological, through cross-programs or sectors. Result: This study found that the ministry of health had compiled various policies to reduce the prevalence of hypertension, including technical guidelines for its implementation, but the strategy has not yet fully reached the minimum service standard, which is because it has not fully involved the relevant cross sectors. Conclusion: Improve the coordination system by “Joint Decree” between the Ministry of Health and the Ministry of Villages, PDT and Transmigration, the Ministry of Social Affairs, Indonesian National Army, police, and NGOs to carry out activities simultaneously to the community.

Background: NSU is generally caused by right cerebral hemisphere lesions with a preeminent localization on the frontoparietal lobe. Aim: To assess the correlation between the typology and the brain lesion site and the consensual consent modality of body image modification after an integrated rehabilitative and neuropsychological treatment. Setting: A rehabilitation institute for the treatment of neurological gait disorders and neuropsichological failures. methods: Patients recruited were divided according to the brain lesion site into 3 groups (IG = ischemic group = 5 patients; HG = hemorrhagic group = 4 patients; IG + HG = ischemic + hemorrhagic group = 3 patients) based on CT brain performed in the post-acute phase. At time T0, the patients recruited underwent a systematic review of their current neuroradiological profile (location delineation and type of brain injury) compared with a consensual framing of the neuromotor and neuropsychological profile acquired at the time of taking charge in the ward. At time T1 and after the drafting and implementation of the rehabilitation treatment plan foreseen in the study (1 to 4 months after T0), the patients in our sample underwent a re-evaluation of their neuromotor and neuropsychological profile with controls of the same outcome parameters considered at time T0. Results: A parametrically but not statistically significant modification of the results obtained was observed by measuring the MI ULl, MI LLl and TCT scales in the group with hemorrhagic brain injury; the analysis of variance did not show any statistical significance in the relationship between the type of stroke (ischemic, hemorrhagic or both) and the motor impairment passing from time T0 to time T1. The analysis of variance did not reveal a statistically or parametrically significant relationship between the type (ischemic, hemorrhagic and ischemic + hemorrhagic) of cerebral stroke and the variations of the neuropsychological profile. The T-Student test showed statistically significant changes in the importance of the lesion site in defining the degree of motor disability. In particular, we observed, about the presence of frontal lobe lesions, a statistically significant variation passing from the T0 time to the T1 time for the following motor scales in 9 of 12 recruited patients: MI LLl (26.4 vs. 62, with p < 0.05), TCT (43.6 vs. 80.6, with p < 0.01 for equal variance assumed and p < 0.05 for equal variance not assumed), FAC (0.8 vs. 2.3 with p < 0,01 for equal variance assumed and p < 0.05 for equal variance not assumed). Conclusion: We have confirmed the importance of the anatomical-dysfunctional correlation as a key concept from which to start in any neurorehabilitative treatment approach. Our work has highlighted the basic role of the right frontal lobe in the programming and execution of the gesture and its kinesthetic control as regards the left lower limb and the trunk.

Background: Post exposure chemoprophylaxis can prevent human immunodeficiency virus (HIV) infection in risk healthcare workers; however routine adoptions of these practices by the workers have been limited. Objective: To assess knowledge and attitude of health workers on HIV post-exposure prophylaxis and exposure to sharp injuries in Dessie referral hospital. Methods: Across-sectional study was conducted on 422 health care workers of Dessie referral Hospital. The study subjects were selected by proportional allocation of each sample in its respective department/ward. Simple random sampling method was used to select study participants. The data was cleaned coded and analyzed by using statistical package for social sciences (SPSS) version 23. Finally the result was presented by graphs, pie chart and statements. Results: A total of 422 study subjects were participated in the study. Among 422 participants 72.5% had good knowledge of post exposure prophylaxis for HIV and the rest 27.5% had poor knowledge of post exposure prophylaxis for HIV. Among 422 study participants 75.2% had positive attitude towards PEP. 283(67.1%) of them had exposure to sharp injuries. Conclusion: Generally most of health care workers had good knowledge about post exposure prophylaxis against HIV/AIDS. This study had shown that a significant number of individuals had a negative attitude with regard to post exposure prophylaxis. Therefore, formal training that aims to improve attitudes and support to improve PEP implementation and completion are needed. 

Dissecting aortic aneurysm with ST segment elevation, and pulmonary embolism with ST segment elevation are two of a number of clinical entities which can simulate ST segment elevation myocardial infarction. Objective: The purpose of this review is to analyse clinical features in anecdotal reports of 138 dissecting aortic aneurysm patients with STEMI-like presentation, and 102 pulmonary embolism patients with STEMI-like presentation in order to generate insights which might help to optimise triage of patients with STEMI-like clinical presentation. Methods: Reports were culled from a literature search covering the period January 2000 to March 2020 using Googlescholar, Pubmed, EMBASE and MEDLINE. Reports were included only if there was a specification of the location of ST segment elevation and an account of the clinical signs and symptoms. Search terms were “ST segment elevation”,”aortic dissection”, “pulmonary embolism”, “myocardial infarction”, and “paradoxical embolism”. Fisher’s exact test was utilised for two-sided comparison of proportions. Proportion was calculated for each group as the number of patients with that parameter relative to the total number of patients assessed for that parameter. Findings: There were 138 patients with aortic dissection, 91 of whom were either fast-tracked to coronary angiography (81 patients) or fast-tracked to thrombolytic treatment (10 patients). There were 47 patients managed with neither of those strategies. There were 102 patients with pulmonary embolism, 71 of whom were fast tracked to coronary angiography, and 31 who did not receive that evaluation. Compared with their dissecting aortic aneurysm counterparts, those dissecting aortic aneurysm patients initially managed by percutaneous coronary intervention or by thrombolysis were significantly (p = 0.0003) more likely to have presented with chest pain, and significantly (p = 0.018) less likely to have presented with breathlessness. The preferential fast-tracking to coronary angiography prevailed in spite of comparable prevalence of back pain in fast tracked and in non-fast tracked subjects. Use of transthoracic echocardiography was also comparable in the two subgroups of dissecting aortic aneurysm patients. Pulmonary embolism patients fast tracked to percutaneous coronary intervention were significantly (p = 0.0008) more likely to have presented with chest pain than their pulmonary embolism counterparts who were not fast-tracked. The prevalence of paradoxical embolism was also significantly (p = 0.0016) higher in fast-tracked patients than in counterparts not fast-tracked. Cardiac arrest was significantly (p = 0.0177) less prevalent in fast-tracked pulmonary embolism patients than in pulmonary embolism patients who were not fast-tracked. Preferential fast-tracking to coronary angiography prevailed in spite of the fact that prevalence of documented deep vein thrombosis was comparable in fast-tracked subjects and in subjects not fast-tracked. The prevalence of use of transthoracic echocardiography was also similar in fast-tracked pulmonary embolism patients vs counterparts not fast tracked. Overall, however, transthoracic echocardiography had been utilised significantly (p = 0.007) less frequently in dissecting aneurysm patients than in pulmonary embolism patients. Conclusion: Given the high prevalence of STEMI-like presentation in aortic dissection there is a need for greater use of point-of-care transthoracic echocardiography to mitigate risk of inappropriate percutaneous coronary intervention(which might delay implementation of aortic repair surgery) and inappropriate thrombolysis(which might precipitate hemorrhagic cardiac tamponade) (75) during triage of patients presenting with ST segment elevation simulating ST segment elevation myocardial infarction (STEMI). Furthermore, during triage of patients with STEMI-like clinical presentation, the combined use of point-of -care echocardiography and evaluation for deep vein thrombosis will facilitate the differentiation between acute myocardial infarction, STEMI-like aortic dissection, and STEMI-like pulmonary embolism. Among STEMI-like patients in whom DAA has been ruled out by point of care TTE, fast tracking to PCI might generate an opportunity to identify and treat paradoxical coronary artery embolism by thrombectomy. Thereby mitigating the mortality risk associated with coronary occlusion. Concurrent awareness of PE as the underlying cause of paradoxical embolism also generates an opportunity to relieve the clot burden in the pulmonary circulation, either by pulmonary embolectomy or by thrombolysis. Above all, frontline clinicians should have a greater awareness of the syndrome of STEMI-like presentation of aortic dissection and STEMI-like pulmonary embolism so as to mitigate the risk of inappropriate thrombolysis and inappropriate percutaneous coronary angiography which seems to prevail even in the presence of red flags such as back pain (for aortic dissection) and deep vein thrombosis(for pulmonary embolism). 

Due to the urgent need for water in all parts of industrial or developing societies, water supply, and transmission facilities are suitable targets for biological risks. Given that even a short interruption in water supply and water supply operations has a great impact on daily activities in the community, the deliberate contamination of urban water resources has irreparable consequences in the field of public health, and the economy of society will follow. Unfortunately, most officials in the public health control departments in our country have received limited training in detecting accidental or intentional contamination of water resources and dealing with the spread of waterborne diseases both naturally and intentionally. For this reason, there is low preparedness in the responsible agencies to deal with waterborne diseases during biological risks. In the first step of this research, a review study has been conducted on water biological risks and operational strategies to deal with them. In the following, it has studied how Escherichia coli (E. coli) bacteria spread in aqueous media. In this regard, the kinetic model of the studied microorganism was analyzed based on the implementation of (Fick Law) in polar coordinates and the combination of (Dirac Distribution) with (Legendre polynomial) distribution. Finally, after studying the factors affecting the microbial pollutant emission coefficient, the effects of all three factors of linear velocity, linear motion time period, and angle of motion on the pollutant emission flux and biofilm diffusion time in the water supply network environment were investigated. Studies have shown that the linear velocity parameter of Escherichia coli with a nonlinear relationship has the greatest effects on the release of microbial contaminants.

Background: Delirium is an acute syndrome of organ dysfunction with long-term consequences which commonly occurs in the Intensive Care Unit (ICU). The incidence of delirium ranges from 30% - 50% in low severity ICU patients and up to 80% in mechanically ventilated patients. This condition is frequently under-recognized and daily routine screening is a key strategy to early intervention. The Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) and the Intensive Care Delirium Screening Checklist (ICDSC) are the most recommended assessment tools for detecting delirium in the critical ill patient. Objective: The main objective of this study is to educate ICU staff about delirium. In addition, nurses were trained to use the CAM-ICU as a standard screening tool. The intervention was evaluated through a survey aimed at ICU staff. Methods: An educational intervention was started in 2014 in our ICU. An educational package for ICU staff consisted of a didactic brochure and explanatory videos. One-on-one teaching, case based scenarios and didactic teaching were strategies used in the implementation process. The entire intervention was evaluated by means of a survey directed to the professionals. Results: The structure of the didactic brochure was simple in order to have an easy understanding of the CAM-ICU tool. We also created 10-minute videos. According to the results of the satisfaction survey (N=62), disorganized thinking was the most difficult feature of CAM-ICU to interpret. When in doubt, consultation between co-workers was the primary resource selected by unit staff. Conclusion: This initiative achieved the objective of training health care professionals in the application of the CAM-ICU tool with a good level of satisfaction from them. Therefore, ICU staff consider delirium management in the broader picture of critically ill patient care as a major activity of daily practice.