A Thesis submitted to The University of Arizona College of Medicine - Phoenix in partial fulfillment of the requirements for the Degree of Doctor of Medicine. / In the United States, bronchiolitis has consistently been the most common diagnosis leading to hospitalization in infants under one year of age, representing over 90,000 cases a year and a significant financial burden on the healthcare system. A condition with such widespread incidence should have an established algorithm for treatment of respiratory symptoms, but studies on the efficacy of certain therapies have been inconclusive. Some reports suggest that the use of positive pressure nebulization may be of benefit in treating bronchiolitis, but it has not yet been studied systematically. 1) To determine whether positive pressure nebulization (PPN) is more effective than standard nebulization (SN) in reducing admission rate in infants with bronchiolitis 2) To determine whether the use of positive pressure nebulization causes a change in Bronchiolitis Score, Pediatric Intensive Care Unit (PICU) admission rate, length of stay (LOS), and unscheduled returns to the pediatric emergency department (PED). The project is a retrospective study conducted at a single‐center tertiary care children's hospital. Participants included in the study were infants 2‐24 months of age with moderate to severe bronchiolitis, who were evaluated by trained respiratory therapists using an objective scoring tool and treatment algorithm that included suctioning, albuterol, and racemic epinephrine. Infants received the above nebulization therapies by either a standard or a positive pressure nebulization delivery device. The two treatment groups were compared to see if one approach was superior as measured by outcomes such as hospital and PICU admission rate, length of stay, and returns to the emergency department. Initial survey of the 2012‐2013 winter season at Phoenix Children's Hospital yielded 2,095 patients who were diagnosed with bronchiolitis. As the majority of patients were excluded due to age, comorbidities, or poor documentation of treatment, our study examined 19 patients who received positive pressure nebulization, which were matched in a 1:3 ratio (PPN:SN), for a total of 57 patients who received standard nebulization. In measuring the primary markers of outcome, we found that 12 of the 19 PPN patients (63%) were admitted to the regular pediatric ward, and 4 of the 19 (21%) were admitted to the PICU. 35 of the 57 SN patients (63%) were admitted to the regular pediatric ward, and 5 of the 57 (8%) were admitted to the PICU. Statistical analysis showed that the estimated minimum 'n' required in each treatment group was 252 patients, but our study was only able to obtain a sample size of 19 patients in the PPN group, which was not enough for statistical significance. An association between hospital admission rate with positive pressure nebulization or standard nebulization was not able to be determined.

Class of 2010 Abstract / OBJECTIVES: The objective of this study was to evaluate whether implementation of new anticoagulation policy at a community hospital resulted in better monitoring of warfarin, increased warfarin patient education prior to discharge, and less bleeding complications due to warfarin. METHODS: This study was a pre-­‐ post-­‐retrospective chart review quality improvement study. A retrospective chart review was conducted of all patients who were inpatients and received warfarin in the time period of April 1, 2008 to July 31, 2008 (historical control group before implementation of the new anticoagulation program) and the time period of April 1, 2009 to July 31, 2009 (after implementation of the new anticoagulation policies). To compare appropriateness of laboratory monitoring, the frequency of warfarin-­‐related laboratory orders that included a baseline international normalized ratio (INR), daily INR, baseline complete blood count (CBC), and CBC every 3 days were assessed before and after program implementation. The analysis was repeated for the frequency of patient education that included documentation by pharmacy, nursing, and dietary services. Finally, data was collected to determine frequencies of bleeding complications associated with warfarin. RESULTS: There were 112 patients in the pre-­‐policy group and 115 patients in the post-­‐policy group. After implementation of the inpatient warfarin policy, obtaining baseline INRs increased from 74% to 90% (p=0.001). In addition, prescriber orders for baseline CBCs increased from 85% to 94% (p=0.026). Obtaining CBCs every 3 days increased from 54% to 74%, (p<0.001). However, there was not a significant increase in orders for daily INR levels (p=0.055). Education by nursing increased from 54% to 80%, (p<0.001). Education by pharmacy increased from 8% to 76%, (p<0.001). Education by dietary increased from 11% to 79%, (p<0.001). Moreover, documentation by all three disciplines in each patient increased significantly from 3.6% to 59%, (p<0.001). There were significantly fewer patients receiving vitamin K and/ or fresh frozen plasma for supratherapeutic INRs with bleeding complications after the policy was initiated compared to baseline (p=0.009). CONCLUSIONS: The implementation of an inpatient warfarin policy led to better monitoring of patients receiving warfarin, and increased patient education. Studies have demonstrated that increased monitoring of warfarin translates to improved patient outcomes. However, a larger and longer assessment is necessary to determine if these changes are maintained and how these changes affect clinical outcomes.

The purpose of this research is to provide a descriptive study of selected social and psychiatric characteristics of adolescent first admissions to a private psychiatric hospital and an analysis of some of the inter-relationships among social, ecological, demographic and psychiatric variables selected for study.

Objetivo: determinar la frecuencia del rechazo de atención por triaje y sus factores relacionados en el servicio de emergencia de un hospital de tercer nivel. Material y métodos: estudio transversal con una muestra consecutiva de consultantes evaluados por el servicio de triaje que no ingresaron a emergencia del Hospital Regional Lambayeque durante el período Febrero-Abril 2015. Resultados: la frecuencia de rechazo por triaje fue 64,68% (628/971). De estos, el 64,29% fueron mujeres, tuvieron un promedio de edad de 38,55 años (IC95 37,22-39,66), siendo la mayoría padres de los pacientes (37,26%). Los síntomas más frecuentes fueron fiebre (12,55%) y dolor abdominal (12,55%). Un 44,02% no consideró su problema una cuestión de vida o muerte. De todos ellos el 16,00% fue atendido previamente en primer nivel de atención. El turno más visitado fue el de noche (42,86%) y el día más concurrido fue el sábado (16,22%). Conclusiones: la frecuencia de rechazo de atención por triaje debido al uso inapropiado del servicio de emergencia es relativamente alta. Recomendamos mejorar y reforzar la educación de la población en general para lograr la concientización del buen uso del sistema de salud y los servicios de emergencia. / Tesis

Unidad de práctica para optar al título de Químico Farmacéutico / Autor no autoriza el acceso a texto completo de su documento / La presente práctica prolongada fue realizada en el Centro de Referencia de Salud Maipú, institución que inicia sus actividades como establecimiento de Salud Pública dependiente del Servicio de Salud Metropolitano Central, con un carácter denominado „Experimental‟, en febrero de 2002, como producto del Decreto con Fuerza de Ley N°31 del Ministerio de Salud, promulgado el año 2000 y publicado el 2001. Proporciona especialidades de mediana complejidad diagnóstica y terapéutica. Desde su creación, ha sido objeto de diversos cambios dentro de los cuales encontramos la implementación del Servicio de Urgencias que proporciona atención ambulatoria a pacientes tanto adultos como pediátricos. La primera parte del informe tiene como objetivo describir de forma breve el escenario en el que se estuvo inmerso y las actividades realizadas durante las primeras semanas de práctica, en donde se adquirieron conocimientos y aptitudes propias del ámbito asistencial en conjunto con el Químico Farmacéutico y los Técnicos Paramédicos en Farmacia. Dentro de estas actividades realizadas se encuentran la dispensación de medicamentos tanto a pacientes ambulatorios como a los distintos servicios clínicos, y el riguroso manejo de medicamentos controlados y su adecuado almacenamiento. Con esta breve pasantía se pudo obtener una visión más clara de lo que significa estar inserto en el sector público del área asistencial y el rol que debe cumplir el Químico Farmacéutico, sirviendo continuamente a la población en materias de selección, adquisición, dispensación, distribución e información de los medicamentos, además de ser el pilar del equipo de trabajo que compone la Unidad de Farmacia. En la segunda parte se realizó una intervención al Botiquín de Urgencia, espacio destinado al almacenamiento y distribución de los medicamentos y dispositivos médicos al interior del servicio de urgencia, con el fin de normar su funcionamiento, garantizar una entrega oportuna, y mejorar las condiciones de almacenamiento que este proporciona. Las intervenciones realizadas en base a las deficiencias detectadas en una primera instancia, resultaron en cambios positivos para la gestión de los medicamentos y dispositivos médicos que se almacenan al interior del servicio de urgencia

Background: Chronic Inflammatory Demyelinating Polyradiculoneuropathy (CIDP) is an immune mediated neuropathy with variable presentation ranging from symmetrical paralysis to a variety of focal manifestations progressing slowly or in a fluctuating pattern. There is no information about the condition in Africa. Method: A Prospective case series of CIDP patients defined according to the criteria of Saperstein. Patients were recruited from the Johannesburg Hospital, South Africa, over a 2-year period. Results: 26 patients were identified. The male to female ratio was 1: 2 with an average age of 41 years. 10 patients were HIV positive. All were black females. There were no differences clinically between the HIV positive and HIV negative groups. The CSF proteins level was raised in only 42% of patients. Conclusion: The patients seen by us at the Johannesburg hospital have a younger age of onset and a female predominance. HIV was identified in 40% of our patients.

A research report submitted to the Faculty of Health Sciences, University of the Witwatersrand, in partial fulfilment of the requirements for the degree of Master of Science in Medicine in Emergency Medicine. Johannesburg, 2015 / Aim: To determine any association between the lunar synodic or anomalistic months and the nature and volume of emergency department patient consultations and hospital admissions from the emergency department (ED). Design: A retrospective, descriptive study. Setting: All South African EDs of a private hospital group. Patients: All patients consulted from 01 January 2005 to 31 December 2010. Methods: Data was extracted from monthly records and statistically evaluated, controlling for calendric variables. Lunar variables were modelled with volumes of differing priority of hospital admissions and consultation categories including; trauma, medical, paediatric, work injuries, obstetrics and gynaecology, intentional self harm, sexual assault, dog bites and total ED consultations. Main Results: No significant differences were found in all anomalistic and most synodic models with the consultation categories. Small but significant increases were found with a small number of synodic models around full moon with some categories, P2 medical, total paediatric consultations and total admissions. Significant decreases in admissions, particulary total admissions, were found around perigee. The effect sizes of all significant lunar associations were smaller than those of the calendric variables. Conclusions: Most comparisons demonstrated no lunar association. Small but significant associations were demonstrated around full moon with some synodic models. A number of anomalistic admission models demonstrated small but significant decreases in admissions at perigee.

ABSTRACT The increasing prevalence of suicidal behaviour especially among adolescents is an important public health problem. With the increasing adverse global economic conditions and HIV/AIDS prevalence, especially in developing world, the problem of suicidal behaviours is expected to get worse, and the impact on the healthcare systems will increase. Objective: This study was done to evaluate the socio-demographic and clinical profile of the patients who were admitted into Leratong Hospital for suicidal behaviours, and the factors associated with these suicidal behaviours. In the context of worsening social and economic problems, and the increasing HIV/AIDS epidemic, it is hoped that the results of this study will help in quantifying needs, defining appropriate management protocols and referral systems, and informing capacity building processes. Methods: This was a descriptive cross-sectional study. All patients admitted to the medical wards for parasuicides and attempted suicide from November 2007 to February 2008 (n=162) were interviewed during the course of their admission. Data on their socio-demographic characteristics, history of previous suicide ideations and attempts, methods of and reasons for the present suicidal behaviours, and past personal and family histories of the patients were extracted and analyzed. Results: Patients admitted for suicidal behaviours constituted about 5% of all medical patients. More than 67% of the patients were younger than 30 years, and more than 60% were females. Only about 16% of the patients were married, and about 45% were unemployed, and among those employed about 40% were unskilled, though more than 60% were living in either formal or RDP houses. Majority of the patients (60%) completed only grade 11 or less. Majority of the patients attempted suicide by ingesting overdose of medications (43%) and organophosphates (32%). The commonest reason given by patients for attempting suicide was domestic or relationship conflicts (75%). About 21% and 14% of the patients had histories of previous suicide ideation and attempt respectively. Common adverse events in the background histories of the patients were stress from their families (56%), unemployment (38%), alcohol abuse (32%), and abandoned by spouse (25%). Common adverse events in the family histories of these patients include at least one death in family in the last two years (70%), alcohol abuse (60%), family member in prison (46%), family member was a victim of crime (46%), and family member had a severe disease (42%). Risk factors found to be significantly associated with suicidal behaviours and the different methods of suicidal attempt include race, sex, younger age group, type of house, and family history of severe illness, death, divorce and substance abuse. The study has demonstrated the socio-demographic profile of these patients, the burden posed by suicidal behaviours on our health systems, and the risk factors associated with such behaviours. Based on these results, it is therefore recommended that health workers should look out for, and assess all patients for, risk factors associated with suicidal behaviours, and patients admitted for suicidal behaviours should be evaluated and managed properly, with appropriate referrals, before they are discharged.

BACKGROUND: District hospitals play an intermediary role between primary health care (PHC) clinics and community health centres; (CHC), (predominantly run by nurses) and regional hospitals, (predominantly run by specialists and doctors). However, in the absence of efficient and adequate network of PHC clinics and CHC’s, district hospitals often have to render these services. In addition, due to geographic distances between district hospitals and regional hospitals, it often has to offer specialist services such as Orthopaedics, Gynaecology, as well. This increases the burden on district hospitals. The profile of patients admitted to district hospitals have not been clearly described and this study seeks to describe and to compare trends over a two year period and factors influencing these trends, to allow for informed decisions to be made for future planning. No formal study on the trends for admissions to District hospitals have been conducted, as far as could be determined, and this study aimed to look into and describe the trends of admissions over a two year period from April 2007 to March 2009, to allow for informed decisions to be made to guide future plans. AIM: To determine the trends of adult admissions in a district hospital in Limpopo Province. METHODOLOGY: A cross-sectional study design was used for this study. A descriptive retrospective review of existing hospital records was conducted from routine information captured on the MEDICOM patient administration system and in ward and OPD/casualty registers. No intervention was done for this study. The setting was F. H. Odendaal Hospital in Modimolle, which is a district hospital situated in a rural area of the Limpopo Province. It serves a catchments population of over 103 000 people. Data was collected from 4481 admitted adult patients from which a random sample (n=800) was selected consisting of males (n=400) and females (n=400). Data on variables such as the case load (number of adult admissions during the research period), patient profile (gender, age, hospital classification and geographic location) and clinical profile (mode of admission, agnoses and associated ICD-10 code/s as well as the mode of discharge) were collected. RESULTS: This study revealed that this hospital experienced an increase number of adult admissions during the two years study period. During the same period it could reduce the length of stay, thereby improve usable bed utilisation rate. This reflected in more discharges and less death. This was probably due to availability of more experienced medical officers and the fact that outreach services has been conducted on a weekly basis by doctors and Clinical Support Services since 2008/09 financial year. The majority of the patients who were admitted over the study period were Africans residing in and around Modimolle. The majority was also classified as H1, meaning that most of the patients admitted to this hospital are capable of paying the nominal fee for services. The institution experienced an increase in the number of admission over the two years by 11.7%. The mean age was 42.5 years for adults. Of the top 5 diseases/conditions for which patients were admitted, Pneumonia, Diarrhoea and Gastroenteritis, Retrovirus infections and Diabetes Mellitus were present for both males and females. Although this disease pattern persists for a number of years, it seems as if services provided manage to reverse discharge trends as more patients were discharged home in the second year than in the first year and the mortality rate decreased by 4.5% for adults between the two years. CONCLUSION: Information obtained through this research could be extrapolated to other district hospitals for the management of services, including the management of beds. It could also serve as the basis for future research, as a reference base to students and the teaching of students.

BACKGROUND: The World Health Organization (WHO) has acknowledged the importance of maternal care and listed it as part of its Millennium Development Goals (MDGs). South Africa has aligned itself with these MDGs. The 5th goal is focused on improving maternal health by reducing the maternal mortality rate by 75% by 2015. There are a number of interventions in place to try and to achieve this goal; the provision of antenatal care is one of these interventions. Antenatal care provides the expectant mother early ongoing monitoring and risk assessment of her pregnancy. It is commonly considered fact that antenatal care improves maternal and perinatal outcomes. In spite of the provision of free maternal health services in South Africa, there are still a significant number of mothers who do not attend antenatal clinics before delivery. No formal study has been done to understand the magnitude of this problem in the Limpopo Province. In view of this, it was decided to conduct this study at the Van Velden Hospital (a rural district hospital in the Mopani District in the Limpopo Province) which has been admitting a significant number of unbooked mothers even after the introduction of free maternal health services in South Africa sixteen years ago. AIM: To compare the pregnancy outcomes (maternal and perinatal) between booked and unbooked mothers who delivered at Van Velden Hospital, a district hospital in the Limpopo Province in South Africa. METHODOLOGY: The setting of this study is the Maternity Unit at the Van Velden Hospital. A cross sectional study design was used. A retrospective record review was done and information for one year (2008/09) will be extracted from the records captured in the District Health Information System. No primary data was collected for this study. RESULTS: This is the first study that looked at broad issues pertaining to the influence of booking status on pregnancy outcomes (maternal and neonatal) at a district hospital in a rural district in the Limpopo Province and probably in South Africa. The study found a prevalence of 15.7% (range: 2.7% to 32.3%) among the study population during the 12 month study period. There were no significant differences in age, marital and employment status of the subjects. However, there were a significant number of teenage pregnancies (13.2%) among the study population, which is of concern. Interestingly, more white women were found not to book in comparison to the black women. There were no significant differences in parity, gravidity and miscarriages between the two groups. Overall, unbooked mothers were more likely to have a preterm baby. This implies antenatal booking can probably prevent preterm deliveries. This study also found unbooked mothers were more likely to have C/S than booked mothers. However, there was no significant difference between booked and unbooked mothers in terms of delivery complications. There was no significant difference between booked and unbooked mothers in terms of birth weight. Although, the babies of unbooked mothers had a significantly lower Apgar score (1 minute) than booked mothers, the difference became insignificant at 10 minutes. There was no maternal mortality during this period. All mothers were discharged home. Overall, perinatal mortality among the study population was 44/ 1000 births. This study found a significant risk of perinatal morbidity (preterm delivery and low Apgar score) among the unbooked mothers. CONCLUSION: This research was undertaken to develop a model that could be used by both the provincial and national governments to evaluate the prevalence and impact of booking status of pregnant women in rural district hospitals in South Africa.