Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Notice: Undefined index: issue_status in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 142
Notice: Undefined index: affilation in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 195
Notice: Undefined index: doiurl in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 198
Warning: Cannot modify header information - headers already sent by (output started at /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php:195) in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 234
Warning: SimpleXMLElement::asXML(): xmlEscapeEntities : char out of range in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 235
Warning: SimpleXMLElement::asXML(): xmlEscapeEntities : char out of range in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 235
Warning: SimpleXMLElement::asXML(): xmlEscapeEntities : char out of range in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 235
Warning: SimpleXMLElement::asXML(): xmlEscapeEntities : char out of range in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 235
Warning: SimpleXMLElement::asXML(): xmlEscapeEntities : char out of range in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 235
Warning: SimpleXMLElement::asXML(): xmlEscapeEntities : char out of range in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 235
Warning: SimpleXMLElement::asXML(): xmlEscapeEntities : char out of range in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 235
Warning: SimpleXMLElement::asXML(): xmlEscapeEntities : char out of range in /home/u845032518/domains/ijcrr.com/public_html/downloadarchiveissuexml.php on line 235
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20Healthcare
Challenges Experienced by ICU Nurses during COVID-19 Pandemic-A Survey from Delhi-National Capital Region (NCR), India
English0308Amit GoelEnglish Deven JunejaEnglish Shikha JainEnglish Sahil KatariaEnglish Omender SinghEnglish
Introduction: Corona Virus Disease-19 (COVID-19) has impacted nursing field profoundly in terms of direct care capabilities, practice issues, emotional and financial challenges. Aims & Objectives: We conducted this survey to understand challenges faced by nurses while working in COVID-ICU during COVID-19 pandemic. Method: This was a survey about the challenges faced by the nurses while working in COVID-ICU consequent to the second wave of COVID-19 in Delhi-national capital region (NCR), India. A Google forms-based questionnaire was prepared on the pertinent issues, having 3 demographic and 25 core survey questions. Results: 168 responses were gathered. Most of our participants (63.7%) were from private hospital, and 56% had worked in ICU previously. 88.1% of all the respondents had received brief orientation about the anticipated challenges in COVID-19-ICU. Personal protective equipment (PPEs) was easily available to the majority (88.7%), but only 45.8%, reported it to be good quality. 85.7% of the respondents regularly interacted with the patients admitted to COVID-19-ICU. Carrying infection home (45.2%) was reported to be the greatest fear while working at such areas. Stress & anxiety are the major behaviour change noted. 97.6% have reported having received vaccine against COVID-19. Conclusion: Poor quality of PPEs, lack of workplace, emotional and financial security continues to be the major challenges faced even after 2years & 2 waves of this pandemic. However, despite all the challenges faced, the zeal to work and fight with this dreaded infection was strong amongst all the participants. Most of them have expressed their readiness to work again in COVID-19 ICUs, if required.Nursing education, constructing, and implementing robust care policies, is need of the hour.
EnglishNursing Challenges, COVID-19 Pandemic, PPE, Exhaustion, SARSCoV-2, ICU
INTRODUCTION
Globally, the coronavirus disease-19 (COVID-19) pandemic has resulted in an unprecedented number of patients requiring hospitalization. As the COVID-19 pandemic accelerated worldwide, the healthcare system is impacted the most and has been facing tremendous pressure. Nurses constitute the largest workforce in the healthcare sector and their safety, both physical and psychological, needs to be prioritized.1 Exploring the issues faced by the nursing staff during these testing times will help support and strengthen the protocols and improve their preparedness better.2 The critical shortage of nurses, beds, and medical supplies including personal protective equipment (PPEs) are the major issues that the nurses have faced during this pandemic.3,4 These challenges cause nurses to face physical and mental strains and complex ethical issues.5 We planned this study to understand the challenges faced based on the nurses’ lived experiences while working in COVID-19-ICU.
MATERIAL AND METHOD
We conducted a survey about the challenges faced by the nurses while working in COVID-Intensive Care Units (ICU), consequent to the second wave of COVID-19 in Delhi-national capital region (NCR) India, in October 2021. A questionnaire was prepared on the pertinent concerns for the same and based on the previous national & international surveys. We prepared a Google Form-based survey with 3 demographic and 25 core survey questions. Our survey had 27 single option selection types and 1 multiple option selection type simple questions. The absolute inclusion criteria were nurses who had worked in COVID-19 ICU. The survey was designed to auto-exclude core responses from nurses who were not involved in managing COVID-19 patients in ICU. After preparing, we distributed this survey to the nurses in Delhi-NCR via social media platform in around 30 centres.
Institutional ethics committee clearance from our institution could not be obtained as the survey involved individual proprietary data of participants and researchers of several centres. We incorporated consent in this survey for participation and use of this data in the publication process.
Data Analysis:
We captured response identities so that duplication of responses was avoided. Only nurses who worked in COVID-19 ICU could respond to our core questionnaire. We are presenting the results of this descriptive cross-sectional survey in actual number and percentage form which were calculated using Google spreadsheets. We report the majority when the response rate reaches >50% in any one observation option.
RESULTS
We gathered 168 responses from the nursing staff from Delhi-NCR, who worked in COVID-19 ICUs during COVID-19 pandemic. Table-1&2 shows the detailed demographic characteristics and core questions of survey participants respectively.
Most of the respondents (n=90, 53.6%) in our study were young (20-30 years), enthusiastic females (n=134, 79.8%) from private hospitals (n=107, 63.7%).
56% (n=94)of them had worked in ICU environment before they were deployed for care of COVID-19 patients admitted in ICU.88.1%(n=148)of all the respondents had received brief orientation about the challenges likely to come across while working in COVID-19 ICU. Most of the participants (n=89, 53%) worked for 4-8 hours shift and only8.3% (n=14) reported to have shift duties for more than 12 hours.
PPE was reported to be easily available to the majority (n=149,88.7%) of the participants. But PPE quality was reported to be good quality by only 45.8%(n=77).Most of the participants from private hospital has reported to have received good quality PPE as compared to that of government hospital (58.4%,n=59 vs 26.5 %, n=18).
Proper donning and doffing of the PPE were taught to most (n=149,88.7%) of the participants and57.1%(n=96) had someone to assist them while donning and doffing procedure. Majority(n=159,94.6%) of the participants had designated PPE donning and doffing area and location for the same was near the ICU with most (n=123,73.2%) of them.
Lot of participants (n=144, 85.7%) regularly interacted with the patients admitted to COVID-19 ICU. Due to very high risk of transmission of covid virus, family were not allowed to meet the patients physically as reported by 44.6%(n=75) of the participant, but a regular health update was being given to the family by majority of them (n=112,66.7%). Most of the participants (n=118,70.2%) reported adequate medicine supply for COVID-19 infection treatment.
While reporting safety against COVID-19 infection at the workplace, most of the participants (n=95, 56.5%) felt safe. The greatest fear while working in COVID-19 ICU was reported to be carrying infection with them to their loved ones at home, which was reported by 45.2%(n=76) of respondents. Most (n=130,77.4%) participants were provided post-duty quarantine period, and many (n=118,70.2%)got COVID test done post-completion of their ICU duties. There is always huge risk associated for contracting disease while caring for patients with COVID-19, however many (n=109, 64.8%) of them reported themselves to be free of COVID-19 while performing COVID duties. No extra incentives were provided for COVID duties to most (n=90,53.6%) of the participants.83.9%(n=141) of the participants have their family safe and did not report any mortality. COVID has affected behaviour of most (n=101, 60.1%) of the participants and the major lifestyle affect reported was, stress & anxiety (n=94,56.3%) and health consciousness (n=73,43.7%). The majority (n=164,97.6%) of the participants have reported to have received vaccine against COVID-19. The zeal to work and fight with this dreaded infection is strong amongst all the participant, and most (n=154,91.7 %) of them have expressed their readiness to work again in COVID-19 ICUs if need arises.
DISCUSSION
This study has examined the challenges experienced by ICU nurses working in a COVID-19 ICU during this pandemic using a qualitative descriptive approach. The survey was done consequent to the second wave of COVID-19 in INDIA.
Private hospitals played measure role while giving care to covid-19 patients. Young females represent the measure percentage of the nursing caregivers in most of countries including India.6 These findings were also noted in our study.
The preparedness of any hospital and nurses plays crucial role in healthcare management in pandemics such as COVID-19. And in our study, most of the nurses were familiarised with the challenges likely to be experienced before going into COVID ICU. The responsiveness of the nurses who work in the ICU setup is finer, as they understand the ICU challenges and it’s working better. Spread of infectious covid virus from patient’s airway to healthcare workers and other patients is always a major concern. All the necessary measures must be established to safeguard oneself and other patients. PPE is an essential tool to protect oneself from contracting this virus while taking care of these patients in ICU. Provision of poor-quality PPEs and lack of PPEs have been reported in most of the studies worldwide.7But in our study, PPE was made available to about 90% of the respondents, but it was of average quality in most (50%) of the cases. Handling of PPEs (donning and doffing areas, buddies, and practice) was reported to be good by most (80%) of our participants.
Nurses play a vital role for the communication and psychological counseling of both relatives and patient who is away from their family and see everyone in PPE attire. This was done in most of the cases (>90%) in our study. But as the risk of contracting virus and getting affected was high, very small number of respondents (11%) reported that the attendants were allowed to meet the patient in person in ICU.
Most of the respondents claimed working in COVID-19 ICU with proper attire made them feel safe against contracting infection. Post duties most of the respondent were provided quarantine. Two third of the participants got a COVID-RTPCR test was done at the end of the quarantine period before they met their family members as most common apprehension among nurses was taking infection home with them post duties.
Unfortunately, one-third of respondents in our study suffered from COVID-19 disease while they were on duties and almost 16% reported deaths in their families due to COVID-19.
COVID pandemic has influenced the lifestyle of every individual in the world and most importantly healthcare workers.8 Nurses have suffered with lack of sleep, developed anxiety and stress, with altered food habits. The positive lifestyle impact had been regular exercises, Yoga and more careful approach to individual health. Nevertheless, all the nurses are ready to offer their services again with great enthusiasm if required.
Strength and Limitation-We have captured the responses of nursing challenges in COVID-ICU in October 2021 consequent to the second wave of COVID-19 in India. We believe study from large population of national and international nursing groups is required to understand the issues better. Further validation from experts would be better to give credibility to these concerns. However, that is beyond the scope of present survey.
CONCLUSION
Nurses are at the forefront of COVID-19 case management. Our survey concluded that the poor quality of PPE and lack of emotional security are the major challenge, which continues to affect nurses during this pandemic. Better quality of PPEs, workplace emotional and financial security must be provided to the nurses. The government and healthcare systems must minimize physical and psychological burdens on nurses. It is high time such recognition needs to be translated into policies to support and protect nurses, which may finally translate into better patient care and outcome.
Acknowledgement-We thank all the respected nurses, who shared their experiences in this study and worked relentlessly.
Conflict of interest-None
Source of Funding-None
Prior publication -None
Authors’ Contribution:
AG, DJ, SJ, conceived study, designed, and analysed the data. AG, SK, OS defined analytic tools and collected data. AG, SJ, SK reviewed literature, edited, and drafted the manuscript. Final manuscript read and approved by all the authors.
Englishhttp://ijcrr.com/abstract.php?article_id=4554http://ijcrr.com/article_html.php?did=4554Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20Healthcare
Challenges of Diabetes Management among TB-Diabetes co-morbid Patients in Udupi District
English0914Ansuman SwainEnglish Arathi P RaoEnglish Prabhath M KalkuraEnglish Manisha GoreEnglish Kirtimayee SoumyadarshineeEnglish
Introduction: India has witnessed a rise in TB-Diabetes co-morbid cases in the past few years. Both TB and diabetes create complications for each other not only in terms of the prognosis but also management. Glycaemic control is pivotal for the successful management of diabetes and co-morbidity. Aim: To understand the barriers and challenges of successful management of diabetes among TB-Diabetes co-morbid patients in the Udupi district. Methods: This cross-sectional study was conducted in the Udupi district of Karnataka from January 2020 to June 2020. Purposively selected Healthcare providers under RNTCP, were interviewed using a semi-structured interview guide. Each interview was fully transcribed. Data collection was terminated on reaching data saturation. A manual thematic analysis of the interview data was done using an inductive approach. Codes and themes were generated by a critical review of the transcripts. Results: Healthcare providers stated that certain patients such as, elderly, the homeless, and those with habits like alcoholism, were particularly difficult to manage. Besides, poor socioeconomic status, misconceptions, and lack of treatment adherence often create difficulties. Finally, participants also stressed the shortage of staff which impedes efficient management of the comorbidity. Conclusion: This study identified several barriers and challenges of diabetes management among TB-Diabetes co-morbid patients. These impediments, such as alcoholism, misconceptions, staff shortage, if addressed could aid in the better management of diabetes and eventually the co-morbidity.
EnglishTB-Diabetes, Diabetes management, RNTCP, co-morbidity, Udupi district, TB challenges
Introduction
Tuberculosis (TB) is responsible for the greatest number of deaths by a communicable disease in the world.1India is home to 27% of global TB cases and is one of the 30 high TB burden countries which contribute to 87% of the total number of TB cases in the world.2 Often termed as a disease of poverty, some of the contributing factors of TB are; overcrowding, smoking, drinking and immunocompromising diseases like diabetes.3 India, known as the Diabetes capital of the world is home to about 75 million diabetics with a prevalence of nearly 8.7%.4 Diabetes has been known to increase the risk of contracting TB infection by impairing the immune responses of the body and thereby increasing the risk.3,5,6
Both TB and Diabetes increase the likelihood of contracting each other. TB-Diabetes co-morbid cases have been rising in the past few years in India.7,8,9 Diabetes is responsible for impaired immunity which often increases the likelihood of getting TB infection. TB on the other hand, adversely affects glucose tolerance, thus elevating the risk of diabetes.10 Studies have shown that TB infection proceeds at a faster rate with Diabetes as comorbidity.10 Further, people with comorbidity are at four times higher risk of dying as compared to people with individual diseases.11 A large fraction of people with both diseases remain undiagnosed and often end up developing complications. Besides, diabetes lengthens TB management and is conducive to treatment failure and relapse.12,13,14 TB-Diabetes comorbidity poses several challenges to the management of both diseases. Glycaemic control is the key to achieve treatment success in TB and consequently diabetes.11
In other words, the successful management of TB is dependent on the successful management of diabetes. The dilemma in the management of comorbidity is multifactorial.15 For instance, while rich nourishment is recommended in case of TB, it is contraindicated for Diabetics.16 According to a study by Thomas et al., in Chennai, India, the health centres face difficulties in the management of TB patients due to reasons such as illegible or missing addresses given by patients, and loss of follow-up.17 Such issues when complemented by persisting blood glucose levels, pose a serious hindrance to TB management. Considering the importance of diabetes management for subsequent TB-diabetes comorbidity management, it is pivotal to understand the difficulties faced by healthcare personnel in diabetes management. Therefore, the purpose of this study was to understand the barriers and challenges of successful diabetes management among TB-diabetes co-morbid patients.
Methods
Study design and setting
This cross-sectional study followed a quantitative study that aimed to understand the factors affecting diabetes management among TB-diabetes co-morbid patients in the Udupi district. It was conducted in the Udupi district of Karnataka from January 2020 to June 2020. The proposal was approved by the Institutional Ethical Committee (IEC 888/2019) of Kasturba Medical College (KMC), Manipal Academy of Higher Education. TB and co-morbidities are within the purview of the District TB control centre, Udupi. The regional community health workers such as Accredited Social Health Activists (ASHAs), auxiliary nurse midwives (ANMs), along senior treatment supervisors (STOs) under the revised national TB control program (RNTCP) collectively function to notify and follow up TB patients in the district. The healthcare providers under the RNTCP conduct the directly observed treatment short-course (DOTS).
TB-DIABETES collaborative strategies
The WHO has come up with a collaborative framework for the management of both diseases in 2011.10 The framework has established guidelines for the detection and management of TB in diabetics and vice-versa. Likewise, the RNTCP, and the NPCDCS, have their own National framework for joint TB-Diabetes collaborative activities in India.11 The framework explains the screening procedure, sensitization of health personnel, reporting, as well as joint management of the co-morbidity.
Data Collection
Purposively selected Healthcare providers under RNTCP, were interviewed using a semi-structured interview guide which contained questions that covered the following domains: introduction and orientation, diagnosis of diabetes in TB-diabetes co-morbid patients, the process of management of Diabetes in TB-diabetes co-morbid patients, follow-up of diabetes in TB-diabetes co-morbid patients. The identity of the participants was kept anonymous. The entire in-depth interviews were recorded using a voice recorder application, after obtaining the consent of the participants. Each interview was fully transcribed. Data collection was terminated on reaching data saturation.
Data Analysis
We resorted to the 'Grounded theory' approach of analysis of the data.18 A manual thematic analysis of the interview data was done using an inductive approach. Each interview transcript was critically reviewed by the researchers. Suitable codes were generated and assigned to sections. The interview transcripts were carefully analyzed to look for similarities and differences. The generated codes were aligned under categories and the categories were reviewed to generate meaningful themes systematically.
Results
The thematic analysis of the 10 participants revealed the following barriers and challenges for the management of diabetes among TB-diabetes co-morbid patients.
Habit of alcoholism is a challenge in the follow-up
The management of patients with habits such as alcoholism was found to impede efficient follow-up. Participants stressed the difficulties of the management of alcoholic patients, elderly patients, patients without a family, and those belonging to the lower socioeconomic strata.
"The only problem is that we come across cases when patients are alcoholics. They are not regular. Just one problem with them is they don't take medications properly if they also are Diabetic then it's probably the worst combination. Alcohol is a big Factor. Because of the alcohol, they miss medication and appointments." (Respondent 3)
Most participants agreed to the added challenges of keeping a track of patients with family problems, or without a family. Besides, such patients are irregular with their medications, thus increasing the difficulties.
Multiple medications and a lengthy treatment lead to non-compliance
TB patients invariably follow a list of medications for the management of the disease and in case of comorbidity, diabetic medication additions often increase the difficulties of the patient. As a result, they end up skipping the medications or stopping them completely.
"See already they are, you know taking a lot of medication for TB, right? And then we are telling them to add on to that list, medications for diabetes. So that's a bit of a worry to them, you know maintaining so many medications, the timings and you are treating the body with a lot of chemicals. So that is never a good thing to have." (Participant 3)
Misconceptions and stress related to the co-morbidity
Many patients have several misconceptions regarding the treatment. Likewise, there is stigma associated with comorbidity as well which affect diabetes management.
" And one wrong notion that many of the patients have is that when they see the fasting and you know, Postprandial blood sugars are normal, they think that they're completely cured of Diabetes and they revert back to the, you know, original lifestyle and this is something that is a big misconception. They do stop medication and like I said, it adds on to the problem and sometimes they even reduce the dosage." (Respondent 7)
Also, having both diseases make some patients stressed. Elderly patients and those of the lower socioeconomic class are often reported to be under a lot of stress due to the management of the comorbidity.
"Patients, especially of the socially backward class are under a lot of stress because of this because of dual management. Yeah, some of them are under stress. The stress levels are according to his age. More the age more the stress like older patients are at more stress." (Respondent 10)
Contradictory diet advice for the co-morbidity
Some participants also mentioned the paradox of dietary management in case of comorbidity, meaning; the patients need to gain weight as they have TB and therefore require to eat well. However, as they also have diabetes, they might need to cut down on a few things which make dietary management tricky.
"They have to take care of the diet as well, which is also contradictory because you know in Tuberculosis, we usually prescribe them to have protein-rich and good food to gain weight and you know to gain mass but it's a contradictory statement when it comes to Diabetes. So like it's a paradox when you have both diseases in one you need to eat, well in the other you don't." (Participant 3)
" See if it was a normal person with Tuberculosis you can ask them to have Banana, Milk and you know anything that is high energy-yielding. But this is absolute contraindication when it comes to Diabetes, so they can't afford to have skimmed milk and all those sort of things. So that becomes a big issue with people those who have Diabetes as well" (Respondent 4)
Poor socio-economic status acts as a hindrance for the dietary management
Patients belonging to the lower socio-economic strata face many issues due to comorbidity, especially due to the necessity of a change of diet and lifestyle. Such patients are often unable to afford the often expensive, high calorific foodstuffs such as meat and milk powder advised by the healthcare personnel, eventually letting the co-morbidity persist.
" The major problem is that they are dependent on Rice, which they can't have in case of Diabetes. So if they had anything other than rice, they don't feel complete. So it's very difficult to alter that kind of a diet because you know, even if I tell them anything, they might not be able to afford it. Green. Most of them here are fishing community people. Rice and fish is the staple. That is my biggest problem." (Respondent 4)?
Non-adherence gives rise to complications
Whether or not a co-morbid patient is compliant with the management, is dependent on several factors ranging from the socio-economic status of the patient to periodic follow-up. Although a majority of patients follow instructions, few of them don't and their follow-up is difficult.
" Patient non-compliance is a very big problem for us. That's whenever we call them for follow-up, they won't come. Yeah, they'll say they have work. Even when the ASHA workers go, their doors will be locked then they'll not pick up the phone." (Respondent 5)
Some patients may discontinue the treatment on their own, either because of financial constraints or sometimes due to negligence.
" There are specific cases where they could discontinue either TB or Diabetes medication on their own because of several reasons. Economic regions, and also nonseriousness. I mean not being aware about it or, aware, but kind of casual attitude." (Respondent 10)?
Several participants reported such casual attitudes of certain patients, which often results in poor outcomes. Consequently, the lack of adherence leads to complications and the development of drug resistance in some cases.
" What happens is one patient if not compliant, the chances of complication are very high. So when I tell them that you are in initial stage of Diabetes, you need to start medication, they usually don't. But after six months they come to me with complaints like I'm having numbness, I feel fatigued, there is chest pain, difficulty in breathing and so on. So, you know once these complications have started it becomes difficult to manage. So, the early stages of treatment is very easy as compared to, when you have developed complications." (Respondent 4)?
Differences in the follow-up protocol after the end of TB treatment
There is a periodic follow-up of co-morbid patients after the completion of TB treatment in almost all healthcare facilities. However, a notable amount of differences was observed in the responses of the participants within the duration and period of follow-up.
" We certainly follow up on a monthly basis. The appointment date is mentioned in the prescription forms." (Respondent 1)
" As soon as the patient is completely of TB, we need to do timely follow-up for two years. As per the latest guidelines, we should be following-up within every six months." (Respondent 2)
" Usually, we prescribe medications for one month after the treatment in between is over and we ask them to regularly come to the centre every 15 days. " (Respondent 7)
Shortage of staff
All the participants mentioned the availability of adequate resources and facilities. However, participants also expressed the issues of the shortage of staff and consequently not being able to manage the comorbidity efficiently.
" In the PHC, I am the only health care provider here so you don't have a counselor. So, you need to have a specialized counsellor. So, you have to counsel them regarding the change of lifestyle, you know they forget about diet and a lot of other things, that needs time. In the community health centre or they have specialized doctor and they have more manpower than a PHC. But here we have difficulty managing all these things with the existing number of staff." (Respondent 9)
Another participant stressed the importance of male health workers in managing alcoholic patients, as understandably, ASHAs (female health workers) would have difficulties dealing with them.
" There's a shortage of male workers. I have nine sub centers under me. All have ANMs. Four female workers are there where there is only one male health worker and 28 ASHAs or ladies. So there should be option for ASHAs to be men also. I believe men would be in a better position to deal with alcoholic patients." (Respondent 2)
Data is sketchy, please read all the transcripts again and add the data to the respective sections You need to rearrange the findings. Bring the common codes under one theme. Suppose theme is about follow up bring all the points related to follow-up under it.
Discussion
This study aimed to understand the barriers and challenges in the effective management of diabetes among TB-diabetes co-morbid patients in the Udupi district of India. Many participants believed that patients who were alcoholics often showed poor adherence to treatment and their follow-up was difficult. This is also the case with elderly patients and patients who do not have a family. The study conducted by Gelmanova et al. in the Russian Federation highlighted the significant negative impact of alcohol and substance abuse on the treatment adherence of TB patients.19 Most participants agreed that the increase in the number of tablets patients has to take periodically, often led to discontinuation of the treatment. Also, the prevailing misconceptions about the treatment, especially among the people from lower socio-economic strata cause the management to extend. Furthermore, healthcare personnel faced difficulties in advising high calorific diets to patients of the lower socio-economic strata due to their financial constraints. A study by Nonogaki et al. revealed that people with a family from the higher socioeconomic strata showed better adherence to Diabetic medication as compared to those from the lower socioeconomic strata.20 Besides, some patients do not take medication as directed, thereby increasing the likelihood of developing drug resistance and complications. The follow-up of some patients, particularly those of the lower socioeconomic class was difficult. There have been cases of drug resistance due to the lack of adherence by some patients. This in turn may also adversely affect the prognosis of TB treatment. A change in the diet of such people is difficult and adds to the list of barriers and challenges of diabetes management in TB-diabetes co-morbid patients. Apart from that, notable differences could be observed in the opinions of participants about the periodicity of the follow-up procedure. Multiple responses ranging from 15 days to 6 months were received. Finally, many stressed the shortage of manpower in the healthcare centres, which meant ineffective treatment provision. In response to the challenges of diabetes management in co-morbid patients, participants also came up with a few suggestions for improving the same.
Some participants acknowledged the importance of adequate counselling of the patients for effective diabetic management and recommended explaining the patient properly as and when necessary. Another suggestion was to include more male health workers in the management process as they are more effective in managing and following up alcoholic patients. An in-depth review of the challenges and the suggestions by the healthcare personnel is pivotal for the effective management of TB-diabetes comorbidity.
Conclusion
This study aimed to understand the barriers and challenges of diabetes management among TB-diabetes patients. In-depth interviews with the healthcare providers under the RNTCP brought out several roadblocks. Alcoholic patients, elderly patients, and patients without a family were identified as the most difficult to manage and follow up. Similarly, the length of the treatment and the increased number of medications often lead to discontinuation. Also, some patients do not take medications as directed which leads to the development of resistance and complications. Difficulties in diet management of certain patients, especially from the lower socio-economic strata as highlighted by the participants as well. Some of the internal challenges such as, discrepancies in the follow-up timelines, and the shortage of staff, were also noted. In this regard, some suggestions such as the inclusion of male health workers in the management and follow-up of co-morbid patients might be effective for the cause. These challenges need to be addressed for the better management of co-morbidity.
Declarations
Source of funding: No funding was received to assist with the preparation of this manuscript
Acknowledgement: Authors acknowledge the immense help received from the scholars whose articles are cited and included in references of this manuscript. The authors are also grateful to authors / editors / publishers of all those articles, journals and books from where the literature for this article has been reviewed and discussed.
Conflict of interest: The authors have no conflicts of interest to declare that are relevant to the content of this article
Availability of data and material: The datasets/themes generated during and/or analyzed during the current study are available from the corresponding author on reasonable request
Ethics approval: Obtained from KMC, Manipal (IEC: 888/2019)
Authors’ Contribution:
Ansuman Swain: Research concept, Research design, Data collection, Data analysis, Manuscript drafting
Arathi P Rao: Research concept, Research design, Data analysis
Prabhath M Kalkura: Research design, Data analysis
Manisha Gore: Research concept, Research design, Data analysis
Kirtimayee Soumyadarshinee: Research concept, Research design, Manuscript drafting
Englishhttp://ijcrr.com/abstract.php?article_id=4555http://ijcrr.com/article_html.php?did=4555
1. MacNeil A, Glaziou P, Sismanidis C, Maloney S, & Floyd K. (2019, March 21). Global Epidemiology of Tuberculosis and Progress Toward Achieving Global Targets - 2017. Retrieved April 8, 2020, from https://www.cdc.gov/mmwr/volumes/68/ wr/mm6811a3.html
2. Global Tuberculosis Report 2019. (2019). Retrieved April 8, 2020, from https://apps.who.int/iris/bitstream/hand le/10665/329368/9789241565714-eng.pdf?ua=1
3. Narasimhan P, James W, MacIntyre C, Mathai D. (2013, February 12). Risk Factors for Tuberculosis. Retrieved April 10, 2020, from https://www.hindawi.com/journals/pm/2013/828939/
4. Tripathy JP. (2018, July 31). Burden and risk factors of diabetes and hyperglycemia in India: findings from the Global Burden of Disease Study 2016. Retrieved April 10, 2020, from https:// www.ncbi.nlm.nih.gov/pmc/articles/PMC6074770/
5. Siddiqui AN, Hussain S, Siddiqui N, Khayyam KU, Tabrez S, & Sharma M. (2018). Detrimental association between diabetes and tuberculosis: An unresolved double trouble. Diabetes Metab Syndr, 12(6), 1101–1107. https://doi.org/10.1016/j. dsx.2018.05.009
6. Kumar P, Babu S. (2017). Influence of diabetes mellitus on immunity to human tuberculosis. Immunology, 152(1), 13–24. https://doi.org/10.1111/imm.12762
7. Restrepo B. (2016, December). Diabetes and Tuberculosis. Reretrieved April 11, 2020, from https://www.ncbi.nlm.nih.gov/pmc/ articles/PMC5240796/
8. Sil A, Patra D, Dhillon P, & Narasimhan P. (2020). Co-existence of diabetes and TB among adults in India: a study based on National Family Health Survey data. J. Biosoc. Sci., 1–15. Advance online publication. https://doi.org/10.1017/S0021932020000516
9. Sembiah S, Nagar V, Gour D, Pal DK, Mitra A, & Burman J. (2020). Diabetes in tuberculosis patients: An emerging public health concern and the determinants and impact on treatment outcome. JFCM. 27(2), 91–96. https://doi.org/10.4103/jfcm. JFCM_296_19
10. Collaborative framework for care and control of tuberculosis and diabetes. (2011). Retrieved April 11, 2020, from https://apps. who.int/iris/bitstream/handle/10665/44698/9789241502252_ eng.pdf?sequence=1
11. National framework for joint TB-Diabetes collaborative activities. (2017). Retrieved April 11, 2020, from https://tbcindia.gov. in/WriteReadData/National framework for joint TB diabetes 23 Aug 2017.pdf
12. Cheng J, Zhang H, Zhao YL, Wang LX, & Chen MT. (2017). Mutual Impact of Diabetes Mellitus and Tuberculosis in China. Biomedical and environmental sciences: BES, 30(5), 384– 389. https://doi.org/10.3967/bes2017.051
13. Kornfeld H, Sahukar SB, Procter-Gray E, KumarNP, West K, Kane K, et al. (2020). Impact of Diabetes and Low Body Mass Index on Tuberculosis Treatment Outcomes. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America, 71(9), e392–e398. https://doi.org/10.1093/cid/ ciaa054
14. Alfarisi O, Mave V, Gaikwad S, Sahasrabudhe T, Ramachandran G, Kumar H, et al. (2018). Effect of Diabetes Mellitus on the Pharmacokinetics and Pharmacodynamics of Tuberculosis Treatment. Antimicrobial agents and chemotherapy, 62(11), e01383-18. https://doi.org/10.1128/AAC.01383-18
15. Harries AD, Kumar AM, Satyanarayana S, Lin Y, Zachariah R, Lönnroth K, et al. (2015). Diabetes mellitus and tuberculosis: programmatic management issues. The international journal of tuberculosis and lung disease(IJTLD): the official journal of the International Union against Tuberculosis and Lung Disease, 19(8), 879–886. https://doi.org/10.5588/ijtld.15.0069
16. Riza AL, Pearson F, Ugarte-Gil C, Alisjahbana B, van de Vijver S, Panduru NM, et al. (2014). Clinical management of concurrent diabetes and tuberculosis and the implications for patient services. The lancet. Diabetes& endocrinology, 2(9), 740–753. https://doi.org/10.1016/S2213-8587(14)70110-X
17. Thomas BE, Subbaraman R, & Sellappan S. Pretreatment loss to follow-up of tuberculosis patients in Chennai, India: a cohort study with implications for health systems strengthening. BMC Infect Dis
18, 142 (2018). https://doi.org/10.1186/s12879-018- 3039-3 18. Chapman AL, Hadfield M, & Chapman CJ. (2015). Qualitative research in healthcare: an introduction to grounded theory using thematic analysis. J. R. Coll. Physicians Edinb., 45(3), 201–205. https://doi.org/10.4997/JRCPE.2015.305
19. Gelmanova IY, Keshavjee S, Golubchikova VT, Berezina VI, Strelis AK, Yanova GV, et al. (2011, March 04). Barriers to successful tuberculosis treatment in Tomsk, Russian Federation: Non-adherence, default and the acquisition of multidrug resistance. Retrieved May 14, 2020, from https://www.who.int/bulletin/volumes/85/9/06-038331/en/
20. Nonogaki A, Heang H, Yi S, van Pelt M, Yamashina H, Taniguchi C, et al. (2019) Factors associated with medication adherence among people with diabetes mellitus in poor urban areas of Cambodia: A cross-sectional study. PLoS ONE 14(11): e0225000. https://doi.org/10.1371/journal.pone.0225000
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20Healthcare
Quality Approach Model Implementation in Public Hospitals - The National Institute of Oncology (Morocco) as a Case Study
English1521Imane El HaouachimEnglish Kaoutara ElomariEnglish Maria BennaniEnglish Rachid BekkaliEnglish
Introduction: The quality approach implementation in Moroccan public hospitals (MPH) is a major challenge for improving access, safety, quality, and performance in health care provision. Faced with the increasingly demanding expectations of the health system users and the universal health recommendations, the development of a national health system in accordance with international quality standards is becoming a challenge for the Moroccan health system, hence the importance of implementing a quality approach adapted to each hospital’s context. Design and Methods: This is a cross-sectional study that occurred from January 01, 2018, to March 31, 2021, at the National Institute of oncology (NIO), 12 resource persons participated in the focus group; the documents used included the NIO establishment project, quality activity reports, and the service quality manual. They were chosen using the non-probability sampling method with the conventional technique for resource persons. Results: The results propose a new framework for the implementation of a sustainable and continuous quality approach in MPH. The latter was tested in the NIO and gave convincing results; such as the reduction in infection rates by (30% in 2018 to 04% in 2020), the reduction of the time taken to receive chemotherapy preparations from (between 1 and 2 hours in 2019) to (less than an hour in 2020) and the improvement in group dynamics and communication with users. Conclusion: In this article, we have highlighted the quality governance model, the conceptual framework, the inputs, and the expected results of such an approach. The generalization of this approach in MPH requires another large-scale validation study.
EnglishPublic hospital, Quality approach, Quality framework, National Institute of Oncology, Quality implementation, Continuous improvement
INTRODUCTION
Hospital organizations face constant changes: changes in technology, in society, and in the user’s role, which is increasingly asserting itself, in addition to the organizational changes recommended by the supervisory authorities without forgetting a large number of reforms. This evolving nature requires hospital organizations to be flexible and quick to adapt to a constantly changing context. 1
The health sector has been little affected by quality procedures, while in industry, quality has been and is still a major issue for the development and sustainability of companies. It was only during the last thirty years that the industrialized countries have all embarked on major reforms of their healthcare system so that they can best respond to the development of technologies, new therapies, the aging population, the appearance of new diseases, and the population's increased demand for access and quality of care. 2
The introduction of quality in hospital organizations has not been carried out in the same way as in the industry field. Quality has been introduced into hospital organizations in a regulatory and legislative manner, such as through certification procedures. 1
The literature review carried out in this article highlights the difficulties encountered by healthcare professionals when implementing quality procedures imposed by regulations and unsuitable for the hospital context.3
In this article, we propose a complete framework to guide public hospital organizations and stakeholders in the definition, development, and implementation of a successful and continuous quality approach taking into account the complexity, limitations, and challenges of the Moroccan health system.
The proposed framework is based on four elements; quality governance to direct, guide, and coordinate quality at the national level, the main inputs to guarantee the success of the quality approach in hospitals, a conceptual quality framework, and the results of the implementation of the quality approach.
This paper is organized into eight sections: Section 1 provides the introduction, Section 2 describes the Moroccan quality implementation context, Section 3 describes the methodology foundations, Section 4 explains the preparatory steps for the National Institute of Oncology’s (NIO) quality implementation, Section 5 presents the quality framework proposed, Section 6 advances the results, section 7 discusses the proposed model with related works and finally, we conclude with a summary of this research and present future work and directions.
CONTEXT
In Morocco, the implementation of the quality approach in hospital organizations is explicitly mentioned in the new constitution of 2011, which stipulates in article 154 that "public services are subject to standards of quality, transparency, accountability, and responsibility". 4
The Ministry of Health history shows that the first stages of the quality approach even date to the 1990s when a process of improving the quality of care and services through some pilot projects such as the Integral Management of Quality (IMQ) had been established in 5 regions of Morocco. Unfortunately, with the absence of a good strategy to generalize the successful approaches, and integrate quality management into the health services culture, the experiences started were limited to a few sites with fragile sustainability; hence, the initiative of the Ministry of Health for the implementation of a comprehensive integrated approach called Quality Competition (QC) for health structures. 5
Like other hospital organizations, the Ibn Sina Hospital Center in Rabat (ISHC) implemented in 2007 a quality management program focused on the continuous improvement process, aiming to engage in a process of hospital accreditation and certification. 6
The key results of this approach were the certification of the Children's Hospital Pharmacy as well as the pharmacy and laboratory of the Rabat Specialty Hospital (RSH).7
However, this approach encountered difficulties in terms of its generalization and its sustainability to other health establishments. Indeed, a study has shown that no action in quality management has been carried out since 2011 at the level of the ISHC’s hospital services. 8 The real mission of a quality assurance program should be assessed against its ability to place concern for quality at the center of hospital system management and this should be on an ongoing basis.9
In the same direction and to respond to the recommendations of the first and second National Cancer Prevention and Control Plans (NCPCP) 2010-2019 and 2020-2029, in addition to the universal health ones2 the NIO of Rabat in partnership with the Lalla Salma Foundation-Cancer Prevention and Treatment has implemented a quality approach since 2018. The interest in the implementation of this process also stems from the motivation and mobilization of health professionals, which was intended to be very broad in this establishment, and from an assumed leadership at the clinical and administrative levels. Thus, the aim of this article is to explain the process of implementing the quality approach at the NIO, highlighting the various stages along the way to suggest a model that can be applied to all Moroccan public oncology centers.
METHODOLOGY AND EPISTEMOLOGICAL FOUNDATIONS
Study design
This study is a cross-sectional study that occurred from January 01, 2018, to March 31, 2021, at the NIO. This type of research offers us the possibility of carrying out an implantation analysis, which consists in specifying all factors influencing the results obtained following the introduction of the quality approach.10 It was executed through the Donabian conceptual model, which allows us to analyze the inputs, processes, and results that interact with each other for the quality approach success in the healthcare sector. 11
Site choice
The National Institute of Oncology (NIO) is a Moroccan public cancer treatment hospital, managed by a chief medical officer and governed by the ISHC in Rabat. It contains 08 activity poles, 270 beds, and 552 healthcare professionals.
The choice of the site was guided by the involvement of the NIO in a participatory and continuous quality process, as well as by the possibility for the researcher to participate in the implementing process and take a critical look at it.
Researcher profile
We adopted an intervening researcher posture because since 2018 and until 2021, we carry out supervision missions coupled with quality management missions in this service. This posture inscribes us in a constructivist epistemological paradigm.
Information sources and sampling
The sources of information are made up of resource people (such as the quality project steering committee members, quality referents, the managers of the NIO quality unit, and some head nurses responsible for the quality circles), administrative documents, progress reports, and regular monitoring of service quality circles.
They were chosen using the nonprobability sampling method with the conventional technique for resource persons.
In total, 12 resource persons participated in the study; the documents used included the NIO establishment project, quality activity reports, and the service quality manual.
Analysis techniques and data collection tools
The data was collected by focus group techniques, observation, and documentary review using the focus group guide, an observation grid, and a documentary review sheet.
The focus group guide was designed based on the experience acquired and accumulated by the researcher working in collaboration with a quality expert: "In knowledge, there is an interdependence between knowing subject and what he studies"12 which comprises 10 items divided into 03 sections.
The document observation grid included 15 items divided into 04 sections.
Data processing and analysis
Manual analysis was done for the observation grid data and the documentary search sheet with a qualitative analysis of the resource persons’ comments.
PROCESS FOR DEVELOPING THE QUALITY MODEL AT THE NIO
To respond to the recommendations of the first and second National Cancer Prevention and Control Plans13, the Lalla Salma Foundation in partnership with the NIO launched in 2018 the first quality program intended for public oncological centers. The aim is to improve the cancer patient’s quality of care.
The process for developing the quality model began with a strategic preparation phase in which decision-makers organized several meetings aiming to define the vision, governing bodies, and process implementation plans. This step was followed by a study of national and international experiences made by quality experts who carried out a benchmark and proposed a draft model to hospital leaders. This model was subsequently discussed with all staff during training and involvement sessions organized before the project kick-off.
All these actions have made the task easy and affordable for health professionals who have themselves participated in the development of the quality model that they should follow and respect.
PROPOSED MODEL FOR THE QUALITY APPROACH IMPLEMENTATION
The proposed conceptual framework represents a combined model between the continuous improvement approach14, the Quality Management System (QMS) approach 15, and the ISO 9001 version 2015 standard. 16
The conceptual framework proposed in this article is composed of the following elements: quality governance, the necessary inputs for the quality approach implementation, the model of quality approach implementation, and the results of the quality approach implementation in public hospitals.(Figure1)
Quality governance
The quality approach implementation in public hospitals requires good governance and assumed leadership at all strategic, clinical, and administrative levels. 17
Thus, the French experience shows that a quality management system cannot succeed in hospital structures without the effective involvement of governance bodies and administrative and clinical leaders. 18
Moreover, the Moroccan experience; in particular, of the ISHC, it has shown that the quality initiatives in this establishment did not achieve the expected objectives and remained limited to certain pilot sites due to the absence of a governing body that oversees and monitors the implementation and sustainability of the project. 19
Based on these experiences, the model that we present in this work proposes the definition of a governance body with the identification of its members and the responsibilities of each one even before the start of any quality project. This body must be composed of the Ministry of Health, the quality division, quality hospital units, and doctors without forgetting the representation of a few bodies involved in hospital structure; in particular, civil society and user representatives. The attributions of this body will be the definition of the overall vision of hospital quality, the quality strategy of its investment plan, the actors concerned, as well as the monitoring and evaluation procedures.
Main inputs for the quality approach implementation
The National Institute of Oncology’s experience has shown that the first thing that must be done before setting up a quality approach is raising awareness and informing human resources; this is mentioned in numerous studies which cite noninvolvement and insufficient staff information as a major obstacles to quality projects’ success. 20
Thus, staff training and involvement in quality is a key factor for the success of any project, this was confirmed in one of the comments by a nurse of the medical oncology department, NIO "We had no concept of quality, the training sessions helped us to join and take ownership of the project".
Without forgetting the clear definition of the quality team’s members, the financial and logistical support for the realization of their activities and the importance of that was mentioned by the representative of the steering committee and quality referent in the digestive oncological surgery department, NIO "The coaching sessions provided by the Lalla Salma Foundation project consultant have enabled us to make good progress in our quality projects". As well as the head nurse of the medical oncology department, NIO, who commented "It is thanks to the Lalla Salma Foundation financial and technical support that we were able to print our protocols, guides and leaflets».
A conceptual framework for the quality approach implementation
Our model is based on a combined approach between the continuous improvement approach, the QMS, and the ISO 9001 version 2015 standard.
The combination of these three approaches finds its legitimacy in the specificity of the hospital context, which is very complicated and complex because of the different logics that reign there (gain, care, and quality), the multitude of profiles who work there (doctors, nurses, administrators) and by user requirements that are becoming increasingly pressing.
We recommend starting with quality circles by following Deming's APDC wheel21 for the resolution of their service’s issues.
Thus, over time, the teams take ownership of the continuous improvement approach and methodology and begin asking to move on to standardizing their quality practices with another QMS method recommended by the ISO 9000/9001 version 1990 standard. 22
The advantage of this approach is that it does not impose any specific technique or method that might not be suitable for the operation or the size of the service. It allows the teams, initially tired and overwhelmed by the classic methodology of continuous improvement, to focus more on the production of procedures and standards for the good functioning of the services (Actions 1,2,3)(Figure1).
After mastering this step and preparing the procedure manual, we suggest switching to the ISO 9001 version 2015 standard 23 which integrates other dimensions such as taking into account the organization context, strengthening leadership, support and planning, performance evaluation, and certifications, and finally continuous improvement and sustainability (Actions 4,5,6,7,8,9,10) (Figure1).
RESULTS
The experience of the NIO, the analysis of the quality reports of the various teams, and the analysis of the interviews with a few resource persons have shown us that the process followed for the quality approach implementation has led to positive achievements on several plans:
Quality of care improvement
The examination of the medical oncology department’s quality manual showed us that there is a decrease in the chemotherapy preparation’s receiving delay (between 1 and 2 hours in 2019) to (less than one hour in 2020).
Thus, the examination of the digestive surgery department’s quality manual showed us a clear reduction in infection rates (Graph 1).
Human resources training
40% of the NIO's staff are trained and involved in the quality process. "Thanks to my training in quality, I was able to pass my 11 scale exam, I am very grateful." (Head nurse, digestive oncological surgery department, NIO).
Interpersonal communication improvement
8 out of 12 people interviewed were pleasantly surprised by the benefits of quality on the group's dynamics and the improvement of interpersonal communication: “The weekly quality meetings are not only an opportunity to apply our knowledge on quality management but above all an opportunity to talk to each other and solve each other's problems, we can now say that we are a real team”(Head nurse, medical oncology department, NIO).
Improved communication with customers
Communication with customers is one of the most important dimensions of quality. According to the comments of the resource persons, the implementation of the quality approach has greatly improved communication with patients. "The quality circles have enabled us to improve our communication with patients, especially since our team has worked on the problem of insufficient communication at the level of the gynoecia-mammary (GM) hospitalization department. According to the feedback from patients during the therapeutic education sessions and the analysis of the register of complaints, we had very positive feedback on the improvement of communication and the conditions of care of our patients. »(Head nurse, gyneco-mammary(GM) department, NIO).
"The quality allowed us the opportunity to listen to the needs of our customers and to improve our services! that’s amazing " (Nurse, Medical Oncology department, NIO).
Other positive achievements
Other results related to improving the environment work and dynamics group were listed during the presentation sessions of the quality circles, so the interview with the resource persons confirmed these results. "After the training and after setting up the first quality circle, we were able to develop not only our skills but also our behavior, especially in terms of:
Team spirit
Group dynamic
Spirit of planning
Listening and communication
Valorization of everything we do
Traceability and documentation of everything we do
The ability to solve any problem with the available resources
Knowledge development
Continuity » (Nurse, digestive oncological surgery department, NIO).
DISCUSSION
The review of the literature showed us that the combined and progressive quality models have been successful in public hospital structures, this was confirmed in the study by R. Slimani and M. Boukrif 24 who argue that the setting up of a quality management system generates significant changes through a gradual process. Thus, the experience of the Saudi health system, which adopted a progressive quality implementation approach starting with quality assurance and gradually evolving towards the integration of the total quality principles, has witnessed great success in the Arab world. 25
CONCLUSION
This work proposed a new framework for implementing the quality approach in public hospital structures; it represents an important basis for guiding healthcare stakeholders in defining and implementing the vision and objectives of hospital quality. In this article, we have highlighted the quality governance model, the conceptual framework, the inputs, and the expected results of such an approach.
Evaluation and monitoring are important parts of this project to identify strengths and areas of improvement in the quality implementation vision. To this end, this research can also be broadened to demonstrate further test results and validation of the approach to enable stakeholders to make the right quality management decisions at the public hospital.
SIGNIFICANCE FOR PUBLIC HEALTH
Public hospitals in developing countries suffers from a crisis of confidence with its users, the numerous dysfunctions, unsuitable reforms and organizational problems consolidate this crisis.
Quality procedures are the best way to change this image and remedy these dysfunctions, provided that they must be adapted to the context and the means of each hospital.
CORRESPONDING AUTHOR
Imane El Haouachim, Faculty of Educational Sciences/ Mohammed V University, Rabat, Morocco
E-mail : imane_elhaouachim@um5.ac.ma
Tel: +212661387407
ACKNOWLEDGEMENTS
This study could not have been carried out without the National Institute of Oncology staff collaboration.
AUTHORS’ CONTRIBUTIONS
IE carried out the research: Conducted the literature review, designed the conceptual model and the framework, collected and analyzed the data and wrote the manuscript in consultation with MB. MB Contributed to the design and implementation of the research, to the analysis of the results and to the writing of the manuscript, others authors read and approved the final manuscript.
CONFLICT OF INTEREST
The author declares no conflicts of interest.
SOURCE OF FUNDING
The author declares that there was no outside funding for the writing of this paper.
DATA AVAILABILITY
The data used and/or analyzed during the current study are available from the corresponding author on reasonable request.
Englishhttp://ijcrr.com/abstract.php?article_id=4556http://ijcrr.com/article_html.php?did=4556Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20Healthcare
Comparison of First Analgesic Demand after Major Surgeries of Obstetrics and Gynecology between Pre-Emptive Versus Intra-Operative Groups by Using Intravenous Paracetamol: A Cross-Sectional Study
English2226Humaira TahirEnglish Pari Gul BalochEnglish Mubushra SaminaEnglish Ifat BalouchEnglish Sundas AhmadEnglish Zakia BanoEnglish
Introduction: Aim/Objective: To compare first analgesic demand in minutes after obstetrics & gynecological operative procedures between pre-emptive versus intra-operative groups by using intravenous paracetamol. Study Design: A cross-sectional study Place and Duration: Department of Obstetrics & Gynecology, Social Security Landhi Hospital, Karachi, and the total duration was 18 months i.e. 1st January 2019 till 30th June 2020. Methodology: Total number of patients were 120 and the age range was between 22- 50 years. Randomly patients were divided into two equal groups, group 1 and group 2. A total of 60 patients were in each group. In group 1, 1gram intravenous paracetamol was given 15 minutes before anesthesia either spinal or general. While in group 2, the same dose of intravenous paracetamol was given during operative procedures. Mean time for the first analgesic demand was observed and recorded. Result: Mean age of the patients was 40.53 ± 9.10 years in group 1 and 39.25 + 10.70 years in group 2 and the p-value was 0.820. The mean weight of patients was 62.25 ± 9.24 kg in group 1 and in group 2, it was 57.21 ± 11.48 kg and the p-value was 0.689. American society of anesthesiology-I status was found in 56 patients and American society of anesthesiology-II status was found in 64 patients. The mean time required for the first analgesic demand in group 1 was 188.75 ± 7.75 minutes and in group 2, it was 158.90 ± 12.50 minutes and the p-value was found EnglishAmerican society of anesthesiology, First analgesic demand, Intra-operative paracetamol, Pre-emptive paracetamol, Standard monitoring, Intravenous paracetamol
Introduction
Post-operative pain is a common issue after major surgeries and its incidence is 80%, among this 39% of patients have faced extreme pain. Opioids are very effective for post-operative pain management but have some side effects like somnolence, hypotension, respiratory depression, and nausea and vomiting.1
Post-operative pain and its complications are a major concern to surgeons and as well for the anesthesiologist. For perioperative pain management, various methods are employed. Optimal pain management can reduce postoperative complications, enhances recovery, and reduces the length of stay in the hospital.2 Inappropriate post-operative pain management is associated with impaired wound healing, delayed gastrointestinal motility, and a higher risk of thromboembolism.3
Acetaminophen (paracetamol) is recommended for perioperative multimodal analgesic according to current guidelines. Acetaminophen is being used as an adjuvant analgesic and reduces opioid related-related side effects. Intravenous acetaminophen has been used for pain management due to its pharmacokinetic property and higher bioavailability.4 Production of mediators which are causing nerve stimulation is reduced by pre-emptive analgesia. Different methods are existing for pre-emptive analgesia i.e. epidural block, local anesthesia, nerve block, etc.5 Paracetamol acts on the central nervous system and belongs to a group of drugs which is called non-opioid.6 Pre-emptive analgesia should be given before starting surgical procedures to avoid the painful stimulus and to prevent post-operative pain as well as pre-emptive analgesia inhibit the central sensitization which is caused by incisional injuries.7
A society of anesthesiologists (ASA) recommended reducing or avoiding opioid drugs in intra-operative procedures and post-operative pain management.8 Still management of post-operative pain is challenging for clinicians, although very rousing techniques and drugs are accessible.9 Paracetamol with NSAIDs (a combination) for postoperative pain are being used for many years but remains controversial.10
Paracetamol is a safe analgesic drug among children for postoperative pain management.11 Intravenous paracetamol has been found to be more novel and has an antipyretic effect through the hypothalamus. It is very safe, cost-effective, easily available and beneficial for the management of pain12. Although oral paracetamol is effective, and well-tolerated but patients require fast starting elimination of pain after surgery. Parenteral paracetamol has additional fast onset of action and also has a lengthier duration than oral paracetamol.13
Methodology
This study was held after approval from ethical committee for research. A total of 120 patients were selected. Non-probability sampling technique was used. Patients were included in the study according to ASA-I status (American society of anesthesiology) and ASA-II status. Age ranges from 22 -50 years.
Patients were excluded from the study who were not willing, were less than 22 years and more than 50 years, had known paracetamol hypersensitivity, chronic liver issues, renal diseases, and who had been taking different painkiller drugs for many years. Patients were registered for major surgeries of Obstetrics & Gynecology like Abdominal Hysterectomy, vaginal hysterectomy, ovarian masses, Ectopic pregnancies, and masses of the uterus. Patients were divided into two different groups, group-1, and group-2, and were equal in numbers. A total of 60 patients were enrolled for group 1, and sixty patients for group 2. In the pre-emptive paracetamol group, 1 gram paracetamol via intravenous was given 15 minutes prior to induction of anesthesia either spinal or general. In the intra-operative paracetamol (group 2) 1 gram I/V paracetamol was given during operative procedures. Standard monitoring was established in the operating room like an electrocardiogram, blood pressure, oxygen saturation by a pulse oximeter, and capnography were recorded. After performing surgeries, patients were shifted to the post-anesthesia care unit (post-anesthesia care unit) for further post-operative care. The mean time required for the first request for analgesic demand in minutes was recorded. On duty, resident doctors collected data. Variables used for data were the meantime for 1st request for analgesia, mean age of patients, ASA-I status, and ASA-II status. SPSS. 20 versions were used for data analysis. Chi-square test and t-test were applied for analysis.
Results
Total patients were 120 and among them 56 were ASA –I status and 64 were ASA-II. The mean time was 188.75 ± 7.75 minutes for first analgesic demand in group 1 and in group 2, it was 158.90 ± 12.50 minutes showing the better analgesic effect in the pre-emptive paracetamol group.
Figure 1: showing ASA Status in both groups. ASA-I patients were 34 (56.67%) in the pre-emptive paracetamol group and 22 (36.67 %) in the intraoperative paracetamol group. While 26 (43.33%) patients having ASA-II status in pre-emptive group and 38 (63.33%) patients in intra-operative group.
Table I: Represent the ages of the patients in both groups. Mean age was 40.53 + 9.10 years in the pre-emptive paracetamol group (group 1) and 39.25 ±10.70 years in intra-operative paracetamol group (group 2). p-value was insignificant i.e. 0.820 and (C.I.) Confidence Interval was -8.1 to 10.59.
Table II: Explain the mean time for first analgesic demand in the pre-emptive and intra-operative paracetamol groups. The mean time for first analgesic demand in group 1 was 188.75 + 7.75 minutes while in group 2, it was 158.90 ± 12.50 minutes. P-value was very significant i.e. 0.001 and (C.I.) confidence interval was 23.26 to 34.66.
Table III: Represent ASA-I Status and mean time required for first analgesic demand in both groups. Total patients were 56 and 34 patients were in pre-emptive group (group-1) and in 22 patients were in intra-operative group. The mean time for first analgesia was 189.75 ± 6.70 minutes in the pre-emptive paracetamol group and 159.91 ± 14.40 minutes in the intra-operative paracetamol group. P-value was less than 0.001 (significant) and confidence interval (C.I.) was between 19.63- 37.11.
Discussion
In a study, the mean time of first analgesic demand after surgery was significantly higher as compared with the control group i.e. 3.6 ± 3.6 versus 2.3 ± 3.1 correspondingly, and the p-value was significant i.e. 0.030.14 In another study intravenous paracetamol (preemptive) group required a long time in minutes for the first request for analgesic requirement and have minimum post-operative side effects. There were no significant differences noted in both groups regarding their age, weight, and ASA physical status, this is correlating with our study. 15
According to Arsalan M et al. Insignificant findings were noted between two groups regarding the demographic variable like age, weight, and as well as ASA physical status.The time required for the first request for analgesia was lengthier in the paracetamol (preemptive group) compared with the intraoperative paracetamol group and placebo group, this is also correlating with our study.13
A study demonstrated that in head and neck cancer surgeries pre-emptive intravenous paracetamol is very effective for post-operative pain management and due to its usage patient can discharge earlier from the hospital. Both groups were found to be similar regarding their age, weightand ASA physical status16
Data of both groups were similar in age, weight, BMI, and gender. The mean VAS pain score in the intravenous paracetamol group was found 6.3 ± 0.99 as compared with 6.20 ± 1.30 in the intravenous tramadol group, showing no significant difference between both groups.17
Patients had more pain in the recovery room (VAS score for pain 7.0 ±1.24 versus 6.15±2.27) in the saline group and the p-value was significant i.e.0.041 and needed further fentanyl intra-operatively (150 micrograms versus 87.7 ± 7.5) and p-value was less than 0.01 18
Patients had higher and more significant VAS pain scores in the pre-emptive group than patients in the intra-operative group (3.9 =+0.3, 3.3+ 0.4 versus 2.8+0.2 and 2.6+0.3) immediately and after 6 hours of surgery and p-value were Englishhttp://ijcrr.com/abstract.php?article_id=4557http://ijcrr.com/article_html.php?did=4557
1. Atkins JR, Titch JF, Norcross WP, Thompson JA, Muckler VC. Preemptive oral acetaminophen for women undergoing total laparoscopic hysterectomy. Nursing for women’s health. 2019; 23(2):105-113.
2. Laporta ML, O’Brien EK, Stokken JK, Choby G, Sprung J, Weingarten TN. Anesthesia Management and Post-anesthetic Recovery Following Endoscopic Sinus Surgery. The Laryngoscope. 2021; 131(3):815-820.
3. Svider PF, Nguyen B, Yuhan B, Zuliani G, Eloy JA, Folbe AJ. Perioperative analgesia for patients undergoing endoscopic sinus surgery: an evidence-based review. Int. forum of allergy & rhinology 2018; 8(7): 837-849.
4. Bhoja R, Ryan MW, Klein K, Minhajuddin A, Melikman E, Hamza M, Marple BF, McDonagh DL. Intravenous vs oral acetaminophen in sinus surgery: a randomized clinical trial. Laryngoscope investigative otolaryngology. 2020 Jun; 5(3):348- 353.
5. Thenarasu V, Gurunathan D, Selvarasu K. Comparison of Efficacy of Diclofenac and Paracetamol as Preemptive Analgesic Agent. Biomedical and Pharmacology Journal. 2018; 11(3):1699-1706.
6. Bilir S, Yurtlu BS, Hanci V, Okyay RD, Erdogan Kayhan G, Ayoglu HP et al. Effects of peroperative intravenous paracetamol and lornoxicam for lumbar disc surgery on postoperative pain and opioid consumption: A randomized, prospective, placebo-controlled study. Agri. 2016; 28(2):98-105.
7. Kharouba J, Hawash N, Peretz B, Blumer S, Srour Y, Nassar M, Sabbah M, Safadi A, Khorev A, SomriM. Effect of intravenous paracetamol as pre-emptive compared to preventive analgesia in a pediatric dental setting: a prospective randomized study. Int. J. of Paediatric Dentistry.2018; 28(1):83-91.
8. Ciftci B, Ekinci M, Celik EC, Kaciroglu A, Karakaya MA, Demiraran Y et al. Comparison of intravenous ibuprofen and paracetamol for postoperative pain management after laparoscopic sleeve gastrectomy. a randomized controlled study. Obesity surgery. 2019; 29(3):765-770.
9. Ekici NY, Alagöz S. The effectiveness of endoscopic sphenopalatine ganglion block in the management of postoperative pain after septal surgery. Int. forum of allergy & rhinology 2019; 9(12): 1521-1525.
10. Aksoy M, ?nce ?, Ahiskalioglu A, Keles S, Doymus O. Effect of intravenous preoperative versus postoperative paracetamol on postoperative nausea and vomiting in patients undergoing strabismus surgery: A prospective randomized study. Agri. 2018; 30(1):1-7.
11. Juan F, Ayiheng Q, Yuqin F, Hua Z, Jun Y, Bin H. Risk Factors of Chronic Rhinosinusitis After Functional Endoscopic Sinus Surgery. Med Sci Monit. 2017; 28(23):1064-1068.
12. Dalal S, Ninave S. Efficacy of intravenous paracetamol infusion for attenuation of hemodynamic responses to laryngoscopy and tracheal intubation. Indian Journal of Sciences and Technology. 2019; 12(36):1-7.
13. Arslan M, Celep B, Çiçek R, Kalender HÜ, Y?lmaz H. Comparing the efficacy of preemptive intravenous paracetamol on the reducing effect of opioid usage in cholecystectomy. Journal of research in medical science.. 2013; 18(3):172-177
14. Atashkhoei S, Nikan F, Kardan R, Pourfathi H. Effect of Different Doses of Paracetamol on Postoperative Pain After Gynecologic Laparoscopy surgery. Int. J.Women health and Repr. Sci 2018; 6(3): 374-379.
15. Hassan HI. Perioperative analgesic effects of intravenous paracetamol: Preemptive versus preventive analgesia in elective cesarean section. Anesthesia, essays and researches. 2014; 8(3):339.
16. Majumdar S, Das A, Kundu R, Mukherjee D, Hazra B, Mitra T. Intravenous paracetamol infusion: Superior pain management and earlier discharge from hospital in patients undergoing palliative head-neck cancer surgery. Perspect Clin Res. 2014; 5(4):172-177.
17. Bandey S, Singh V. Comparison between I/V paracetamol and Tramadol for post-operative analgesia in patients undergoing laparoscopic cholecystectomy. J Clin Diag Res. 2016; 10(8):05- 09.
18. Soltani G, Molkizadeh A, Amini S. Effect of Intravenous Acetaminophen (Paracetamol) on Hemodynamic Parameters Following Endotracheal Tube Intubation and Postoperative Pain in Caesarian Section Surgeries. Anesth Pain Med. 2015; 5(6):e30062.
19. Hassan HI. Perioperative analgesic effects of intravenous paracetamol: Preemptive versus preventive analgesia in elective cesarean section. Anesthesia, essays and researches. 2014; 8(3):339-344
20. Koteswara CM, D S. A Study on Pre-Emptive Analgesic Effect of Intravenous Paracetamol in Functional Endoscopic Sinus Surgeries (FESSs): A Randomized, Double-Blinded Clinical Study. J Clin Diagn Res. 2014; 8(1):108-111.
21. Moon YE, Lee YK, Lee J, Moon DE. The effects of preoperative intravenous acetaminophen in patients undergoing abdominal hysterectomy. Archives of gynecology and obstetrics. 2011; 284(6):1455-1460.
22. Mac TB, Girard F, Chouinard P, Boudreault D, Lafontaine ER, Ruel M, Ferraro P. Acetaminophen decreases early post-thoracotomy ipsilateral shoulder pain in patients with thoracic epidural analgesia: a double-blind placebo-controlled study. Journal of cardiothoracic and vascular anesthesia. 2005; 19(4):475-478.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20HealthcareSelf-medication among Udupi Migrant Workers
English2732Sushma Dayanand KotianEnglish Kumar SumitEnglish Sabah Mohd ZubairEnglishIntroduction: Self-medication is an essential public health issue specifically, self-medication with antibiotics is adding to the antimicrobial resistance which has become a global threat. There is a necessity to assess and understand the self-medication practices particularly, the migrant workers as they are considered to be a vulnerable community in society. The study aimed to assess self-medication practices among the migrant workers and the objective was to understand the practices associated with self-medication among the migrant workers in Udupi Taluk, Karnataka. Material & Methods: A present study was a community-based cross-sectional study conducted in Udupi Taluk and 382 migrant workers were interviewed using a validated questionnaire. Data was entered and analyzed using IBM SPSS version 20. Results: The prevalence of self-medication was found to be 68.8% 263 of (382). The majority of the participants reported that pharmacy (88.6%) is the primary source of self-medication. The majority of the participants mentioned their symptoms to pro-cure the medicines (70%). The majority of the participants were practicing self-medication for cough (24.7%) followed by fever (20.9%). Among these factors, gender and daily wage were found to be statistically significant (p valueEnglishMigrant workers, Self-medication, Udupi, India, Healthcare, Health educationhttp://ijcrr.com/abstract.php?article_id=4558http://ijcrr.com/article_html.php?did=4558Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20Life SciencesIsolation and Identification of Endo-Parasites from Fecal Pellets of Avian Species in Captivity
English3341Maria MahnoorEnglish Tariq AhmadEnglish Anum RazzaqEnglish Bushra Allah RakhaEnglish Faiz Ur RehmanEnglish Muhammad SulimanEnglish Ihsan UllahEnglish Muhammad Tayyab KhanEnglish Sindho WaganEnglish Hira ShahzadiEnglishEnglishEndo-parasites, Avian species, Fecal pellets, Captivity, Pathogens, Centrifugal flotationhttp://ijcrr.com/abstract.php?article_id=4559http://ijcrr.com/article_html.php?did=45591. Adejinmi JO, Oke M. Gastrointestinal parasites of domestic ducks (Anas platyrhyncho) in Ibadan Southwestern Nigeria. AJPS 2011;5:(1), 46-50.
2. Ashraf S, Javid A, Ashraf M, Akram M, Altaf M,Ali, Z. et al.Studies on parasitic prevalence in ring-necked pheasants (Phasianuscolchicus) in captivity. Journal of Animal and Plant Sciences (JAPS), 2015; 25:(3), 359-364.
3. Balicka-Ramisz A, Pilarczyk B. Occurrence of coccidia infection in pigeons in amateur husbandry. Diagnosis and prevention. Annals of Parasitology, 2014; 60(2).
4. Barnes HJ. Parasites. Clinical Avian Medicine and Surgery,1986; 472-485.
5. Borgsteede FH, Okulewicz A. Justification of the species Cyathostoma (Hovorkonema) americana (Chapin, 1925) (Syngamidae-nematoda). Helminthologia,2001; 38:151-154.
6. Dovc A, Zorman-Rojs O, VerglesRataj A, Bole-Hribovšek V, Krapež U, Dobeic M. Health status of free-living pigeons (Columba livia domestica) in the city of Ljubljana. Acta Veterinaria Hungarica, 2004; 52: (2), 219-226.
7. Globokar, M, Fischer D, Pantchev N. Occurrence of endoparasites in captive birds between 2005 to 2011 as determined by faecal flotation and review of literature. Berliner Und Munchener Tierarztliche Wochenschrift 2017; 130:(11-12), 461-473.
8. Kathiravan RS, Ramachandran P, Shanmuganathan S, Karthikeyan A, Sathiyamoorthy N, Gollapalli SK et al. Prevalence of Endoparasitic Infection in Free-Ranging Peacocks.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20Healthcare
Improving Clinical Outcomes of Orbital Volume Restoration Using Peri-Operative Diagnostic Tools in Management of Orbital Fractures - A Prospective Study
English4250Janani NarayananEnglish Vivek NarayananEnglish Saravanan ChandranEnglish Karthik RamakrishnanEnglish Prashanthi GurramEnglish Abinaya SubramanianEnglish
Introduction: Accurate evaluation of change in orbital volume occurring due to trauma is of paramount importance to achieve an optimal final outcome. Thus, the purpose of this study was to assess and evaluate the orbital volume both radiological and clinical means for accurate surgical correction. Aim: To assess the final surgical outcome using standardized clinical and radiological tools perioperatively to restore orbital volume in patients with orbital wall fractures. Materials and Methods: A prospective interventional study of patients with unilateral orbital wall fractures which was carried out for 24 months. A thorough clinical evaluation and ophthalmological assessments including visual acuity, field of vision was performed. All patients had HRCT for volumetric assessment and assessed clinically for enophthalmos using Hertel exophthalmometer. Based on the level of enophthalmos and orbital volume change, treatment plan was formulated. Intraoperatively Hertel exophthalmometer is used to correct the predetermined enophthalmos. Postoperatively the patients are followed-up at designated intervals to assess the surgical outcome. RESULT: Road Traffic Accident (RTA) was the common etiology of orbital fractures which accounts for 84.1% (n=53) and the most common clinical sign was enophthalmos which accounted for 76.2% (n=48). The mean and standard deviation of orbital volume is 35.20 ± 4.21 and change in orbital volume is 4.29±2.76. The mean and standard deviation were calculated for all patients in different time intervals. The result showed a statistically significant difference in pre-operative phase, intra-operative phase and it maintained throughout the postoperative phase. CONCLUSION: In our study we have found that meticulous preoperative and intraoperative tools to assess in orbital reconstruction gives a desired surgical outcome. Hertel exophthalmometer and HRCT-based 3D reconstructed volumetric analysis can be an excellent tool to evaluate anteroposterior globe malposition and volume change.
EnglishOrbital volume, Orbital trauma, Orbital reconstruction, Enophthalmos, Hertel exophthalmometer, 3D reconstructed digital volumetric analysis
INTRODUCTION:
Accurate evaluation of change in orbital volume occurring due to trauma is of paramount importance to achieve an optimal final outcome. Computed Tomography scan has radically increased the scope of accurate assessment based on which contemporary reconstruction practices are structured upon.1 Multi-slice imaging and advanced computer software allow precise measurement of the dimension, area, and volume of orbital structures.2 The change in volume of the fractured orbit becomes extremely challenging to reconstruct due to the complex orbital anatomy.3,4 Though a change in orbital volume could occur due to the fracture in any of the four walls, it occurs largely due to the defects of the floor and thin medial wall.5,6,7
Orbital wall injuries constitute more than 40% of maxillofacial trauma. About 4 to 16% account for isolated orbital floor fractures. Orbital fractures result in volume change in most instances, which inaccurately assessed and inadequately addressed will result in post-traumatic deformities such as persistent enophthalmos, dystopia, diplopia, and restricted extra-ocular movements.8,9 These symptoms may affect the final functional and aesthetic outcome.
Enophthalmos is considered to be a pathognomonic sign of orbital wall fractures.8 The presence of enophthalmos dictates the necessity of surgical exploration and reconstruction for superior clinical outcomes. Enophthalmos is clinically evident when there is a measurable change of 2mm or more is present.10 But early enophthalmos is difficult to assess due to the presence of periorbital edema. However, radiographic measurement of orbital volume using standardized CT scans can be helpful in detecting early enophthalmos in order to improve treatment outcomes and prevent associated complications. There are enough evidence in the literature that proved that there is a direct and distinct relationship between change in orbital volume and the degree of enophthalmos.11,12
Thus, the purpose of this study was to assess and evaluate the orbital volume both radiological and clinical means. In this study, the measurements are planned to be taken pre-operatively to assess the change in orbital volume, intra-operatively to assess accurate surgical correction and post-operatively to assess the efficacy of correction.
AIM AND OBJECTIVES:
The primary aim of our study was to evaluate perioperative orbital volume changes of the fractured and normal orbits at regular follow-ups. The secondary aim was to assess the final clinical outcome of orbital reconstruction which necessitates volume correction by intra-operative evaluation methods.
METHODOLOGY:
This study is a Prospective Interventional study to assess perioperatively the orbital volume changes in patients with orbital wall fractures using standardized clinical and radiological methods. Study period was between August 2018 and March 2020. The minimum follow-up period of 6 months has been completed for all patients. The patients who reported to our institution with orbital wall fractures were included in the study. The patients were recruited either directly from the Department of Oral & Maxillofacial Surgery or from the Department of Accident and Emergency. The study comprised of a sample size of 63 patients with 53 males and 10 females. The age group ranged from 18 – 50 years with a mean range of 34 years. None of the patient showed immediate indication for surgical intervention.
Selection Criteria:
The inclusion criteria include patients of age 18 years and above diagnosed with unilateral orbital wall fractures. Presence of congenital deformities of the face such as facial asymmetry or syndromes involving the orbital cavity, such as Treacher Collin Syndrome, previous history of orbital wall fractures, bilateral orbital wall fractures, Ocular injuries or ocular diseases, such as glaucoma, cataract, or contralateral blindness, who are not willing to be a part of the study were excluded.
Pre-operative Assessment:
Clinical Evaluation:
Initially the patients went through a complete general examination fulfilling the criteria of trauma protocol. Patients who were hemodynamically stable and with GCS-15/15 were taken under Oral and Maxillofacial Surgery care.A thorough Maxillofacial examination was conducted including all inspectors and palpatory findings. Initially, the patients presented with periorbital edema and ecchymosis which made the assessment of enophthalmos, hypogeous and restriction of eye movements difficult. After resolution of the periorbital edema the patients are clinically assessed for enophthalmos, hypogeous and restriction in eye movements. Patients were subjected to an outright Ophthalmological examination. The evaluation included visual acuity using Snellen’s charting, fundus examination and diplopia charting were done.
A Hertel exophthalmometer was used to assess the clinical enophthalmos. A fixed base was assigned for each patient, ie the distance between the lateral orbital rims. The anterior-most point in the sclera-corneal junction is measured on both eyes.13,14,15,16,17 The amount of enophthalmos was calculated by comparing the uninjured and fractured sides.
Radiological Evaluation:
High-resolution Computed Tomography scan of facial bones with 0.6mm thin bone sections were done who experienced orbital trauma. Radiologically enophthalmos was measured by calculating the distance between corneal and orbital apices in the affected and unaffected side. Three-dimensional reconstructions for orbital volume were made by Materialise Interactive Medical Image Control System (MIMICS, Materialise, Leuven, Belgium) according to DICOM files. Gantry tilt was set to be parallel to the Frankfort horizontal plane and 0.6 mm slice thickness were used. Three-dimensional orbital cavity reconstruction was done with Mimics software considering Hounsfield Units (HU): -200 to +100 HU for bony structures.To calculate the volume of the bony orbital cavity, all contours along the orbital walls were included in the following boundaries:
-The anterior aspect of optic canal was considered as the posterior boundary of orbital cavity.
-The line between lateral orbital rim and lacrimal bone was considered as the anterior boundary of orbital cavity.
Segmenting was done along a straight line from the anterior lacrimal crest to lateral orbital wall(Figure 1).11,12Afterwards, the 3D structure was reconstructed (Figure 2). The difference between the two orbits, un-fractured and injured, gives the orbital volume change.
Surgical protocol:
All the surgical procedures were carried out under General Anaesthesia in an Operation Theatre (Figure 3). Using standard armamentarium and surgical protocols fixation or reconstruction of orbital wall fractures done using alloplastic material or autogenous graft (Figure 4&5).18,19,20,21 Intraoperatively Hertel exophthalmometer is used to correct the predetermined enophthalmos (Figure 6). Post-operatively Hertel exophthalmometer was used to re-assess the clinical enophthalmos. A fixed base distance between the lateral orbital rims which was measured pre-operatively is used as a guide. Post-operatively the measurements are done on the 7th day,30th day, 3 months and 6 months.
RESULTS:
During the study period 65 patients with orbital wall fractures were encountered. Out of which 63 patients met the criteria for inclusion. The remaining 2 patients were excluded from the study since they were under the age of 18 years. 84% (n=53) of them were males and 16% (n=10) were females. The majority of the patients were in the age group of 20-30 years (Figure 7) (n=31, 49.3%) with a mean age of 34.5 ±14.88 years. Road Traffic Accident (RTA) was the common etiology which accounts for 84.1% (n=53) followed by interpersonal violence 7.9%(n=5). The most common clinical sign was enophthalmos which accounted for 76.2% (n=48). Twenty-two patients (34.9%) had dystopia, five patients (79%) had diplopia and one patient (1.6%) had only restriction of eye movements.
All patients are classified into single, two, three and four wall defects based on preoperative HRCT images. Two-wall orbital defect accounts for 47.6% (n= 30), 44.4% (n=28) of patients had single wall defect and around 7.9% (n=5) had a three-wall orbital defect (Figure 8). The mean and standard deviation of orbital volume is 35.20 ± 4.21 (Table 1) and the change in orbital volume is 4.29±2.76. An Independent t-test was done to compare the pre-operative orbital volume of normal and fractured sides (Table 2). The results showed a statistically significant difference.
Based on the number of fractured walls, enophthalmos, volumetric change and other clinical symptoms the treatment plan was decided. Undisplaced orbital wall fractures with no gross volumetric change and absence of clinical symptoms like enophthalmos, diplopia and ophthalmoplegia are managed conservatively which accounts for 14.2% (n=9).
Patients with the displaced orbital wall showing volume change and enophthalmos greater than 3mm underwent orbital exploration with orbital reconstruction which accounted for 14% (n=11). Patients with no gross orbital volume change but showed clinical symptoms like restricted eye movements and diplopia underwent orbital exploration which accounts for 38% (n=30). Patients with displaced orbital rims underwent either two-point or single-point fixation which accounted for 36% (n=28) and 12% (n=9) respectively.
Two types of statistical tests were performed in our study. Initially, an independent t-test was done to compare the enophthalmos values between the fractured and normal sides at different time intervals. Later paired t-test was performed to compare enophthalmos values between each time interval amongst the fractured side. The mean and standard deviation were calculated for all patients in different time intervals. The results showed a statistically significant difference in the pre-operative phase (Table 3) and the intra-operative phase, which is maintained throughout the post-operative phase.
A comparison of Pre-op enophthalmos with other time intervals was done and the results are tabulated (Table 4). There is a statistically significant difference between pre-operative enophthalmos and enophthalmos assessed at different time intervals. The mean difference and standard deviation for 3 months post-op enophthalmos with 6 months post-op is 0.083 ± 0.404 mm.
Patients who underwent orbital reconstruction are statistically analyzed separately to compare with the patients who underwent single-point fixation. The Hertel mean values and standard deviation are calculated. The mean of Hertel values at various time intervals showed a significant decrease in the enophthalmos which has been corrected intra-operatively for patients who underwent orbital reconstruction (Table 5). Whereas there is no significant difference in the Hertel values throughout the pre-operative, intra-operative and post-operative phases in patients who underwent single point fixation (Table 6).
Paired t-test was done to compare the enophthalmos values between different time intervals in patients who underwent orbital reconstruction and single point fixation. There is a statistically significant difference between pre-operative enophthalmos (Table 7) and enophthalmos assessed at different time intervals. However, we are unable to generate results for paired t-tests in patients who underwent single-point fixation because there no significant difference in enophthalmos values between different time intervals.
DISCUSSION:
Restoration of the normal facial appearance is probably the most repeated requisition by any victim who experienced maxillofacial trauma. The orbit is the prominent structure plays a vital role in restoring facial balance, which constitutes the biggest challenge for the maxillofacial surgeon when dealing with orbital injuries which may be associated with significant functional and aesthetic discrepancies. Orbital fractures are often presented as dramatic symptoms like black eye or red eye even in an un-displaced fracture, which is more disconcerting to the patients. However, in some patients especially in the pediatric group shows minimal soft-tissue signs of trauma and can be easily missed out. According to Miller and Glaser, 1966, clinical signs include periorbital edema, ecchymosis, sub-conjunctival hemorrhage, subcutaneous emphysema, diplopia in horizontal gaze, hypogeous and enophthalmos.8 Enophthalmos, restricted eye movements, infraorbital paraesthesia and diplopia are the most persistent clinical symptom which needs a more careful assessment for proper treatment planning.In our study, the most common clinical sign was enophthalmos which accounted for 76.2%, followed by diplopia 79%. Twenty-two patients (34.9%) had dystopia and one patient (1.6%) had only restriction of eye movements.
In a retrospective study conducted by Catone et al. 27 cases of untreated orbital blow-out fractures presented with minimal ophthalmologic symptoms.10 Of 27 patients, 2 patients had enophthalmos greater than 2mm, 1 patient had restricted ocular movement and 1 Patient had residual diplopia. Based on their clinical experience, the author suggested surgical intervention is required if there is a presence of enophthalmos greater than 2mm, residual diplopia in primary gaze, restricted ocular motility which persists for more than 10-14 days, and gross disruption of the orbital floor as confirmed by CT. The majority of studies generally do not recommend surgical invention for diplopia; since diplopia is self-limiting.
Several theories exist for the mechanism of post-traumatic enophthalmos which includes enlargement of the bony orbit, increase in orbital volume, loss of ligament support, post-traumatic fat atrophy, fat displacement and fat contracture.9 The correct reduction, effective fixation of tripod zygomatic fracture and reconstruction of the orbital floor are crucial for optimal results which avoid secondary enophthalmos and hypogeous. Catone et al. detected 7% to 10% of patients undergoing conservative treatment for blow-out fractures suffered from persistent enophthalmos.21 This is because the position of the globe immediately after trauma is usually not representative of the final position which will appear after the resolution of the edema. There are chances of development of late enophthalmos as the edema resolves.22Correction of secondary enophthalmos and facial asymmetry are not easily achievable and showed satisfactory aesthetic results in 77% of cases.23 Thus the outcome is better when appropriate fracture reduction and fixation is done at the first surgery. This can be achieved only if the assessment of enophthalmos and orbital volume is done intra-operatively after the reduction of fractures.
Shen et al. performed a retrospective study in 64 patients with delayed orbitozygomatic fractures with enophthalmos treated by surgery.25 They reported that enophthalmos will develop later, even after surgery in some cases because of orbital fat atrophy. Whitehouse et alpresented evidence for a correlation between the increase in orbital volume after orbital trauma and enophthalmos, suggesting that posttraumatic enophthalmos is caused by the dislocation of the bony fragments rather than fat atrophy or fibrosis. The authors conducted a study in 11 patients with orbital blow-out fractures and confirmed that enophthalmos after blowout fractures is linearly related to increases in the volume of the orbit. They concluded that each cm3 increase in volume caused 0.77mm of enophthalmos.24
Forbes et al. used Computed tomographic digital data and special off-line computer graphic analysis to measure volumes of the normal orbital. They reported that volumes of the bony orbit and total orbital soft tissue vary from 0% to 8% between the right and left orbits when measured in the same person which likely reflects both small anatomic differences and the accuracy of the technique used.26 So in our study we have used unfractured orbit as a control to evaluate the volume change.
A cadaveric study was done by Gregory S. Parsons and Robert H. Mathog to study the traumatic effects of the displaced orbital wall on globe positions and orbital volume. They determined that a 2.8% volume change resulted in a globe position change of 1mm.27 In a study done by Hong-Ryal Jin et al. in nine patients with blowout fractures of the orbital wall, there was a relationship between the extent of fracture and enophthalmos. They reported that a defect size of 1.9cm2 is presented with 2mm of enophthalmos and a defect size of 3.2cm2 was associated with 3mm of enophthalmos.7 Dolynchuk et al. detected that if the overall orbital volume difference between normal and fractured orbit was more than 4 to 5%, enophthalmos would be greater than 3mm.28 The mean orbital volumes in this study were similar to those found in other studies, in which the same software was used. We found a significant difference in volume between the fractured and normal orbits, which is in accordance with the findings of previous studies.
The Hertel values taken intra-operatively show a reduction in enophthalmos level and restoration of the orbital volume. During the post-operative phase, the enophthalmos level remained stable which was achieved intra-operatively. Our study showed statistically significant results in measurements taken at all intervals using the Hertel exophthalmometer. Hence it can be considered the standard tool to restore the orbital volume accurately. However, Hertel exophthalmometer measures only the anteroposterior position of the globe and it requires intact lateral orbital rim.13,14,15 It cannot be used to measure enophthalmos in case of bilateral orbitozygomatic fractures. Hertel exophthalmometer gives a relative globe position and does not give an accurate numerical measurement of enophthalmos in millimeters which will be helpful for surgical planning. So further innovations are required to overcome the above-stated shortcomings which we encountered in this study.
CONCLUSION:
Orbital reconstruction with accurate orbital volume restoration remains a challenge in Maxillofacial Traumatology. With the advent of new generation imaging modalities, understanding the complex orbital anatomy and accurate orbital reconstruction for optimal functional and aesthetic results are feasible.
Surgical innovations like intra-operative navigation are a step in this direction.29 Surgical outcome of secondary reconstruction for post-traumatic deformities is usually unpredictable. Hence, accurate primary reconstruction is the goal for all maxillofacial surgeons. Surgical navigation though considered superior is not available everywhere across the world. Intra-operative usage of commonly available tools like Hertel exophthalmometer can significantly improve the final surgical outcome.
In our study sixty-three patients who had orbital wall fractures were evaluated pre-operatively by HRCT-based 3D reconstructed volumetric analysis and assessed clinically for enophthalmos using Hertel exophthalmometer. Intra-operatively Hertel exophthalmometer was used to achieve the desired orbital volume correction. Post-operatively all the patients were followed-up at designated intervals. Clinical assessment using Hertel exophthalmometer confirmed the stable results of orbital volume correction which was achieved intra-operatively. Hertel exophthalmometer and HRCT-based 3D reconstructed volumetric analysis can be an excellent tool to evaluate anteroposterior globe malposition and volume change.
Acknowledgment: Dr. Shantanu Patil, Head and Consultant, Department of Translational Medicine and Research, SRM Medical College, Hospital and Research Centre.
ETHICAL APPROVAL:
This study was approved by Institutional Ethical Committee Board (IEC NO: 1477/IEC/2018).
CONFLICT OF INTERESTS:
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
SOURCE OF FUNDING:
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Authors’ Contribution:
1. Janani Narayanan- Original research done and compilation of the data into an article
2. Vivek Narayanan- Agreed to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
3. Saravanan Chandran- Have made a substantial contribution to the concept or design of the article; or the acquisition, analysis, or interpretation of data for the article
4. Karthik Ramakrishnan- Have made a substantial contribution to the concept or design of the article and also drafted the article or revised it critically for important intellectual content
5. Prashanthi Gurram- One of the operating surgeons.
6. Abinaya Subramanian- Corrected the version to be published.
Englishhttp://ijcrr.com/abstract.php?article_id=4560http://ijcrr.com/article_html.php?did=4560
1. Van Hout WM, Van Cann EM, Muradin MS, Frank MH, Koole R. Intraoperative imaging for the repair of zygomaticomaxillary complex fractures: a comprehensive review of the literature. J Craniomaxillofac Surg. 2014;42(8): 1918-1923.
2. Ploder O, Klug C, Voracek M, Burggasser G, Czerny C. Evaluation of the computer-based area and volume measurement from coronal computed tomography scans in isolated blowout fractures of the orbital floor. J Oral Maxillofac Surg. 2002 Nov;60(11):1267- 72; discussion 1273-4.
3. Manson P.N., Clifford C.M., Su C.T, Iliff NT, Morgan R. Mechanism of global support and posttraumatic enophthalmos: The anatomy of the ligament sling and its relation to intramuscular cone orbital fat. Plast Reconsr. Surg 1986; 77:193.
4. Whitnall SE: On a tubercle on the malar bone, and on the lateral attachments of the tarsal plates, J Anatomy Physiology 45:426,1911.
5. Fischbein and Lesko: Blowout fracture of medial orbital wal. Arch Ophthal 51:162-3,1969.
6. DeVisscher JG, van der Wal KG. Medial orbital wall fracture with enophthalmos. J Craniomaxillofac Surg. 1988 Feb;16(2):55-9.
7. Jin HR, Shin SO, Choo MJ, Choi YS. Relationship between the extent of fracture and the degree of enophthalmos in isolated blowout fractures of the medial orbital wall. J Oral Maxillofac Surg. 2000 Jun;58(6):617-20
8. Miller and Glasser: Retraction syndrome. Arch Ophthal 70:662,1966. 9. Zide MF. Late posttraumatic enophthalmos corrected by dense hydroxylapatite blocks. J Oral Maxillofac Surg. 1986 Oct;44(10):804-6.
10. Catone GA, Morrissette MP, Carlson ER. A retrospective study of untreated orbital blow-out fractures. J Oral Maxillofac Surg. 1988;46(12):1033-1037.
11. Choi SH, Kang DH, Gu JH. The correlation between the orbital volume ratio and enophthalmos in unoperated blowout fractures. Arch Plast Surg. 2016;43(6):518-522.
12. Ebrahimi A, Kalantar Motamedi MH, Rasouli HR, Naghdi N Enophthalmos and orbital volume changes in Zygomaticomaxillary complex fractures: Is there a correlation between them. J Oral Maxillofac Surg(2018)
13. Sleep TJ, Manners RM. Interinstrument variability in Herteltype exophthalmometers. Ophthal Plast Reconstr Surg. 2002 Jul;18(4):254-7.
14. O’Donnell NP, Virdi M, Kemp EG. Hertel exophthalmosetry: the most appropriate measuring technique. Br J Ophthalmol1999;83:1096.
15. Ameri H, Fenton S. Comparison of unilateral and simultaneous bilateral measurement of the globe position, using the Hertel exophthalmometer. Ophthalmic Plast Reconstr Surg. 2004;20(6):448-451.
16. Kashkouli MB, Beigi B, Noorani MM, Nojoomi M. Hertel exophthalmometry: reliability and interobserver variation. Orbit. 2003;22(4):239-245.
17. Musch DC, Frueh BR, Landis JR. The reliability of Hertel exophthalmometry. Observer variation between physician and lay readers. Ophthalmology. 1985 Sep;92(9):1177-80.
18. Converse JM: Reconstruction of floor of the orbit by bone grafts. Arch Ophthalmol 44: 1,1950.
19. Lee GH, Ho SY. Orbital Adherence Syndrome following the Use of Titanium precontoured orbital mesh for the reconstruction of posttraumatic orbital floor defects. Craniomaxillofac Trauma Reconstr. 2017 Mar;10(1):77-83.
20. Carrol W. B: Alloplastic materials in orbital repair. AJO 63:955,1967. 105. 21. Carrol W. B: Use of Alloplastics in 45 cases of orbital floor reconstruction. AJO 1965; 63:684-699.
22. Hammer B, Prein J. Correction of post-traumatic orbital deformities: operative techniques and review of 26 patients. J Craniomaxillofac Surg. 1995;23(2):81-90.
23. Mazock JB1, Schow SR, Triplett RG. Evaluation of ocular changes secondary to blowout fractures. J Oral Maxillofac Surg. 2004 Oct;62(10):1298-302.
24. Whitehouse RW, Batterbury M, Jackson A, Noble JL. Prediction of enophthalmos by computed tomography after “blow out” orbital fracture. Br J Ophthalmol. 1994; 78:618.
25. He D, Li Z, Shi W, Sun Y, Zhu H, Shen G. Orbitozygomatic fractures with enophthalmos: analysis of 64 cases treated late. J Oral Maxillofac Surg, 2012Mar; 70(3):562-76
26. Forbes G, Gehring DG, Gorman CA, Brennan MD, Jackson IT. Volume measurements of normal orbital structures by computed tomographic analysis. AJR Am J Roentgenol. 1985 Jul;145(1):149-54.
27. Parsons GS, Mathog RH. Orbital wall and volume relationships. Arch Otolaryngol Head Neck Surg. 1988 Jul;114(7):743-7.
28. Dolynchuk KN, Tadjalli HE, Manson PN: Orbital volumetric analysis: Clinical application in orbitozygomatic complex injuries. J Cranio Maxillofac Trauma 2:56, 19
29. Copelli C, Manfuso A, d’Ecclesia A, Catanzaro S, Cassano L, Pederneschi N et al. Endoscopic transnasal approach and intraoperative navigation for the treatment of isolated blowout fractures of the medial orbital wall. J Craniomaxillofac Surg. 2015 Dec;43(10):1974-8.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20Healthcare
Comparison of Outcomes of the Radial Forearm Free Flap Vs Pectoralis Major Pedicled Flap for the Reconstruction of Oral Soft Tissue Defects
English5157Abdul Malik MujahidEnglish Musadiq AsrarEnglish Ifrah RahedEnglish Kashif MehmoodEnglish Usman IshaqueEnglish Noor AliEnglishEnglishRadial forearm free flap, Pedicled Pectoralis Major myocutaneous flap, Survival rate, Peri oral defects, Tumor, Oral cancers
INTRODUCTION
Head and neck cancers are one of the common cancers with peri oral cancer are more prevalent in areas with use of tobacco, gutka, and alcohol. Peri oral soft tissue defects can occur after tumor ablation or trauma. Surgical management of oral squamous cell carcinoma typically involves resection of the tumor with a 1 cm margin under frozen section control that may create a full-thickness defect, requiring more complex methods of reconstruction.1 The reconstruction of peri-oral defects has been a challenge for plastic surgeons, especially with the involvement of commissure to achieve both functional and aesthetic favorable appearance. The competence of the orbicularis muscle sphincter must be maintained, as this is critical to achieving a functional recovery. The functional goals of the cheek and lip reconstruction are to maintain intraoral mucosal lining and to preserve the surface area of the oral aperture. The aesthetic goals are to provide replacement of external soft tissue following the subunit principles of vermiliocutaneous junction and lip aesthetic units.2
The basic principle of plastic surgery is to replace like with like tissue. The selection of reconstructive options is based on the nature, size and location of the defect as well as on the general health and prognosis of the patient.3 In 1979, use of the pectoralis major flap was first described for reconstruction of oral soft tissue defects. Since that it has become a commonly used option because of its relative reliability, availability, and ease of dissection.4 In last two decades there was a significant advancement in plastic surgery techniques and with the advent of microsurgical methods, different other options came into practice for the reconstruction of oral and peri oral soft tissue reconstruction. Nowadays, Radial forearm free flap is in routine practice in reconstructive head and neck surgery and is used as a workhorse flap because of its reliable anatomy, long pedicle length, good size vessels, suitable thinness and relative scarcity of hair and to substitute mobile oral mucosa.5
In 2010, O‘Neill et al. compared radial forearm free flap and Pectoralis Major Myocutaneous pedicled flap for reconstruction of oral and oropharyngeal defects and found 5.4% of flap loss with wound dehiscence with pectoralis myocutaneous flap while no flap loss and wound dehiscence in Radial forearm free flap reconstruction.6 In another study, C. Avery stated that free tissue transfer has become the preferred reconstructive option with success rates of 95% or higher with fewer complications and better functional outcomes.7 Pipkorn et al. in his study, emphasized on functional considerations in oral cavity reconstruction and mentioned Different assessment tools for oral functions.8 Li and Zhang et al. and Yang and Li et al. use 14 item oral health impact profile (OHIP-14) and the University of Washington quality of life (UW-QOL) questionnaire and showed better outcome in RFFF group as compared to PMMF.9, 10
The rationale of my study is that Radial forearm free flap is better choice than pedicled pectoralis major myocutaneous flap in terms of functionality and aesthetic outcome.As no local data is available regarding the comparison of both options, so this study will set a baseline data regarding the management of perioral soft tissue defects reconstruction andwill not only help in selecting the suitable option in our developing population but also addresses local patient concerns regarding functional outcome in terms of oral competence post-surgery.
Materials and Methods: A Randomized control trials was conducted at Department of Plastic and Reconstructive Surgery Bahawal Victoria Hospital Bahawalpur from July 2019 to December 2020. A sample size of 60 was calculated with the 5% level of confidence, 80% power of study and taking flap loss as 0% in group A (Radial forearm free flap) and 5.4% in group B (Pectoralis Major pedicled flap).7 Sampling was done Through a non-Probability consecutive sampling and patients were divided into two equal groups. Patient with oral and perioral soft tissue defects of upper lip, commissure, lower lip involving mucosa and buccal mucosal defects > or =50% of the lip size after trauma or tumor resection presenting within 6 months of diagnosis, aged between 15-65 years of either gender were included. Patients with prior head and neck surgery advanced staged disease, history of diabetes mellitus or peripheral vascular disease or bleeding disorders were excluded. After approval from ethical institutional review board (Ref.No ET/12510/P-290-PF, Dated.20 June, 2019), written informed consent was taken from all the patients. All the patients were operated by a consultant plastic surgeon with 10 year of post-fellowship experience. If surgery remained uneventful, then he/she was discharged on 5th postoperative day in both groups. All the patients were followed up by researcher himself/herself on weekly basis for first month then monthly up to 6 months. The data was entered and analyzed by using SPSS version 27. Mean and Standard Deviation were calculated for quantitative variables like age, defect size. Frequency and percentage was calculated for qualitative variables like gender, defect location, type of flap used, flap loss, oral competence and flap outcome. Chi-square test was used to compare the flap survival and oral competence between the groups and p Englishhttp://ijcrr.com/abstract.php?article_id=4561http://ijcrr.com/article_html.php?did=4561Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20HealthcarePharmacogenomics: A Tool for Precision Medicine
English0102Dr. Pramod Kumar ManjhiEnglishEnglishhttp://ijcrr.com/abstract.php?article_id=4562http://ijcrr.com/article_html.php?did=45621. Zhou S. Teaching of clinical pharmacogenetics for pharmacy students at the National University of Singapore. Pharm Educ 2005;5:1-6.
2. Evans WE, Relling MV. Pharmacogenomics: translating functional genomics into rational therapeutics. Science 1999;286:487-491.
3. Roden D, Altman R, Benowitz N, et al. Pharmacogenomics: challenges and opportunities. Ann InternMed 2006;145:749-57.
4. Evans W, McLeod H. Pharmacogenetics- drug disposition, drug targets, and side effects. N Engl J Med 2003;348:538-49.
5. de Leon J, Susce MT, Murray-Carmichael E. The AmpliChip CYP450 genotyping test: Integrating a new clinical tool. Mol Diagn Ther. 2006;10(3):135-51. doi: 10.1007/BF03256453. PMID: 16771600.
6. Clinical Pharmacogenetics Implementation Consortium. Genes drugs, htpp://cpicpgx.org/genes-drugs/. Accessed May 7, 2022.
7. PharmGKB FAQs. https://www.pharmgkb.org/page/faqs#what is-the-difference-between-pharmacogenetics-and-pharmacogenomics. Accessed May 11, 2022.
8. ClinGen – Clinical Genome Resource https://clinicalgenome. org/start/#loc_1550536143-7476-1.Accessed May 11, 2022.
9. Table of pharmacogenomic biomarkers in drug labelling. https:// www.fda.gov/media/124784/pdf . Accessed May 11, 2022.
10. P450 drug interactions. https://drug-interactions.medicine. iu.edu/MainTable.aspx. Accessed May 11, 2022.
Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20HealthcareTheory Guided Practices: An Approach to Better Nursing Care through Roy Adaptation Model
English5863Santosh KumarEnglish Rafat JanEnglish Salma RattaniEnglish Adnan YaqoobEnglishIntroduction: The nursing discipline is considered an integral part of the health care delivery system. Effective nursing practice needs the application of knowledge, skills, critical thinking, and art of care in an efficient, effective, and considerate method. This can be achieved through an amalgamation of understanding, practice, and nursing theories. The theory provides a logical way to organize for and give direction to nursing care. Theory-guided nursing practices act as a fundamental framework for the development of proactive and organized nursing care that assist to improve quality nursing care. Aim: The paper aims to elaborate on the theory-guided nursing practice by utilization of the Roy Adaptation Model in the clinical setup for delivering effective nursing care. Methodology: This paper will illustrate the case study of a breast cancer patient and the application of Sister Calista Roy’s Adaptation Model into nursing practice and the nursing process. Discussion: Theory-guided assessment, nursing care, and interventions provide the foundation for the development of suitable and meaningful nursing practices. Theories and models provide a basis for quality nursing practices and are considered a vital component of patient, family, and community care. Conclusion: The theory-guided practices are more efficient and possess better control over the outcome of nursing care through a purposeful and systematic approach.
EnglishNursing Theory, Roy Adaptation Model, Clinical Practices, Theory-based Nursing Practices, Breast Cancer, Evidence based Nursing, Theory Implicationhttp://ijcrr.com/abstract.php?article_id=4563http://ijcrr.com/article_html.php?did=4563Radiance Research AcademyInternational Journal of Current Research and Review2231-21960975-52411414EnglishN2022July20HealthcarePatients having Lung Fibrosis after Covid-19: A Problematic Sequelae in Surviving Patients
English6468AllahrasanEnglish Mahnaz BalochEnglish Muhammad YousufEnglish Abdul WaheedEnglish Sara ShahidEnglish Zeeshan JamalEnglishIntroduction: COVID-19 has infected people all over the world. By the end of November 2020, it was confirmed that about 67M people were suffering from COVID-19 and almost 1.7 million people had died due to it. The symptoms of COVID-19 had a wide range from mild upper respiratory indications to severe acute respiratory distress syndrome. Certain factors of COVID-19 include old age, males, hypertension, and diabetes. Aim: To detect and predict those patients who would develop lung fibrosis after Covid-19 infection as early introduction of anti-fibrotic drugs can be started. Methodology: Overall, 85 individuals were involved in this study. Patients who were having COVID-19, confirmed by PCR, were examined by follow-up MDCT. CT scan was performed and similar research was involved with some follow-up data that include residual fibrotic changes and different radiological signs. Some risk factors were predicted that were said to be the source of lung fibrosis after COVID-19. These factors include cigarette smoking, old age, CT severity score being high and mechanical ventilation in the long term. Results: The analysis of 85 patients, from which males were 43 and females were 42. Their age varied from 24 to 76 years old. A total of 30 (37.5%) individuals had a history of cigarette smoking of more than 25 cigarettes per day for more than ten years. People in the age group 60 to 76 years old had the highest commonness of getting post-COVID-19 pulmonary fibrosis. About 15 out of thirty-two patients, which is 46.2 percent, had pulmonary fibrosis. Patients of the age group 45 to 60 years had mild prevalence which is 7 out of 27 patients (25.9 percent). Conclusion: If post-COVID-19 pulmonary fibrosis is detected early in individuals, there may be some changes to prevent such long-term complications.
English Covid-19, Complications, CT scan chest, Lung fibrosis, PCR, MDCThttp://ijcrr.com/abstract.php?article_id=4564http://ijcrr.com/article_html.php?did=4564