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Let $\mathit{\Pi}$ be a cohomological irreducible cuspidal automorphic representation of ${\rm GL}_2(\mathbb{A}_{\mathbb F})$ with central character $\omega_{\mathit{\Pi}}$ over a totally real number field ${\mathbb F}$. In this paper, we prove the algebraicity of the near central non-critical value of the symmetric fourth $L$-function of $\mathit{\Pi}$ twisted by $\omega_{\mathit{\Pi}}^{-2}$. The algebraicity is expressed in terms of the Petersson norm of the normalized newform of $\mathit{\Pi}$ and the top degree Whittaker period of the Gelbart-Jacquet lift ${\rm Sym}^2\mathit{\Pi}$ of $\mathit{\Pi}$.

Aims: There have been links between healthcare-acquired infections, contaminated surfaces, and medical instruments. The aim of this study was to: (i) investigate the variety of microorganisms that persist on inanimate/noncritical devices at Benue State University Teaching Hospital Makurdi, Nigeria, as a possible source of healthcare-acquired bacterial and fungal infections, and (ii) determine the prevalence of microorganisms on the instruments sampled. Study design: This study was a hospital-based cross-sectional study. Place and duration of study: Microbiology Laboratory (Bacteriology, Media/Washroom, Serology, and Phlebotomy Units), Benue State University Teaching Hospital Makurdi, Nigeria, between January 2021 and May 2021. Methodology: Swab specimens were collected from tables (14), sinks (8), hand jars (7), scissors (5), inoculating loops (7), refrigerators (6), and autoclaves (3) using sterile stick swabs. The bacterial and fungal investigation was performed using standard culture tests-gram stain, colony morphology, and biochemical tests. Results: All the samples tested positive for either bacteria or fungi, indicating a contamination rate of 100%. Tables were the most contaminated (28%), sinks (16%), inoculating loops (14%), hand jars (14%), refrigerators (12%), scissors (10%), and autoclaves (6%). Salmonella spp., Staphylococcus aureus, Streptococcus spp., Pseudomonas aeuroginosa, Escherichia coli, Klebsiella pneumonia, and the fungi Aspergillus niger and Candida albicans were identified. Conclusion: The results of this study have shown that hospital surfaces and healthcare-associated equipment is a potential source of nosocomial infections for patients, visitors, and health care workers. Hospitals should enforce regular cleaning and decontamination to forestall the occurrence of nosocomial infections.

Introduction: The corona virus disease 2019 is an infectious disease caused by severe acute respiratory syndrome coronavirus 2 belonging to corona viruses which are enveloped positive stranded RNA viruses. Non-critical coronavirus disease 2019 patients often lack follow up visits which has led to incomplete understanding of disease process. The aim of this study was to find out the prevalence of persistent symptoms in such patients during two months follow-up to a district hospital. Methods: This descriptive cross-sectional study was conducted in a district hospital from September 2020 to February 2021 among non-critical corona virus disease 2019 patients admitted to the isolation center of Nepal. Ethical approval was taken from the ethical review board of Nepal Health Research Council (reference number: 1707). Convenience sampling was done. Data was collected using a structured questionnaire. Data analysis was done using Statistical Package for the Social Sciences version 26. Point estimate at 95% Confidence Interval was calculated along with frequency and proportion for binary data. Results: Out of 132 patients, 66 (50%) (41.5-58.5 at 95% Confidence Interval) patients had persistent symptoms at two-month follow-up. Forty-eight (36.4%) patients showed one symptom, 15 (11%) had two symptoms, and 3 (2%) had two or more symptoms. The most frequent symptom reported was fatigue in 17 (13%), cough in 15 (11%), myalgia in 9 (7%), and headache in 9 (7%). Conclusions: The prevalence of persistent symptoms at two months follow up in our study was lower than findings from other international studies.

BACKGROUND Pseudomonas aeruginosa is the most common gram-negative bacterium associated with nosocomial infections. Active observation of changes in antibiotic resistance of Pseudomonas aeruginosa is necessary for the selection of appropriate antimicrobial agent for empirical therapy. This study was conducted to determine the antibiotic susceptibility pattern of Pseudomonas aeruginosa isolated from various clinical samples collected from patients admitted in critical and non-critical areas. METHODS Pseudomonas aeruginosa isolates obtained from various samples in critical and non-critical areas during one-year period were included in the study. The isolates were identified using standard laboratory procedures, and the susceptibility was checked using the Kirby-Bauer disk-diffusion assay according to Clinical and Laboratory Standard Institute (CLSI) guidelines-2019. RESULTS During one-year period, 224 Pseudomonas aeruginosa isolates were isolated from patients admitted to various units, out of which 143 (63.8 %) were from noncritical areas and 81 (36.1 %) were from critical areas. Highest isolation from noncritical area was observed from pus sample 49 (34.26 %) followed by sputum and urine samples 46 (32.16 %) and 27 (16.78 %) respectively. Pseudomonas aeruginosa isolated from critical areas were mainly from endotracheal aspirates 36 (44.4 %) and all were multidrug resistant (MDR) (36.3 %). CONCLUSIONS The present study helps in understanding the emergence of MDR strains in intensive care units (ICUs). Thus, regular surveillance of antibiotic susceptibility pattern is important for reducing the healthcare associated infection (HAI) rates and antimicrobial resistance. KEYWORDS Antibiotic Susceptibility Pattern, Pseudomonas aeruginosa, Critical and Non-Critical Areas

Introduction: Patient’s environment in Health care settings responsible for causing variety of infections to patients and to the healthcare professions. Many of them are MDRO which may get transmitted as hospitals acquired infections that increases the chances of mortality and morbidity. These study was undertaken to isolate and identify aerobic bacteria with their resistance pattern in high touch areas of critical and noncritical care units of tertiary care hospital in absence of defined outbreaks. Materials and Methods: The cross sectional analytical study was carried out in the Microbiology Department, after obtaining the Institutional Ethics Committee clearance with waiver of consent during a period of two months. A total 100 samples from nine surface locations of critical and non critical care units of tertiary care hospital were included in this study. All tubes were vortexed and 0.5 ml of the peptone water was inoculated immediately on Blood Agar and MacConkey Agar for semi-quantitative estimation of the organisms. Result: The environmental screening for MDROs from high touch areas was carried out in the 650 bedded tertiary care hospital.. A total of 34/126 (26.98%) samples from various areas had the growth of microorganisms where Staphylococcus aureus predominated. 24.60% showed S. aureus growth while 2.38% were E.coli. A total of 47.05% strains were isolated from the critical care areas all of which were S. aureus whereas 52.94% strains were from the non-critical areas. Conclusion: This study established to isolate and identify aerobic bacteria with their resistance pattern in high touch areas of critical and non critical care units of tertiary care hospital in absence of defined outbreak. These creates awareness regarding emerging of MDROs in hospital settings and also leads to improve in imperfect techniques of hand hygiene practices as well as inadequate surface disinfection practices especially in high touch areas. Keywords: MDROs, MRSA, Blood aga

Aims: The hospital environment is an important reservoir of microorganisms, including multidrug-resistant pathogens, which can cause in-patient contamination and healthcare-related infections. The objective of this study was to describe the epidemiology of bacterial contamination (contaminated sites, pathogen species and their antimicrobial susceptibility, and identifying of multidrug-resistant microorganisms - MDR) of inert hospital surfaces and medical equipment in two public hospitals in Northern Brazil. Methods: This was a cross-sectional study with 243 samples (n = 208, from Hospital A; and n = 35, from Hospital B) collected by friction with humidified swabs from inert surfaces and equipment. Sequentially the samples were cultivated and bacterial species were identified by culture-based methods and tested for their susceptibility through agar diffusion assay according to the Clinical and Laboratory Standards Institute (CLSI). Results: Most inert surfaces and equipment analyzed presented bacterial contamination (95.5%). Staphylococcus aureus was the main pathogen of clinical significance detected both in Hospital A (61.8%) and B (68.6%). Hospital A showed higher rates of isolated MDR bacteria than Hospital B, especially in the Adult Intensive Care Unit, which included methicillin-resistant Staphylococcus aureus (MRSA) (52.7%), Enterobacteria resistant to 4th generation cephalosporins (19.4%), and multidrug-resistant Pseudomonas aeruginosa (2.8%). Conclusion: The failures in the control of bacterial contamination of inert surfaces and equipment in the two hospitals analyzed reinforce the need for a revised protocol for cleaning and disinfection of the inert surfaces and equipment, and for regulation of antibiotic dispensing, mainly in the AICU of Hospital A, which was found to be a reservoir of MDR pathogens.

Background & Objective Current evidence shows that telemetry monitoring is commonly overutilized for ‘non-cardiac’ diseases such as COPD exacerbation, pneumonia, pulmonary embolism and sepsis. This issue has not been addressed clearly in the recent American Heart Association (AHA) guidelines and no standard recommendations on the use of telemetry in non-cardiac conditions exist; therefore, clinicians continue to make such decisions based on personal preferences. As medical residency is an important phase during which young physicians develop clinical skills and habits for their future practice, the aim of this study was to understand the prevalent trends related to inappropriate telemetry use amongst the medical residents at a community hospital and the associated factors which influence the use of telemetry monitoring in non-cardiac patients. Methods All the residents undergoing internal medicine training at a community hospital were surveyed with the help of a questionnaire regarding the utility of telemetry in non-critical patients admitted with non-cardiac conditions. Results Survey was completed by 37 residents. Analysis of the responses showed that despite the frequent use of telemetry in non-cardiac conditions, majority of the medical residents are unaware of the correct indications. Seventy-three percent choose ‘continuous’ telemetry when placing the order while only 16% (often or always) discontinue telemetry after 24 hours of uneventful use. Although 84% residents admitted that telemetry is overutilized, still 49% felt that it leads to better patient care while 70% considered it superior to frequent vitals monitoring for early detection of hemodynamic instability. Possible causes of inappropriate use included ‘Lack of knowledge about the related literature’ and ‘Following trends set by the peers’. Conclusion Majority of the medical residents overutilize telemetry in non-cardiac conditions due to lack of knowledge, perceived sense of security and inappropriate trends set by their colleagues. In order to abolish these tendencies, we propose the provision of adequate educational resources to the clinical staff at every level along with other system-based strategies.

Background\ud Decontamination of non-critical objects shared by patients is key in reducing hospital-acquired infections (HAIs), but it is a complex process that needs precise guidance from UK National Health Service (NHS) acute care organizations (ACOs).\ud \ud Aim\ud To review the indications given by NHS ACOs' policies regarding the decontamination of shared non-critical devices.\ud \ud Methods\ud Detailed lists of decontamination protocols for shared non-critical objects were retrieved from cleaning, disinfection and decontamination policies of 35 NHS ACOs. Three parameters were considered for each object: decontamination method, decontamination frequency, and person responsible for decontamination.\ud \ud Findings\ud In total, 1279 decontamination protocols regarding 283 different shared non-critical objects were retrieved. Of these, 689 (54%) did not indicate the person responsible for decontamination, and only 425 (33%) were complete, giving indications for all three parameters analysed. Only 2.5% (32/1279) of decontamination protocols were complete and identical in two policies. In policies where cleaning represented the major decontamination method, chemical disinfection was rarely mentioned and vice versa. General agreement among policies was found for four main decontamination methods (detergent and water, detergent wipes, disinfectant wipes, and use of disposable items), two decontamination frequencies (between events and daily) and two responsible person designations (nurses and domestic staff).\ud \ud Conclusions\ud Decontamination protocol policies for shared non-critical objects had some similarities but did not concur on how each individual object should be decontaminated. The lack of clear indications regarding the person responsible for the decontamination process put at risk the ability of policies to serve as guidance.

Machine learning uses historical data to make predictions about new data. It has been frequently applied in healthcare to optimise diagnostic classification through discovery of hidden patterns in data that may not be obvious to clinicians. Congenital Heart Defect (CHD) machine learning research entails one of the most promising clinical applications, in which timely and accurate diagnosis is essential. The objective of this scoping review is to summarise the application and clinical utility of machine learning techniques used in paediatric cardiology research, specifically focusing on approaches aiming to optimise diagnosis and assessment of underlying CHD. Out of 50 full-text articles identified between 2015 and 2021, 40% focused on optimising the diagnosis and assessment of CHD. Deep learning and support vector machine were the most commonly used algorithms, accounting for an overall diagnostic accuracy > 0.80. Clinical applications primarily focused on the classification of auscultatory heart sounds, transthoracic echocardiograms, and cardiac MRIs. The range of these applications and directions of future research are discussed in this scoping review.

Background:High-flow nasal cannula (HFNC) is a recent respiratory support technique used for patients with hypoxemic respiratory failure; its use usually takes place in critical care wards. During the second wave of Covid-19, almost 400 000 people were hospitalized in France, and intensive care units were overwhelmed. For patients who did not meet criteria for admission to an intensive care unit because of their age or their medical background, we proposed HFNC in non-critical care unit instead of standard oxygen therapy to improve patient survival and comfort.Objectives: To describe characteristics and outcomes of patients infected with SARS-CoV-2 with HFNC in non-critical care wards between September 2020 and June 2021.Methods: This was a single-center, retrospective cohort study conducted between September and June 2021 in Clamart Hospital, France. Patients infected with SARS-CoV-2 confirmed, who were not suitable for intensive care unit escalation, and who were proposed HFNC because of respiratory failure were assessed.Results:Thirty-one patients with SARS-CoV-2 were included, median age 87.0 years (interquartile range (IQR), 82.0-91.0), 52% men. Nineteen (61%) patients were OMS score 0, i.e. no disability in daily-life activities. HNFC was started a median of 3 days (IQR, 1-5.5) after hospitalization. Overall, median duration of HNFC was 6 days (IQR, 4-10). Eleven patients (35.5%) survived and were discharged from hospital.Conclusions:Our experience of HFNC for patients with COVID-19 outside of a critical care environment because of their age and comorbidities is positive allowing survival of 35% of old patients not admitted to an intensive care unit. Trial registration:Not applicable

Corticosteroids are largely recommended in patients with severe COVID-19. However, evidence to support high-dose methylprednisolone (MP) pulses is not as robust as that demonstrated for low-dose dexamethasone (DXM) in the RECOVERY trial. This is a retrospective cohort study on severe, non-critically ill patients with COVID-19, comparing 3-day MP pulses ≥ 100 mg/day vs. DXM 6 mg/day for 10 days. The primary outcome was in-hospital mortality, and the secondary outcomes were need of intensive care unit (ICU) admission or invasive mechanical ventilation (IMV). Propensity-score matching (PSM) analysis was applied. From March 2020 to April 2021, a total of 2,284 patients were admitted to our hospital due to severe, non-critically ill COVID-19, and of these, 189 (8.3%) were treated with MP, and 493 (21.6%) with DXM. The results showed that patients receiving MP showed higher in-hospital mortality (31.2% vs. 17.8%, p &lt, 0.001), need of ICU admission (29.1% vs. 20.5%, p = 0.017), need of IMV (25.9% vs. 13.8, p &lt, 0.001), and median hospital length of stay (14 days vs. 11 days, p &lt, 0.001). Our results suggest that treatment with low-dose DXM for 10 days is superior to 3 days of high-dose MP pulses in preventing in-hospital mortality and need for ICU admission or IMV in severe, non-critically ill patients with COVID-19.

The aim of this paper is to present the concept of a simple and cheap upgrade for electric water boilers, allowing them to provide power quality services to the distribution grid. The upgrade requires only minimum additional hardware and it is easily installable. “Smart Boilers”, as the upgraded boilers are named, perform precise active and reactive power control, but most significantly mitigate line current harmonics. Αctive and reactive power control is implemented by appropriate regulation of the modulation sinewave amplitude and phase, respectively. This type of control is easily customizable in order to accommodate a variety of power quality targets, depending on the required level of services and available grid monitoring equipment. The method used for line current harmonic compensation is based on the injection of mirror harmonics created at the modulation stage of the converter. It is indifferent of harmonic source: it is equally successful at mitigating harmonics caused by the power electronic converter of the Smart Boiler, other sources of current harmonics or loads. The achieved grid services are clearly beyond the “on/off” operation of electric boilers, currently implemented by Demand Side Management (DSM) in order to shift load away from peak hours. It has been demonstrated through simulations, that Smart Boilers can assist voltage regulation at terminal buses, compensate reactive power and suppress harmonic currents at lines.

Objectives This study was aimed at assessing the cleaning practice of non-critical medical equipment (NCME) in the era of corona virus disease-2019 of nurses working in Debre-Tabor comprehensive specialized hospital (DTCSH), north-central Ethiopia. Design Facility based cross-sectional study was conducted in DTCSH, Ethiopia, from July 05 to August 05, 2020. Setting The study was conducted in inpatient and outpatient units of the hospital. Participants A total of 76 randomly selected staff nurses and 6 head nurses were included for observational study and interview respectively. Results Only 1.3%–5.3% of nurses cleaned stethoscopes, thermometers, pulse oximeters, and glucometers right after using these devices for patients. None of them cleaned the blood pressure apparatus before or after checking a patient's blood pressure and glucometer before determining blood glucose levels. Lack of disinfecting materials and lack of training on infection prevention were perceived by head nurses as major barriers for proper cleaning practices. Conclusion Nurses’ cleaning practice of NCME was very low. Therefore, proper supply of materials needed to clean these devices need to be secured. Besides, nurses need to get training on infection prevention., Nurse, Cleaning, Non-critical medical equipment, COVID 19.

Introduction: Tocilizumab is one of the main repurposed therapies investigated for COVID-19 pneumonia since the start of the pandemic, but there has been conflicting evidence for its use. Areas covered: This review covers the physiology of interleukin-6 and its role in the pathophysiology of COVID-19. We discuss the use of tocilizumab in other diseases and the rationale for its use in COVID-19. We summarize the design, contrasting results, and implications of the clinical trials of tocilizumab in COVID-19 to date and discuss the current guidance for its use. Expert opinion: The evidence to date suggests benefit with the use of tocilizumab in some but not all patients with COVID-19. Benefit seems to be greatest when given early after clinical deterioration with the presence of systemic inflammation. However, questions remain around the optimal timing, patient selection, and concomitant treatments.

Objectives To investigate therapeutical drugs other than antimicrobials as risk factors for the acquisition of ESBL-producing Enterobacterales (ESBL-E). Methods This matched case–control study is based on rectal surveillance screening data obtained during a larger trial between 2014 and 2016 upon patients’ admission and at least once before discharge in eight non-ICU wards. Patients with ward-acquired ESBL-E (cases) were matched 1:1 to non-ESBL-E carriers (controls) based on ward, number of screening samples, days at risk and Charlson comorbidity index (CCI). Daily medication data were documented according to the Anatomical Therapeutic Chemical classification system. Multivariable conditional logistic regression models were used to calculate risk factors for ESBL-E acquisition. Results Of the 232 cases and 232 controls analysed, baseline characteristics such as gender (male 56.9%), median age (65 years old, IQR 52–74), number of screening samples (N = 3, IQR 2–4), days to first sample (2, IQR 1–2), days at risk (8, IQR 6–11) and CCI (4, IQR 2–6) were similar. Multivariable analysis showed that glucocorticoids, opium alkaloids and selective β-2-adrenoreceptor agonists increased the chance to detect ESBL-E (OR 1.07, 95% CI 1.001–1.13, P = 0.047; OR 1.06, 95% CI 1.007–1.12, P = 0.027; and OR 1.31, 95% CI 1.105–1.55, P = 0.001, respectively), while antihistamines decreased it (OR 0.61, 95% CI 0.39–0.97, P = 0.034). In a sensitivity analysis, including drugs prescribed to at least 50 patients, proton pump inhibitors remained as risk factors (OR 1.049, 95% CI 1.001–1.100, P = 0.047). Conclusions In a non-ICU setting, drugs other than antimicrobials were determined as potential independent risk factors for ESBL-E acquisition.

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for non-intensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to managing complications that can arise in patients receiving invasive mechanical ventilation.

Due to the limited number of critical care providers in the United States, even well-staffed hospitals are at risk of exhausting both physical and human resources during the outbreak of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). One potential response to this problem is redeployment of non-critical care providers to increase the supply of available clinicians. To support efforts to increase capacity as part of surge preparation for the coronavirus disease (COVID-19) outbreak, we created an online educational resource for nonintensivist providers to learn basic critical care content. Among those materials, we created a series of one-page learning guides for the management of common problems encountered in the intensive care unit (ICU). These guides were meant to be used as just-in-time tools to guide problem-solving during the provision of ICU care. This article presents five guides related to the evaluation and management of patients with hypoxemic respiratory failure and the basics of invasive mechanical ventilation.

Introduction: Clinical education is the basic pillar and heart of medical education. In fact, it is one of the most important manifestations of teaching and learning in professions related to medical sciences, which leads to the clinical competency of learners. Assessing new physicians before entering the field of clinical activities can be a reliable criterion for evaluating the quality of their clinical skills.The current study was done to investigate the knowledge, practice, and general clinical competency of general medicine graduates before entering the field of clinical activities. The study was in line with according to the document of the minimum competency expected from general practitioners in Iran. Methods In this descriptive cross-sectional study, the scores of different stations of the national Objective Structured Clinical Examination (OSCE), which be held at the end of the general medicine course in Iran, were collected at Mashhad University of Medical Sciences. These scores were subdivided into four specific areas and two critical and non-critical indicators of capability were gathered from the exam assessors' checklists. Totally, 266 students who participated in six periodicities of clinical competency tests at the end of the general medicine course at Mashhad University of Medical Sciences were included in the study by the census method. The clinical competency of general medicine graduates assessed in the areas of problem-solving, communication skills, practical action (procedures and critical skills), taking the history, performing physical examinations, and critical and non-critical indicators by the OSCE. Data were analyzed using descriptive statistics (frequency, mean and standard deviation) and inferential statistics including independent t-test, one-way and two-way analysis of variance by using SPSS. Results The results showed that the effect of different areas of the OSCE (F(3,5652) = 7.022 and P = 0.001) and participants' performance based on their critical and non-critical indicators (T = 1.976 and P = 0.04) are significant with 95% confidence interval. Conclusion The OSCE improves the standards of clinical competencies of new physicians and can make beneficial changes in clinical education at medical schools.

Introduction Telephone triage services (TTS) play an increasing role in the delivery of healthcare. The objective of this study was to characterize the adult users of a TTS for non-critical emergencies, describe the types of advice given and their subsequent observation, and assess the influence of TTS on the use of the healthcare system in a sanitary region of Switzerland. Methods Data from a TTS based in the French part of Switzerland were analyzed. This service consists of a medical contact center for non-critical emergencies, with trained nurses available 24/7. A random selection of 2,034 adult calls was performed between July and December 2018. Research students contacted users 2 to 4 weeks after the initial call and assessed sociodemographic and clinical data, as well as the impact of the advice received on the use of the healthcare system. Results A sample of 412 users was included in the analyses. The average age was 49.0 (SD 20.4) years; 68.5% were women and 72.8% of Swiss origin. The two main recommendations provided by nurses were to consult the emergency department (ED) (44.6%, n = 184) and to contact a physician on duty (33.2%, n = 137). The majority of users followed the advice given by the nurses (substantial agreement [k = 0.79] with consulting the ED and perfect agreement [k = 0.87] with contacting a physician on duty). We calculated that calling the TTS could decrease the intention to visit the ED by 28.1%. Conclusion TTS for non-critical emergencies have the potential to decrease the use of ED services.

INTRODUCTION. Emerging evidence associates COVID-19 to an increased risk of acute pulmonary embolism (APE). The present study aimed to assess the prevalence of APE in patients admitted to internal medicine department wards for non-critical COVID-19 who presented clinical deterioration, and to investigate the association of clinical and biochemical variables with a confirmed diagnosis of APE in these subjects. METHODS. All consecutive patients admitted to the internal medicine department of a general hospital with a diagnosis of non-critical COVID-19, who performed a Computer Tomography Pulmonary Angiography(CTPA) for respiratory deterioration in April 2020, were included in this retrospective cohort study. RESULTS. Study populations: 41 subjects, median(IRQ) age: 71.7(63-76) years, CPTA confirmed APE=8(19.51%,CI95%:8.82%-34.87%). Among patients with and without APE, no significant differences were found with regards symptoms, comorbidities, treatment, Wells score and outcomes. The optimal cut-off value of D-dimer for predicting APE was 2454 ng/mL, sensitivity(CI95%):63(24-91), specificity:73(54-87), Positive Predictive Value:36(13-65), Negative Predictive Value: 89(71-98) and AUC:0.62(0.38-0.85). The standard and age-adjusted D-dimer cut-offs, and the Wells score > 2 did not associate with confirmed APE, albeit a cut-off value of D-dimer=2454 ng/mL showed an RR:3.21;CI95%:0.92-13.97;p=0.073.CONCLUSION. Among patients presenting pulmonary deterioration after admission to internal medicine wards for non-critical COVID-19, the prevalence of APE was high. The traditional diagnostic tools to identify high APE pre-test probability patients does not seem to be clinically useful. These results support the use of a low threshold of suspicion for performing CTPA to exclude or confirm APE as the most appropriate diagnostic approach in this clinical setting.

Our modern era doesn’t mean only that we have industrialized or have advancements in technology but the increment in pollution is also the result of modernization. With the increase in population, the burden on the urban infrastructure of city centers is increasing with each passing day. This increased burden is specially manifested in the increase in traffic density on roads and traffic flow and is mainly known for the production of noise pollution. University Road, Peshawar Pakistan which is a very dense and important hub for education, hospitals and other commercial markets was studied for noise pressure levels and identification of vulnerable regions. Among 30 regions of section 8 were categorized as non-critical,17 were found moderate critical and 5 were found most critical regions.

Background Delays in diagnosing tuberculosis lead to longer infectious periods, posing a challenge in tuberculosis control. This is particularly relevant in high incidence areas (critical). Thus, the objectives of this work were to characterize tuberculosis diagnosis delay and its components (patient delay and health delay) in incidence critical and non-critical areas in Portugal, as well as associated factors. Methods Notified cases of pulmonary tuberculosis diagnosed due to symptoms (passive screening) in the Portuguese Tuberculosis Surveillance System were analysed (2008-2017). Patient, health and overall delays were calculated. Factors associated with each delays' components were identified utilising Cox regression, while adjusting for sex, age and education level. Analyses were stratified by area type (critical and non-critical). Results Median (1st-3rd quartile - Q1-Q3) delays in patient, health and overall delay in critical areas were: 40 (Q1-Q3: 21-76), 8 (Q1-Q3:1-31), and 65 (Q1-Q3: 40-105) days, respectively; similar delays in non-critical areas were 32 (Q1-Q3:16-63); 9 (Q1-Q3: 1-34) and 58 (Q1-Q3: 35-98), respectively. More recent cases, adults younger than 65 years and alcoholic presented longer patient delays (both areas); healthcare professionals and patients with HIV infection presented shorter patient delays (only critical areas). Tuberculosis high-risk groups (males, alcohol dependency, homelessness, community residency) presented shorter health delays in both areas; drug use also presented shorter health delays but only in critical areas. Existing comorbidities was associated with longer health delays in both areas. Conclusions Patient delays increased between 2008 and 2017. Groups with longer/shorter delays differed between delay type and area type. Intervening in tuberculosis diagnosis delays requires different action for critical and non-critical areas, targeting health literacy from the general population and training of healthcare professionals. Key messages Delays in diagnosing in Portugal are mainly driven by delays in patient seeking care and are longer in areas of higher tuberculosis incidence. Intervening in tuberculosis diagnosis delays in Portugal requires different action in different areas, targeting health literacy in the general population and training of professionals.

IMPORTANCE: Critical access hospitals (CAHs) provide care to rural communities. Increasing mortality rates have been reported for CAHs relative to non-CAHs. Because Medicare reimburses CAHs at cost, CAHs may report fewer diagnoses than non-CAHs, which may affect risk-adjusted comparisons of outcomes. OBJECTIVE: To assess serial differences in risk-adjusted mortality rates between CAHs and non-CAHs after accounting for differences in diagnosis coding. DESIGN, SETTING, AND PARTICIPANTS: Serial cross-sectional study of rural Medicare Fee-for-Service beneficiaries admitted to US CAHs and non-CAHs for pneumonia, heart failure, chronic obstructive pulmonary disease, arrhythmia, urinary tract infection, septicemia, and stroke from 2007 to 2017. The final date of follow-up was December 31, 2017. EXPOSURE: Admission to a CAH vs non-CAH. MAIN OUTCOMES AND MEASURES: Discharge diagnosis count including trends from 2010 to 2011 when Medicare expanded the allowable number of billing codes for hospitalizations, and combined in-hospital and 30-day postdischarge mortality adjusted for demographics, primary diagnosis, preexisting conditions, and with vs without further adjustment for Hierarchical Condition Category (HCC) score to understand the contribution of in-hospital secondary diagnoses. RESULTS: There were 4 094 720 hospitalizations (17% CAH) for 2 850 194 unique Medicare beneficiaries (mean [SD] age, 76.3 [11.7] years; 55.5% women). Patients in CAHs were older (median age, 80.1 vs 76.8 years) and more likely to be female (58% vs 55%). In 2010, the adjusted mean discharge diagnosis count was 7.52 for CAHs vs 8.53 for non-CAHs (difference, −0.99 [95% CI, −1.08 to −0.90]; P

BackgroundThe coronavirus disease 2019 (COVID-19) crisis created pressure on healthcare institutions to be prepared with maximum workforce and bed capacity. Clinical education during COVID-19 has high risk of disease transmission to learners due to contamination of equipment, supplies and surfaces, in addition to increased clinical-related stress and fear. Simulation-based education (SBE) has potential to help manage the pandemic by rapidly upskilling nurses’ clinical responsibilities.MethodsUpskilling of 445 non-critical care nurses was conducted using SBE between 14th March and 30 May 2020. Training consisted of completing a mandatory online critical care awareness module, followed by 3 hours of critical care simulation-based scenarios using demonstration and return-demonstration approach.ResultsAll 445 non-critical care nurses completed required modules and simulation experiences. The critical care simulation-based upskilling programme was evaluated as an effective way to learn how to manage critically ill patients. The majority of evaluation items were rated over 95% for effectiveness of the education; four items were less than 95% (88–94%). Lower rated items considered training and practice time, improved competency and commitment to apply learning.ConclusionRapidly developed and implemented upskilling of critical care nurses was effectively accomplished with SBE. However, learners noted the need for longer learning times and increased practice opportunity to improve competency. Lack of intent to apply the patient care techniques requires further study. SBE has potential as an effective educational method for rapid preparedness in future crisis.

This article is a Letter to the Editor and does not include an Abstract.

Background: Ultrasound is used to observe the imaging manifestations of COVID-19 in order to provide reference for real-time bedside evaluation.Purpose: To explore the ultrasonic manifestations of peripulmonary lesions of non-critical COVID-19, so as to provide reference for clinical diagnosis and efficacy evaluation.Materials and Methods: The clinical and ultrasonic data of 20 patients with clinically diagnosed non-critical COVID-19 treated in Xi'an Chest Hospital during January and February 2020 were retrospectively analyzed. Conventional two-dimensional ultrasound and color Doppler ultrasound were used to observe the characteristics of lesions. Results: All 20 patients (40 lungs and 240 lung areas) had a history of travel, residence or close contact in/with Wuhan, and 5 of them caught COVID-19 after family gatherings. Lesions tended to occur in both lungs. Lesions in the lung areas: 14 in L1+R1 area (14/40), 17 in L2+R2 area (17/40), 17 in L3+R3 area (17/40), 17 in L4+R4 area (17/40), 20 in L5+R5 area (20/40), and 28 in L6+R6 area (28/40). Lesion types: rough and discontinuous pleural line (36/240), subpleural consolidation (53/240), air bronchogram sign or air bronchiologram sign in subpleural peripleural consolidation (37/240), visible B lines (91/240), localized pleural thickening (19/240), localized pleural effusion (24/240), poor blood flow in the consolidation detected by color Doppler ultrasound (50/53).Conclusion: The non-critical COVID-19 has characteristic ultrasonic manifestations, which are visible in the posterior and inferior areas of the lung. The lesions are mainly characterized by a large number of B lines, subpleural pulmonary consolidation and poor blood flow. Lung ultrasound can provide reference for the clinical diagnosis and efficacy evaluation. Chinese Clinical Trial Registry: ChiCTR2000030032Approval for Scientific Research Project: No. 2020-S0001

In current literature, one is offered a number of ways of discussing critical thinking, and furthermore, authors follow different tracks grounded in a variety of disciplines (philosophical, psychological and educational) to approach the concept. The only consensus within this topic seems to be the claim that there is no consensus concerning the definition and the construct of critical thinking. I propose that the critical thinking is a complex concept, which simultaneously involves components at three levels, at the level of the culture, the individual and the language. I call the resulting framework a multilevel model (MLM) of the critical thinking concept. The paper argues that the study of critical thinking and non-critical thinking instances within the framework of the MLM allows us a better understanding of the phenomena internationally, and in addition, that no one level can be singled out as the only appropriate level of analysis of critical thinking instances. Keywords: Critical thinking, language, emotion, context, social environment, culture.

Background Telehealth has been used extensively in emergency departments to improve healthcare provision. However, its impact on the management of non-critical emergency presentations within rural and remote emergency department settings has not been adequately explored. The objective of this systematic review is to identify how telehealth has been used to assist in the management of non-critical presentations in rural and remote emergency departments and the outcomes. Methods Articles were identified through database searches of CINAHL, Cochrane, MEDLINE (OVID), Informit and SCOPUS, as well as the screening of relevant article reference and citation lists. To determine how telehealth can assist in the management of non-critical emergencies, information was extracted relating to telehealth programme model, the scope of service and participating health professionals. The outcomes of telehealth programmes were determined by analysing the uptake and usage of telehealth, the impact on altering a diagnosis or management plan as well as patient disposition including patient transfer, discharge, local hospital admission and rates of discharge against medical advice. Results Of the 2532 identified records, 15 were found to match the eligibility criteria and were included in the review. Uptake and usage increased for telehealth programmes predominantly utilised by nursing staff with limited local medical support. Teleconsultation conservatively altered patient diagnosis or management in 18–66% of consultations. Although teleconsultation was associated with increased patient transfer rates, unnecessary transfers were reduced. Simultaneously, an increase in local hospital admission was noted and fewer patients were discharged home. Discharge against medical advice rates were low at 0.9–1.1%. Conclusion The most widely implemented hub-and-spoke telehealth model could be incorporated into existing referral frameworks. Telehealth programmes may assist in reducing unnecessary patient transfer and secondary overtriage, while increasing the capacity of emergency department staff to diagnose and manage patients locally, which may translate into increased local hospital admission and reduced discharge rates following teleconsultation.

This is a descriptive qualitative study of speaking classroom discourse. This study aims to discuss an authentic spoken discourse of an EFL class by employing Bowers’ model (1980) to determine which teaching functions enhance the communication opportunities for students. In this article, the concept of Bower’s model is first discussed and how it is of a vital significance to classroom interaction in an EFL class and the efficiency and effectiveness of the various patterns of discourse. In this article, the distribution of teacher-talk and student-talk is investigated and who has a higher degree of control over the discourse in the class is highlighted. It also examines the structure of interactions and how the teacher manages the conversation and turn-taking. The article includes how teachers understand their language affects the role in the classroom as well as how learners are aware of when and where they have to engage in the speaking process. In addition, the article also investigates the functions in a speaking class and how different teacher acts are used in urging learners to participate in classroom discussion. The last section is a conclusion to summarize the main ideas discussed in the article.

Part 2: Infrastructure Protection; International audience; This chapter examines potential attack vectors that exist in a nuclear power plant and correlates the likelihood of an attack from each vector. The focus is on the boron monitoring system, which directly affects the reactivity in the core; cyber attacks on this system can lead to increased core wear, unsafe reactivity levels and poor power performance. A mockup model is developed using open-source software and hardware, which is tested to evaluate the potential of cyber attacks. A man-in-the-middle attack is implemented to demonstrate a cyber attack and its potential effects. Additionally, a redundancy-based cyber attack mitigation method is implemented using a hardware device that compares the input/output values of multiple programmable logic controllers. The approach for modeling general attack and defense steps is applicable to industrial control systems in the energy sector.

The combination of the progressive growth of an aging population, increased life expectancy and a greater number of chronic diseases all contribute significantly to the growing demand for emergency medical care, and thus, causing saturation in Emergency Departments (EDs). This saturation is usually due to the admission of non-urgent patients, who constitute a high percentage of patients in an ED. The Agent-based Model (ABM) is one of the most important tools that helps to study complex systems and explores the emergent behavior of this type of department. Its simulation more accurately reflects the complexity of the operation of real systems. Our proposal is the design of an ABM to schedule the access of these non-critical patients into an ED, which can be useful for the service management dealing with the actual growing demand for emergency care. We suppose that a relocation of these non-critical patients within the expected input pattern, provided initially by historical records, enables a reduction in waiting time for all patients, and therefore, it will lead to an improvement in the quality of service. It would also allow us to avoid long waiting times. This research offers the availability of relevant knowledge for Emergency Department managers in order to help them make decisions to improve the quality of the service, in anticipation of the expected growing demand of the service in the very near future.

There has been a rising trend of telemetry use in non-critical care setting for non-cardiac related diagnoses. This practice had led to overusing of telemetry monitoring. The objective of our study was to evaluate the impact of multifaceted interventions to reduce telemetry utilization at a tertiary

Introduction: Health care environment usually remains stressful for health care professionals which may have impact on their psycho-physiological health. Aim: This study was conducted to find the differences in Heart Rate (HR) and Galvanic Skin Response (GSR) among critical and non-critical care unit nurses. Materials and Methods: A comparative study was conducted to find the differences in HR and GSR value of nurses posted in critical and non-critical units. Critical and non-critical care units were classified using patient’s acuity category classification. A total of 100 nurses, 50 from critical and 50 from non-critical care units were selected by simple random sampling technique. HR and GSR were recorded on a digital polygraph (Medicaid systems). Descriptive and inferential statistics were used to analyse the data. Results: The mean heart rate (beats per minute) and GSR (Amp ~ K) score of nurses working in critical care units (88.32±9.63 and 916.9±473.4) was higher than the nurses working in noncritical units (83.56±5.82 and 687.8±270.0). The difference in the scores of critical care unit nurses were significantly higher than the non-critical unit nurses (p

Background. Almost 50% of stroke caused by blood pressure increase. Management Non Haemorrhagic Stroke patients in non critical phase to lowering blood pressure can be done with non-pharmacologic therapy and pharmacologic therapy. Slow Stroke Back Massage is one of the non-pharmacological therapy relaxation which can lower blood pressure. The purpose of this research is to 1) Determine the effect of slow stroke back massage therapy to changes in blood pressure in patients with non-hemorrhagic stroke. 2) To describe characteristics of patients with non-hemorrhagic stroke 3) Determine the change in blood pressure in patients with non-hemorrhagic stroke before and after slow-stroke back massage therapy. Methods. Type of this research is quasi experiment with the design of One Group Pretest-Posttest Design. The Results. The result of this research is there influence of Slow Stroke Back Massage therapy to changes in blood pressure in patients with non-hemorrhagic stroke in Melati 4. This is evidenced by the results of the Wilcoxon test analysis where the systolic blood pressure before and after therapy SSBM ρ = 0.000 and a significance value of diastolic blood pressure before and after therapy SSBM ρ = 0.003. Because the value of ρ

Introduction Major haemorrhage is a common medical emergency in endoscopy rooms where on site critical care support is not always standard. Successful management includes resuscitation, appropriate and safe use of blood products alongside effective communication between clinical and laboratory teams. NICE, the National Patient Safety Association and the Serious Hazards of Transfusion organisation all specifically refer to the need for major haemorrhage protocols. NHS Tayside’s Blood Transfusion Service launched an updated major haemorrhage policy (MHP) in May 2017. We developed a protocol that combines practical clinical response within both the endoscopy room and the laboratory. We wish to describe the development and implementation of this policy. Methods A time and space study was completed looking at staff roles within the endoscopy room, typically endoscopist, nurse (RN) and Health Care Assistant (HCA); and the unit as a whole during major GI bleeds. Barriers to effective resuscitation, timely provision of blood products, communication with laboratories/other clinical teams were identified. Results We identified variation in the following key areas: Staff roles and numbers in room Communication between nursing, medical and laboratory teams Need for a team leader to free up the endoscopist The following protocol was developed. Endoscopist Declares major haemorrhage. Assesses haemostasis/patients global status, requests additional clinical support (eg anaesthetics). Nursing Room RN activates in-room buzzer triggering protocol. Three additional RNs and 1 HCA supplement the original room team. RN A (Team Leader) Activates Laboratory MHP via ‘2222’ call, coordinates the room, allocates staff roles, runs resuscitation, communicates with additional teams RN B - assists with therapeutics RN C - patient observations, fluid/medication delivery, scribes HCA A - runner for equipment etc Porter - available throughout Laboratory ‘2222’ call triggers the laboratory and blood bank to prepare and dispatch: 4 units packed red cells, 4 units fresh frozen plasma and 1 pool of platelets directly to the endoscopy unit by a dedicated porter. The lab remains on standby as required. The policy’s introduction was supplemented by training sessions including simulated scenarios to increase staff awareness, confidence and responsiveness to major haemorrhage. Conclusions We believe this protocol is the first to give a practical description of a process dovetailing clinical and laboratory response to major haemorrhage. Having a clearly defined team leader and standardising individual staff roles allows streamlined communication with other clinical groups in a non critical care environment.

Background Diabetes is a chronic pathology of high prevalence and a large number of associated comorbidities that have an impact on patients’ quality of life. In the hospital environment, poor insulin adherence may lead to episodes of hyperglycaemia or severe hypoglycaemia, increasing long-term complications, as well as morbidity and mortality. Purpose To evaluate the clinical results obtained after the implantation of the insulinisation protocol in non-critical patients in our hospital. This protocol recommends the suspension of oral antidiabetic drugs (OADs) at admission, and if blood glucose >150 mg/dl, baseline insulin control is recommended along with control of preprandial glycaemias by administering rapid-acting insulin. Material and methods On 25 November 2015, a cross-sectional study (submitted to the Ethical Committee for Clinical Research) was carried out. In this study, all patients diagnosed with diabetes who were hospitalised and who had undergone validation of pharmacological treatment were located. The Electronic Clinical History (SELENE ® ) and the Pharmacy Service Managing Software (FARMATOOLS ® ) were used for the location and collection of clinical data. Results A total of 132 patients were evaluated. Sixty-four per cent and 36% of them were males and females respectively, with an average age of 69 years (range 29–93) and an average weight of 80 kg at admission. Fifty per cent of patients’ weight was not registered and this is a vital fact for the evaluation of the patients’ nutritional status and the calculation of the dose of insulin. Ninety per cent of patients had type-2 diabetes and 3% of them were diagnosed during their hospital admission. 46.4% of patients were treated with OADs in monotherapy, 15.2% with OADs plus insulin and 10.4% under a basal-bolus pattern. The overall compliance rate of the treatment to the basal-bolus pattern was very low (32%). These results are in line with the rest of the studies carried out in hospitalised diabetic patients. Conclusion In spite of gaining better glycaemic control with the basal-bolus regimen, the adherence to it was low. In the future, the suspension of the OADs, or their change to insulin after admission, will be a difficult target that we have to reach. References and/or Acknowledgements I would like to express my very great appreciation to the staff of the service. No conflict of interest

E. Guy, P. Punpongsanon, D. Iwai, K. Sato and T. Boubekeur, "LazyNav: 3D ground navigation with non-critical body parts," 2015 IEEE Symposium on 3D User Interfaces (3DUI), 2015, pp. 43-50, doi: 10.1109/3DUI.2015.7131725., With the growing interest in natural input devices and virtual reality, mid-air ground navigation is becoming a fundamental interaction for a large collection of application scenarios. While classical input devices (e.g., mouse/keyboard, gamepad, touchscreen) have their own ground navigation standards, natural input techniques still lack acknowledged mechanisms for travelling in a 3D scene. In particular, for most applications, navigation is not the primary interaction. Thus, the user should navigate in the scene while still being able to perform other interactions with her hands, and observe the displayed content by moving her eyes and locally rotating her head. Since most ground navigation scenarios require only two degrees of freedom to move forward or backward and rotate the view to the left or to the right, we propose LazyNav a mid-air ground navigation control model which lets the users hands, eyes or local head orientation completely free, making use of a single pair of the remaining tracked body elements to tailor the navigation. To this end, we design several navigation body motions and study their desired properties, such as being easy to discover, easy to control, socially acceptable, accurate and not tiring. We also develop several assumptions about motions design for ground navigation and evaluate them. Finally, we highlight general advices on mid-air ground navigation techniques.

The paper presents results of ZigBee communication tests performed in a specifically set electromagnetic environment, with the purpose to determine the applicability of ZigBee technology in non-critical messaging for vehicular communications. Known for its low energy consumption, the ZigBee technology might be used in background messaging for cooperative driving, with the purpose to reduce the overload on the main channels used for emergency message warning, or other critical applications. In the paper are presented the test bed, results and solutions for new approaches with usability to vehicular communications.

This paper addresses challenges with prompt health care delivery using Network Analysis of Critical Path Model (CPM) to plan the hospital capacity with a view to achieving prompt health care service delivery. Hospital activities were identified as either critical and non critical, time or cost consideration was factored in. In all, 16 state health institutions were purposively selected on the basis of most equipped from 55 state health institutions. Data on patients’ arrival and departure were observed and recorded for a period of six months. This was subjected to further analysis to identify the most important activities (critical path) and less important together with their time duration. The average total time spent in the hospital was 43 minutes but with effective capacity planning using network analysis the total time was reduced to 18 minutes and the critical path (activities) were identified to be: A - Card section, F - Medical Doctor and H – Medical Team. Keywords : Critical Path Model (CPM), Capacity Planning (CP), Hospital Services, Network Analysis

Background: Proton pump inhibitors are one of the most commonly used drugs worldwide. Often they are used for inappropriate indications too, imposing economic burden to patients and governments. Many studies have showed equipotent efficacy of oral and intravenous proton pump inhibitor therapy. Despite that, most of the hospitalized patients receive intravenous proton pump inhibitor without appropriate indications. This study aimed to assess use of proton pump inhibitors in government hospital.Methods: It was an observational cross-sectional study done in the general medicine department of a tertiary care teaching hospital in Eastern India, including 800 noncritical patients. Objective was to assess the use of proton pump inhibitors (indications, route of administration, dosing frequency).Results: 100% patient received intravenous proton pump inhibitor irrespective of diagnosis. 80% of them received it twice daily and 18% received it once daily. Majority of the patients received intravenous proton pump inhibitor despite taking other drugs by oral route.Conclusions: Most of the PPI administration was done without appropriate indication. All patients received Intravenous proton pump inhibitors, which may impose economic burden on a government hospital. Majority of the patients received proton pump inhibitors twice daily. These approaches are not cost effective and need to be rectified.