ABSTRACT
With the advent of advanced information technology and related tools in late 1990s, the scope, nature, and avenues of the business opportunities and its financial perspectives changed. Stabilization and equating of the demand and supply for the sources of inflows and outflows of funds remained the challenges across the industry. The struggling players during this time remained MSMEs due to their limited scale and more importantly limited cushioning capacity to absorb the shocks of financial downs. The micro, small, and medium enterprise (MSME) sector has emerged as a highly vibrant and dynamic sector of the Indian economy over the last five decades. It contributes significantly to the economic and social development of the country by fostering entrepreneurship and generating many employment opportunities at comparatively lower capital cost, next only to agriculture. MSMEs are complementary to large industries as ancillary units, and this sector contributes significantly to the inclusive industrial development of the country. © 2023, IGI Global.
ABSTRACT
Background: Tracheoesophageal fistula (TEF) is a rare condition that can be congenital or acquired. Patients of COVID-19 remain intubated for prolonged periods that can give rise to a multitude of complications. We came across a case where patient develop TEF after 7 days of tracheostomy. Case Study: 34 years female admitted with Covid pneumonia. Patient required ICU care for respiratory distress, required intubation. Patient was treated with standard treatment and kept on controlled ventilation. Patient underwent tracheostomy on day 12 of intubation. On day 17 of patient had an episode of sudden severe respiratory distress, desaturation, hypotension tachycardia not generating tidal volumes and rising peak pressures on ventilator. Patient developed bilateral tension pneumothorax immediately bilateral intercostal drainage tubes insertion done and patient settled. On day 19 patient had persistent cough with RT feeds coming through tracheostomy tube and site. Suspecting TEF CT neck with thorax was done. A rent is seen in the tracheal and esophageal walls close to the bulb of tracheostomy tube. with a TEF. Long tracheostomy tube was inserted as conservative management. Discussion: COVID-19 patients with severe pneumonia may require and remain on prolonged mechanical ventilation. The sudden deterioration of respiratory status, gastric distension and food particles in intubated tube are suspicious to TEF. Conclusion: Early tracheostomy can prevent some complications of prolonged intubation. If a patient develops sudden desaturation, gastric distension and food particles in tracheostomy tube then TEF should always be in the differential diagnosis.
ABSTRACT
Background: Deep vein thrombosis (DVT) is a common diagnosis with a worldwide incidence of 10 million cases per year. The diagnosis requires treatment with anticoagulation that can have both high cost and high risk for bleeding and has traditionally been managed with an inpatient admission. Recent guideline updates from the American Society of Hematology have demonstrated that patients meeting certain criteria can be managed as an outpatient. A retrospective chart review of patients presenting for acute DVT in 2019 demonstrated 58.1% of patients who met criteria for outpatient management were admitted. In order to improve value of care for UF Health patients presenting to the Emergency Department (ED) for acute DVT, a multidisciplinary team consisting of physicians from the departments of Hematology and Emergency Medicine developed a step-by-step ED treatment pathway for the management of acute DVT based on evidenced-based guidelines. The project goal was to achieve less than a 25% admission rate for patient's meeting outpatient management criteria within 1 year. Methods: Recent American Society of Hematology anticoagulation management guidelines supporting outpatient management of DVT presented an opportunity to reduce cost to patients while maintaining safety and improving resource utilization and evidence-based practice. To identify patients that are safe for outpatient management, the HAS-BLED risk stratification tool was implemented. To improve both quality of outpatient treatment and patient compliance, recommended treatment options were updated to reflect current practice standards with an appropriate emphasis on direct oral anticoagulants (DOACs). Finally, a standard documentation template was created for patients being discharged to reduce variation in post-discharge recommendations. A cause-and-effect diagram and interviews were utilized to determine the reasons for patient management decisions including disposition and choice of anticoagulation. These quality improvement tools were added to the ED treatment pathway, which was published in the standard location for similar clinical tools for ED clinicians at our institution. Furthermore, lectures were given at the Emergency Medicine residency conference to educate clinicians on the updates and answer questions. We subsequently reviewed charts of applicable ED encounters. A run chart was utilized to monitor admission and discharge rates over time. ED encounters with assigned ICD codes for acute and acute-on-chronic lower extremity DVT were reviewed for data collection. Outcomes: Chart review of ED patient encounters for acute DVT in 2019 demonstrated 255 cases. Of those, 93 patients were identified as meeting criteria for outpatient management. Only 41.9% (n=39) of patients who met criteria for outpatient management were discharged. Unexpectedly, 92% of all encounters did not document bleeding risk. Review of data from January through October 2020 demonstrated an overall decreased incidence of encounters for acute DVT. This is likely a reflection of decreased ED encounters in the setting of the COVID-19 pandemic. Over a 10-month period, 38 patients met criteria for outpatient management. Of these, 76.3% (n=29) of patients meeting criteria for outpatient management for DVT were discharged and 23.7% (N=9) were admitted. This demonstrates a significant improvement in admission rates (59.2% relative reduction) compared to a 58.1% admission rate in 2019 and met our goal of less than 25% admission rate. Furthermore, 89.7% (N=26) of patients who were discharged were prescribed direct oral anticoagulants. Similar to 2019, bleeding risk was documented in only 6.9% of discharged patients. This was an unexpected finding and while not the primary objective of the project, certainly demonstrates a significant opportunity for further care improvements. Conclusions: The next PDSA cycle will focus on appropriate use of bleeding risk stratification tools and documentation of bleeding risk. Of note, 37.3% of admitted patients who did not meet outpatient management criteria ere not discharged because of a concomitant pulmonary embolism. This may present an additional future opportunity for improving value of care for patients with different types of venous thromboembolism. [Formula presented] Disclosures: No relevant conflicts of interest to declare.
ABSTRACT
Aims & Objectives: To assess utility of haematological parameters and infection biomarkers in identifying COVID19 disease severity. Patients/Materials & Methods: The test results for complete blood counts, Coagulation screen and inflammatory markers of 100 covid 19 positive patients were recorded and analysed based on their admission to Intensive care units,High Dependency Units or Ward. Those parameters with significant differences were assessed by receiver operating curve and the best screening cut-off was selected. Results: 100 adults were analysed, area under the curve for total leukocyte count (TLC), Absolute neutrophil count (ANC), Neutrophil- to-Lymphocyte ratio (NLR) was found>0.800, with p<0.05. The best cut-off value obtained for TLC was 8100/cmm, with sensitivity and specificity of 91% and 62.5%;ANC-6739/cmm, with 91.7% and 75% respectively;NLR - 6.9 with sensitivity and specificity 91.7% and 87.5% respectively. On comparing data between ward and ICU admissions, those needing ICU admissions had significantly lower Hb and ALC, while TLC, ANC, NLR, PLR were significantly higher (p<0.05). The hematological parameters have been compared in the table. Lymphocytopenia was a prominent and the most consistent feature in all affected patients, although ICU patients suffered from greater lymphocytopenia thus significantly associated with severity. We observed no thrombocytopenia in either ICU/HDU admissions or ward patients in our study. Discussion & Conclusion: Study suggests that in adults, using TLC, ANC and NLR, obtained from the basic preliminary workup may segregate patients requiring intensive care at the time of admission enabling risk stratification and guide intervention. Procalcitonin was also studied as a sepsis marker in these patients, though it showed a higher mean value in ICU patients but did not show statistical significance in these patients.