A retrospective study was carried out to evaluate the clinical course and outcome of disseminated strongyloidiasis treated in a regional hospital in Hong Kong over a 10-year period. Seven cases were identified, and the case history of each patient was analysed. The most common presenting symptom was fever (100%). Five (71%) patients had gastrointestinal symptoms, the most common being abdominal pain and diarrhoea. Three (42%) patients had a significant drop in haemoglobin. Six (85%) patients had bronchoalveolar infiltrates on chest radiographs. Most patients were immunosuppressed by means of steroid treatment for their underlying primary disease. One patient was diabetic, and another had lymphoma and was receiving chemotherapy. Strongyloides larvae were identified in stool specimens in two patients, in sputum smears in two patients, and in gastric biopsies in three patients. Five (71%) of the patients with lung involvement progressed to respiratory failure and died. Two (29%) cases were complicated by gram-negative bacterial infection. No patient had eosinophilia on presentation. All patients received antihelminthic treatment of variable duration. The case fatality rate in the cohort was 71% despite aggressive supportive therapy. Pulmonary and bowel symptoms were prominent in our series. In conclusion, the diagnosis of disseminated strongyloidiasis is often delayed because of nonspecific presenting symptoms. Early diagnosis relies on a high index of clinical suspicion, especially in immunocompromised hosts. Screening for Strongyloides infection before the initiation of immunosuppressive therapy should be considered, especially in endemic areas.
Study Objectives: Patients visiting the emergency department (ED) commonly face delays in care that can affect patient and staff satisfaction, patient throughput and patient safety. Often these delays can be resolved with minimum resources but are challenging during times of high patient and ongoing care. The objective of our quality improvement (QI) initiative was to assemble an interdisciplinary team to identify the category, type, and location of issues within the department while improving communication and visibility of administrative staff. Once the issues were identified, the appropriate team was contacted to resolve the problem. This process required increasing communication between department leadership and staff and allowed the team to measure the time to issue resolution. Methods: This QI initiative was conducted at an academic, quaternary-care, level one trauma center with an approximate annual volume of 90,000 patients. We assembled an ED interdisciplinary team composed of the vice chair, associate chairs, nursing director, inventory coordinator, and research associates. The team rounded through each section of the department and spoke to physicians, PAs, nurses and ancillary staff to address any issues hindering patient care. The data collection sheet was optimized throughout the first month until pertinent metrics were being captured in an efficient manner. The finalized data collection sheet included inventory, information technology, equipment, patient throughput and staffing. The group contacted the appropriate team to resolve the problem and confirmed resolution during the next rounds. We documented the section of the ED where the issue arose and tracked who had been contacted to resolve it. Results: The interdisciplinary team rounded periodically from October 2018 through January of 2019 at approximately noon. We rounded a total of 40 times throughout the four months. We identified 115 issues and 61 were resolved. On average, it took 19 days to resolve issues, depending on the severity of the problem as well as which teams needed to get involved. The issues identified ranged from fixing otoscopes and lightbulbs to building a new lactation room in the department. We found that staff satisfaction improved through the employee engagement survey done 8 months apart from 80% to 89%. Conclusion: There are several factors that can impact the ability to perform daily interdisciplinary rounds which will ultimately influence the effectiveness of the rounds. We found that when we were able to perform the rounds on a consistent basis, we were more likely to have staff engaged and actual issues resolved. We also found that the resolution of these items led to faster turnaround times for our patients' care. However, the cost of administrative rounding may need to be considered when evaluating improved employee satisfaction. Some limitations were that specific issues were not resolved because the incorrect team members were assigned the tasks.
In patients with aSpA, the clinical response rate and improvement in pain and quality of life (QoL) were similar between GLM and PAM groups after 48 weeks. However, significant reduction in inflammatory markers and MRI inflammation was only observed with GLM treatment.
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