Exploring vaccination coverage and attitudes of health care workers towards influenza vaccine in Cyprus

Seasonal influenza is a major public health problem. Nosocomial influenza is particularly concerning as it may affect patients at high risk for complications. Unvaccinated health care workers (HCWs) are an important source of nosocomial influenza and therefore a priority target group for vaccination. Despite the fact that some European countries have high coverage rates such as UK (76.8% in season 2020/21), others continue to have low coverage rates for influenza vaccines. This study aims to estimate vaccination coverage in HCWs in Cyprus, an island country located in the Eastern Mediterranean region and describe their attitudes towards influenza vaccination.

METHODS

This is a questionnaire based, nation-wide study assessing flu vaccination coverage in 2019-2020 and attitudes related to vaccination acceptance, of 962 HCWs in both public and private health care facilities. Multivariable logistic regression was used to investigate factors associated with flu vaccination status.

RESULTS

Flu vaccination coverage was estimated as 31.8%. The top two reasons for getting vaccinated were to protect their family (81.4%) and themselves (77.4%). The top two reasons for not getting immunised, besides "no particular reason" (25.7%), included disbelief for vaccine effectiveness (21.5%) and safety (29.3%). The regression model showed that doctors compared to nurses had 10 times the odds of being vaccinated. Other factors positively associated with flu vaccination were encouragement by the supervisor, having sufficient knowledge on flu and flu vaccination and easy access to vaccination. A percentage of 54.8% of participants stated that COVID-19 pandemic strongly or somewhat influenced their decision to get vaccinated.

CONCLUSION

Flu vaccination coverage in HCWs in Cyprus is rather low, similar to some other European countries. Barriers and facilitators in this study can be considered in strategies to increase flu vaccination uptake. Such questionnaire-based surveys should be repeated in order to evaluate effectiveness of targeted vaccination campaigns.

Exploring the factors associated with the mental health of frontline healthcare workers during the COVID-19 pandemic in Cyprus

INTRODUCTION

The spread of COVID-19 into a global pandemic has negatively affected the mental health of frontline healthcare-workers. This study is a multi-centre, cross-sectional epidemiological study that uses nationwide data to assess the prevalence of stress, anxiety, depression and burnout among health care workers managing COVID-19 patients in Cyprus. The study also investigates the mechanism behind the manifestation of these pathologies, as to allow for the design of more effective protective measures.

METHODS

Data on the mental health status of the healthcare workers were collected from healthcare professionals from all over the nation, who worked directly with Covid patients. This was done via the use of 64-item, self-administered questionnaire, which was comprised of the DASS21 questionnaire, the Maslach Burnout Inventory and a number of original questions. Multivariable logistic regression models were used to investigate factors associated with each of the mental health measures.

RESULTS

The sample population was comprised of 381 healthcare professionals, out of which 72.7% were nursing staff, 12.9% were medical doctors and 14.4% belonged to other occupations. The prevalence of anxiety, stress and depression among the sample population were 28.6%, 18.11% and 15% respectively. The prevalence of burnout was 12.3%. This was in parallel with several changes in the lives of the healthcare professionals, including; working longer hours, spending time in isolation and being separated from family.

DISCUSSION

This study indicates that the mental health of a significant portion of the nation's workforce is compromised and, therefore, highlights the need for an urgent intervention particularly since many countries, including Cyprus, are suffering a second wave of the pandemic. The identified risk factors should offer guidance for employers aiming to protect their frontline healthcare workers from the negative effects of the COVID-19 pandemic.

Beyond the physical risk: Psychosocial impact and coping in healthcare professionals during the COVID-19 pandemic

AIMS AND OBJECTIVES

This study aimed to examine the psychosocial impact and identify risk factors for poor psychosocial outcomes in healthcare professionals during the Coronavirus disease 2019 (COVID-19) pandemic in Cyprus.

BACKGROUND

Healthcare professionals are in the forefront of the COVID-19 pandemic facing an unprecedented global health crisis, which can have consequences on their psychosocial health. There is a need to identify risk factors for poor psychosocial outcomes to inform the design of tailored psychological interventions.

DESIGN

Cross-sectional online study.

METHODS

A total of 1071 healthcare professionals completed self-report questionnaires. Measures included sociodemographic information, COVID-19-related characteristics, quality of life (Brief World Health Organization Quality of Life; WHOQOL-Bref), anxiety (Generalized Anxiety Disorder-7; GAD-7), depression (Patient Health Questionnaire-8; PHQ-8), occupational burnout (Copenhagen Burnout Inventory; CBI), and coping (Brief Coping Orientation to Problems Experienced; Brief COPE). This article follows the STROBE reporting guidelines.

RESULTS

The prevalence of moderate to severe anxiety and clinically significant depression was 27.6% and 26.8%, respectively. Significant risk factors for poor psychological outcomes included being female, being a nurse or doctor (vs non-medical professional), working in frontline units (inpatient, intensive care), perceptions of inadequate workplace preparation to deal with the pandemic, and using avoidance coping. Depression and occupational burnout were significant risk factors for poor quality of life.

CONCLUSION

The findings suggest several individual, psychosocial, and organisational risk factors for the adverse psychological outcomes observed in healthcare professionals during the COVID-19 pandemic.

RELEVANCE TO CLINICAL PRACTICE

This study highlights the urgent need for screening for anxiety and depression and psychological interventions to combat an imminent mental health crisis in healthcare professionals during the COVID-19 pandemic. Pandemic response protocols and public health initiatives aiming to improve and prevent mental health problems in healthcare professionals during the current and future health crises, need to account for the various factors at play.

Role of postoperative computed tomography in patients with severe liver injury

BACKGROUND

The role of postoperative computed tomography (CT) in asymptomatic patients with severe liver injury has not been investigated. The aim of the present study was to investigate the nature and incidence of significant liver-related abnormalities detected by postoperative CT in asymptomatic patients with severe liver injury.

METHODS

This was a prospective study of survivors with severe liver injury (grades III-V) who were treated surgically. The patients underwent CT to evaluate the liver after operation, irrespective of symptoms.

RESULTS

During the study interval there were 181 patients with severe liver injury, of whom 49 fulfilled the criteria for inclusion. The overall incidence of liver-related complications detected by CT was 49 per cent (necrotic areas in the liver in seven patients, seven bilomas, four abscesses, three perihepatic collections and three false aneurysms). In the subgroup of 17 asymptomatic patients CT revealed four abnormalities: two large bilomas, one false aneurysm and one fluid collection. Two of these patients required therapeutic intervention and the other two remained under observation.

CONCLUSION

In view of the incidence of asymptomatic significant liver abnormalities following operative management of severe liver injury, it is recommended that these patients undergo routine postoperative CT.

Pelvic fractures in pediatric and adult trauma patients: are they different injuries?

BACKGROUND

Many aspects of pediatric trauma are considerably different from adult trauma. Very few studies have performed comprehensive comparisons between pediatric and adult pelvic fractures. The purpose of this study was to compare the incidence of pelvic fracture, the epidemiologic characteristics, type of associated abdominal injuries, and outcomes between pediatric (age </= 16 years) and adult (age > 16 years) patients.

METHODS

This was a trauma registry study that included all blunt trauma admissions at a Level I trauma center during an 8-year period. The incidence and severity of pelvic fractures, associated abdominal injuries, need for blood transfusion, and mortality in the two age groups were compared with the two-sided Fisher's exact test. Stepwise logistic regression analysis was used to identify independent risk factors for associated abdominal injuries in pelvic fractures in the two age groups.

RESULTS

The incidence of pelvic fractures was 10.0% (1,450 of 14,568) in the adult group and 4.6% (95 of 2,062) in the pediatric group (p < 0.0001). In motor vehicle and pedestrian injuries, adults were twice as likely and in falls from heights > 15 ft seven times as likely as children to suffer pelvic fractures. However, age group was not a significant predictor of the severity of pelvic fracture. Only 9.5% of pediatric fractures and 8.8% of adult fractures had a pelvis Abbreviated Injury Scale (AIS) score >/= 4. The incidence of associated abdominal injuries was high but similar in the two age groups (16.7% in adults and 13.7% in children, p = 0.48). Motor vehicle crash, pelvis AIS score >/= 4, and fall from height > 15 ft were significant predictors of associated abdominal injuries in the adult but not the pediatric group. The incidence of associated gastrointestinal injuries was similar in the two age groups (5.3% in children and 3.3% in adults, p = 0.37). The incidence of solid organ injuries was nearly identical in both groups (11.6% in children and 11.5% in adults). The need for blood transfusions and angiographic intervention was not significantly different between the two age groups. Exsanguination because of bleeding related to the pelvic fracture was responsible or possibly responsible in 42 deaths (2.9%) in the adult group and no deaths in the pediatric group.

CONCLUSION

Pediatric trauma patients are significantly less likely than adults to suffer pelvic fractures, although the age group is not a significant risk factor for the severity of pelvic fracture. The incidence of associated abdominal injuries is high and similar in the two age groups. Motor vehicle crash, fall from a height, and pelvis AIS score >/= 4 were significant predictors of associated abdominal injuries in the adult but not the pediatric patients. The need for blood transfusion is similar in both groups irrespective of Injury Severity Score and pelvis AIS score. The mortality resulting from exsanguination related to pelvic fractures is very low, especially in pediatric patients.

Abdominal insufflation for prevention of exsanguination

BACKGROUND

Currently, traumatic intra-abdominal hemorrhage continues unchecked during transport and triage, and a simple technique of prehospital hemostasis might improve outcomes. The hemostatic effect of abdominal hypertension has not been studied.

PURPOSE

To examine the effect of iatrogenic abdominal insufflation on blood loss and hemodynamic performance after major abdominal vascular injury.

METHODS

Following laparotomy, a 2.7 mm hole was created in the inferior vena cava of 10 anticoagulated pigs and controlled with a partially occlusive, laparoscopic vascular clamp. After abdominal closure the clamp was released and the pig was randomized to either control (n = 5) or immediate abdominal CO2 insufflation at 20 cm H2O pressure (n = 5). Lactated Ringer's solution was used as needed to maintain a mean arterial pressure of 60 mm Hg. After 15 minutes of hemorrhage and hemodynamic monitoring, the animals were killed and blood loss measured. Mean blood loss was compared between groups using the Student test, as were final values for physiologic variables. Temporal changes in physiologic parameters were compared using analysis of variance.

RESULTS

Mean blood loss was reduced by 61% in insufflated pigs versus controls (695 +/- 244 versus 1764 +/- 328 cc, p < 0.001). Compared with controls, insufflated pigs had significantly higher mean arterial pressure (64 versus 25 mm Hg, p < 0.001), end-tidal CO2 (40.8 versus 17.8 mm Hg, p < 0.001), and pulmonary capillary wedge pressure (10.2 versus 5.8 mm Hg, p = 0.026) immediately before the pigs were killed.

CONCLUSION

Iatrogenic abdominal insufflation significantly decreased blood loss and improved hemodynamics in a porcine model of traumatic venous hemorrhage. Iatrogenic abdominal insufflation may be useful in the prehospital management of abdominal injury.

Normal electrocardiography and serum troponin I levels preclude the presence of clinically significant blunt cardiac injury

BACKGROUND

Uncertainty about the definition and diagnosis of blunt cardiac injury (BCI) leads to unnecessary hospitalization and cost while trying to rule it out. The purpose of this study was to examine whether the combination of two simple tests, electrocardiography (ECG) and serum troponin I (TnI) level, may serve as reliable predictors of BCI or the absence of it.

METHODS

Over a period of 30 months (September 1999-February 2002), 333 consecutive patients with significant blunt thoracic trauma were followed prospectively. Serial ECG and TnI tests were performed routinely and echocardiography was performed selectively. Clinically significant BCI (SigBCI) was defined as the presence of cardiogenic shock, arrhythmias requiring treatment, or posttraumatic structural deficits.

RESULTS

SigBCI was diagnosed in 44 patients (13%). Of 80 patients with abnormal ECG and TnI, 27 (34%) developed SigBCI. Of 131 with normal serial ECG and TnI, none developed SigBCI. Of patients with abnormal ECG only or TnI only, 22% and 7%, respectively, developed SigBCI. The positive and negative predictive values were 29% and 98% for ECG, 21% and 94% for TnI, and 34% and 100% for the combination of ECG and TnI. The admission ECG or TnI was abnormal in 43 of 44 patients with SigBCI. Only one patient had initially normal ECG and TnI and developed abnormalities 8 hours after admission. Forty-one patients without other significant injuries stayed 1 to 3 days in the hospital only to rule out SigBCI and could have been discharged earlier. Besides ECG and TnI, other independent risk factors of SigBCI were an Injury Severity Score > 15, the presence of significant skeletal trauma, and history of cardiac disease.

CONCLUSION

The combination of normal ECG and TnI at admission and 8 hours later rules out the diagnosis of SigBCI. In the absence of other reasons for hospitalization, such patients can be safely discharged.

Nonoperative Management of Blunt Renal Trauma: A Prospective Study

Despite the abundance of literature on nonoperative management (NOM) of blunt trauma to the liver and spleen there is limited information on NOM of blunt renal injuries. In an effort to evaluate the role of NOM 37 consecutive unselected patients with renal injuries (grade 1, four; grade 2, 12; grade 3, 11; grade 4, six; and grade 5, four) were followed prospectively over 30 months (March 1999 to September 2001). Patients without peritonitis or hemodynamic instability were managed nonoperatively regardless of the appearance of the kidney on CT scan. Six (16%) patients were operated on immediately but only two (5.4%) for the kidney (grades 3 and 5 respectively). Of the remaining 31 patients 26 (84%) were managed successfully without an operation (grade 1 or 2, 12; grades 3–5, 14). Five patients were taken to the operating room after a period of observation (3, 3.5, 9, 36, and 44 hours respectively) but only three for the kidney (grades 4 and 5). The overall failure rate was 16 per cent (5 of 31); the rate of failure specifically related to the renal injury was 9.6 per cent (three of 31). Compared with the patients with successful NOM the five patients with failed NOM were more severely injured (Injury Severity Score ≥15 in 80% vs 27%, P = 0.04), required in the first 6 hours more fluids (4.17 ± 1.72 vs 1.87 ± 1.4 liters, P = 0.003) and blood transfusions (2.40 ± 2 vs 0.42 ± 1.17 units, P = 0.005), and more frequently had a positive trauma ultrasound (80% vs 11.5%, P = 0.005). We conclude that NOM is the prevailing method of treatment after blunt renal trauma. It is successful in the majority of patients without peritonitis or hemodynamic instability and should be considered regardless of the severity of renal injury. Predictors of failure may exist on the basis of injury severity, fluid and blood requirements, and abdominal ultrasonographic findings and need validation by a larger sample size.

Nonoperative management of blunt renal trauma: a prospective study

Despite the abundance of literature on nonoperative management (NOM) of blunt trauma to the liver and spleen there is limited information on NOM of blunt renal injuries. In an effort to evaluate the role of NOM 37 consecutive unselected patients with renal injuries (grade 1, four; grade 2, 12; grade 3, 11; grade 4, six; and grade 5, four) were followed prospectively over 30 months (Match 1999 to September 2001). Patients without peritonitis or hemodynamic instability were managed nonoperatively regardless of the appearance of the kidney on CT scan. Six (16%) patients were operated on immediately but only two (5.4%) for the kidney (grades 3 and 5 respectively). Of the remaining 31 patients 26 (84%) were managed successfully without an operation (grade 1 or 2, 12; grades 3-5, 14). Five patients were taken to the operating room after a period of observation (3, 3.5, 9, 36, and 44 hours respectively) but only three for the kidney (grades 4 and 5). The overall failure rate was 16 per cent (5 of 31); the rate of failure specifically related to the renal injury was 9.6 per cent (three of 31). Compared with the patients with successful NOM the five patients with failed NOM were more severely injured (Injury Severity Score > or = 15 in 80% vs 27%, P = 0.04), required in the first 6 hours more fluids (4.17 +/- 1.72 vs 1.87 +/- 1.4 liters, P = 0.003) and blood transfusions (2.40 +/- 2 vs 0.42 +/- 1.17 units, P = 0.005), and more frequently had a positive trauma ultrasound (80% vs 11.5%, P = 0.005). We conclude that NOM is the prevailing method of treatment after blunt renal trauma. It is successful in the majority of patients without peritonitis or hemodynamic instability and should be considered regardless of the severity of renal injury. Predictors of failure may exist on the basis of injury severity, fluid and blood requirements, and abdominal ultrasonographic findings and need validation by a larger sample size.

Effect on outcome of early intensive management of geriatric trauma patients

BACKGROUND

Despite significant injuries elderly patients (aged 70 years or more) often do not exhibit any of the standard physiological criteria for trauma team activation (TTA), i.e. hypotension, tachycardia or unresponsiveness to pain. As a result of these findings the authors' TTA criteria were modified to include age 70 years or more, and a protocol of early aggressive monitoring and resuscitation was introduced. The aim of the present study was to assess the effect of the new policy on outcome.

METHODS

This trauma registry study included patients aged 70 years or more with an Injury Severity Score (ISS) greater than 15 who were admitted over a period of 8 years and 8 months. The patients were divided into two groups: group 1 included patients admitted before age 70 years and above became a TTA criterion and group 2 included patients admitted during the period when age 70 years or more was a TTA criterion and the new management protocol was in place. The two groups were compared with regard to survival, functional status on discharge and hospital charges.

RESULTS

There were 336 trauma patients who met the criteria, 260 in group 1 and 76 in group 2. The two groups were similar with respect to mechanism of injury, age, gender, ISS and body area Abbreviated Injury Score. The mortality rate in group 1 was 53.8 per cent and that in group 2 was 34.2 per cent (P = 0.003) (relative risk (RR) 1.57 (95 per cent confidence interval 1.13 to 2.19)). The incidence of permanent disability in the two groups was 16.7 and 12.0 per cent respectively (P = 0.49) (RR 1.39 (0.59 to 3.25)). In subgroups of patients with an ISS of more than 20 the mortality rate was 68.4 and 46.9 per cent in groups 1 and 2 respectively (P = 0.01) (RR 1.46 (1.06 to 2.00)); 12 of 49 survivors in group 1 and two of 26 in group 2 suffered permanent disability (P = 0.12) (RR 3.18 (0.77 to 13.20)).

CONCLUSION

Activation of the trauma team and early intensive monitoring, evaluation and resuscitation of geriatric trauma patients improves survival.

Pelvic fractures: epidemiology and predictors of associated abdominal injuries and outcomes

BACKGROUND

Pelvic fractures are often associated with major intraabdominal injuries or severe bleeding from the fracture site.

OBJECTIVE

To study the epidemiology of pelvic fractures and identify important risk factors for associated abdominal injuries, bleeding, need for angiographic embolization, and death.

METHODS

Trauma registry study on pelvic fractures from blunt trauma. Stepwise logistic regression was used to identify risk factors of severe pelvic fractures, associated abdominal injuries, need for major blood transfusion, therapeutic embolization, and death from pelvic fracture. Adjusted relative risks and 95% confidence intervals were derived.

RESULTS

There were 16,630 trauma registry patients with blunt trauma, of whom 1,545 (9.3%) had a pelvic fracture. The incidence of abdominal injuries was 16.5%, and the most common injured organs were the liver (6.1%) and the bladder and urethra (5.8%). In severe pelvic fractures (Abbreviated Injury Scale [AIS] > or =4), the incidence of associated intraabdominal injuries was 30.7%, and the most commonly injured organs were the bladder and urethra (14.6%). Among the risk factors studied, motor vehicle crash is the only notable risk factor negatively associated with severe pelvic fracture. Major risk factors for associated liver injury were motor vehicle crash and pelvis AIS > or = 4. Risk factors of major blood loss were age > 16 years, pelvic AIS > or =4, angiographic embolization, and Injury Severity Score (ISS) > 25. Age> 55 years was the only predictor for associated aortic injury. Factors associated with therapeutic angiographic embolization were pelvic AIS > or =4 and ISS > 25. The overall mortality was 13.5%, but only 0.8% died as a direct result of pelvic fracture. The only pronounced risk factor associated with mortality was ISS>25.

CONCLUSIONS

Some epidemiological variables are important risk factors of severity of pelvic fractures, presence of associated abdominal injuries, blood loss, and need of angiography. These risk factors can help in selecting the most appropriate diagnostic and therapeutic interventions.

Severe trauma is not an excuse for prolonged antibiotic prophylaxis

HYPOTHESIS

For critically injured patients, a limited course of antibiotics is as effective as a prolonged course in preventing sepsis and organ failures.

DESIGN

Prospective nonrandomized study.

SETTING

Surgical intensive care unit (SICU) of an academic hospital with a level I trauma center.

PATIENTS

A population of 250 trauma patients who required an operation and SICU stay of 3 days or more received antibiotic prophylaxis by 1 antibiotic for 24 hours (SHORT group, n = 133) or 1 or more antibiotics for more than 24 hours (LONG group, n = 117).

MAIN OUTCOME MEASURES

Twenty-two outcome variables, including 9 conventional outcomes (eg, sepsis, septic shock, and organ failure) and 13 objective outcomes (days with temperature >38.5 degrees C, days with white blood cell count >14.0 x10(3)/microL, positive cultures, cultures with antibiotic-resistant bacteria, SICU and hospital stay, and death).

RESULTS

The LONG group included more patients with orthopedic injuries (60 patients [51%] vs 52 [39%], P =.05) and orthopedic operations (47 patients [40%] vs 30 [23%], P =.003) than did the SHORT group. No other difference was identified in compared characteristics between the 2 groups. There was no difference in any of the examined outcomes except for a higher incidence of resistant infections in the LONG group compared with the SHORT group (59 patients [50%] vs 47 [35%], P =.02). Patients with resistant infections stayed in the hospital longer (mean +/- SD, 33 +/- 18 vs 15 +/- 11 days, P<.001) and had a higher mortality rate (13% vs 1%, P<.001) compared with patients without resistant infections. Prolonged prophylaxis by multiple antibiotics was an independent risk factor of resistant infection (odds ratio, 2.13, 95% confidence interval, 1.22-3.74; P =.008).

CONCLUSIONS

The prophylactic administration of more than 1 antibiotic for more than 24 hours following severe trauma does not offer additional protection against sepsis, organ failure, and death, but increases the probability of antibiotic-resistant infections.