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Site map. To previous section. To next section. Hospitals, doctors, pharmacies and police. Zanzibar Travel Guide. Zanzibar Town. Travelling around. Where to stay. Where to eat and drink. Bars and clubs. Freddie Mercury. Local services. Medical serv. Places to visit. East African slave trade. Hospitals, doctors, pharmacies and police Zanzibar island's main public hospital is Mnazi Moja General Hospital , on the south side of stone town. During the island's revolutionary heyday it was called the lenin hospital, but this title has now been dropped. Like many hospitals in developing countries, the staff are dedicated but the wards are badly under-funded, under-supplied and in very poor condition. Equally distressing is the pile of rubbish including drip-feeds and needles simply dumped on the beach behind the hospital. In case of real emergency, the nearest major hospital, fully staffed and equipped, is the Aga Khan Hospital in Mombasa. You may even need to fly there by charter plane if necessary if things are really serious, but this should be covered by your insurance. Most tourists go to one of the private medical clinics where staff speak English and the service is usually better. The medical centres also have pharmacies selling medicines and other supplies. Just off Vuga Rd, near the Majestic Cinema, this clinic is recommend by most expatriates. It's a fully equipped facility, run to European standards, and the staff members speak several European languages. Zanzibar Medical Group Other medical centres If your insurance covers only major medical problems, and you want to keep costs down for something minor, you could go to one of Zanzibar's other medical centres: Afya Medical Hospital ; Also on Vuga Rd. Pharmacies If you need to buy medicines, Zanzibar Town has several pharmacies stocking drugs which are mostly imported from Europe and India, and other items such as toiletries and tampons. Stocks are not always reliable, so if you know you're likely to need a specific drug during your visit, it's best to bring a sufficient supply with you. Straightforward medicines, toiletries and tampons are also available at the 'container stores' on Creek Road. Police In case of emergency in zanzibar town, the main police station is in the Malindi area, on the north side of Stone Town or This is also the central police station for the whole of Zanzibar. Robberies can be reported here travel insurance companies usually require you, if you are making a claim, to prove you have notified the local police , but you should not expect any real action to be taken as the police are not particularly well motivated. Zanzibar also has a platoon of Tourist Police, supposedly to assist and protect Zanzibar's foreign visitors, although many people question their effectiveness. They are mostly seen driving around town in fancy new patrol cars, while touts continue to hassle tourists unimpeded. Click on the logo to buy this book online. Meanwhile for links relevant to this page: An introduction to African safari.
PDF | In this essay I analyze the HBO prison drama Oz as a cultural artifact of the current era of rampant incarceration. I argue that Oz's hyperviolent.
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Multivariate analysis showing odds of major complications by device type. Question In patients with difficult intravenous access or those who require short-term intravenous antibiotics, are midline catheters safer than peripherally inserted central catheters PICCs? Meaning Judicious use of midlines over PICCs may improve patient safety; randomized clinical trials to compare these devices appear necessary. Importance Peripherally inserted central catheters PICCs and midlines are frequently used for short-term venous access; whether one is safer than the other in this setting has not been adequately reported. Objective To compare outcomes between patients who had a PICC vs midline placed for the indication of difficult vascular access or antibiotic therapy for 30 or fewer days. Design, Setting, and Participants This cohort study analyzed data from a multihospital registry including patients admitted to a participating site from December through January who had a PICC or midline placement for the indications of difficult venous access or intravenous antibiotic therapy prescribed for 30 or fewer days. Data were analyzed from October to March Main Outcomes and Measures Major complications, including a composite of symptomatic catheter-associated deep vein thrombosis DVT , catheter-related bloodstream infection, and catheter occlusion. Logistic regression and Cox proportional hazards regression models taking into account catheter dwell were used to estimate risk for major complications, adjusting for patient and device characteristics and the clustered nature of the data. Sensitivity analyses limiting analyses to 10 days of device dwell were performed. After adjusting for patient characteristics, comorbidities, catheter lumens, and dwell time in logit models, patients who received PICCs had a greater risk of developing a major complication compared with those who received midlines odds ratio, 1. Reduction in complications stemmed from lower rates of occlusion 2. In time-to-event models, similar outcomes for bloodstream infection and catheter occlusion were noted; however, the risk of DVT events was lower in patients who received PICCs vs midlines hazard ratio, 0. Results were robust to sensitivity analyses. Conclusions and Relevance In this cohort study among patients with placement of midline catheters vs PICCs for short-term indications, midlines were associated with a lower risk of bloodstream infection and occlusion compared with PICCs. Randomized clinical trials comparing these devices for this indication are needed. Reliable venous access is essential in providing safe and effective care for hospitalized patients. In the US, an estimated million peripheral and 5 million central venous catheters CVCs are inserted annually. Peripherally inserted central catheters are CVCs inserted into peripheral veins such that their tips end at the cavoatrial junction near the right atrium. While they can be conveniently placed at the bedside and provide extended venous access, like other central lines, they are associated with complications, including central line—associated bloodstream infection CLABSI and deep vein thrombosis DVT. As use of midlines has grown, concerns regarding premature failure and major complications from these devices have also emerged. Thus, for short-term venous access, the optimal device that balances safety and meets clinical needs is unclear. Given this gap, we used data from a statewide, multihospital quality improvement registry to compare outcomes of patients who received PICCs vs those who received midlines. We hypothesized that use of midline catheters placed specifically for the indications of difficult vascular access or antibiotic therapy for 30 or fewer days would be associated with fewer complications than use of PICCs. The design and setting of this consortium have been previously described. Patients who are 1 younger than 18 years; 2 pregnant; 3 admitted to nonmedical services eg, general surgery ; or 4 admitted under observation status are excluded. At each hospital, trained data abstractors collect detailed demographic eg, age, sex, race, ethnicity and clinical data using a defined protocol directly from patient records. Following PICC and midline placement, all patients are followed up until device removal, death, or 30 days whichever occurs first. For this study, we included data on patients admitted to a participating site from December through January We focused on these indications because clinically, these are the 2 primary considerations when it comes to choosing between a PICC or midline in a hospitalized patient. Because the purpose of Hospital Medicine Safety Consortium is to improve the quality of care to hospitalized patients, it is deemed not regulated by the institutional review board of the University of Michigan HUM Patient consent was waived because deidentified data were collected. Peripherally inserted central catheters were defined as vascular access devices that were inserted in the veins of the upper extremity that terminated in the superior vena cava or right atrium. Patient demographic data, medical diagnoses, comorbidities, clinical findings, medications, laboratory values at the time of device placement, and duration of infusion therapy were abstracted directly from medical records. Device variables, including indication for insertion, number of insertion attempts, placement arm and vein of insertion, catheter gauge, and number of catheter lumens, were also abstracted from patient records. Catheter dwell time was recorded as days between insertion and removal and was reported as median dwell time with interquartile ranges. All venous thrombosis events were diagnosed in the setting of clinical suspicion eg, patients reported arm pain or swelling with imaging confirming DVT or PE. To compare complication rates by device type, we fit a logistic mixed-effect model with hospital-specific random intercepts. We used a published and validated conceptual model to clinically select variables for adjustment. For device factors, we adjusted for number of catheter lumens, device dwell time days , and number of insertion attempts. We created separate models to examine risk of all major complications, then each major complication. Given that the dwell time of PICCs and midlines may vary and be associated with the risk of complications, we also fit a Cox proportional hazards model for each complication to identify whether variation in catheter dwell time was associated with complication hazards. All models were adjusted to account for the clustered nature of the data. Finally, to further account for brief dwell influencing complication hazard, we performed sensitivity analyses and recalculated the baseline model, limiting complications to those occurring within 10 days of line placement. For patients with multiple device placements in the data set, only the first placement occurrence was retained for analysis. All analyses were performed in SAS, version 9. The median IQR age of device recipients was Single-lumen devices represented In terms of indications for use, more patients with midlines had these inserted for the indication of difficult IV access or blood draws than PICCs Differences by arm of insertion were observed, with the right arm used for placement in patients with PICCs more frequently than in patients with midlines Patients with midline placement more frequently had a recent history of venous thromboembolism than patients with PICCs 6. Overall, 9. The most prevalent complication was catheter occlusion, which occurred in 7. With respect to bloodstream infection, a total of 93 PICCs 1. In comparison, only 19 midlines 0. Deep vein thrombosis occurred in 86 patients with PICCs 1. Catheter removal owing to a complication occurred in 7. Results were similar across both indications for device insertion. For example, in patients for whom difficult IV access was the indication for device insertion, PICCs were more likely to result in a complication than midlines OR, 2. With respect to individual complications, risk of both catheter occlusion and bloodstream infection was greater in patients who received PICCs vs midlines. When outcomes were fit using a Cox proportional hazard model to take device dwell into account, higher hazard of major complications including bloodstream infection and catheter occlusion were observed in patients who received PICCs vs midlines consistent with logistic regression models. In sensitivity analyses limiting complications to those occurring in the first 10 days after device placement, greater odds for major complications OR, 1. The Michigan Appropriateness Guide for Intravenous Catheters MAGIC recommends midlines as the preferred vascular access in patients with difficult vascular access, for treatment that will likely exceed 6 days, and for patients requiring infusions including antibiotics for up to 14 days. Thus, our study supports recommendations from MAGIC and other vascular access guidelines that promote midlines as the optimal device for use for these indications. However, given variation in dwell times and the possibility of confounding by indication, head-to-head randomized clinical trials comparing midlines with PICCs for short-term indications are needed to confirm these findings. We observed that midlines were associated with a significantly lower risk of CRBSI compared with PICCs, even after adjusting for important predictors, including number of lumens and line duration. Some authors have argued that lack of robust surveillance of midline-related bloodstream infections and longer duration of IV access are important confounding variables when it comes to this comparison. Of note, our results are in line with findings from many US hospitals that have launched midline programs as part of their CLABSI reduction efforts and have also reported positive outcomes with greater substitution of these devices for PICCs. Catheter-associated DVT is an important and potentially lethal complication of vascular access devices. After adjusting for patient, device, and hospital characteristics, our study showed no statistically significant difference between the overall risk of DVT or PE when comparing these 2 devices in logistic regression models. However, when examining time-to-event models, we observed that midlines appeared to be associated with greater daily hazard of DVT, potentially owing to a similar number of events occurring within a shorter catheter dwell time associated with these devices. This finding serves as a reminder to not dismiss the risk of thrombosis associated with midlines, especially in patients with hypercoagulability or preexisting risk factors for DVT eg, cancer. In view of these findings and absence of randomized clinical trial data, a thoughtful, evidence-based deliberation of the pros and cons of device use before placement is needed in clinical decision-making. Limiting catheter use—both midline and PICC—or reducing days of dwell especially in the case of midlines may be vital to ensuring safety. While occlusion itself may not be life threatening, they have the potential for treatment delays, are associated with significant declotting costs, and could lead to premature device removal. Our findings suggest that midlines outperform PICCs when it comes to this outcome. Our study has several limitations. First, as this is an observational study, unmeasured confounding may affect study conclusions. Second, although the variables included in models were clinically chosen and based on plausible pathways, our models do not imply causation and only show associations between exposure and outcomes. Third, we did not account for difference in manufacturers, coatings, or device-specific features that may be peculiar to various PICCs and midlines. Because these are inherently different devices and such factors are on the causal pathway, adjusting for these explanatory variables would not be appropriate. Finally, our findings should be viewed as preliminary in regard to the debate of midline vs PICCs. Only a well-designed randomized clinical trial comparing the 2 devices head-to-head can definitively evaluate the performance and safety of these devices. Despite these limitations, our study has important strengths. To our knowledge, this is the largest multicenter study to compare PICC vs midline catheter complications for prespecified indications. Through use of robust statistical techniques, sensitivity analyses, inclusion of patients receiving care in large and small hospitals, manual medical record abstraction to capture and adjudicate findings, and long-term follow-up of device outcomes, our results are clinically relevant and internally valid and lend a high degree of generalizability to various settings. Finally, by validating guidelines recommending midlines as preferred vascular devices for select hospitalized patients, our study also has important implications for clinicians, hospitals, and policy makers alike. These data help affirm the validity of appropriateness criteria when making decisions regarding vascular access in hospitalized patients. In this cohort study among hospitalized patients who required venous access for the indications of difficult access and IV antibiotics for up to 30 days, PICCs appeared to have twice the rate of major complications compared with midlines. Thoughtful selection between these 2 devices, balancing the risk of venous thrombosis, appears necessary in clinical care. Randomized clinical trials comparing these devices are needed to help inform patient safety. Published Online: November 29, Critical revision of the manuscript for important intellectual content: All authors. Administrative, technical, or material support: Flanders, Horowitz, Zhang, Chopra. No other disclosures were reported. Download PDF Comment. Sample Selection. View Large Download. Table 1. Table 2. Table 3. Table 4. Multistate point-prevalence survey of health care-associated infections. Reducing peripherally inserted central catheters and midline catheters by training nurses in ultrasound-guided peripheral intravenous catheter placement. The midline catheter: a clinical review. The safety of midline catheters for intravenous therapy at a large academic medical center. Bloodstream infection, venous thrombosis, and peripherally inserted central catheters: reappraising the evidence. Variation in use and outcomes related to midline catheters: results from a multicentre pilot study. The practice and complications of midline catheters: a systematic review. Use of and patient-reported complications related to midline catheters and peripherally inserted central catheters. The efficacy of midline catheters-a prospective, randomized, active-controlled study. A quality improvement project to decrease utilization of multilumen peripherally inserted central catheters. Infection free midline catheter implementation at a community hospital 2 years. The clinical performance of midline catheters—an observational study. A comparison of the incidence of midline catheter-associated bloodstream infections to that of central line-associated bloodstream infections in 5 acute care hospitals. Comparison of venous thrombosis complications in midlines versus peripherally inserted central catheters: are midlines the safer option? Intravenous catheter-related adverse events exceed drug-related adverse events in outpatient parenteral antimicrobial therapy. The risk of adverse events related to extended-dwell peripheral intravenous access. Improving peripherally inserted central catheter appropriateness and reducing device-related complications: a quasiexperimental study in 52 Michigan hospitals. Use of peripherally inserted central catheters in patients with advanced chronic kidney disease: a prospective cohort study. Summary of recommendations: guidelines for the prevention of intravascular catheter-related infections. A compendium of strategies to prevent healthcare-associated infections in acute care hospitals: updates. Patterns and predictors of peripherally inserted central catheter occlusion: the 3P-O study. Safety and utilization of peripherally inserted central catheters versus midline catheters at a large academic medical center. Variations in peripherally inserted central catheter use and outcomes in Michigan hospitals. Save Preferences. Privacy Policy Terms of Use. During internship and residency in the s a common procedure at the bedside was the insertion of a venous catheter in to an upper limb peripheral vein by 'cutting down' on the vein to facilitate insertion. I would classify these 'cut downs' as midline access. Procedure was simple and effective for administering intravenous solutions and drugs. These venous insertions were not used after PICC lines appeared on the scene. I often wondered why. This Issue. Views 43, Citations Comments 1. View Metrics. X Facebook More LinkedIn. Original Investigation. Key Points Question In patients with difficult intravenous access or those who require short-term intravenous antibiotics, are midline catheters safer than peripherally inserted central catheters PICCs? Study Setting and Design. Covariates and Definitions. Clinical Outcomes. Statistical Analysis. General Characteristics. Unadjusted Risk of Complications. Adjusted Risk of Complications. Limitations and Strengths. Back to top Article Information. Access your subscriptions. Access through your institution. Add or change institution. Free access to newly published articles. Purchase access. Rent article Rent this article from DeepDyve. Sign in to access free PDF. Save your search. Customize your interests. Create a personal account or sign in to:. Privacy Policy. Make a comment.
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Rule-making power of the Supreme Court. Limitations on the rule-making power of the Supreme Court. Power of the Supreme Court to amend and.
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