Role of Computed Tomography in Blunt Abdominal Trauma

Introduction: Blunt abdominal trauma is one of the commonly encountered surgical emergencies. The diagnostic modality that helps in optimum management of these patients includes chest and abdominal x-rays, Focused Assessment Sonography for Trauma scan and Computed Tomography. In selected hemodynamically stable patients who are candidates for non-operative management, Contrast Enhanced Computed Tomography is not considered essential and hence avoiding its own radiation hazards and decreasing extra financial burden to the patients. Aims: To evaluate whether Contrast Enhanced Computed Tomography is necessary or not in case of blunt trauma abdomen. Methods: This is a hospital based prospective study done in the department of surgery at Nepalgunj Medical College, Kohalpur conducted from October 2020 to March 2021. The patients with blunt abdominal trauma who were hemodynamically stable at the time of presentation and those who became stable after resuscitation were included. These patient’s detailed history was taken, clinical examination done. Focused Assessment Sonography for Trauma scan was done at the time of presentation along with chest x-ray and other necessary blood investigation. Data were analyzed with Statistical Package for Social Sciences version 25 and p-value <0.05 was taken as significant. Results: Out of total 53 patients, age group between 11-20 and 21-30 years comprising of 13 patients with male: female ratio of 1.94:1 were affected more. Fall injury, being the most common mode, comprised 20 patients. The commonest organ involved was spleen seen in 17 patients (32.1%), liver in 16 patients (30.2%). In 44 (83.0%) patients, Computed Tomography scan was done only in nine patients who were also managed conservatively, except one who underwent laparoscopic evacuation of collected blood. Seventeen (32.1%) patients underwent repeat ultrasonography without any new findings. Conclusion: Patients with blunt abdominal trauma with stable hemodynamics can be managed conservatively with limited use of Contrast Enhanced Computed Tomography scan.

National Institutes of Health Stroke Scale as an Outcome in Stroke Research: Value of ANCOVA Over Analyzing Change From Baseline

National Institutes of Health Stroke Scale (NIHSS), measured a few hours to days after stroke onset, is an attractive outcome measure for stroke research. NIHSS at the time of presentation (baseline NIHSS) strongly predicts the follow-up NIHSS. Because of the need to account for the baseline NIHSS in the analysis of follow-up NIHSS as an outcome measure, a common and intuitive approach is to define study outcome as the change in NIHSS from baseline to follow-up (ΔNIHSS). However, this approach has important limitations. Analyzing ΔNIHSS implies a very strong assumption about the relationship between baseline and follow-up NIHSS that is unlikely to be satisfied, drawing into question the validity of the resulting statistical analysis. This reduces the precision of the estimates of treatment effects and the power of clinical trials that use this approach to analysis. ANCOVA allows for the analysis of follow-up NIHSS as the dependent variable while adjusting for baseline NIHSS as a covariate in the model and addresses several challenges of using ΔNIHSS outcome using simple bivariate comparisons (eg, a t test, Wilcoxon rank-sum, linear regression without adjustment for baseline) for stroke research. In this article, we use clinical trial simulations to illustrate that variability in NIHSS outcome is less when follow-up NIHSS is adjusted for baseline compared to ΔNIHSS and how a reduction in this variability improves the power. We outline additional, important clinical and statistical arguments to support the superiority of ANCOVA using the final measurement of the NIHSS adjusted for baseline over, and caution against using, the simple bivariate comparison of absolute NIHSS change (ie, delta).

Chlorhexidine – a commonly used but often neglected culprit of dialysis associated anaphylactic reactions (case report)

Background Hemodialysis-associated anaphylactic reactions are rare and frequently complex in nature due to the sheer number of possible culprit agents. Unfortunately, dialysis is often unavoidable or strictly essential for life-saving solute clearance or fluid removal in patients with end stage kidney failure and those with severe acute kidney injury. It is of utmost importance that the culprit agent is identified and avoided to allow continuation of dialysis treatment as needed. Case presentation We present 2 cases of hemodialysis-associated anaphylactic reactions. These patients developed anaphylactic reactions peri-dialysis and were initially suspected to have dialyser reactions. They were investigated in a controlled healthcare setting and possible culprit agents were systemically identified and eliminated. They both underwent allergy testing and were diagnosed with chlorhexidine allergy. Of note, Case 1 was an incident dialysis patient at the time of presentation and Case 2 was a prevalent dialysis patient. This suggests that the time from initial sensitization to reaction may not always be helpful in determining if a particular agent is the culprit of an anaphylactic reaction. In both cases, the patients were dialysed through a tunnelled dialysis catheter. We postulate that the presence of an exit site, which represents a compromise to the integrity of the skin’s epidermal barrier, may have a significant role in the development of these reactions. As chlorhexidine is a widely used disinfectant in hemodialysis, it is imperative that we consider it as a possible culprit agent when these reactions arise. To our knowledge, there are no other reported cases of anaphylaxis secondary to chlorhexidine use in dialysis patients other than a previous report in 2017. Our report also highlights the possibility of these reactions occurring more frequently in patients with damaged epidermal barriers and in patients exposed to higher environmental concentrations of chlorhexidine. These are novel concepts that can be explored with further research. Conclusion Chlorhexidine associated anaphylactic reactions can occur in the peri-dialysis setting and a high index of suspicion is paramount to diagnosis.

Predictors of hospital prenotification for STEMI and association of prenotification with outcomes

BackgroundDelay to reperfusion in ST-elevation myocardial infarction (STEMI) is detrimental, but can be minimised with prehospital notification by ambulance to the treating hospital. We aimed to assess whether prenotification was associated with improved first medical contact to balloon times (FMC-BT) and whether this resulted in better clinical outcomes. We also aimed to identify factors associated with use of prenotification.MethodsThis was a retrospective study of prospective Victorian Cardiac Outcomes Registry data for patients undergoing primary percutaneous coronary intervention for STEMI from 2013-2018. Postcardiac arrest were excluded. Patients were grouped by whether they arrived by ambulance with prenotification (group 1), arrived by ambulance without prenotification (group 2) or self-presented (group 3). We compared groups by FMC-BT, incidence of major adverse cardiac and cerebrovascular events (MACCE), mortality and factors associated with the use of prenotification.Results2891 patients were in group 1 (79.3% male), 1620 in group 2 (75.7% male) and 1220 in group 3 (82.9% male). Patients who had prenotification were more likely to present in-hours (p=0.004) and self-presenters had lowest rates of cardiogenic shock (p<0.001). Prenotification had shorter FMC-BT than without prenotification (104 min vs 132 min, p<0.001) Self-presenters had superior clinical outcomes, with no difference between ambulance groups. Groups 1 and 2 had similar 30-day MACCE outcomes (7.4% group 1 vs 9.1% group 2, p=0.05) and similar mortality (4.6% group 1 vs 5.9% group 2, p=0.07). In multivariable analysis, male gender, right coronary artery culprit and in-hours presentation independently predicted use of prenotification (all p<0.05).ConclusionDifferences in clinical characteristics, particularly gender, time of presentation and culprit vessel may influence ambulance prenotification. Ambulance cohorts have high-risk features and worse outcomes compared with self-presenters. Improving system inequality in prehospital STEMI diagnosis is recommended for fastest STEMI treatment.

A Prediction Model for Bacteremia and Transfer to Intensive Care in Pediatric and Adolescent Cancer Patients With Febrile Neutropenia

Objectives:Febrile neutropenia (FN) is a common condition in children receiving chemotherapy. Our goal in this study was to develop a model for predicting blood stream infection (BSI) and transfer to intensive care (TIC) at time of presentation in pediatric cancer patients with FN. Methods: We conducted an observational cohort analysis of pediatric and adolescent cancer patients younger than 24 years admitted for fever and chemotherapy-induced neutropenia over a 7-year period. We excluded stem cell transplant recipients who developed FN after transplant and febrile non-neutropenic episodes. The primary outcome was onset of BSI, as determined by positive blood culture within 7 days of onset of FN. The secondary outcome was transfer to intensive care (TIC) within 14 days of FN onset. Predictor variables include demographics, clinical, and laboratory measures on initial presentation for FN. Data were divided into independent derivation (2009-2015) and prospective validation (2015-2016) cohorts. Prediction models were built for both outcomes using logistic regression and random forest and compared with Hakim model. Performance was assessed using area under the receiver operating characteristic curve (AUC) metrics. Results: A total of 505 FN episodes (FNEs) were identified in 230 patients. BSI was diagnosed in 106 (21%) and TIC occurred in 56 (10.6%) episodes. The most common oncologic diagnosis with FN was acute lymphoblastic leukemia (ALL), and the highest rate of BSI was in patients with AML. Patients who had BSI had higher maximum temperature, higher rates of prior BSI and higher incidence of hypotension compared with patients who did not have BSI. FN patients who were transferred to the intensive care (TIC) had higher temperature and higher incidence of hypotension at presentation compared to FN patients who didn’t have TIC. We compared 3 models: (1) random forest (2) logistic regression and (3) Hakim model. The areas under the curve for BSI prediction were (0.79, 0.65, and 0.64, P < 0.05) for models 1,2, and 3, respectively. And for TIC prediction were (0.88, 0.76, and 0.65, P < 0.05) respectively. The random forest model demonstrated higher accuracy in predicting BSI and TIC and showed a negative predictive value (NPV) of 0.91 and 0.97 for BSI and TIC respectively at the best cutoff point as determined by Youden’s Index. Likelihood ratios (LRs) (post-test probability) for RF model have potential utility of identifying low risk for BSI and TIC (0.24 and 0.12) and high-risk patients (3.5 and 6.8) respectively. Conclusions: Our prediction model has a good diagnostic performance in clinical practices for both BSI and TIC in FN patients at the time of presentation. The model can be used to identify a group of individuals at low risk for BSI who may benefit from early discharge and reduce length of stay, also it can identify FN patients at high risk of complications who might benefit from more intensive therapies at presentation.

Implementation of Modified Problem Based Learning (PBL) in Improving Learning Outcomes of Physics Vocational School for Optical Materials

The purpose of research on the implementation of Problem Based Learning (PBL) can improve students' physics learning outcomes in terms of knowledge and skills. Classroom Action Research was conducted in two cycles, the research subject was class X APHP 03 with 35 students. Method data collection uses tests for knowledge and skills aspects through observation. Data analysis is descriptive qualitative for aspects of knowledge by percentage of students' mastery level classically and aspects of skills through scoring observation sheets. Learning outcomes from cycle I and cycle II have increased in the knowledge by 17.14%. Aspects of student skills increase in the indicators of systematic presentation, mastery of the material and pronunciation at the time of presentation, so that the implementation of Problem Based Learning (PBL) can improve student learning outcomes.

Occupational-Seasonal Spine and Other Orthopaedic Injuries due to Fall from Java Plum Tree

Background: Falling from a Java Plum (Jamun) tree is one of the primary causes of Spine and other extremity fractures during the Monsoon season (when it is harvested) in Pakistan. Objective: To assess the distribution of patients with different facture types presented with the history of fall from Jamun tree during Monsoon season. Study Design: Retrospective study Place and Duration of Study: Department of Orthopaedics & Spine Surgery, Ghurki Trust Teaching Hospital, Lahore 1st May 2020 to 31st August 2020, Methodology: Forty two male patients age ranged from 12-55 years of age were enrolled. Information was obtained from the hospital’s trauma registry, and medical records were retrospectively reviewed for data about the type of fractures, occupational status, pre-hospital immobilization, time of presentation, and the time between fall and management and length of hospital stay were reviewed. Results: The average age of the patient was 34.6 years. Twenty four (57.14%) had spine fractures and 18 (42.8%) suffered other axial and skeletal fractures. Nearly three-fourths needed surgical intervention. In contrast, 26.1 % were managed conservatively. Conclusion: During monsoon season, we received 4.6% of extra patients with different injuries following fall from Jamun tree. In most cases, young men from lower socio-economic status suffer from varying degrees of disability and experience financial problems. Keywords: Fall, Java Plum, Mass awareness, Occupational-seasonal injury, Spine fractures

551 Killip class predictors and prognostic role in acute myocardial infarction

Aims Killip classification is a simple and fast clinical tool for risk stratification in patients with acute coronary syndrome (ACS). However, predictors of high Killip class at admission and its prognostic impact in the clinical contest of myocardial infarction with nonobstructive coronary artery (MINOCA) are still poorly known. To identify the clinical predictors of high Killip class and its potential prognostic role on in-hospital and follow-up outcomes in patients with MINOCA compared to patients with myocardial infarction with obstructive coronary artery (MIOCA). Methods and results We included all consecutive patients with myocardial infarction (MI) undergoing coronary angiogram between 2016 and 2019 at our hospital. According to 2016 ESC Position Paper criteria, we considered as MINOCA all patients with acute MI and with the angiographic conventional cut-off of &lt; 50% coronary stenosis without clinically apparent alternative diagnosis (e.g. sepsis, stroke, pulmonary embolism, myocarditis, and Tako-tsubo). We analysed Killip class of MINOCA patients comparing with those of MIOCA (coronary stenosis ≥50%). Kaplan–Meier (KM) curves were developed for the comparison of overall-mortality among MINOCA with high Killip class (major than 1) compared to other. Multivariate logistic regression analysis was used to determine the predictors of high Killip class both in the MINOCA and MIOCA populations. Among 3165 MI, 260 patients fulfilled the 2016 ESC criteria for MINOCA. Overall, 62.3% were males and the mean age was 68.6 ± 13.2 years. The median follow-up time was 23.3 ± 14.5 months. Killip class &gt;1 occurred in 24 patients in MINOCA group and 507 in MIOCA group (17.5% vs. 9.2%, P = 0.001). The KM survival distributions were significantly different across Killip class &gt;1 (P &lt; 0.001) in both populations with higher mortality in patients with higher Killip class. Finally, the multivariate logistic regression showed that the predictors of high Killip class at time of presentation in MIOCA population were older age [odds ratio: 1.04, 95% CI: (1.03–1.06), P &lt; 0.001], diabetes [odd ratio 0.63, 95% CI (0.48–0.81), P &lt; 0.001], ST elevation [odds ratio: 0.65, 95% CI (0.48–0.89), P = 0.008], left ventricle ejection fraction [odds ratio: 0.95, 95% CI (0.94–0.96), P &lt; 0.001], and elevated cardiac troponin [odds ratio: 1.00, 95% CI (1.00–1.00), P = 0.01]. Older age [odds ratio: 1.08, 95% CI (1.03–1.14), P = 0.003], ST elevation [odd ratio 0.14, 95% CI (0.02–0.93), P = 0.042], and diabetes [odd ratio 3.60, 95% CI (1.08–1.96), P = 0.037] were predictors of high Killip class in MINOCA, however left ventricle ejection fraction (P = 0.3) and elevated cardiac troponin (P = 0.6) did not predict the high Killip class in MINOCA patients. Conclusions Our data suggest that Killip classification performed at the time of admission is a useful clinical marker of a high risk of early and late adverse cardiovascular events even in patients with MINOCA. The predictors of the high Killip class at time of presentation in MIOCA were older age, diabetes, ST elevation, left ventricle ejection fraction, and elevated cardiac troponin. Older age, ST elevation, and diabetes were predictors of high Killip class even in MINOCA, however left ventricle ejection fraction and elevated cardiac troponin did not predict the high Killip class in MINOCA patients. These results could reflect the different pathogenetic myocardial damage in MINOCA and MIOCA populations. Further studies are needed to evaluate these pathological mechanisms.

Biliary Atresia: Clinical Phenotypes and Aetiological Heterogeneity

Biliary atresia (BA) is an obliterative condition of the biliary tract that presents with persistent jaundice and pale stools typically in the first few weeks of life. While this phenotypic signature may be broadly similar by the time of presentation, it is likely that this is only the final common pathway with a number of possible preceding causative factors and disparate pathogenic mechanisms—i.e., aetiological heterogeneity. Certainly, there are distinguishable variants which suggest a higher degree of aetiological homogeneity such as the syndromic variants of biliary atresia splenic malformation or cat-eye syndrome, which implicate an early developmental mechanism. In others, the presence of synchronous viral infection also make this plausible as an aetiological agent though it is likely that disease onset is from the perinatal period. In the majority of cases, currently termed isolated BA, there are still too few clues as to aetiology or indeed pathogenesis.

Impact of COVID-19 pandemic on outcome of acute appendicitis: a retrospective analysis

Background: Acute appendicitis is the most common abdominal surgical emergency. Lockdown and stay-at-home orders are strategies that were implemented globally during the acute pandemic period of COVID-19 to prevent disease dissemination, health system overload and mortality. However, there are concerns that patients did not seek necessary health care because of these rules.Methods: Retrospective observational study was conducted on patients who presented with acute appendicitis from January 2020 to May 2020. They were classified according to the time of presentation that is before declaration of the state of alarm (pre-COVID-19), and after its declaration (post-COVID-19) in India (24 March 2020). An evaluation was made of demographic variables, complications and duration of hospital stay in both the groups.Results: 45 patients were included, 20 in pre-COVID-19 group and 25 in post-COVID-19 group. In post-COVID-19 group, the interval from onset of symptoms to admission was 65.0 hour, which is significantly longer than the 17.3 hour interval noted in pre-COVID-19 group (p<0.001). The prevalence of complicated appendicitis after the epidemic outbreak was significantly higher than before the outbreak (52% versus 20%, p<0.001).The mean hospital stay was longer in post-COVID-19 group (5.6±5.9 versus 3.2±4.3 days; p=0.041).Conclusions: COVID-19 pandemic influenced the time of diagnosis of appendicitis, as well as its course, and mean hospital stay. Complicated appendicitis was more common in patients with acute appendicitis after the outbreak of COVID-19 pandemic.