Pneumomediastinum: retrospective analysis of 19 cases and an innovation proposal in classification

Background Guidelines to standardize treatment and follow-up strategies in pneumomediastinum cases are lacking. The aim of the study was to evaluate the etiology in pneumomediastinum cases and the results of treatment and follow-up. Results Nineteen patients with pneumomediastinum who were followed up in our clinic between 2015 and 2020 comprised the study population. Among the patients, 16 (84.2%) were male, and the mean age was 31.15 years. The chief presenting complaints were chest pain and dyspnea. Pneumomediastinum was spontaneous in 15/19 patients (including spontaneous pneumomediastinum with an underlying pathology in 3/15), traumatic in 3/19, and iatrogenic in 1/19. Spontaneous pneumomediastinum without underlying pathology was seen in younger adults (mean age: 23 years). Surgical intervention in traumatic and iatrogenic pneumomediastinum cases was compared with spontaneous cases and no statistically significant difference was observed (p=0.178). The mean hospital stay of all patients was 3.15 days. Only one patient had a recurrence and died, which was later determined to be a secondary spontaneous pneumomediastinum case. Conclusion Pneumomediastinum often occurs with an underlying pathology in advancing age and as spontaneous in younger patients. Therefore, “secondary spontaneous pneumomediastinum” subclass should be evaluated in the classification to facilitate to create a standard guideline and prevent overdiagnosis and overtreatment.

Analysis of key criteria and requirements in implementing green procurement for green construction projects in Malaysia

Construction industry is one key driver in stimulating Malaysia’s economic growth. Green procurement is known as procurement that is consistent with the principles of sustainable development, such as ensuring a strong, healthy and just society, living within environmental limits and promoting good governance. Malaysian government has published a standard guideline of green procurement known as Government Green Procurement (GGP) guideline; however, it does not merely used for the construction development. Hence, this paper aims to analyse the criteria and requirements to implement green procurement for construction projects. Questionnaires were distributed to 60 respondents, comprising of project stakeholders that has experience in the development of green construction projects. Limiting to category commercial and office building projects only, hence, the respondents’ population was drawn using purposive method. The analysis uses descriptive statistics via mean score, and the standard deviation was used to measure the variables and the mean’s dispersion. It is revealed that all of the criteria stated are important and one or more criteria are more important than the rest. This study recommends that the government focus on these criteria to help implement green procurement for green construction projects in Malaysia.

EP.TH.1025The necessity of pre-operative investigations for elective surgical patients

Introduction Patients admitted for elective surgeries tend to get quite a few investigations at pre assessment. Are these strictly necessary? Are there significant cost implications? National Institute for health and Care Excellence first issued guidance on routine preoperative tests for elective surgery in 2003. Aims To carry out an audit of pre-operative investigations of elective surgical patients at pre-admission. To determine level of unnecessary tests. Results Regarding correlation between ASA grades and over testing, grade 4 is the highest and grade 2 is the lowest in meeting standard guideline per ASA grade. Only 20% intermediate surgical cases meet the guideline whereas 30% of minor and 85% of major cases meet guideline per surgery grade respectively. Majority of unnecessary tests are carried out in minor and intermediate cases. Very few cases of missing tests. Only four tests that should have been taken as per the guideline weren’t done in the whole cohort. For all cases,57.4% of FBC,38.2% of U&Es, 48.5% ECG and 5.9% lung function tests carried out unnecessarily. Conclusion Generally we are over-testing patients at pre-assessment. This seems to be an issue with minor and intermediate cases, with majors generally doing better in fulfilling the guidelines. This may not be deliberate but coincidence as major surgeries call for more tests. Over-testing is more of an issue in lower (1-2) ASA grades in minor and intermediate surgeries. Under-testing is very rare. Using NICE’s estimated costs for each test, approximately £965.78 was spent in 1.5 months for tests which were not needed.

Role of Colchicine in Prevention of Contrast Induced Nephropathy in Patient Undergoing Primary Percutaneous Coronary Intervention

Background Contrast-induced nephropathy (CIN) is a frequent complication after intravascular contrast media administration. The incidence of CIN in STEMI patients undergoing primary PCI is around 19.8%. The pathophysiologic basis of CIN includes an oxidative stress and inflammatory process, and colchicine has been used as an anti-inflammatory and anti-oxidant agent to improve cardiovascular outcomes, hence the aim of the current study is to demonstrate the effect of colchicine on CIN in patients undergoing primary PCI. Patients and methods 100 STEMI patients planned for primary PCI were enrolled in this study. They were randomized into two groups of fifty patients: A control group receiving standard guideline based medical treatment alone and a study group receiving same treatment in addition to colchicine. CIN was defined based on serum creatinine that was measured repeatedly over 3 days, with absolute rise of 0.5mg/dl or relative rise of 25% or more from baseline signifying CIN. Results There was a trend towards lower CIN incidence, although not statistically significant, in patients receiving colchicine, in whom CIN incidence was 8%, in comparison to incidence of 20 in those receiving standard guideline-based therapy alone % (χ2 = 2.99 & p = 0.083) with relative risk reduction of 60%. The reduction of CIN incidence was found to be statistically significant in diabetic subgroup, with CIN incidence of 32% in those receiving standard guideline-based therapy alone, in comparison to incidence of 7% in those receiving colchicine with p = 0.033. Multiple regression analysis including colchicine as a covariable concluded that colchicine use was the most important CIN risk lowering factor in the current study (β = -0.223 and p = 0.039). Conclusion There was a trend towards lower incidence of CIN in patients undergoing primary PCI receiving colchicine, although not statistically significant. However, this trend became significant when studied in diabetic subgroup.

Comparative study of the need for re-intervention after chest tube remove in two groups with and without chest x-ray in Patients Admitted into Razi and Poursina hospital in Rasht city

Introduction: The most common types of injuries following blunt or sharp trauma of lungs and the pleural space are pneumothorax, hemothorax and hemopneumothorax, which in most cases are resolved through supportive care and thoracostomy (use of chest tubes). Removal of the CT (chest tube) can result in complication such as pneumothorax and accumulation of fluid in the pleural space. Despite the lack of a standard guideline regarding the management of patients post CT removal, it is advised to procure a CXR as a means of a conservative approach. However, most of the findings acquired from the post CT removal CXR are not clinically significant and in the case of patients requiring intervention, there are almost always clinical signs and symptoms present. Considering the prior statements, the lack of a standard guideline even in the general and thoracic surgery references, show cases the importance of this study. This study is set upon proving that, the omission of post CT removal CXR in asymptomatic patients will not have an impact on the clinical outcome of the case and will reduce the costs as well as the patients' exposure to radiation and hospital stay. Methods: This study is designed as cross-sectional study with a sample size of 200 patients who were hospitalized for CT insertion in the Surgery clinic of Razi and Poursina Hospitals in Rasht between 21/4/2019 and 20/4/2020 and matched our entry criteria. The patients were divided into 2 groups of 100, with one group being monitored without CXR and the other with the use of CXR. Some forms were designed as checklists for the task of data collection. The data analysis was done through Fisher's exact test, Chi square test and Mann Whitney U test. In addition, the Significance level was set at 0.05 (p value ≤ 0.05). Result: Out of the 200 patients included in our study, 120 were male (60%) and the rest (40%) were female. The most common underlying disease in both groups (with and without CXR) of our study was Hip fracture. In both groups, The most frequent reason for CT insertion was pleural effusion (36% and 43% in with CXR and without CXR groups respectively), but the difference between the 2 groups was not statistically significant (p = 0.597). In most of the cases, 1 CT was inserted and there was no statistically significant difference between the 2 groups. The difference between the 2 groups regarding the need for intervention (11 cases in the CXR group and 6 cases in the Non CXR group) was also statistically insignificant. The duration of hospital stay did not show a statistically significant difference between the 2 groups (p = 0.644). Conclusion: Our study suggests that whether a post CT removal CXR is obtained or not, will not make a statistically significant difference in the number of interventions, the cause of intervention, and the number of inserted CTs and the duration of hospital stay. Therefore, it can be suggested that the need for reintervention in post CT removal patients can be determined through clinical signs, symptoms and the surgeon's judgment, without the need for a routine CXR.

Systemic Therapy in Hepatocellular Carcinoma

Systemic therapy of advanced stage hepatocellular carcinoma (HCC) was limited to the sorafenib in the past decade since 2007. Novel agents including multiple targeting agents, immune checkpoint inhibitors and anti-angiogenesis reported efficacy in treatment. This is the first time, the combination of atezolizumab and bevacizumab as first-line treatment is superior to sorafenib. Standard guideline in advanced HCC was changing. New novel drugs increase in available including multiple targeting agents and immune checkpoint blockade such as Lenvatinib, regorafenib, cabozantinib, ramucirumab and immunotherapy as first line or second line therapy will benefit in term of survival benefit and quality of life in advanced stage or unresectable hepatocellular carcinoma

Measurement of NORM in Building Materials to Assess Radiological Hazards to Human Health and Develop the Standard Guidelines for Residents in Thailand: Case Study in Sand Samples Collected from Seven Northeastern Thailand Provinces

A total of 223 sand samples collected from seven provinces in Northeastern Thailand were analyzed for their gamma radioactivity from naturally occurring radioactive materials (NORMs), and the data were used to calculate the concentrations of Ra-226, Th-232, and K-40. Radiological safety indicators such as the indoor external dose rates (Din), the annual indoor effective dose (Ein), the activity concentration index (I), the radium equivalent activity (Raeq), the external hazard index (Hex), the internal haphazard index (Hin), and the excess lifetime cancer risk (ELCR) were calculated. The activity concentrations were found to be 36 ± 10 Bq/kg for Ra-226, 2.64 ± 0.58 Bq/kg for Th-232, and 323 ± 168 Bq/kg for K-40. Din is 62 ± 23 nGy/h. The Ein is 0.30 ± 0.11 mSv/y. The activity concentrations and other indicators were reported by each province and compared with the safety standards and are found to be within the safe limits in this study. The results can be used to develop the standard guideline levels for choosing building materials in Thailand.

Necessity of developing a disability evaluation guideline

Background: Although doctors expend their best effort in treating their patients’ illnesses or injuries, the patients may retain some disabilities even after treatment. Accordingly, some conflicts occur between the patients’ expectations of financial compensation for their disabilities and the financial manager’s policy to efficiently distribute limited resources. The mediation of these social conflicts requires the determination of the degree of physical disability, which can be done by doctors alone. Hence, a reliable disability evaluation guideline should be established. However, currently, only a few educational programs on disability evaluation are available for doctors and there is no reliable guideline for disability evaluation.Current Concepts: There were attempts to implement the American Medical Association guideline in Korea; however, it is currently not being used efficiently because it is quite complicated and unsuited to Korean settings. Mcbride’s disability evaluation, published 60 years ago, is being used, but it is not realistic and unreasonable in Korea. To prepare a standard guideline for disability evaluation, the Korean Academy of Medical Sciences published a booklet, “Disability Evaluation Guideline: Explanation and Case Studies”, based on the American Medical Association guideline. The academy published the booklet’s revised version (2nd edition), ‘Disability evaluation guideline and utilization’, in 2016. However, Korean Academy of Medical Sciences guideline still not being used because it is too complicated to use.Discussion and Conclusion: Fair disability evaluation is a social responsibility given to doctors, and there should be a useful guideline for disability evaluation that reflects the characteristics of each medical society or association.

Survey of Quaternary Neonatal Management of Posthemorrhagic Hydrocephalus

Objective This study aimed to determine clinical care practices for infants at risk for posthemorrhagic hydrocephalus (PHH) across level IV neonatal intensive care units (NICUs). Study Design Cross-sectional survey that addressed center-specific surveillance, neurosurgical intervention, and follow-up practices within the Children's Hospitals Neonatal Consortium. Results We had a 59% (20/34 sites) response rate, with 10 sites having at least two participants. Respondents included neonatologists (53%) and neurosurgeons (35%). Most participants stated having a standard guideline for PHH (79%). Despite this, 42% of respondents perceive inconsistencies in management. Eight same-center pairs of neonatologists and neurosurgeons were used to determine response agreement. Half of these pairs disagreed on nearly all aspects of care. The greatest agreement pertained to a willingness to adopt a consensus-based protocol. Conclusion Practice variation in the management of infants at risk of PHH in level IV NICUs exists despite the perception that a common practice is available and used. Key Points

Public Health: Prevention

Nowadays, colorectal cancer prevention strategies play an essential role in reducing the incidence and mortality of the cases. A well-designed and establishment of the clinical pathway of screening programme needed in all country. Types of screening tools used may vary between the country with the use of FOBT and colonoscopy. The standard guideline related to screening programme such as for high-risk group should be emphasized more as compared to the low-risk group. The uptake of screening for CRC should be highlighted more as the program have showed a significantly reduction of the cases and mortality. The barrier of CRC screening uptake mainly due to poor awareness, discomfort, low physician recommendation, low socioeconomic and improper screening programme. Therefore others prevention strategies beside screening program such as health education and interactive intervention strategies need to be empower.