Right Ventricular Dimensions and Tricuspid Annular Plane Systolic Excursion among Medical Students of Tertiary Care Hospital: A Descriptive Cross-sectional Study

Introduction:

The change in morphology and functions of the right ventricle is an important predictor of heart and lung disease. There is limited data on the normal dimension of the right ventricle. The study aimed to find the right ventricular diameter, its thickness, and tricuspid annular plane systolic excursion in healthy male medical students of a tertiary care hospital.

Methods:

It is a descriptive cross-sectional study conducted in healthy medical students of Kathmandu Medical College and Teaching Hospital, from February-April, 2019. Ethical approval was taken from the institutional review committee (reference number 120720193). Convenient sampling method was used. We measured various dimensions of the right ventricle in different views. The data was analyzed in the Statistical Package for the Social Sciences.

Results:

In the 96 male students included in the study, the mean right ventricular basal diameter was 36.45±3.49 mm, right ventricular mid cavity diameter was 29±3.63 mm, right ventricular longitudinal dimension was 65.72±7.52 mm, right ventricular outflow tract in parasternal long-axis view was 27.07±2.12 mm, proximal and distal right ventricular outflow in parasternal short-axis view was 25.33±2.57 mm and 20.08±1.99 mm, right ventricular thickness was 4.20±0.54 mm, and tricuspid annular plane systolic excursion was 23.02±3.54 mm.

Conclusions:

The study found that the values of right ventricular dimensions and the right ventricle's tricuspid annular plane systolic excursion among male medical students of a tertiary care hospital to be in accordance with the guidelines by the American Society of Echocardiography. The upper limits of the normal values of the right ventricle could be very helpful in clinical practice in determining the right ventricle dimension.

Functional Outcome Estimation of Calcaneum Fractures Treated by Open Reduction and Internal Fixation with Plate and Screws in A Tertiary Centre: A Descriptive Cross-sectional Study

INTRODUCTION

Calcaneum fractures constitute about 60% of all tarsal bone fractures. Intra-articular fractures account for 70% of all calcaneal fractures. There are controversies regarding the operative treatment of calcaneum fractures. Therefore this study aimed to estimate the functional outcomes of calcaneum fractures treated by open reduction and internal fixation with plate and screws.

METHODS

This descriptive, cross-sectional study was carried out at the tertiary care center in the western region of Nepal among the patients with displaced intra-articular calcaneum fractures from February 2017 to July 2020 after approval from the Institutional review committee. Convenient sampling was done to reach the sample size. Fifteen cases were included in the study. Data were recorded in proforma and Data analysis was done in the statistical package for social sciences. The American Orthopedic Foot and Ankle Society Hindfoot score was used to assess the final outcome.

RESULTS

According to the American Orthopedic Foot and Ankle Society hindfoot scores, there were five excellent (33.33%), seven good (46.66%), two fair (13.33%) and one poor (6.66 %) results.

CONCLUSIONS

In displaced intra-articular calcaneum fractures, open reduction and internal fixation with plates and screws result in a good number of satisfactory outcomes with very few unsatisfactory results. Hence it can be a better option of treatment in displaced intra-articular calcaneum fractures.

Prevalence and correlates of depressive symptoms among people living with HIV attending tertiary care hospitals in Oman

INTRODUCTION

depressive symptoms have been widely reported among people living with HIV (PLHIV) around the world. The extent of this on PLHIV in the Arabian Peninsula is unclear. This study aims to examine the prevalence of depressive symptoms using the Patient Health Questionnaire-9 (PHQ-9) in adult Omani patients with HIV attending a tertiary care hospital. It also aims to investigate the relationship between clinical and socio-demographic variables and depressive symptoms.

METHODS

LHIV, age >18 (n=101), participated in the study who were followed up at a teaching hospital in Muscat, Oman. Participants were identified by a convenient and consecutive sampling of eligible patients who came for consultation on the days that the investigator conducted recruitment. The presence of depressive symptoms was quantified by the Patient Healthcare Questionnaire-9 (PHQ-9). Various socio-demographic backgrounds and risk factors will be also sought as well as activities of daily living (ADL). Chi-square test, Fisher´s exact test, t-test and logistic regression were used to explore which variables were associated with patients having depressive symptoms.

RESULTS

the prevalence rate of depressive symptoms in this cohort was 41.6%. Depression among PLHIV was found to be significantly associated with age (p <0.001), HIV disease duration (p <0.001), total dependency for ADL (p <0.001) and comorbid hypertension (p <0.001).

CONCLUSION

depressive symptoms are common in Omani patients living with HIV. HIV care providers are urged to be vigilant to recognize depressive symptoms in these mood-vulnerable populations and to call for a multidisciplinary team with mental health professionals, for the prevention and treatment of depressive symptoms among PLHIV in Oman.

Clinical and imaging features predict mortality in COVID-19 infection in Iran

The new coronavirus disease 2019 (COVID-19) pandemic has challenged many healthcare systems around the world. While most of the current understanding of the clinical features of COVID-19 is derived from Chinese studies, there is a relative paucity of reports from the remaining global health community. In this study, we analyze the clinical and radiologic factors that correlate with mortality odds in COVID-19 positive patients from a tertiary care center in Tehran, Iran. A retrospective cohort study of 90 patients with reverse transcriptase-polymerase chain reaction (RT-PCR) positive COVID-19 infection was conducted, analyzing demographics, co-morbidities, presenting symptoms, vital signs, laboratory values, chest radiograph findings, and chest CT features based on mortality. Chest radiograph was assessed using the Radiographic Assessment of Lung Edema (RALE) scoring system. Chest CTs were assessed according to the opacification pattern, distribution, and standardized severity score. Initial and follow-up Chest CTs were compared if available. Multiple logistic regression was used to generate a prediction model for mortality. The 90 patients included 59 men and 31 women (59.4 ± 16.6 years), including 21 deceased and 69 surviving patients. Among clinical features, advanced age (p = 0.02), low oxygenation saturation (p<0.001), leukocytosis (p = 0.02), low lymphocyte fraction (p = 0.03), and low platelet count (p = 0.048) were associated with increased mortality. High RALE score on initial chest radiograph (p = 0.002), presence of pleural effusions on initial CT chest (p = 0.005), development of pleural effusions on follow-up CT chest (p = 0.04), and worsening lung severity score on follow-up CT Chest (p = 0.03) were associated with mortality. A two-factor logistic model using patient age and oxygen saturation was created, which demonstrates 89% accuracy and area under the ROC curve of 0.86 (p<0.0001). Specific demographic, clinical, and imaging features are associated with increased mortality in COVID-19 infections. Attention to these features can help optimize patient management.

Retrospective analysis of medical malpractice claims in tertiary hospitals of China: the view from patient safety

OBJECTIVES

The study analysed medical malpractice claims to assess patient safety in hospitals. The information derived from malpractice claims reflects potential risks and could help lead to reducing medical errors and improving patient safety.

DESIGN, SETTING

We analysed 4380 medical malpractice claims from 351 grade-A tertiary hospitals in China for 2008-2017. We examined the characteristics of medical errors and patient safety, including the types of medical errors, proportionate liabilities and payments for medical malpractice in different clinical specialties.

MAIN OUTCOME MEASURES

We assessed claim characteristics, payment amounts and liability.

RESULTS

Our data analysis demonstrated that 72.5% of the claims involved medical errors, with average payments of US$31 430. The hospital's errors in medical malpractice resulted in 41.4% average liability in patient injury payments. Most medical malpractice cases occurred in Shanghai (817 claims, 18.7%) and Beijing (468 claims, 10.7%). The highest risks for medical error and malpractice claims were related to orthopaedics (11.3% of all claims, 72.8% with medical errors) and obstetrics and gynaecology (10.0% of all claims, 76.0% with medical errors). The highest rates related to proportionate liabilities were observed in otolaryngology (51.9%) and endocrinology (47.7%). Respiratory medicine had the highest proportion of claims in death rates (77.3%). Medical technology errors accounted for 91.8% of the claims and medical ethics errors for 5.8%. The highest average payment was found in cardiovascular surgery (US$41 733) and the lowest in stomatology (US$8822).

CONCLUSIONS

A previous study found that grade-A tertiary hospitals in China have similar medical error rates to general Chinese hospitals. ³⁶Different specialties had different risk characteristics regarding medical errors, payments and proportionate liabilities. Orthopaedics had the highest number of malpractices claims and higher proportionate liability but lower death rates.

A web visualization tool using T cell subsets as the predictor to evaluate COVID-19 patient's severity

Wuhan, China was the epicenter of the 2019 coronavirus outbreak. As a designated hospital for COVID-19, Wuhan Pulmonary Hospital has received over 700 COVID-19 patients. With the COVID-19 becoming a pandemic all over the world, we aim to share our epidemiological and clinical findings with the global community. We studied 340 confirmed COVID-19 patients with clear clinical outcomes from Wuhan Pulmonary Hospital, including 310 discharged cases and 30 death cases. We analyzed their demographic, epidemiological, clinical and laboratory data and implemented our findings into an interactive, free access web application to evaluate COVID-19 patient's severity level. Our results show that baseline T cell subsets results differed significantly between the discharged cases and the death cases in Mann Whitney U test: Total T cells (p < 0.001), Helper T cells (p <0.001), Suppressor T cells (p <0.001), and TH/TSC (Helper/Suppressor ratio, p<0.001). Multivariate logistic regression model with death or discharge as the outcome resulted in the following significant predictors: age (OR 1.05, 95% CI, 1.00 to 1.10), underlying disease status (OR 3.42, 95% CI, 1.30 to 9.95), Helper T cells on the log scale (OR 0.22, 95% CI, 0.12 to 0.40), and TH/TSC on the log scale (OR 4.80, 95% CI, 2.12 to 11.86). The AUC for the logistic regression model is 0.90 (95% CI, 0.84 to 0.95), suggesting the model has a very good predictive power. Our findings suggest that while age and underlying diseases are known risk factors for poor prognosis, patients with a less damaged immune system at the time of hospitalization had higher chance of recovery. Close monitoring of the T cell subsets might provide valuable information of the patient's condition change during the treatment process. Our web visualization application can be used as a supplementary tool for the evaluation.

Burden of scrub typhus among patients with acute febrile illness attending tertiary care hospital in Chitwan, Nepal

OBJECTIVES

Scrub typhus is an emerging neglected tropical disease, reported from many parts of Asia including Nepal. This study aims to determine the seroepidemiology of scrub typhus among febrile patients attending Chitwan Medical College Teaching Hospital (CMC-TH), Bharatpur, Nepal.

STUDY DESIGN AND SETTING

This was a hospital laboratory-based prospective study conducted in CMC-TH (a 750-bed hospital) located in Bharatpur, Chitwan district of Nepal.

PARTICIPANTS

A total of 1797 patients visiting CMC-TH with acute febrile illness (temperature more than 38°C) were enrolled in this study.

METHODS

A total of 1797 blood samples were collected from patients presenting with acute febrile illness. The samples were processed for detection of antibody for scrub typhus by ELISA for specific IgM antibody and Weil-Felix test.

RESULTS

Out of 1797 serum sample of febrile patients, 524 (29.2%) were scrub typhus positive. Maximum seropositive cases were from Chitwan district, 271 (51.7%) with predominance among women, 314 (35.9%). Scrub typhus was common among age group 51-60 years (37.2%) and farmers, 182 (37.8%). Highest seropositivity was found in July, 60 (57.7%). Fever was common clinical symptom. Thrombocytopenia was seen in 386 (73.7%) and raised transaminase aspartate aminotransferase, 399 (76.1%) among seropositive cases. Weil-Felix test positive were 397 (22.1%) and IgM ELISA positive were 524 (29.2%). The correlation between IgM ELISA and Weil-Felix test showed statistically significant association (r=0.319, p<0.001).

CONCLUSION

High prevalence of scrub typhus implies that patients with acute febrile illness should be investigated for scrub typhus with high priority. There is utmost need of reliable diagnostic facilities at all levels of healthcare system in Nepal. Infection with scrub typhus was found high and this calls for an urgent need to introduce vaccine against scrub typhus. More sustain and vigorous awareness programmes need to be promoted for early diagnosis, treatment and control.

Covid-19 associated Guillain-Barre Syndrome: Contrasting tale of four patients from a tertiary care centre in India

Background

Globally, more than 12 million people have been infected with COVID −19 infection till date with more than 500,000 fatalities. Although, Covid-19 commonly presents with marked respiratory symptoms in the form of cough and dyspnoea, a neurotropic presentation has been described of late as well.

Objective

In this brief communication we report four cases of Covid-19 who presented to our hospital with features suggestive of Guillain-Barre Syndrome (GBS).

Discussion

The mechanisms by which SARS-CoV-2 causes neurologic damage are multifaceted, including direct damage to specific receptors, cytokine-related injury, secondary hypoxia, and retrograde travel along nerve fibres. The pathogenesis of GBS secondary to Covid-19 is not well understood. It is hypothesised that viral illnesses related GBS could be due to autoantibodies or direct neurotoxic effects of viruses.

Conclusion

Nervous system involvement in Covid-19 may have been grossly underestimated. In this era of pandemic, it is very important for the physicians to be aware of association of GBS with Covid-19, as early diagnosis and treatment of this complication could have gratifying results. To the best of our knowledge, this is the first such case series of Guillain-Barre Syndrome associated with Covid-19 to be reported from India.

ASSESSMENT OF OCCUPATIONAL EXPOSURE OF RADIATION WORKERS AT A TERTIARY HOSPITAL IN ANHUI PROVINCE, CHINA, DURING 2013-18

Data on occupational radiation exposure of radiation workers at a tertiary hospital in China during 2013-18 were analyzed to provide decision-making advice for hospitals and health administrative departments. A total of 1255 exposure records of radiation workers were collected. The average annual effective doses of radiation workers during 2013-18 was 0.4977 mSv, with 1150 (91.63%) records ranging between 0 and 1 mSv, 91 (7.25%) between 1 and 2 mSv, 10 (0.80%) between 2 and 5 mSv and 4 (0.32%) records exceeding 5 mSv. There was a significant difference in the average annual effective dose of radiation workers among different occupational categories except in 2015 indicating that hospitals and administrative authorities should pay more attention to the radiation workers in the nuclear medicine and intervention department. The average annual effective doses did not show significant differences between male and female workers except in 2017; in that year the average individual dose of female workers was higher than male workers'. There were no significant differences in the average annual effective doses among doctors, nurses and radiologic technologists except in 2016 and 2017; during that period the individual dose of nurses was higher than doctors' and radiologic technologists'.

High-risk clones and novel sequence type ST4497 of Klebsiella pneumoniae clinical isolates producing different alleles of NDM-type and other carbapenemases from a single tertiary-care centre in Egypt

Enterobacteria producing NDM carbapenemases represent a severe diagnostic and therapeutic challenge in healthcare settings. Infections caused by NDM-positive strains are usually associated with high mortality rates and very limited treatment options. A total number of 33 carbapenem-resistant Klebsiella pneumoniae (CRKP) isolates were included in this study, comprising 30 recovered from clinical diagnostic samples and 3 cultured from screening rectal swabs taken at patient admission. Bacterial identification was performed by matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry (MALDI-TOF/MS) and antibiotic susceptibility testing was performed by reference broth microdilution and a commercial automated method. Isolates were investigated for carbapenemase production using the β-CARBA test, the modified carbapenem inactivation method (mCIM) and, for the 30 clinical isolates, by MALDI-TOF/MS, using the MBT STAR^Ⓡ-Carba IVD Kit. Carbapenem resistance genes were characterised by PCR and sequencing. Seven different bla_NDM gene variants were identified in 94% of the isolates, whilst three variants of bla_OXA-48-like were detected in 27% of the isolates. Most CRKP corresponded to high-risk clones (ST147, ST11 and ST15). Novel ST4497 is reported for the first time in this study as well as the first emergence of K. pneumoniae ST231 producing OXA-232 in Egypt. These results indicate an ongoing evolution of the bla_NDM genes in our area and confirm the need for a maintained surveillance system in order to monitor the spread of these mobile bla_NDM genes.

Utility of Bronchiectasis severity index (BSI) as prognostic tool in patients with post tubercular bronchiectasis: An experience from a tertiary care hospital in North India

BACKGROUND

Bronchiectasis severity Index (BSI) score which predicts the severity of the disease along with future exacerbations and mortality rate has been well validated in European patients; however there is paucity of data evaluating its validity in Indian patients. The authors therefore decided to evaluate the utility of BSI to predict exacerbations and mortality rate in patients with post tubercular bronchiectasis presenting to our facility.

METHODS

The study was a retrospective observational study done in patients with bronchiectasis secondary to tuberculosis. These patients were followed up for 4 years. BSI was calculated from different variables and descriptive statistics along with regression analysis were used to evaluate utility of BSI.

RESULTS

A total of 48 patients of post tubercular bronchiectasis were included in the study. Majority of our patients belonged to severe bronchiectasis group seen in 23 patients (48%) while those with mild and moderate bronchiectasis were seen in 13 (27%) and 12 (25%) patients respectively. The exacerbation rate in mild group was comparable to the predicted BSI exacerbation at 1 year while the predicted and observed rates were statistically significant for moderate and severe bronchiectasis group (p value < 0.05). Mortality rates at 1 year were comparable in all the groups of bronchiectasis while it was comparable only in mild and moderate group bronchiectasis at 4 years.

CONCLUSION

Bronchiectasis severity index seems to predict mortality at 1 year in post tuberculosis bronchiectasis. However, it under predicts 1 year and 4 year exacerbation rates. Hence BSI may not be useful as a prognostic tool in Indian patients with bronchiectasis. Larger multi-centred studies may be required to further evaluate the clinical utility of BSI among Indian population.

Discordant Clostridioides difficile diagnostic assay and treatment practice: a cross-sectional study in a tertiary care hospital, Geneva, Switzerland

OBJECTIVES

To determine the proportion of patients who received a treatment for Clostridioides difficile infection (CDI) among those presenting a discordant C. difficile diagnostic assay and to identify patient characteristics associated with the decision to treat CDI.

DESIGN

Cross-sectional study.

SETTING

Monocentric study in a tertiary care hospital, Geneva, Switzerland.

PARTICIPANTS

Among 4562 adult patients tested for C. difficile between March 2017 and March 2019, 208 patients with discordant tests' results (positive nucleic acid amplification test (NAAT+)/negative enzyme immunoassay (EIA-)) were included.

MAIN OUTCOME MEASURES

Treatment for CDI.

RESULTS

CDI treatment was administered in 147 (71%) cases. In multivariate analysis, an abdominal CT scan with signs of colitis (OR 14.7; 95% CI 1.96 to 110.8) was the only factor associated with CDI treatment.

CONCLUSIONS

The proportion of NAAT+/EIA- patients who received treatment questions the contribution of the EIA for the detection of toxin A/B after NAAT to limit overtreatment. Additional studies are needed to investigate if other factors are associated with the decision to treat.

Validation of SARS CoV-2 detection by real-time PCR in matched pooled and deconvoluted clinical samples before and after nucleic acid extraction: a study in tertiary care hospital of North India

The diagnosis of coronavirus disease-19 (COVID-19) relies on the detection of severe acute respiratory syndrome coronavirus 2 (SARS CoV-2) RNA by real-time reverse-transcription polymerase chain reaction in respiratory samples. Rapid increase in the COVID-19 cases across the world requires fast and efficient testing as testing capacity is a bottleneck in diagnosis. In this context, pooling strategy can be opted for rapid testing in a cost-effective manner. In this study, the authors have optimized and compared the effect of pooling (5 and 10 samples) before and after nucleic acid extraction. It was concluded that there was no significant difference in the SARS CoV-2 RNA detection in the pools prepared at sample or RNA level. Even after pooling, 10-fold dilution was detectable with 3-cycle threshold value change in both type of pools when compared with individual samples. Hence, sample pool size of 10 can be used in low-prevalent areas, and testing capacity can be substantially increased.

Abdominal tuberculosis in a tertiary care centre in Saudi Arabia

OBJECTIVES

Abdominal tuberculosis (ATB) is the second most common type of extra-pulmonary tuberculosis. Though it does not usually pose a significant risk of infectivity, ATB can go unidentified and progress to disseminated infection. The aim of this study is to highlight the incidence and outcome of this infection in a tertiary care centre in the Kingdom of Saudi Arabia (KSA).

METHODS

In this retrospective study, we included all ATB patients admitted to our centre between January 1 ^st, 2010 and December 31, 2018. A total of 42 patients with a median age of 49 (range 18-83 years, 78.6% males) were identified.

RESULTS

The most common presentation was abdominal pain, weight loss, and abdominal distension. All the patients were HIV negative; however, 50% had a comorbid condition, mainly diabetes mellitus, chronic renal failure, and liver cirrhosis. Tuberculous peritonitis was the predominant type of ATB. Suspicious and potentially malignant abdominal masses appeared on the abdominal CT scans of six patients. This suggest that TB should be excluded in patients from endemic area presenting with abdominal masses. All patients received standard anti-tuberculous medication for an average duration of 7.4 months. The outcome was excellent with 88%% achieving complete response. Adjunctive corticosteroids were not used, and none of the patients had a surgical complication.

CONCLUSION

The diagnosis of ATB is challenging. It can mimic inflammatory bowel disease in young populations and malignancy in middle-aged and elderly population. For this reason, a high index of suspicion with prompt treatment is required to improve the prognosis and prevent complications.

Classification performance of administrative coding data for detection of invasive fungal infection in paediatric cancer patients

BACKGROUND

Invasive fungal infection (IFI) detection requires application of complex case definitions by trained staff. Administrative coding data (ICD-10-AM) may provide a simplified method for IFI surveillance, but accuracy of case ascertainment in children with cancer is unknown.

OBJECTIVE

To determine the classification performance of ICD-10-AM codes for detecting IFI using a gold-standard dataset (r-TERIFIC) of confirmed IFIs in paediatric cancer patients at a quaternary referral centre (Royal Children's Hospital) in Victoria, Australia from 1st April 2004 to 31st December 2013.

METHODS

ICD-10-AM codes denoting IFI in paediatric patients (<18-years) with haematologic or solid tumour malignancies were extracted from the Victorian Admitted Episodes Dataset and linked to the r-TERIFIC dataset. Sensitivity, positive predictive value (PPV) and the F1 scores of the ICD-10-AM codes were calculated.

RESULTS

Of 1,671 evaluable patients, 113 (6.76%) had confirmed IFI diagnoses according to gold-standard criteria, while 114 (6.82%) cases were identified using the codes. Of the clinical IFI cases, 68 were in receipt of ≥1 ICD-10-AM code(s) for IFI, corresponding to an overall sensitivity, PPV and F1 score of 60%, respectively. Sensitivity was highest for proven IFI (77% [95% CI: 58-90]; F1 = 47%) and invasive candidiasis (83% [95% CI: 61-95]; F1 = 76%) and lowest for other/unspecified IFI (20% [95% CI: 5.05-72%]; F1 = 5.00%). The most frequent misclassification was coding of invasive aspergillosis as invasive candidiasis.

CONCLUSION

ICD-10-AM codes demonstrate moderate sensitivity and PPV to detect IFI in children with cancer. However, specific subsets of proven IFI and invasive candidiasis (codes B37.x) are more accurately coded.

Urethral Strictures and its Management at Tertiary Hospital of Nepal

BACKGROUND

Urethral stricture can occur from urethral meatus to bladder neck. Treatment of urethral stricture include dilatation, endoscopic incision and anastomotic urethroplasty. The aim of this study is to report our experience in the management of different types of urethral strictures.

METHODS

We retrospectively reviewed the chart of all the patients of urethral stricture who received treatment at Kathmandu model hospital between January 2015 and October 2019. Different types of urethral stricture along with various modalities of treatment given were recorded.

RESULTS

Fifty patients were included in this study, all were males. Mean age was 49 (16-82) years. Bulbar urethra was the most common site in 54% of cases and bulbomembranous least common, only 10% of cases. Depending on sites and size of stricture, different types of surgery performed were meatoplasty, dviu and anastomotic urethroplasty.

CONCLUSIONS

Urethral stricture is a troublesome disease and can occur anywhere from meatus to the bladder neck. Different surgical techniques are present and the treatment should be individualized, depending on location and length of the stricture.

Pancreatic Configuration Index in Predicting Postoperative Pancreatic Fistula in a Tertiary Care Center in Nepal

BACKGROUND

Post-operative pancreatic fistula is the single most common and most significant cause of post-operative morbidity and perioperative mortality. Identification of at risk patient preoperatively help to take policy of extra vigilance to act on time. This study evaluated the predictive role and cut-off value of pancreatic configuration index to predict post-operative pancreatic fistula.

METHODS

This was a prospective observational study in patients who had undergone pancreaticoduodenectomy from March 2017 to June 2018 at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. The patients with age <16 years, those who underwent re-exploration or mortality before 3rd postoperative day, additional surgery besides pancreaticoduodenectomy were excluded from the study. Pancreatic configuration index was calculated as a ratio of pancreatic parenchymal thickness and pancreatic duct diameter. Predictive value of pancreatic configuration index in predicting post-operative pancreatic fistula was evaluated.

RESULTS

Among 58 patients, 9 were excluded from study and 49 patients were included in the study. The mean age of the patients was 56.6 ± 13.9 years (21 to 79 years) and male to female ratio was 1.1:1 (26 vs 23). Post-operative pancreatic fistula developed in 13/49 (26.5%) patients. On both univariate and multivariate analysis, pancreatic texture (p = 0.022), main pancreatic duct diameter at neck (p = 0.002) and pancreatic configuration index (p = 0.001) were significantly associated with development of post-operative pancreatic fistula. The sensitivity and specificity of pancreatic configuration index to predict post-operative pancreatic fistula are 92.3% and 91.7% with positive predictive value of 80% and negative predictive value of 97.1%.

CONCLUSIONS

Pancreatic configuration index is a useful preoperative predictor of post-operative pancreatic fistula after pancreaticoduodenectomy.

Clinical Outcome of Patients Hospitalized in a Tertiary Care Hospital of Nepal with Confirmed Influenza A/pdm 09(H1N1) in 2018/2019

BACKGROUND

It is important to monitor the cases affected by Influenza A/pdm09 as it is difficult to predict the behavior of Influenza A/pdm09 virus as a seasonal influenza. This study aimed to measure the clinical outcomes of patients with Influenza A/pdm 09 in a tertiary care hospital of Nepal in post pandemic period.

METHODS

A retrospective study was conducted in a tertiary care hospital of central Nepal to record the confirmed cases of Influenza A/pdm 09 from April 2018 to March 2019.The medical records of those patients whose throat sample had been sent to laboratory for testing Influenza A/pdm 09 were referred. The outcomes were then abstracted from the hospital system/medical record department.

RESULTS

Among 141 influenza suspected cases, 35.5%(N=50) were Influenza A/Pdm 09 positive. Both male and female were equal in distribution (N=25). Most positive cases were from the age group of 15-64 yrs. Out of total,72 %( N=36) with Influenza A/pdm 09 were discharged after treatment whereas case fatality rate was 22 %( N=11). Twenty-one positive cases were admitted in intensive care unit in which 52.4% expired. The average length of stay in I.C.U and mechanical ventilation were 6.4 days and 5.8 days respectively.

CONCLUSIONS

This study in post pandemic period in Nepal shows the outcomes of patients with confirmed influenza A/pdm 09 in a year time period with comparably high case fatality rate.

Differences between frequent emergency department users in a secondary rural hospital and a tertiary suburban hospital in central Japan: a prevalence study

OBJECTIVES

Although frequent emergency department (ED) use is a global issue, little research has been conducted in a country like Japan where universal health insurance is available. The study aims to (1) document the proportion of ED visits that are by frequent users and (2) describe the differences in characteristics of frequent ED users and other ED users including expenditures between a secondary and a tertiary hospital.

DESIGN

A prevalence study for a period of 1 year.

SETTING

A secondary hospital and a tertiary hospital in central Japan.

PARTICIPANTS

All patients who presented to the EDs.

PRIMARY OUTCOME MEASURES

We defined frequent ED user as a patient who visited the ED≥5 times/year. The main outcome measures were the proportion of frequent ED users among all ED users and the proportion of healthcare expenditures by the frequent ED users among all ED expenditures.

RESULTS

Of 25 231 ED visits over 1 year, 134 frequent ED users accounted for 1043 visits-0.66% of all ED users, comprised 4.1% of all ED visits, and accounted for 1.9% of total healthcare expenditures. Median ED visits per one frequent ED user was 7.9. At the patient level, after adjusting for age, gender and receiving public assistance, older age (OR 1.01, 95% CI: 1.00 to 1.02) and receiving public assistance (OR 7.19, 95% CI 2.87 to 18.07) had an association with frequent ED visits. At the visit-level analysis, evaluation by internal medicine (OR 1.27, 95% CI 1.02 to 1.57), psychiatry (OR 124.69, 95% CI 85.89 to 181.01) and obstetrics/gynaecology (OR 2.77, 95% CI 2.09 to 3.67) were associated with frequent ED visits.

CONCLUSION

The proportion of frequent ED users, of total visits, and of expenditures attributable to them-while still in the low end of the distribution of published ranges-are lower in this study from Japan than in reports from many other countries.

Age distribution and types of breast lesions among Afghan women diagnosed by fine needle aspiration cytology (FNAC) at a tertiary care centre in Afghanistan: a descriptive cross-sectional study

OBJECTIVES

In Afghanistan, breast diseases are a common reason for women to visit hospitals. This is the first study in Afghanistan aimed to describe the age distribution and types of breast diseases among patients diagnosed by fine needle aspiration cytology.

DESIGN

Descriptive cross-sectional study.

SETTING

French Medical Institute for Mothers and Children, Kabul, Afghanistan.

PARTICIPANTS

The study included 650 patients with breast lesions between 1 April 2015 and 1 April 2019.

RESULTS

The mean age of diagnosis was 35.38 (SD ±13.11) years, ranging from 15 to 75 years. The most common diagnosis was cancer (24% of all cases). The second most common diagnosed lesion was fibroadenoma, constituting 22.4%, and the third most common lesion was fibrocystic changes, with 15.4% of cases. Inflammatory conditions were diagnosed in 9.7% of cases, granulomatous inflammation in 9.1%, lesions only suspicious for malignancy in 5.5%, lipoma in 2.8% and miscellaneous benign lesions in 11.1%. Cancer was diagnosed at the youngest age of 20 years. Cancer was more common on the left side (62%), and only one case (0.9%) was bilateral.

CONCLUSION

Our study showed that cancer was the most commonly diagnosed lesion and was reported at younger ages too. This suggests that physicians should not ignore any breast lump in younger patients and that the possibility of cancer must be considered. Further country-wide studies are suggested to assess breast cancer and associated risk factors.

SARS-CoV-2 infection among healthcare workers of a gastroenterological service in a tertiary care facility

BACKGROUND AND STUDY AIMS

Frontlines healthcare workers (HCWs) during the coronavirus disease 2019 (COVID-19) pandemic are at increased risk of infection by SARS-CoV-2, but there are limited data on the prevalence of COVID-19 among HCWs in Egypt. This study aimed to assess SARS-CoV-2 infection among HCWs providing gastroenterological services.

SUBJECTS AND METHODS

Seventy-four HCWs at the gastroenterological service of Al-Manial University Hospital, the main hospital of the largest tertiary university hospitals complex in Egypt (Kasr Al-Ainy Faculty of Medicine, Cairo University) were tested using real-time reverse transcription-polymerase chain reaction (RT-PCR) on nasopharyngeal samples, and rapid serological IgM/IgG tests (RST). A questionnaire was used to collect demographic, occupational and clinical data.

RESULTS

Of the 74 HCWs, 10 tested positive by RT-PCR (13.5%). In 9/74 (12.2%) HCWs, antibodies could be detected by RST: three with both IgM and IgG lines; six with IgM line only and none with IgG line only. Frequency of positive tests was more among subjects with minor symptoms compared to completely asymptomatic HCWs (50% vs 16.1%, respectively). Neither age, gender or occupation was a risk factor for SARS-CoV-2 infection.

CONCLUSIONS

Point prevalence of COVID-19 in gastroenterology HCWs is 13.5% by RT-PCR. Continued measures are warranted to assure HCWs safety and reduce transmission from healthcare settings to the community during COVID-19 pandemic. Presence of positive test results among asymptomatic HCWs illustrates the importance of screening all HCWs irrespective of symptoms.

Risk of stroke in hospitalized SARS-CoV-2 infected patients: A multinational study

BACKGROUND

There is an increased attention to stroke following SARS-CoV-2. The goal of this study was to better depict the short-term risk of stroke and its associated factors among SARS-CoV-2 hospitalized patients.

METHODS

This multicentre, multinational observational study includes hospitalized SARS-CoV-2 patients from North and South America (United States, Canada, and Brazil), Europe (Greece, Italy, Finland, and Turkey), Asia (Lebanon, Iran, and India), and Oceania (New Zealand). The outcome was the risk of subsequent stroke. Centres were included by non-probability sampling. The counts and clinical characteristics including laboratory findings and imaging of the patients with and without a subsequent stroke were recorded according to a predefined protocol. Quality, risk of bias, and heterogeneity assessments were conducted according to ROBINS-E and Cochrane Q-test. The risk of subsequent stroke was estimated through meta-analyses with random effect models. Bivariate logistic regression was used to determine the parameters with predictive outcome value. The study was reported according to the STROBE, MOOSE, and EQUATOR guidelines.

FINDINGS

We received data from 26,175 hospitalized SARS-CoV-2 patients from 99 tertiary centres in 65 regions of 11 countries until May 1st, 2020. A total of 17,799 patients were included in meta-analyses. Among them, 156(0.9%) patients had a stroke-123(79%) ischaemic stroke, 27(17%) intracerebral/subarachnoid hemorrhage, and 6(4%) cerebral sinus thrombosis. Subsequent stroke risks calculated with meta-analyses, under low to moderate heterogeneity, were 0.5% among all centres in all countries, and 0.7% among countries with higher health expenditures. The need for mechanical ventilation (OR: 1.9, 95% CI:1.1-3.5, p = 0.03) and the presence of ischaemic heart disease (OR: 2.5, 95% CI:1.4-4.7, p = 0.006) were predictive of stroke.

INTERPRETATION

The results of this multi-national study on hospitalized patients with SARS-CoV-2 infection indicated an overall stroke risk of 0.5%(pooled risk: 0.9%). The need for mechanical ventilation and the history of ischaemic heart disease are the independent predictors of stroke among SARS-CoV-2 patients.

FUNDING

None.

The proposed algorithm for emergency endoscopy during the coronavirus disease 2019 outbreak

Following the coronavirus disease 2019 outbreak in China, more than 10,765 patients tested positive for severe acute respiratory syndrome coronavirus 2 from February 18, 2020 to April 30, 2020 in South Korea. Performing emergency endoscopy is extremely challenging from the clinicians' viewpoint during the viral outbreak. There are no available guidelines for emergency endoscopy in tertiary hospitals during this pandemic. We set up an algorithm as a guide for emergency endoscopy in patients presenting to the emergency room with bleeding, foreign body, or impending cholangitis. From February 18, 2020 to April 30, 2020 of outbreak, 130 patients underwent emergency endoscopy in our center. Owing to the simple and streamlined algorithm for performing emergency endoscopy, no endoscopy-related infection to other patients or medical workers was reported in our center.

[Assessment of outcomes of implementing the Sepsis Code in the emergency department of a tertiary hospital]

INTRODUCTION

A Sepsis Code (CS) is a comprehensive multidisciplinary system which has the aim of optimising the identification and intervention times of patients with sepsis, as well as improving their monitoring and treatment adjustments in order to reduce their mortality.

OBJECTIVES

To present the outcomes of the first year of introducing the CS in the emergency department of a tertiary hospital.

MATERIAL AND METHODS

A single-centre retrospective descriptive observational study was conducted on all patients in whom the CS was activated in the emergency department of a tertiary hospital during the first year of implementation. The variables included: demographics, CS activation, comorbidities, focus of infection, microbiology, antibiotic treatment, and mortality.

RESULTS

CS was activated in 555 patients, of which 302 (54.4%) had a definitive diagnosis of sepsis or septic shock on discharge from the emergency department. The degree of completion of the protocol variables was variable (41.8-95%).The large majority (86.1%) of the patients received antibiotics in the first hour, and in 76.2% blood cultures were collected prior to the antibiotic. Of the blood cultures performed, 13.3% of the isolated germs were multi-resistant and the level of contamination of blood cultures was 9.1%. All patients received empirical treatment and recommendations were followed in patients with septic shock in 28.3%. During follow-up, 64.4% the antibiotic treatment was targeted, and 39.5% received sequential therapy. In-hospital mortality was 32.2%.

CONCLUSIONS

Areas of improvement in the completion of the variables, contamination of blood cultures, and empirical treatment received were detected, with the strong points being the early administration of the antibiotic and the collection of blood cultures.

Clinical Characteristics, Comorbidities,and Outcome among 365 Patients of Coronavirus Disease 2019 at a Tertiary Care Centre in Central India

RATIONALE

The knowledge about the presenting characteristics, comorbidity, and outcomes of Indian patients for COVID-19 is limited.

OBJECTIVE

To describe the clinical characteristics and outcomes of COVID-19 patients in Central India and to evaluate risk factors leading to requirement of oxygen, mechanical ventilation and mortality.

DESIGN, SETTING, AND PARTICIPANTS

In this retrospective, we included 365 RT-PCR confirmed cases of 2019-nCoV in Sri Aurobindo Medical College and PG Institute, Indore, Madhya Pradesh from March 25, 2020 to May 15, 2020.

RESULTS

A total of 365 patients - 329 adults (Median age 49 years, 58.66% males) and 36 pediatric patients (Median age 10.5 years) were included. There was presence of comorbidity in 47.11% adults with most common being hypertension (24.92%), and diabetes (25.18%). 45.28% of adult patients were asymptomatic at presentation, with fever as the most common symptom (38.29%) and epidemiological contact history present in 69.90%. During hospitalization, 14.52% adults (median age, 50 years; 49.05% male) were on oxygen support, and 13% received mechanical ventilation (median age, 54 years; 63.26% male). As of May 15 2020, 8.4% adult patients died(median age, 57 years; 67.74% male). Presence of Lymphopenia, and Comorbid condition were identified as risk factors for requirement of oxygen, mechanical Ventilation and death.

CONCLUSIONS AND RELEVANCE

This case series provides characteristics and outcomes of COVID-19 patients in Indore region.