Non-operative treatment of hepatic trauma: A changing paradigm. A Six year review of liver trauma patient in a single institute

OBJECTIVE

To review the managing strategies of adult patients with liver trauma in a tertiary care hospital during a six years period.

METHODS

The medical records of all patients admitted with a diagnosis of liver trauma from January 2012 to December 2017 in the Aga Khan University Hospital were retrospectively reviewed. The details of demographic, clinical, and outcome variables including morbidity and mortality rates were noted.

RESULTS

A total of 182 patients were admitted at AKUH with liver trauma between January 2012 and December 2017. Twenty-two patients were excluded according to our study criteria. Of 160 patients, 139 were male and 21 were female. One hundred twenty seven (79.4%) patients were less than 45 years of age. Most patients (89.4%) had no comorbids and 48 (44%) arrived at the hospital within 4 hours of injury. Majority, 101 (63.1%) of the patients had blunt trauma and 142 (89%) met with road accidents. A total of 109 (68.1%) patients were stable at arrival and 77 (48.1%) had abdominal signs present on examination. FAST ultrasound was done on 75 (46.9%) patients and CT scan abdomen on 145 (90.6 %) patients. Liver injuries were associated with other abdominal or systemic injuries in 139 (86.6%) patients. Low grade (Grade I & II) liver injuries were found in only 41 (25.6%) patients, with the remainder being high grade (Grade III- 41 patients, Grade IV-42 patients and Grade V-2 patients). Conservative treatment was offered to 68 (41.9%) patients, of which 57 (85.1%) remained stable and were eventually discharged. Of these, 2 expired and 3 required intervention. There were a total of 92 (57.2%) interventions done of which 60 patients were cured, 14 expired and 18 readmitted. Interventions included perihepatic packing (n=18), hepatorraphy (n=3), angioembolization (n=12) and hepatectomy (n=1). There were 16(10%) deaths in which liver haemorrhage and sepsis were the most common cause of mortality. Mean hospital stay in our study population was 8.9 days. Second admission was observed in 28 (17.5%) patients (n=28). Morbidity rate in our patients was 17.5% (n=28). The most common complication noted was that of a liver abscess, developing in 2 (1.3%) patients. Other significant problems were intra-abdominal collections (n=2) and biliary complications (n=3). Unstable haemodynamic status at arrival and prolonged stay in high dependency unit were noted to be independent risk factors for mortality.

CONCLUSIONS

Conservative treatment was found successful in most of our patients with an intervention rate of 57.5% and overall mortality rate of 10%. So, NOMLI can be safely offered to liver trauma patients, even in high grade injuries.

Association of obesity measures and multimorbidity in Pakistan: findings from the IMPACT study

OBJECTIVE

Obesity is a major factor leading to multimorbidity. However, the relative importance of obesity measures, including body mass index (BMI), body fat percentage (BF%) and visceral fat (VF), in relation to multimorbidity has not been extensively studied in Asia. Therefore, the objective of this study was to examine the relation of these measures of obesity with multimorbidity in a representative community sample in Pakistan.

STUDY DESIGN

This is a community-based cross-sectional study.

METHODS

This study was conducted among residents of Gulshan town, Karachi, Pakistan. Data on healthy individuals and individuals with chronic conditions were recorded. All self-reported chronic conditions were further assessed by physical examination, medical history of the participants and laboratory findings. Multivariate logistic regression and receiver operating characteristic (ROC) curve analyses of BMI, BF% and VF as predictors of obesity were used to examine the association with multimorbidity.

RESULTS

A total of 1500 participants (738 men and 762 women) were recruited, with a median age of 54.5 years. Multivariate logistic regression showed a significant association of BMI (odds ratio [OR] = 1.28, 95% confidence interval [CI] = 1.00-1.81, P-value 0.049) and BF% (OR = 2.28, 95% CI = 1.50-3.45, P-value <0.001) with multimorbidity. However, the ROC analysis for BMI, BF% and VF showed very similar results, even when the analysis was stratified by gender. In this exploratory analysis, increasing age and female gender were significantly associated with multimorbidity compared with their counterparts.

CONCLUSIONS

Adult populations with high BF% levels carry a higher risk of multimorbidity than those with high BMI scores. In a population with differing metabolic characteristics, BMI might be less precise than direct adiposity measurements. Additional studies are needed to confirm the potential use of measuring the anatomical location and metabolic characteristics of lean and fat mass to identify risk of diseases.

Enhancement of Cellulase Activity from a New Strain of Bacillus subtilis by Medium Optimization and Analysis with Various Cellulosic Substrates

The cellulase activity of Bacillus subtilis AS3 was enhanced by optimizing the medium composition by statistical methods. The enzyme activity with unoptimised medium with carboxymethylcellulose (CMC) was 0.07 U/mL and that was significantly enhanced by CMC, peptone, and yeast extract using Placket-Burman design. The combined effects of these nutrients on cellulase activity were studied using 2² full factorial central composite design. The optimal levels of medium components determined were CMC (1.8%), peptone (0.8%), and yeast extract (0.479%). The maximum enzyme activity predicted by the model was 0.49 U/mL which was in good agreement with the experimental value 0.43 U/mL showing 6-fold increase as compared to unoptimised medium. The enzyme showed multisubstrate specificity, showing significantly higher activity with lichenan and β-glucan and lower activity with laminarin, hydroxyethylcellulose, and steam exploded bagasse. The optimised medium with lichenan or β-glucan showed 2.5- or 2.8-fold higher activity, respectively, at same concentration as of CMC.