Clinical Scoring Systems to Diagnose Complicated Acute Appendicitis in a Rural Hospital: Are They Good Enough?

Introduction Acute appendicitis (AA) is the most common surgical emergency in developed countries, whose incidence peaks in the second and third decades. The risk of mortality in uncomplicated AA is very low. There are many scoring systems to predict AA. Prediction scores are used less frequently to predict complicated AA. Rural hospitals are often constrained by a lack of round-the-clock imaging or special laboratory services, which may enable accurate diagnosis. Materials and methods This study aimed to determine whether prediction scores without imaging or C-reactive protein (CRP) levels could predict complicated AA in a rural setting. All cases of AA for the previous 13 months were recruited for the study. Demographic data, clinical signs and symptoms, complete blood counts, intraoperative findings, and the corresponding histopathological results were collated. The scoring systems (Alvarado, RIPASA, Tzanakis, and Ohmann) were calculated from the clinical and laboratory data. Demographic variables, clinical features, and histopathological findings are described as frequencies/proportions. Chi-squared and Student's t-tests were used to analyze differences between patients with complicated and uncomplicated AA. A receiver operating curve (ROC) analysis was performed to calculate the area under the curve (AUC) and determine whether appendicitis scores could predict complicated AA. Results There were 76 patients with a mean age of 29.1±13.0 years. Serositis was observed in 65% of the patients; mucosal ulceration was the most common microscopic finding, with a pathological diagnosis of AA in 58 (76.3%) patients. Rovsing's sign and the presence of phlegmon and granuloma were significantly different between those with and without complicated AA. The clinical prediction scores were not significantly different between the two groups. The Tzanakis and Ohmann scores were significant (cutoff: 6.5 and 7.25, p=0.001 and 0.01, respectively) in diagnosing AA (sensitivity/specificity of 98.3/66.7 and 98.3/94.4, respectively). With a cutoff of 5.75, the RIPASA score, with an AUC of 0.663 (p=0.09), showed the highest sensitivity (90.7) and specificity (76.6) for diagnosing complicated AA. Conclusion Diagnosing AA based solely on clinical presentation remains a challenge. This study showed that clinical scores such as those of Alvarado, RIPASA, Tzanakis, and Ohmann could not accurately predict complicated AA. Scoring systems without imaging and intraoperative diagnoses are not infallible; therefore, histopathological examination of the resected appendix is mandatory.

Acute Pain Transfusion Reaction: A Case Report.

Transfusion-related adverse events involving packed red blood cells (PRBCs) and fresh frozen plasma (FFP) are not unusual. Reactions can happen at any time during the transfusion, as well as hours or days later. An acute pain transfusion reaction (APTR) is defined as sudden, intense joint pain, usually in the back and trunk, that appears right after transfusion after all other potential causes of transfusion reactions have been eliminated. The present article discusses two similar cases. A 38-year-old female presented with complaints of right-sided headache and photophobia for four days, associated with nausea, vomiting, and vertigo. She was evaluated for a migraine headache. Due to anemia, a one-unit PRBC was requested. After pre-transfusion testing, a one-unit non-leuko-reduced, coombs cross-match compatible B-positive packed red blood cell (PRBC) was issued and transfused. During the transfusion, the patient complained of chest pain. The transfusion was stopped. Her vitals did not vary much from the baseline. No other symptoms were present at that time. A 69-year-old female presented with complaints of vomiting, abdominal pain, and black tarry stool for a one-month duration. On evaluation, she was diagnosed with adenocarcinoma of the stomach. Given the increased prothrombin time/international normalized ratio (PT/INR) of 1.8, four-units of fresh frozen plasma (FFP) was requested, which was issued after performing minor cross-match compatibility. After five minutes of transfusion, she complained of severe pain at the transfusion site with chills and rigors. The transfusion was stopped. There was no change in the vitals of the patient from baseline. A complete workup was done to rule out other transfusion reactions in both cases. Thus, these patients experienced what is known as an acute pain transfusion reaction. APTR is typically self-limited and requires treatment of symptoms with pain control, supplemental oxygen, and emotional support. In both cases, supportive treatments were enough to control the pain symptoms of the patients.

Histomorphological Spectrum of Cervical Lesions in a Rural Hospital.

Background Pathologically the cervix is affected by infective, inflammatory, and neoplastic diseases. Non­neoplastic lesions of the cervix are seen often in sexually active women. Inflammatory lesions include chronic granulomatous cervicitis, acute and chronic cervicitis. In India, cervical cancer is a significant health problem. Many factors contribute to the differences in the spectrum of cervical diseases in the rural population compared to urban areas, but the studies in these populations are scarce. Materials and methods A retrospective analysis of all gynecological lesions over one year was studied. All case files were manually extracted, and the data was entered in an Excel sheet. The information included was clinical history (symptoms, signs, menstrual history, duration of illness, parity status), physical examination, per vaginal examination, investigations, including pathological diagnosis. The curated data was then analyzed using IBM SPSS for Windows version 22 (IBM Corp., Armonk, NY). Results There were 164 women in the study, with a mean age of 46.07 ± 8.17 years. A majority (n = 124, 75.6%) presented with excessive bleeding. Two-thirds of the study population had a normal cervix on examination. Twenty-seven women had squamous metaplasia, six had low-grade (LSIL) and high-grade squamous intraepithelial lesions (HSIL), and one had malignancy. Excessive bleeding was significantly associated only with LSIL. Among the microscopic findings, only squamous metaplasia (p < 0.001) and dysplasia (p < 0.001) were significantly associated with the final diagnoses, such as LSIL, HSIL, and chronic cervicitis. Conclusion Most studies involving rural populations have involved the knowledge, attitude, and practices of the study cohort rather than the histomorphological spectrum of cervical lesions. Since these disorders are also influenced by education, parity, hygiene, and socioeconomic status, it behooves us to be aware of the spectrum of cervical lesions in a rural cohort who differ in these aspects when compared to urban populations. Most of such lesions of the cervix in the population that our medical institution served were benign in nature.

Prevalence of Anemia Among Adolescent Girls in a Rural Area of Tamil Nadu, India.

BACKGROUND: Anemia accounts for a majority of the nutritional problem across the globe. The prevalence of anemia is inordinately higher among developing nations, because of low socioeconomic status and indigent access to the healthcare services. Adolescent period is signalized by marked physical activity and rapid growth spurt; therefore they need additional nutritional supplements and are at utmost risk of developing nutritional anemia. This study was carried out to find out the prevalence of anemia among adolescent girls. MATERIALS AND METHODS: This study was a cross-sectional study conducted among 255 adolescent girls. After getting informed consent from the subjects, the information regarding age, sociodemographic status, menstrual history, and short clinical details were recorded. Blood samples were collected and analyzed using automated hematology analyser. RESULTS AND DISCUSSION: Overall prevalence of anemia was found to be 48.63% (n = 124). The majority of the anemic girls (55.64%, n = 69) were having mild degree of anemia. Among 255 girls, 188 (73.73%) were from the early adolescent age group (10-14 years). Prevalence of anemia (52.24%) was high among the late adolescents and those belonging to low socioeconomic class. CONCLUSION: There is a significant relationship between anemia and socioeconomic status, dietary modification, nutritional supplementation, and helminth control; in addition, compliance with consumption of iron and folic acid tablets will prevent anemia to a great extent among adolescent girls.

Effect of Azadirachta indica Crude Bark Extracts Concentrations against Gram-Positive and Gram-Negative Bacterial Pathogens.

BACKGROUND: Today's pharmaceutical markets are crowded with antibacterial agents, yet their toxicities and resistance are always contentious. Azadirachta indica is used in India as an age-old treatment for diverse medical conditions. This study was put forth to analyze the antibacterial action of A. indica bark extract on different bacterial pathogens. MATERIALS AND METHODS: A. indica bark extract was prepared using Soxhlet extraction method. The bark extract of A. indica was screened for antibacterial activity by agar well diffusion assay technique against Staphylococcus aureus, Enterococcus faecalis, Pseudomonas aeruginosa, and Proteus mirabilis. Ciprofloxacin (5 µg per disc) was used as positive control. All assays were carried out under strict aseptic precautions. All the concentrations included were duplicated, and the results obtained were the average of two independent experiments. Broth microdilution method was used to study the minimum inhibitory concentration of the bark extract of A. indica. RESULTS: A. indica bark extract has shown antibacterial activity against all concentrations of bark extract, whereas antibacterial activity against S. aureus was observed at higher concentration of >500 µg/mL. The bark extract of A. indica showed zone of clearance against E. faecalis, P. aeruginosa, and P. mirabilis at all concentrations. Zone of inhibition was observed in higher concentrations against S. aureus. CONCLUSION: This study has shown that A. indica bark extract has a potent antibacterial property against S. aureus, E. faecalis, P. aeruginosa, and P. mirabilis. Further isolation of bioactive compounds may lead to a new scope in the treatment of bacterial infections.

An Audit of Requests for Fresh Frozen Plasma in a Tertiary Care Center in South India.

AIM: To audit the fresh frozen plasma (FFP) usage with an insight into various guidelines. MATERIALS AND METHODS: The blood bank records pertaining to FFP usage in patients admitted in our medical college hospital were retrospectively reviewed for 2 years for usage of FFP in various departments and evaluated for appropriateness of usage based on various guidelines, which included the 2013 guidelines published by the National Health and Medical Research Council and the Australasian Society for Blood Transfusion. RESULTS: A total of 785 units of FFPs were transfused to 207 patients during the study period. The appropriate usage was found to be 59.3%, and the usage was most appropriate in massive transfusions. CONCLUSION: This study highlights the nonadherence to guidelines among clinicians which is mainly due to lack of knowledge of appropriate usage.

Sarcomatoid salivary duct carcinoma of minor salivary gland: a rare case.

A 35-year-old female presented with swelling in the soft palate. Fine needle aspiration cytology (FNAC) revealed pleomorphic adenoma, and on histopathological examination, it was diagnosed as carcinosarcoma/salivary duct carcinoma in the minor salivary gland, which was confirmed by immunohistochemical stains. We report this case for its rarity.