Asymptomatic spontaneous expulsion of a long foreign body through the gastrointestinal tract - a curious case report.

Foreign body ingestion and its natural elimination are common in children. However, this is uncommon for long foreign bodies. Here, we report the spontaneous removal of an ingested pencil in an asymptomatic child. To our knowledge, this is the first case report of asymptomatic spontaneous elimination of a normally-sized ingested pencil. A 7-year-old male child presented with a history of ingestion of a pencil 4 hours back, without any complaints. Immediate abdominal radiography revealed a pencil in the stomach with an estimated length of approximately 10 cm and no signs of complications. He was conservatively treated under a semi-solid diet, presumably due to lack of available endoscopic option. Subsequently, he passed the pencil in stool within 24 hours of ingestion. He was asymptomatic and playful during the course and at discharge. Conservative management of a quickly moving long foreign body initially located below the esophagus in an asymptomatic child is possible with the help of imaging guidance, particularly in settings lacking an endoscopy. Although, this should not be considered a norm. However, this suggests that the treatment of ingested foreign bodies must be individualized. Thus, multiple factors related to the child and the foreign body must be assessed before committing to invasive procedures like laparotomy. Similarly, plain X-rays can be helpful even for radiolucent foreign bodies, for diagnosis and ruling out complications. All of these are vital in underdeveloped countries, where endoscopy and computed tomography facilities might be either lacking or unaffordable by patients.

Jejunal duplication cyst in a female neonate: a case report.

Introduction and importance: Duplications are the abnormal portion of the intestine, either externally attached to the intestine or intrinsically placed within the bowel lumen. Their prevalence is noted to be around one in 25 000 deliveries. The rare gastrointestinal tract duplication may be located in any part of the gastrointestinal system from the oral cavity to the anus. The most common site of enteric duplication cyst (DC) is the terminal part of the ileum. Hence, duplications in jejunum are rare. Case presentation: Hereby, the authors report a case of jejunal DC in a female neonate which was managed successfully via surgery and adequate post-operative care without any complications. Clinical discussion: Duplications are more frequently single. They are usually located in the mesenteric border of the associated native bowel and may vary in shape and size. Most of them are cystic, followed by tubular and mixed type, with or without other congenital anomalies. More than 80% of the cases present before the age of 2 years as an acute abdomen or bowel obstruction, but many duplications remain silent unless complications occur, and therefore may not be diagnosed until adulthood. Complications of enteric DC include volvulus, bleeding, and, rarely, malignant degeneration. Conclusion: It is important for paediatric surgeons to include DC in the differential diagnosis if a neonate presents with features of intestinal obstruction.

Type IIIb jejunal atresia treated surgically with two end-to-end anastomoses.

A term newborn presented after birth with abdominal distension and vomiting in a developing country in Asia. Ultrasonography suggested intestinal obstruction and abdominal X-ray showed a 'double-bubble' sign suggestive of intestinal atresia. The newborn was diagnosed with early-onset neonatal sepsis secondary to intestinal obstruction and transferred to the neonatal intensive care unit. Surgery was performed and type IIIb jejunal atresia was found. Type IIIa/b jejunal atresia is associated with high incidence of poor outcome in lower socioeconomic countries. The affected intestinal segment and a distal serosal tear were resected and two end-to-end anastomoses formed. Oral feeding commenced on day 13 postoperatively. The patient was discharged on day 20 with adequate nutritional status. At follow-up, the patient continued to thrive. An operation involving resection of two different segments of bowel repaired with two end-to-end anastomoses in a neonate had a successful outcome for the patient.

Homozygous Lepore Syndrome: A case report.

•Lepore Hemoglobin is a structurally abnormal type of haemoglobin consisting of an abnormal globin chain which is a hybrid or fused globin chain comprising an N-terminal amino acid sequence of a delta chain and the C-terminal amino acid sequence of a beta chain.•The synthesis of these hybrid chains is substantially less than that of the ß-chains, resulting in an overall reduction in the non-α globin chains and patients present with a clinical picture of haemolytic anemia.•But Hb Lepore can be differentiated from ß-Thalassemia by the presence of a distinct Hb Lepore band on cellulose acetate electrophoresis or quantification in High Performance Liquid Chromatography (HPLC).•Presumptive diagnosis can be made in lab by a multi-faceted approach consisting of a series of blood count/red cell indices, Hb electrophoresis and haemoglobin analysis by HPLC. Quantitative analysis for any Hb variant disorder is made by HPLC better than Hb Electrophoresis, the same was done in our case report.

Strengthening emergency care systems to improve patient care for ST-elevation myocardial infarction (STEMI) at a high-volume tertiary care centre in India.

BACKGROUND: ST-elevation myocardial infarction (STEMI) is a highly time-sensitive and life-threatening condition. Early recognition and timely management are challenging in a busy emergency department (ED), especially in low/middle-income countries where emergency systems are often fragmented. The aim of our quality improvement (QI) project was to increase the percentage of patients with STEMI undergoing primary percutaneous coronary intervention (PCI) with door to balloon (D2B) time of <90 min by 30% over 12 months. METHODS: As part of the first step in QI, baseline data were collected at different points in the process of care. Using process maps and fishbone analysis, delays in patient registration, ECG and communication with cardiology were identified as some bottlenecks, and change ideas were tested using plan-do-study-act cycles using point-of-care QI methodology. The majority of the change ideas focused on interventions in the ED like strengthening triage, training frontline staff, early diagnosis and quick transportation of patients. RESULTS: During the baseline phase, 22.22% of patients were found to have a D2B time of <90 min. We achieved an increase of 47.78% in patients receiving PCI within 90 min and hence increased to 70% at the end of the intervention phase. Data collected for 4 months after the intervention phase were found to have sustained the effort. CONCLUSION: Significant improvement in the door to reperfusion time resulted from a meticulous assessment of emergency care processes by drawing process flow chart and implementation of change ideas like introduction of fast-track policy for patients with chest pain, reducing staff turnover in the triage area, formal training of staff, continuous engagement with cardiology team and by interchanging of processes which led to a reduction in time to ECG.

Characteristics of an Unscheduled Emergency Department Revisit Within 72 hours of Discharge.

Background An unscheduled emergency department (ED) revisit is defined as a patient presenting to the ED with the same problem within 72 hours of discharge. The revisits result in overcrowding and compromise the care provided by the ED. We assume that the poor quality of care provided by the ED is the reason for revisiting. However, the circumstances surrounding these revisits are not well-understood. We conducted this study to understand the characteristics associated with the revisits. Objectives We aimed to identify the common causes of ED revisits within 72 hours of discharge and determine the outcome of these patients during the revisit. Methods We conducted a prospective observational study at a tertiary care center from July 2015 to June 2017, including patients presenting at the ED within 72 hours after their first visit. Our study selected 50 patients using a simple random sampling method and identified the leading causes of revisit as doctor-related, patient-related, and illness-related. Results We found that 56% (28/50) of patients returned to the ED for illness-related reasons, 26% (13/50) for doctor-related reasons, and 18% (9/50) for patient-related reasons. In addition, we found that 62% (31/50) of patients who returned to the ED within 72 hours required in-patient admission. Conclusion The most common cause of ED revisit was illness-related causes, and more than half of the patients during a revisit required in-patient admission. The modifiable causes of the ED revisit, such as doctor-related and patient-related factors, were discovered in this study. These findings may aid in reducing ED revisits and improving the ED quality.

Engaging Private Health Care Providers to Identify Individuals with TB in Nepal.

In Nepal, 47% of individuals who fell ill with TB were not reported to the National TB Program in 2018. Approximately 60% of persons with TB initially seek care in the private sector. From November 2018 to January 2020, we implemented an active case finding intervention in the Parsa and Dhanusha districts targeting private provider facilities. To evaluate the impact of the intervention, we reported on crude intervention results. We further compared case notification during the implementation to baseline and control population (Bara and Siraha) notifications. We screened 203,332 individuals; 11,266 (5.5%) were identified as presumptive for TB and 8077 (71.7%) were tested for TB. Approximately 8% had a TB diagnosis, of whom 383 (56.2%) were bacteriologically confirmed (Bac+). In total, 653 (95.7%) individuals were initiated on treatment at DOTS facilities. For the intervention districts, there was a 17%increase for bacteriologically positive TB and 10% for all forms TB compared to baseline. In comparison, the change in notifications in the control population were 4% for bacteriologically positive, and -2% all forms. Through engagement of private sector facilities, our intervention was able to increase the number of individuals identified with TB by over 10% in the Parsa and Dhanusha districts.

Impact of edaphic factors and nutrient management on the hepatoprotective efficiency of Carlinoside purified from pigeon pea leaves: An evaluation of UGT1A1 activity in hepatitis induced organelles.

Carlinoside is a unique compound well-known for its excellent curative potential in hepatitis. There is a substantial research gap regarding the medicinal use of carlinoside, as its concentrations are greatly variable (depending on locality). We cultivated Cajanus cajan using vermicompost as a major organic amendment at two locations (Sonitpur and Birbhum) with different soil types, but identical climate conditions. Sonitpur soils were richer in soil organic C (SOC), enzyme activation, and N/P content than Birbhum. However, vermi-treatment improved many soil properties (bulk density, water retention, pH, N/P/K, and enzyme activity) to narrow the locational gap in soil quality by 15-28%. We also recorded a many-fold increment in SOC storage capacities in both locations, which was significantly correlated with carlinoside, total phenol, and flavonoid contents in Cajanus leaves. This significantly up-regulated the carlinoside induced expression of the bilirubin-solubilizing UGT1A1enzyme in HepG2 cell and rat liver. Leaf extracts of vermicompost-aided plants could cure hepatitis in affected rat livers and in the HepG2 cell line. Accordingly, vermi-treatment is an effective route for the growth of Cajanus as a cash crop for biomedical applications and can produce a concurrent improvement in soil quality.

Environmental footprints of brick kiln bottom ashes: Geostatistical approach for assessment of metal toxicity.

Coal fired brick kiln factories generate significant of brick kiln bottom ash (BKBA) that contaminate soil and water environments of areas near the dumping sites through leaching of toxic metals (Pb, Cr, Cd, Zn, Mn, and Cu). However, characteristics and environmental effects of BKBAs are yet unknown. We collected BKBA samples from 32 strategic locations of two rapidly developing States (West Bengal and Assam) of India. Scanning electron microscope images indicated spherical and granular structures of BKBAs produced in West Bengal (WBKBA) and Assam (ABKBA) respectively; while energy dispersive spectroscopy and analytical assessments confirmed substantial occurrence of total organic C and nutrient elements (N, P, K, Ca, Mg, and S) in both the BKBAs. FTIR analysis revealed greater predominance of organic matter in ABKBAs than WBKBAs. Occurrence of toxic metals (Cd, Cr, Pb, Zn, Mn, and Cu) was higher in ABKBAs than in WBKBAs; while organic and residual fractions of metals were highly predominant in most of the BKBAs. Principal component analysis showed that metal contents and pH were the major distinguishing characteristics of the BKBAs generated in the two different environmental locations. Human health risk associated with BKBAs generated in Assam is of significant concern. Finally, geo-statistical tools enabled to predict the spatial distribution patterns of toxic metals contributed by the BKBAs in Assam and West Bengal respectively. Assessment of contamination index, geo-accumulation index, and ecological risk index revealed some BKBAs to be more toxic than others.