Role of low-pressure negative pleural suction in patients with thoracic trauma - a randomized controlled trial.

BACKGROUND: Thoracic trauma frequently includes a pneumothorax, hemothorax, or hemopneumothorax, which may necessitate an Intercostal drainage (ICD) for air and fluid evacuation to improve breathing and circulatory function. It is a simple and life-saving procedure; nevertheless, it carries morbidity, even after its removal. Efforts have been made continuously to shorten the duration of ICD, but mostly in non-trauma patients. In this study, we evaluated the impact of negative pleural suction over the duration of ICD. METHODS: This study was a prospective randomized controlled interventional trial conducted at Level 1 Trauma Centre. Thoracic trauma patients with ICD, who met the inclusion criteria (sample size 70) were randomized into two groups, the first group with negative pleural suction up to -20 cm H2O, and the second group as conventional, i.e. ICD connected to underwater seal container only. The primary objective was to compare the duration of ICDs and the secondary objectives were the length of hospital stay and various complications of thoracic trauma. RESULTS: Duration of ICD was measured in median days with minimum & maximum days. For the negative suction group, it was 4 days (2-16 days); for the conventional group, it was also 4 days (2-17 days). There was also no significant difference among both groups in length of hospital stay. CONCLUSION: The beneficial effect of negative pleural suction to ICD could not be demonstrated over the duration of ICD and hospital stay. In both groups, there was no significant difference in complication rates like recurrent pneumothorax, retained hemothorax, persistent air leak, and empyema. LEVEL OF EVIDENCE: Therapeutic Study, Level II TRIAL REGISTRATION: This trial was registered with the Clinical Trial Registry of India (CTRI) with registration no. REF/2020/11/038403.

Outcome predictors of patients who underwent limb amputation/s following trauma at a level I trauma center in North India.

PURPOSE: Limb amputation is one of the oldest medical operations, dating back over 2500 years to Hippocrates' time. In developing countries like India, most of the patients are young, and trauma is the primary cause of limb amputation. The objectives of this study were to investigate the factors that can predict the outcome of patients who underwent upper or lower limb amputations. MATERIALS AND METHODS: This was a retrospective analysis of the prospectively collected data of patients who underwent limb amputations from January 2015 to December 2019. RESULTS: From January 2015 to December 2019, 547 patients underwent limb amputations. Males predominated (86%). Road traffic injuries (RTI) were the most common (323, 59%) mechanism of injury. Hemorrhagic shock was present in 125 (22.9%) patients. Above-knee amputation was the most common (33%) amputation procedure performed. The correlation of hemodynamic status at presentation with the outcome was statistically significant (p-0.001). Outcome measures like delayed presentation, hemorrhagic shock, Injury severity scores (ISS), and the new injury severity scores (NISS) were statistically significant (p-0.001) when compared to the outcome. There were 47 (8.6%) mortalities during the study period. CONCLUSION: Factors that affected the outcome were delayed presentation, hemorrhagic shock, higher ISS, NISS, MESS scores, surgical-site infection, and associated injuries. Overall mortality during the study was 8.6%.

Revisiting the Role of Amniotic Membrane Dressing in Acute Large Traumatic Wounds: A Randomized Feasibility Study at a Level 1 Trauma Centre.

Introduction: Acute large traumatic wounds require temporary dressing prior to the definitive soft tissue reconstruction, as the physiological derangement during the immediate postinjury period delays the definitive surgical intervention. Selecting an ideal dressing material from numerous available synthetic dressings and skin substitutes poses a challenge. Although amniotic membrane (AM) scaffold has a definitive role in promoting wound healing in burns and chronic wounds, however, its efficacy in acute large traumatic wound is lacking. The present trial aimed to evaluate the safety and efficacy of AM in wound bed preparation before the definitive soft-tissue reconstruction in acute large traumatic wounds. Methods: Sixty patients with acute large traumatic wounds (>10 cm × 10 cm) were divided into two groups (conventional dressing and AM dressing) using simple mixed block randomization. Wounds were assessed using the Bates Jensen Score at various timelines for the signs of early wound healing. The primary outcome was to evaluate the time taken for the wound bed preparation for definitive soft-tissue reconstruction. The secondary outcome was the pain assessment and complications, if any. Results: There was significant reduction in the wound exudate as well as peripheral tissue edema in the intervention group (P = 0.01). AM dressing was significantly less painful (P = 0.01). The incidence of wound infection and need for debridement was decreased in the intervention group. However, the time interval to definitive soft-tissue coverage was statistically insignificant and comparable in both the groups. No adverse reactions were seen in either group. Conclusion: AM dressings are safe and efficacious with significant reduction in wound exudates and peripheral edema. However, these dressings do not hasten the wound maturation as compared to conventional dressings. AM dressings can be used as a less painful alternative to conventional dressing in the management of large acute posttraumatic wounds.

Blunt Trauma to Brachiocephalic Artery: Presentation and Management.

Isolated innominate artery injury is very rare and accounts for less than 3% of recognized arterial injuries. Surgical exploration of the artery, especially at the origin of the artery from the arch of the aorta, is surgically challenging. Due to its rarity, any 1 surgeon's experience in dealing with innominate artery injury is bound to be limited. We report 2 cases of innominate artery injury post-blunt chest trauma. Both patients underwent thoracotomy and innominate artery Dacron graft repair and both had an uneventful postoperative course.

Acute Limb Ischemia Caused by Dissection following Percutaneous Coronary Intervention Using Right Radial Approach.

Iatrogenic aortic dissection is a rare but potentially fatal complication of percutaneous coronary intervention (PCI). Iatrogenic aortic dissection following PCI is rare with most cases reporting dissection originating within the coronary vessels with propagation into the ascending aorta. In this specific case, dissection was without coronary involvement, with dissection extending from the ascending aorta into the descending aorta and iliac vessels. Although PCI via radial approach is associated with fewer vascular complications than with femoral approach, significant adverse outcomes may still occur and require prompt intervention. This case highlights the highly atypical presentation of iatrogenic aortic dissection following cardiac catheterization presenting as acute limb ischemia. In such patients as with ours, immediate surgical intervention is necessary with overall poor prognosis.

The impact of minor injury cases at a level I trauma center: a retrospective observational study.

INTRODUCTION: Few studies have been done on the burden of minor injuries on trauma centers. Patients with minor injuries require care in the ED, which diverts staff time and resources from patients with more serious injuries and which can sometimes overwhelm the functioning of even the best trauma facility. OBJECTIVE: This study was conducted to assess the burden of minor trauma and thus emphasize the need to develop further management protocols. METHODS: A retrospective observational study was conducted at a level I trauma center for a period of 1 month (February 14, 2020 through March 14, 2020) to assess the burden of minor injuries at that facility. The study population included all patients who required ED care for minor injuries. Data collected included age, sex, time of presentation, anatomical region involved, and interventions done. RESULTS: Of the 3293 patients, 1255 were triaged as green. Seven hundred ninety-one patients with 849 injuries required ED intervention in the minor operation theater. Of the 791 patients, most were male (84.32%), and 61.4% were aged 21 to 40 years. In decreasing order, the most common modes of injury were road traffic injuries (68.4%), fall (15%), and interpersonal violence (13.8%). Maxillofacial injuries were present in 26.15% of patients, 25.8% of patients presented with injuries to the head and neck, 24% with lower extremity injury, and 21.9% with upper extremity injury. CONCLUSIONS: The burden of minor trauma should be recognized. Knowledge of local trauma epidemiology and injury patterns is essential for trauma centers to function well. It is important that all trauma centers should have dedicated protocols in place and trained personnel to address these minor trauma cases.

Repair by Primary Closure of Traumatic Blunt Duodenal Injuries: Simple is Not Always Safe.

INTRODUCTION: Recent literature on managing traumatic duodenal injuries suggests the superiority of primary repair. We hypothesized that duodenal trauma repair by primary closure might not be a safe strategy in an environment dealing predominantly blunt injuries with limited resources. METHODS: Data analysis was done from the prospectively maintained trauma registry. The study period chosen was from January 1, 2014 to December 31, 2018. Data of 63 patients were analyzed for demographics, injuries, management, and outcome. Logistic regression was used to identify mortality predictors. RESULTS: The most common mechanism of injury was blunt (56/63, 88.9%). Forty (63.5%) patients had associated intraabdominal injuries. The most common American Association for the Surgery of Trauma grade of injury to the duodenum was three in 21 patients. Univariate analysis showed that mortality was associated with hypotension on presentation, higher duodenal grade, associated abdominal vascular injuries, primary closure, and duodenal leak. Logistic regression showed associated associated abdominal vascular injuries, primary closure, and leak remained significant predictors of mortality. CONCLUSIONS: Primary repair was found to be an independent predictor of mortality. A patient's physiology is a critical determinant of the outcome. Liberal use of tube duodenostomy over primary repair seems reasonable for blunt duodenal injury management.

Protocolized approach saves the limb in peripheral arterial injury: A decade experience.

PURPOSE: Outcomes of peripheral arterial injury (PAI) depend on various factors, such as warm ischemia time and concomitant injuries. Suboptimal prehospital care may lead to delayed presentation, and a lack of dedicated trauma system may lead to poorer outcome. Also, there are few reports of these outcomes. The aim of this study was to review our experience of PAI management for more than a decade, and identify the predictors of limb loss in these patients. METHODS: This is a retrospective analysis of prospectively maintained database of trauma admissions at a level I trauma center from January 2008 to December 2019. Patients with acute upper limb arterial injuries or lower limb arterial injuries at or above the level of popliteal artery were included. Association of limb loss with ischemia time, mechanism of injury and concomitant injuries was studied using multiple logistic regressions. Statistical analysis was performed using STATA version 15.0 (Stata Corp LLC, Texas). RESULTS: Out of 716 patients with PAI, the majority (92%) were young males. Blunt trauma was the most common mechanism of injury. Median ischemia time was 4 h (interquartile range 2-7 h). Brachial artery (28%) was the most common injured vessel followed by popliteal artery (18%) and femoral artery (17%). Limb salvage rate was 78%. Out of them, 158 (22%) patients needed amputation, and 53 (7%) had undergone primary amputation. The majority (86%) of patients who required primary or secondary amputations had blunt trauma. On multivariate analysis, blunt trauma, ischemia time more than 6 h and concomitant venous, skeletal, and soft tissue injuries were associated with higher odds of amputation. CONCLUSION: Over all limb salvage rates was 78% in our series. Blunt mechanism of injury and associated skeletal and soft tissue injury, ischemia time more than 6 h portend a poor prognosis. Injury prevention, robust prehospital care, and rapid referral to specialized trauma center are few efficient measures, which can decrease the morbidity associated with vascular injury.

Profiling of inflammatory biomarkers in mild to critically ill severe acute respiratory syndrome corona virus-19 (SARS Covid-19) patients from Karachi, Pakistan.

SARS-Covid-19 infection got spread in many countries and WHO declared it as a serious global Pandemic. Pro-inflammatory cytokines storm generated by Covid-19 infection hyper-activates inflammatory response in host body, resulting in elevated release of inflammatory biomarkers. Present article describes the characteristic profile of these inflammatory and related biomarkers in a total of 48 critically ill Covid-19 patients, (Male = 38, F = 10), with mildly ill to severe, critically ill status and thus grouped accordingly. Inflammatory Biomarkers, Ferritin, ProCalcitonin, C-Reactive Protein, coagulation marker-D-Dimer, chemical analytes, Protein, Albumin, BUN, Bilirubin, Creatinine, and enzymes, Lactate Dehydrogenase, γ-Glutamyl transpeptidases, Alkaline phosphatase were routine analyzed by standard methods described earlier. D-dimer, Ferritin, CRP and Procalcitonin exhibited variable alterations (P<0.05 to P<0.001), more markedly in critically ill patients than in the mild and severe. Biochemical analytes and enzymatic parameters showed elevated levels (P<0.05 to P<0.01) mostly in critically ill category of patients when compared with mild or severe, except total protein and albumin, which remained non-significant. It is concluded that cytokine, chemokines and pro-inflammatory markers, which released in abnormally high concentrations in Covid-19 patients of variable syndrome intensity, are significant indicators of disease severity, progression and success of treatments. As the pharmacological options may vary with the different stages of the disease therefore identifying the correct stage of the disease may be very useful in selecting the best option.

Antibiotic Prescribing Patterns at COVID-19 Dedicated Wards in Bangladesh: Findings from a Single Center Study.

BACKGROUND: As evidence is mounting regarding irrational and often unnecessary use of antibiotics during the COVID-19 pandemic a cross-sectional Point Prevalence Survey (PPS) (in accordance with WHO guideline) was conducted across COVID-19 dedicated wards in Dhaka Medical College and Hospital (DMCH). METHODOLOGY: Antibiotic usage data were collected from 193 patients at different COVID-19 dedicated wards at DMCH on 11 June 2020. Comparisons in antibiotic usage were made between different groups using Pearson chi-square and Fisher's exact test. RESULT: Findings reveal all surveyed patients (100%) were receiving at least one antibiotic with 133 patients (68.91%) receiving multiple antibiotics. Overall, patients presenting with the severe disease received more antibiotics. Third-generation cephalosporins (i.e. ceftriaxone) (53.8%), meropenem (40.9%), moxifloxacin (29.5%), and doxycycline (25.4%) were the four most prescribed antibiotics among surveyed patients. Diabetes mellitus (DM) was independently associated with multiple antibiotic prescribing. Abnormal C-reactive protein (CRP) and serum d-dimer were linked with higher odds of multiple antibiotic prescribing among study patients. CONCLUSION: Prevalence of multiple antibiotic prescriptions was high among severely ill patients and those with abnormal CRP and d-dimer levels. Data regarding the quality of antibiotic prescribing were lacking.

High-Frequency Magnetoimpedance (MI) and Stress-MI in Amorphous Microwires with Different Anisotropies.

Magnetoimpedance (MI) in Co-based microwires with an amorphous and partially crystalline state was investigated at elevated frequencies (up to several GHz), with particular attention paid to the influence of tensile stress on the MI behavior, which is called stress-MI. Two mechanisms of MI sensitivity related to the DC magnetization re-orientation and AC permeability dispersion were discussed. Remarkable sensitivity of impedance changes with respect to applied tensile stress at GHz frequencies was obtained in partially crystalline wires subjected to current annealing. Increasing the annealing current enhanced the axial easy anisotropy of a magnetoelastic origin, which made it possible to increase the frequency of large stress-MI: for 90mA-annealed wire, the impedance at 2 GHz increased by about 300% when a stress of 450 MPa was applied. Potential applications included sensing elements in stretchable substrates for flexible electronics, wireless sensors, and tunable smart materials. For reliable microwave measurements, an improved SOLT (short-open-load-thru) calibration technique was developed that required specially designed strip cells as wire holders. The method made it possible to precisely measure the impedance characteristics of individual wires, which can be further employed to characterize the microwave scattering at wire inclusions used as composites fillers.

REPORT- Varying pattern of blood gases, ferritin, procalcitonin, C-Reactive protein, interleukin 6 and lactate dehydrogenase in Covid-19 patients suffering from diverse Co-Morbid, suspected cytokine storm and periodic effects of antiviral and steroidal treatments.

This study depicted varying pattern of inflammatory markers and blood gases of selected SARS Covid-19 patients with triggered cytokine storm, during their stay in ICUs, HDUs, on ventilators for 21 days. All were treated with Antiviral (remdesivir), steroid (dexamethason) and antipyretic (paracetamol) medications. Procalcitonin, PCT, C-reactive protein CRP, Interleukin 6 (IL6) and Lactate dehydrogenase (LDH) blood gases pressure (pO2, pCO2), coagulation (D-Dimer DD) and Iron storage proteins (Ferritin Ft) were analyzed by fully automated analyzers. All biomarkers of each patient category was statistically compared with days 1st, 4th, 7th versus 10th, 14th and 17th days and reported as significant where p<0.05, to assess progression, worsening or recovery status. IL6 (P<0.0224, P< 0.0228) and CRP (P<0.0277) exhibited none or mild statistical significance difference, with the exception of Ferritin (P<0.0185; P<0.0088) and D Dimer (P<0.0086), demonstrating slow recovery, revealing stronger cytokine storming assault. LDH, pCO2 and pO2 exhibited variable significance difference when data of earlier days were compared with recovery phase, thus advocating blended treatment or progressing of disease. Analysis confirms overwhelming pathogenesis of SARS Covid-19 distinctive cytokine storm, which needed to be cautiously monitored as infection progressed using pro-inflammatory biomarkers as indicators of recovery or worsening of the disease.

Prospective randomized comparative study of percutaneous catheter drainage and percutaneous needle aspiration in the treatment of liver abscess.

BACKGROUND: This study aimed to assess the effectiveness and safety of percutaneous needle aspiration (PNA) and percutaneous catheter drainage (PCD) in the treatment of liver abscess. METHODS: A prospective randomized study was conducted in the Department of Surgery, JN Medical College, Aligarh Muslim University, Aligarh, UP, India, between February 2018 and August 2019, after getting approval from the institutional ethics committee. A total of 543 patients with liver abscess were randomized into two groups using computer-generated randomization method. Appropriate details regarding patients' clinico-demographic profile and investigations were also collected. The effectiveness of either treatment was measured in terms of duration of intravenous antibiotic, clinical improvement, reduction in the size of cavity, treatment success rate, duration of hospital stay including long-term outcomes such as sonographic resolution of cavity and recurrence rate at 6 months post-treatment. RESULTS: The PCD group had statistically significant rate of duration of antibiotics need, days for clinical improvement and time for 50% reduction in abscess cavity and treatment success rate with comparable long-term outcomes. CONCLUSION: PCD is more efficient than PNA and can be used primarily in the treatment of both amoebic and pyogenic liver abscesses along with systemic antibiotics. However, PNA can serve as a safe alternative when PCD is not available.

Soft Magnetic Amorphous Microwires for Stress and Temperature Sensory Applications.

Amorphous ferromagnetic materials in the form of microwires are of interest for the development of various sensors. This paper analyzes and argues for the use of microwires of two basic compositions of Co71Fe5B11Si10Cr3 and Fe3.9(4.9)Co64.82B10.2Si12Cr9(8)Mo0.08 as stress/strain and temperature sensors, respectively. The following properties make them suitable for innovative applications: miniature dimensions, small coercivity, low anisotropy and magnetostriction, tunable magnetic structure, magnetic anisotropy, and Curie temperature by annealing. For example, these sensors can be used for testing the internal stress/strain condition of polymer composite materials and controlling the temperature of hypothermia treatments. The sensing operation is based on the two fundamental effects: the generation of higher frequency harmonics of the voltage pulse induced during remagnetization in wires demonstrating magnetic bistability, and magnetoimpedance.

Thrombolytic therapy at systemic lupus onset with secondary antiphospholipid syndrome. A rare stroke experience.

Strokes are a major cause of disability in systemic lupus erythematosus (SLE). Classical neurological manifestations are rare at onset. The use of thrombolytic therapy improves clinical outcome in eligible stroke patients who present early. Modern imaging modalities augment decision making. This 37-year-old woman presented with an acute stroke with National Institute of Health stroke scale 10. The CT showed a hyperdense middle cerebral artery (MCA) dot sign. The magnetic resonance angiography revealed focal thromboembolic occlusion at the insular MCA segment (M2). Intravenous recombinant tissue plasminogen activator (rtPA) was administered with successful recanalization. The present case was a rare event for rtPA use in acute MCA occlusion with underlying latent lupus. Acute vascular event thrombolysis as the presenting manifestation of autoimmune disease has not previously been encountered on literature review. Stroke pathophysiology in conditions of hypercoagulability is a significant clinical entity where the implication for thrombolytic use requires further studies. An ischemic stroke with underlying connective tissue disease benefits from timely multimodal brain imaging and should be considered for reperfusion.

Dyslipidaemia in woman with polycystic ovarian syndrome: a case control study in tertiary care hospital of Karachi.

OBJECTIVE: To compare lipid profile in lean and obese women with polycystic ovary syndrome with normal weight and obese controls. METHOD: The case-control study was conducted at the Department of Chemical Pathology, Liaquat National Hospital, Karachi, from March 2006 to April 2007. It comprised 50 cases of polycystic ovary syndrome along with 50 healthy controls matching for age, gender and weight. SPSS 14 was used for statistical analysis. RESULT: The mean fasting levels of triglyceride and Low density lipoprotein cholesterol were considerably higher in women with polycystic ovary syndrome than those in the control group (p < 0.05), while high-density lipoprotein cholesterolwas significantly low in patients than the controls (p <0.001). Obese patients had high triglyceride value (p < 0.05). There was significant interaction between polycystic ovary syndrome, obesity and triglyceride levels (p < 0.05). CONCLUSION: Polycystic ovary syndrome is associated with a more pronounced atherogenic lipid profile. Lipid parameters were adversely affected in a subgroup that was obese. As such, women with polycystic ovary syndrome are at high risk of developing cardiovascular disease due to the presence of dyslipidaemia.

Hepatoprotection by chemical constituents of the marine brown alga Spatoglossum variabile: a relation to free radical scavenging potential.

CONTEXT: In the course of searching hepatoprotective agents from natural sources, the protective effect of chemical constituents of the marine brown alga Spatoglossum variabile Figaro et DE Notar (Dictyoaceae) against CCl4-induced liver damage in Wistar rats was investigated. The compounds were first investigated for in vitro radical scavenging potential and were also tested for ß-glucuronidase inhibition to further explore the relationship between hepatoprotection and antiradical potential. METHODS: The compounds cinnamic acid esters 1 and 2 and aurone derivatives 3 and 4 were first investigated for in vitro radical scavenging potential against 1,1-diphenyl-2-picrylhydrazyl radicals (DPPH), and superoxide anion radicals. In vivo hepatoprotective studies were performed in seven groups (n = 6) of Wistar rats. The test groups were pretreated with compounds (10 mg/kg body weight, po) orally for 30 min before the intraperitoneal administration of a dose of 20% CCl4 diluted with dietary cooking oil. Moreover, compounds were also tested for ß-glucuronidase inhibition to explore the relationship between hepatoprotection and radical scavenging potential. RESULTS: The test compounds 1-4 were found to exhibit antiradical activity against 1,1-diphenyl-2-picrylhydrazyl radicals with IC50 values ranging between 54 and 138 µM, whereas aurone derivatives 3 and 4 additionally exhibited superoxide anion scavenging effects with IC50 values of 95 and 87 µM, respectively. In addition, these compounds were found to be weak inhibitors of xanthine oxidase (IC50 ≥1000 µM). In animal model, pretreatment with compounds 2-4 significantly blocked the CCl4-induced increase in the levels of the serum biochemical markers. CONCLUSION: It appears that the hepatoprotection afforded by these compounds was mainly due to their radical scavenging activity that protected the cells from the free radicals generated by CCl4-induced hepatotoxicity.

Apolipoprotein B in type 2 diabetics--a cross sectional study in a tertiary care set-up.

OBJECTIVE: To analyze the pattern of dyslipidaemias including apolipoprotein B in type 2 diabetes. METHODS: A total of 120 diabetics were studied for their lipid profile including serum triglycerides, total cholesterol, HDL cholesterol and LDL cholesterol in fasting state, along with apolipoprotein B levels. RESULTS: Raised apolipoprotein B was the most frequent lipid disorder in type 2 diabetics, occurring in 56.7% of the studied patients. This was followed by high serum triglycerides levels in 55.8% and low HDL cholesterol levels in 55% of patients. Notably, 6% patients had normal triglyceride levels accompanied by raised LDL cholesterol, compared to 20% patients who had normal triglycerides with high apolipoprotein B levels. Overall, 36% of patients had normal LDL cholesterol values but elevated apolipoprotein B. CONCLUSION: Apolipoprotein B is the most frequently occurring dyslipidaemia in type 2 diabetes. It identifies individuals with high risk of coronary heart disease not otherwise detected on routine lipid profile.