Forensic age estimation in living children: how accurate is the Greulich-Pyle method in Sabah, East Malaysia?

Background: The Greulich and Pyle's Radiographic Atlas of Skeletal Development of the Hand and Wrist (GP Atlas) is the most widely used method of determining the bone age (BA) of a child. It is also a widely accepted method for forensic age determination. As there is limited local bone age data for forensic age estimation, the purpose of this study was to assess the accuracy of the GP Atlas for forensic age determination in living Sabahan children. Method: This study recruited 182 children between the ages of 9 years to 18 years. BA estimation of the left-hand anteroposterior radiographs were performed by two experienced radiologists using the Greulich-Pyle method. Results: The BA estimates from two radiologists had very high interobserver reliability (ICC 0.937) and a strong positive interobserver correlation (r > 0.90). The GP method, significantly and consistently underestimated chronological age (CA) by 0.7, 0.6 and 0.7 years in overall children, boys and girls respectively with minimal errors. Mean absolute error and root of mean squared error for overall children was 1.5 and 2.2 years respectively, while mean absolute percentage error was 11.6%. This underestimation was consistent across all age groups but was statistically significant only at 13-13.9 and 17-18.9 years old age groups. Conclusion: Despite high interobserver reliability of BA estimation using the GP Atlas, this method consistently underestimates the age of the child in all children to a significant degree, for both boys and girls across all age groups, with an acceptably low level of error metrics. Our findings suggest that locally validated GP Atlas or other type of assessments (artificial intelligence or machine learning) are needed for assessment of BA to accurately predict CA, since current GP Atlas standards significantly underestimated chronological age with minimal error for children in Sabah. A larger population-based study would be necessary for establishing a validated atlas of a bone age in Malaysia.

Barriers to the identification of possible organ donors among brain-injured patients admitted to intensive care units.

Background: Improving organ donation rates requires better detection of possible organ donors, which in turn necessitates identifying barriers preventing the identification of possible organ donors. The objectives of this study were to determine the actual rate of possible deceased organ donors among nonreferred cases and to identify barriers to their identification as possible donors. Methods: This retrospective observational study used 6 months of data collected from two intensive care units (ICUs). Possible organ donors were defined as patients with a Glasgow Coma Scale score <5 and evidence of severe neurological damage. Barriers that led to the nonidentification of these patients as possible organ donors were also identified. Results: Fifty-six of 819 patients admitted to the ICUs during the study period were detected as possible organ donors, representing a 6.83% possible organ donor detection rate. Nonclinical barriers to the identification of possible organ donors were found to be more significant than clinical barriers (55% vs. 45%, respectively). The most significant nonclinical barrier was an unknown reason, despite patients being medically suitable for deceased organ donation and fulfilling the criteria for possible organ donor classification. Unresolved sepsis was the main clinical barrier. Conclusions: The significant rate of unreferred possible deceased organ donors found in this study reveals the need to increase awareness and knowledge among clinicians of the proper detection of possible donors at an early stage to avoid the loss of possible deceased organ donors, and thereby increase the deceased organ donation rate in Malaysian hospitals.

Challenges in managing a critically ill patient with decompensated Eisenmenger syndrome.

Eisenmenger syndrome (ES) is the most severe form of pulmonary arterial hypertension and is associated with congenital heart disease. ES itself is a challenging condition to manage, further compounded if the patient is critically ill and acutely decompensated. We share our experience of managing a critically ill adult patient with ES who presented with acute decompensation due to sepsis.

Clinical characteristics and outcomes of critically ill coronavirus disease 2019 patients in Malaysia during the first wave: A multi-center observational study (COVIDICU-MY).

Background: Coronavirus disease 2019 (COVID-19) emerged with a wide range of clinical presentations; Malaysia was not spared from its impact. This study describes the clinical characteristics of COVID-19 patients admitted to intensive care unit, their clinical course, management, and hospital outcomes. Methods: COVIDICU-MY is a retrospective analysis of COVID-19 patients from 19 intensive care units (ICU) across Malaysia from 1 March 2020 to 31 May 2020. We collected epidemiological history, demographics, clinical comorbidities, laboratory investigations, respiratory and hemodynamic values, management, length of stay and survival status. We compared these variables between survival and non-survival groups. Results: A total of 170 critically ill patients were included, with 77% above 50 years of age [median age 60, IQR (51-66)] and 75.3% male. Hypertension, diabetes mellitus, hyperlipidemia, chronic cardiac disease, and chronic kidney disease were most common among patients. A high Simplified Acute Physiology Score (SAPS) II score [median 45, IQR (34-49)] and Sequential Organ Failure Assessment (SOFA) score [median 8, IQR (6-11)] were associated with mortality. Patients were profoundly hypoxic with a median lowest PaO2/FiO2 ratio of 150 (IQR 99-220) at admission. 91 patients (53.5%) required intubation on their first day of admission, out of which 38 died (73.1% of the hospital non-survivors). Our sample had more patients with moderate Acute Respiratory Distress Syndrome (ARDS), 58 patients (43.9%), compared to severe ARDS, 33 patients (25%); with both ARDS classification groups contributing to 25 patients (54.4%) and 11 patients (23.9%) of the non-survival group, respectively. Cumulative fluid balance over 24 h was higher in the non-survival group with significant differences on Day 3 (1,953 vs. 622 ml, p < 0.05) and Day 7 of ICU (3,485 vs. 830 ml, p < 0.05). Patients with high serum creatinine, urea, lactate dehydrogenase, aspartate aminotransferase and d-dimer, and low lymphocyte count throughout the stay also had a higher risk of mortality. The hospital mortality rate was 30.6% in our sample. Conclusion: We report high mortality amongst critically ill patients in intensive care units in Malaysia, at 30.6%, during the March to May 2020 period. High admission SAPS II and SOFA, and severe hypoxemia and high cumulative fluid balance were associated with mortality. Higher creatinine, urea, lactate dehydrogenase, aspartate aminotransferase and d-dimer, and lymphopenia were observed in the non-survival group.

Challenges in electromyographic endotracheal tube (EMG ETT) placement via awake fibreoptic intubation during emergency thyroidectomy.

Recurrent laryngeal nerve (RLN) injury is one of the main complications of total thyroidectomy. If the injury is bilateral, total airway obstruction, aphonia and hoarseness of voice could be precipitated. Hence, it is wise for the operating surgeon to be guided by neural monitoring during thyroidectomy. We present a valuable experience handling a middle-aged man with a huge papillary thyroid carcinoma . He needed an urgent thyroidectomy due to obstructive symptoms. We highlight our intraoperative dexterity in handling his surgery in the context of continuous monitoring of RLN using electromyography.

Anaesthetic management in a patient requiring one lung ventilation during COVID-19 pandemic.

Placement of a double-lumen tube to achieve one lung ventilation is an aerosol-generating procedure. Performing it on a patient with COVID-19 will put healthcare workers at high risk of contracting the disease. We herein report a case of its use in a patient with traumatic diaphragmatic rupture, who was also suspected to have COVID-19. This article aims to highlight the issues, it presented and ways to address them as well as the perioperative impact of personal protective equipment.