Management of pancreatic trauma in adult patients: a single centre experience

Background: Pancreatic trauma is very rare and its management is complex. The aim of this study was to report our experience in the management of pancreatic trauma.Methods: All patients who were admitted with pancreatic trauma from May 2017 to May 2019 were reviewed retrospectively. Demographic data and baseline characteristics were recorded. Grading of pancreatic trauma was carried out according to the American Association for surgery for Trauma (AAST). Data were represented by frequency and mean.Results: A total of 24 patients were admitted with pancreatic trauma in the study period. Road traffic accident (n=17) was the leading cause followed by falls (n=5) and assault (n=2). Out of 24 patients, 3 patients had grade I pancreatic injury, 6 patients had grade II AAST injury, 9 patients had grade III injury and 6 patients had grade IV injury. No patients had grade V injury. Mean hospital stay was 12.3±4.2 days. One patient with grade 2 injury underwent surgery for liver laceration, all others were managed conservatively. Patients with grade 3 and 4 injuries were managed conservatively. One patient with grade 3 injury required, cystogastrostomy for pseudocyst 1 month after the index admission. Two patients of grade 4 injury underwent surgery, one patient for traumatic pseudocyst after 1 month and another patient for bleeding pseudoaneurysm of gastroduodenal artery 1 month after trauma. No patient underwent pancreatectomy. There was no mortality in the study population.Conclusions: Pancreatic trauma can be managed conservatively irrespective of the grade of injury in haemodynamically stable patients.

Postoperative day 3 drain amylase versus fistula risk score: predicting clinically relevant postoperative pancreatic fistula following pancreatico-duodenectomy

Background: Clinically relevant postoperative pancreatic fistula (CR-POPF) remains the most common cause of perioperative morbidity following pancreatico-duodenectomy (PD). Early and accurate prediction of CR-POPF can be helpful in postoperative drain management as well as stratifying patients for enhanced recovery protocol after surgery. Both fistula risk score (FRS) and postoperative drain amylase levels have been analyzed in past. However, currently there is no clear consensus regarding the ideal predictor. Present study sought to assess the utility of postoperative day 3 drain amylase (POD-3DA) level as a predictor of CR-POPF in comparison with FRS.Methods: A retrospective analysis was done on 57 patients who underwent PD at our institute between 2014 to 2018. POPF was defined and graded in accordance with ISGPF definition. Receiver operating characteristic (ROC) analysis predicted a threshold of POD3DA >486 IU/l associated with CR-POPF. Sensitivity, specificity and odds ratios with 95%CI calculated and ROC curves were plotted for POD3DA of ≥500 IU/l and FRS (negligible/low vs. moderate/ high) as predictors of CR-POPF.Results: Incidence of POPF and CR-POPF was 63% and 32% respectively. Sensitivity and specificity of POD3DA ≥500 and moderate/high FRS for predicting CR-POPF were 83%, 79% & 78%, 51% respectively. Difference between ROC area under the curve (AUC) for POD3DA ≥500 IU/l (0.868) and FRS (0.692) was significant (p=0.028). Combining FRS and POD3DA ≥500 IU/l improved specificity (87%) at the cost of sensitivity (67%). The negative predictive value of POD3DA <500 IU/l and negligible/low FRS were 91.2% and 83.3% respectively.Conclusions: POD3DA level greater than 5 times of upper normal range is more precise at predicting CR-POPF, hence clinically more reliable for drain and postoperative management.

Socio-economic & demographic determinants of hypertension & knowledge, practices & risk behaviour of tribals in India.

Background & objectives: An increase in prevalence of hypertension has been observed in all ethnic groups in India. The objective of the present study was to estimate prevalence and determinants of hypertension among tribals and their awareness, treatment practices and risk behaviours in nine States of India. Methods: A community based cross-sectional study adopting multistage random sampling procedure was carried out. About 120 Integrated Tribal Development Authority villages were selected randomly from each State. From each village, 40 households were covered randomly. All men and women ≥ 20 yr of age in the selected households were included for various investigations. Results: A total of 21141 men and 26260 women participated in the study. The prevalence of hypertension after age adjustment was 27.1 and 26.4 per cent among men and women, respectively. it was higher in the states of Odisha (50-54.4%) and Kerala (36.7-45%) and lowest in Gujarat (7-11.5%). The risk of hypertension was 6-8 times higher in elderly people and 2-3 times in 35-59 yr compared with 20-34 yr. Only <10 per cent of men and women were known hypertensives and more than half on treatment (55-68%). Men with general and abdominal obesity were at 1.69 (CI: 1.43-2.01) and 2.42 (CI: 2.01-2.91) times higher risk of hypertension, respectively, while it was 2.03 (CI=1.77-2.33) and 2.35 (CI 2.12-2.60) times higher in women. Those using tobacco and consuming alcohol were at a higher risk of hypertension compared with the non users. Interpretation & conclusions: The study revealed high prevalence of hypertension among tribals in India. Age, literacy, physical activity, consumption of tobacco, alcohol and obesity were significantly associated with hypertension. Awareness and knowledge about hypertension and health seeking behaviour were low. Appropriate intervention strategies need to be adopted to increase awareness and treatment practices of hypertension among tribals.

Study of Magnesium, Copper, Zinc, Iron and Ceruloplasmin in Liver Cirrhosis and Ovarian Cancer Ascitic Patients.

Introduction: The excess accumulation of free fluid in the peritoneal cavity is due to its multitude causes. Certain cytological and biochemical markers are reported for the differential diagnosis of ascites. In the present study, ascitic patients with liver cirrhosis and ovarian carcinoma are investigated. Aim: To study the concentrations of certain trace elements and ceruloplasmin levels in ascitic fluid and in serum of patients with liver cirrhosis in comparison to ovarian cancer patients. Study Design: The study includes 170 patients with liver cirrhosis, 95 patients with ovarian cancer and 100 serum controls. Place and Duration of Study: The study is performed in the department of Gastroenterology, Osmania General Hospital Hyderabad, A.P, INDIA, between December 2011 to July 2013. Methodology: The trace elements such as magnesium, copper, zinc, iron and ceruloplasmin were investigated in 170 patients with liver cirrhosis (120 males, 50 females, 22-75 years; mean age 46.2±11.2) and 95 ovarian cancer patients (19-84 years; mean age 50.2±12.2). All the analysts were measured in serum and ascitic fluid by using standard commercial kits. 100 serum samples from healthy controls were also included in the study. Results: The mean serum concentrations of copper and ceruloplasmin were significantly increased in ovarian cancer patients when compared to that of liver cirrhosis and healthy controls (P<. 001, P<. 001) respectively. The mean zinc levels in serum samples were low in both the groups when compared to controls (P<. 001). The ascitic fluid zinc levels in ovarian cancer were higher when compared to that of liver cirrhosis (P<. 001). Similar results were noted in the serum iron levels in both the groups. The serum magnesium levels in liver cirrhosis are comparable to that of controls but the levels of magnesium in ovarian cancer ascitic patients are high when compared to that of controls. Conclusion: Our results showed that there are differences in trace elements and ceruloplasmin levels in liver cirrhosis and ovarian cancer patients in both serum and ascitic fluid samples. The cutoff value of copper and ceruloplasmin in serum samples are 134.5 μg/dl and 43.5 mg/dl, while in ascitic fluid were 46.5 μg/dl and 21.0 mg/dl respectively. As the diagnostic efficiency of copper and ceruloplasmin in serum and ascitic fluid samples are 97% to 99% with highest sensitivity and specificity, analysis of trace elements with ceruloplasmin in depth with their ratios may be helpful in differentiating the cirrhotic and neoplastic illness.

Evaluation of vaginal pH for detection of bacterial vaginosis.

Background & objectives: Bacterial vaginosis (BV) is highly prevalent among women in reproductive age group. Little information exists on routine vaginal pH measurement in women with BV. We undertook this study to assess the utility of vaginal pH determination for initial evaluation of bacterial vaginosis. Methods: In this cross-sectional study vaginal swabs were collected from women with complaints of white discharge, back ache and pain abdomen attending a government hospital and a community health clinic, and subjected to vaginal pH determination, Gram stain, wet mount and whiff test. Nugent score and Amsel criteria were used for BV confirmation. Results: Of the 270 women included in the analysis, 154 had BV based on Nugents’ score. The mean vaginal pH in women with BV measured by pH strips and pH glove was 5 and 4.9, respectively. The vaginal pH was significantly higher in women with BV. Vaginal discharge was prevalent in 84.8 per cent women, however, only 56.8 per cent of these actually had BV by Nugent score (NS). Presence of clue cells and positive whiff test were significant for BV. Vaginal pH >4.5 by pH strips and pH Glove had a sensitivity of 72 and 79 per cent and specificity of 60 and 53 per cent, respectively to detect BV. Among the combination criteria, clue cells and glove pH >4.5 had highest sensitivity and specificity to detect BV. Interpretation & conclusions: Vaginal pH determination is relatively sensitive, but less specific in detecting women with BV. Inclusion of whiff test along with pH test reduced the sensitivity, but improved specificity. Both, the pH strip and pH glove are equally suitable for screening women with BV on outpatient basis.

Prevalence of Clinical and Sub-Clinical Vitamin A Deficiency Among Rural Preschool Children of West Bengal, India.

A community based cross-sectional study was carried out in rural areas of West Bengal with the aim to assess the prevalence of vitamin A deficiency (VAD) among rural preschool children. Clinical examination was carried out on 9,228 children for the signs and symptoms of VAD and a sub-sample of 590 children were covered for the estimation of blood vitamin A levels using dried blood spot (DBS) method. The prevalence of Bitot’s spots was 0.6% (95% CI=0.44, 0.76), which is more than the public health significance, and it increased with increase in age. The prevalence was significantly higher (P<0.001) among boys (0.8%) as compared to girls (0.4%). The proportion of children with subclinical vitamin A deficiency (blood vitamin A < 20μg/dL) was 61% (95% CI: 52.3-65.1), and it was significantly (P<0.01) higher among the children of lower socioeconomic communities.

Breakfast eating habit and its influence on attention-concentration, immediate memory and school achievement.

OBJECTIVE: To study the relationship of breakfast to the attention -concentration, immediate recall memory, nutritional status and academic achievement of school children. DESIGN: Cross-sectional study. SETTING: Two schools catering to middle class families in Hyderabad city. METHODS: 379 urban 11 to 13 years old school children studying in 6th, 7th and 8th grades. Data collected in a single way blind procedure using Letter Cancellation test, immediate memory from the PGI Memory Scale, school marks of the previous year and nutritional status. RESULTS: Comparison between groups indicated significant differences in the letter cancellation (LC) total scores with the regular breakfast group achieving the highest mean scores compared to the no breakfast group (P< 0.05). Marks scored by the regular breakfast group in subjects - Science, English and total Percentage were significantly higher compared to those scored by the children in the no breakfast group. Regular breakfast eating habit and weight for age percent were significantly (P< 0.001) associated with immediate recall memory score explaining 4.3 percent variation. CONCLUSIONS: Regular habit of eating breakfast as opposed to irregular consumption or skipping breakfast altogether had beneficial influence on attention-concentration, memory and school achievement.

Validation of hemoglobin estimation using Hemocue.

OBJECTIVE: This piece of work is an attempt to compare Hemocue and Cyanmethemoglobin methods for hemoglobin estimation. METHODS: In 100 apparently healthy children of 1-6 years of age, Hb was estimated using Hemocue and cyanmethemoglobin methods from finger prick blood sample. The results obtained by the two methods were compared using appropriate statistical methods. RESULTS: Mean +/- SD values for hemoglobin (g/dl) were 9.33 +/- 2.719 by Hemocue and 8.14 +/- 2.448 by cyanmethemoglobin method. When assessed by Hemocue method the proportion of children with anemia was 66% while it was 88% with cyanmethemoglobin method. The sensitivity of Hemocue method was 0.75 and specificity 1.0 considering cyanmethemoglobin method as gold standard. The corresponding values by cyanmethemoglobin method for a given Hemocue value fell within the Mean difference +/- 2 SD with correlation coefficient being r = 0.922. Despite the good association, the two methods agreed, the magnitude of difference being -1.19 g/dl (CI: -1.40 to -0.98) thus suggesting an overestimate of hemocue values ranging from 10 to 15%. A correction factor was arrived for converting Hb values obtained by Hemocue method to arrive at the expected value by the reference method, this factor being 0.389 + 0.831 Hb (Hemocue). CONCLUSION: As there are limitations expressed for both the methods in accurately estimating Hb, it is difficult to decide whether one is an overestimate or the other an underestimate. By virtue of the principle involved in estimating Hb, cyanmethemoglobin method may be taken as an indirect indicator of iron status. However, it is not clear whether such a principle is involved in estimating Hb by Hemocue. Therefore, these two methods need to be further validated against a sensitive and specific indicator for iron status like circulating transferrin receptor to decide which of the methods can be used to accurately determine the prevalence of iron deficiency anemia in the community.

Association of tumour necrosis factor alpha & malnutrition with outcome in children with acute bacterial meningitis.

BACKGROUND & OBJECTIVES: Tumour necrosis factor alpha (TNF alpha) is implicated in the pathogenesis of acute bacterial meningitis (ABM). However, we do not know if the nutritional status influences the concentration of TNF alpha in the CSF in children with ABM. The present study evaluates the association between malnutrition and TNF alpha detectability in CSF and the outcome from ABM in children. METHODS: A total of 120 children aged 1-5 yr diagnosed as ABM, based on the standard criteria of CSF changes were recruited for the study. A CSF sample was collected at the time of admission. TNF alpha was measured by ELISA and CSF culture was done by standard technique. Nutritional status was assessed by anthropometry. Outcome was measured by clinical examination. RESULTS: Of the 120 children, 20 died, 36 developed complications and 64 children recovered without sequelae. TNF alpha was detectable in 94 (78.3%) CSF samples, with a range of 32 to 1714 pg/ml. TNF alpha detectability was not associated with either nutritional status or with death and sequelae. However, death and sequelae were significantly (P = 0.01) associated with malnutrition. INTERPRETATION & CONCLUSION: CSF TNF alpha was not associated with nutritional status. However, malnutrition was associated with adverse outcome due to ABM in children.

Suitability of CANSCORE for the assessment of the nutritional status of newborns.

The suitability of Clinical Assessment of Nutritional Status Score (CANSCORE) for the assessment of foetal malnutrition among 372 local Hyderabad newborns was studied. Details of length, weight and body mass index (BMI) at birth were related to total CANSCORE which consisted of scores ranging from 1 to 4 based on the grades of clinical status of hair, cheeks, buttocks, chest, legs, back, neck, arms and skin of anterior abdominal wall. The correlation coefficients of CANSCORE with the length, weight and BMI of newborns indicated that score of hair was least correlated with nutritional status. Normal newborns were found to have the lowest prevalence of foetal malnutrition. In those with retarded measurements of length and weight or BMI, the prevalence of foetal malnutrition was higher. The newborns with retardation of both length and BMI had higher prevalence of foetal malnutrition. The feasibility of the suggested limits of CANSCORE for the foetal malnutrition was assessed. Values of 24 for total CANSCORE and of 22 for "Modified CANSCORE" (score excluding hair as a parameter) were found appropriate for the assessment of foetal malnutrition. Modified CANSCORE is a simple, rapid and quantifiable method for the assessment of foetal malnutrition in term newborns.

Post-vaccination scenario of measles: a retrospective analysis.

BACKGROUND: Routine vaccination against measles was introduced in India during 1985-86 through the Universal Immunization Programme. Its effect on the current prevalence of measles is not known. METHODS: Information on the total number of patients admitted and deaths due to measles from January 1982 to December 1997 were obtained from the records of the Institute of Tropical Medicine, Hyderabad, the only infectious diseases hospital in the city. Details on age, sex, number of complications, duration of hospital stay, vaccination status and information on vitamin A administration in the hospital were collected from the case records. RESULTS: A total of 20,926 cases of measles were admitted from 1982 to 1997. There was a 69% reduction in hospital admissions from the pre-vaccination to the post-vaccination period, and deaths due to measles decreased by 90%. Over the years, a rise in the age of children admitted with measles was observed. Boys were admitted more frequently to the hospital (p < 0.001) than girls. All the children showed one or more complications. From 1992 onwards, vitamin A was administered to 45.4% of the children admitted. CONCLUSION: A significant reduction was observed in the number of cases admitted to the hospital as well as deaths due to measles. Apart from the effect of the vaccination programme, this could also be due to increased awareness and availability of better health care facilities in the hospital and peripheral health clinics. Administration of vitamin A to children with measles as recommended by the World Health Organization needs to be implemented. A significant increase in the number of older children (> 5 years) with no significant reduction in the infants affected by measles indicates inadequate vaccine coverage and accumulation of susceptible older children.

Effect of dose and formulation on iron tolerance in pregnancy.

BACKGROUND: The National Nutritional Anaemia Prophylaxis Programme (NNAPP) in India was launched in 1971. However, anaemia continues to be a major public health problem. Partial coverage of the population, inadequate dose of the iron supplement, defective absorption due to intestinal infestations and problems with formulation have been recognized as factors responsible for its failure. Therefore, the bioavailability of iron from different formulations containing 60 mg of elemental iron and of tablets with varying doses of elemental iron was undertaken. METHODS: One hundred and fifteen women were randomly allotted to receive different formulations and doses of iron and then undergo iron tolerance tests. They received ferrous sulphate tablets containing 60 mg, 120 mg and 180 mg of elemental iron; formulations containing 60 mg of elemental iron as pure ferrous sulphate salt, ferrous fumarate tablets, ferrous fumarate syrup, excipients added to pure ferrous sulphate salts, powdered ferrous sulphate tablets, iron tablets distributed by the NNAPP and pure ferrous salt in gelatin capsules. RESULTS: The data obtained from 32 subjects were excluded because of non-compliance, intolerance of the medication and lack of results of blood tests. Data from the remaining 83 subjects indicated that increasing the dose of elemental iron from 60 mg to 180 mg improved the bioavailability of iron, but was associated with unacceptable side-effects. Also, liquid formulations of iron had a better bioavailability, with ferrous fumarate syrup and gelatin capsules being the most superior. CONCLUSION: Providing the iron formulation with a high bioavailability should enable the NNAPP to be more successful in decreasing the prevalence of anaemia.

Effect of administration of 200,000 IU of vitamin A to women within 24 hrs after delivery on response to PPV administered to the newborn.

OBJECTIVE: To explore the effect of maternal supplementation of vitamin A on the immune response to oral polio vaccine in breastfed infants. DESIGN: Randomized controlled trial. SETTING: Hospital based. METHODS: One hundred mothers having uncomplicated deliveries randomly received either 200,000 IU vitamin A orally (Experimental) or placebo (Control). All the newborns were given a dose of oral polio vaccine within 72 hours after birth and were breastfed. Type specific neutralizing antibodies to polio viruses in test sera diluted from 1:4 to 1:512 and serum retinol levels were determined from the cord blood and at the age of 6 weeks. Breast milk retinol levels were determined at 3, 10, 30, 45 and 90 days of lactation. RESULTS: Seroconversion to OPV and geometric means of antibody titers to the three types of polio viruses were comparable between the groups of infants belonging to the experimental and control mothers. Breast milk retinol levels were significantly higher in the experimental group upto 45-90 days of lactation. Majority of the infants at birth had serum retinol levels < 15 micrograms/dl which improved significantly by 6 weeks irrespective of the maternal supplementation status. CONCLUSIONS: Maternal vitamin A supplementation soon after delivery improves vitamin A intakes of breastfed infants during the first 3 months and has no interference with the seroconversion to a neonatal dose of OPV. OPV administered to newborn in turn has no adverse effect on the vitamin A status of the breastfed infants.

Feasibility of Broka's index for the nutritional status of adults.

The utility and feasibility of Broka's index for assessing the nutritional status of adults was studied in comparison with the efficacy of weight for height (%) and body mass index (BMI). The coefficients of correlation, sensitivity, specificity and efficiency and Kappa statistic for agreement were determined and tested for significance. The data pertaining to urban adults of Hyderabad belonging to better socio-economic class were utilised. Broka's index was well correlated with weight for height (%) (r = 0.97) and BMI (r = 0.99). Broka's index, BMI and weight for height (%) were least correlated with stature indicating that these indices were of use for classifications of nutritional status irrespective of variations in stature. There was a good agreement between classifications of nutritional status based on Broka's index, weight for height (%) and BMI. The values of sensitivity, specificity and efficiency were in the range of 90-100 per cent. The Kappa statistic of agreement between Broka's index, BMI and weight for height (%) for all forms of nutritional status was 0.839 (P < 0.0001). The mean values of Broka's index, BMI and weight for height (%) were higher in the better socio-economic group as compared to the poor ones. Broka's index which is simple and easy to calculate is useful for the assessment of the grades of body built and nutritional status in adults.

Comparative evaluation of calf, thigh and arm circumferences in detecting low birth weight infants--Part II.

In an earlier study usefulness and validity of calf circumference in the identification of low birth weight (LBW) infants was reported. To evolve a simple indicator in identifying LBW in community, comparative evaluation of three simple measurements, i.e., circumferences of calf (CC), thigh (TC) and arm (AC) was done with respect to their sensitivity and specificity. Though all the three measurements showed a high degree of correlation with the birth weight, calf circumference tended to be most sensitive in identifying almost 95% of LBW infants. Having established the superiority of CC, a two color tape demarcating LBW zone from normal birth weight using 10 cm CC as cut off point was tested by two independent investigators and two ANMs. It was observed that only 5% of cases were misclassified either as LBW or normal weight by the tape with hardly any inter individual variation. Measurement of calf circumference being simple and easy even in the hands of paramedics, it would be used as indicator of LBW and neonatal mortality in the community.

Usefulness of calf circumference as a measure for screening low birth weight infants.

Usefulness of calf circumference (CC) for screening low birth weight (LBW) was assessed in comparison with other anthropometric measurements, crown heel and crown rump lengths (CHL, CRL), Chest (Ch C), head (HC) and arm (AC) circumferences in 256 infants within 24 hours of birth. Calf circumference showed highest degree of correlation (r = 0.83) with birth weight followed by arm and chest circumference and crown heel length. Step down multiple linear regression analysis of birth weight showed highest R2 value with combination of calf, arm and crown heel length (82.1%). Addition of other measurements did not improve the predictive value of the model. Sensitivity of these parameters in screening LBW infants (less than 2500 g) showed 95.7% critical limit for calf followed by 82.6% with arm circumference and 72.5% with crown heel length. False positive responses were similar (18-20%) with all the three parameters. Calf circumference being highly sensitive and easy to measure, is useful in screening most of the low birth weight infants in the communities where weighing scales are not available or cannot be used by peripheral workers.

Discriminant function analysis: a case study of some socioeconomic constraints on child nutrition.

Discriminant function analysis was used to understand the combination of socioeconomic variables in various forms of malnutrition in preschool children. Data available (1976) from two sets viz., 4000 children of rural and urban areas of Hyderabad (in south India) and 215 children of urban and rural areas of Jaipur (in north India) were used for the study. The prevalence rates of various forms of malnutrition in children were different by variations in socioeconomic status and sex (P less than 0.05). Discriminant function analysis of all socioeconomic indicators showed that educational levels and occupational status of parents and percaput income were most important for differentiation of children who were normals and undernourished. Occupational status of the father and the child's calorie intake or duration of lactation improved the differentiation of normals from those who were under-nourished. Higher prevalence of malnutrition in female children than in the male children was found due to variations in per capita income and levels of maternal education. Closely associated best set of factors could be traced using the discriminant function analysis.

Use of body mass index for assessing the growth status of infants.

Growth status of infants measured by weight and height was assessed from birth to 12 months in a randomly selected community from the urban slums of Hyderabad City. Mean birth weight was 2.82 kg. Weight/height indicator of body mass index (BMI) showed a progressive increase till 4th month, followed by more or less a constant figure with a mean value of 1.50 in longitudinal, semi-longitudinal and cross sectional data till one year. Critical limit for BMI at birth for given weight of 2.5 kg was 1.20 and subsequently increased to 1.35. BMI was well correlated with weight and weight for height (%) and least correlated with height. Children with height of 90% or above and birth weight of above 2.5 kg were observed with better growth and better maintenance of weight for height (%) and BMI till 6 months.