Symptom-based scoring technique by machine learning to predict COVID-19: a validation study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) surges, such as that which occurred when omicron variants emerged, may overwhelm healthcare systems. To function properly, such systems should balance detection and workloads by improving referrals using simple yet precise and sensitive diagnostic predictions. A symptom-based scoring system was developed using machine learning for the general population, but no validation has occurred in healthcare settings. We aimed to validate a COVID-19 scoring system using self-reported symptoms, including loss of smell and taste as major indicators. METHODS: A cross-sectional study was conducted to evaluate medical records of patients admitted to Dr. Sardjito Hospital, Yogyakarta, Indonesia, from March 2020 to December 2021. Outcomes were defined by a reverse-transcription polymerase chain reaction (RT-PCR). We compared the symptom-based scoring system, as the index test, with antigen tests, antibody tests, and clinical judgements by primary care physicians. To validate use of the index test to improve referral, we evaluated positive predictive value (PPV) and sensitivity. RESULTS: After clinical judgement with a PPV of 61% (n = 327/530, 95% confidence interval [CI]: 60% to 62%), confirmation with the index test resulted in the highest PPV of 85% (n = 30/35, 95% CI: 83% to 87%) but the lowest sensitivity (n = 30/180, 17%, 95% CI: 15% to 19%). If this confirmation was defined by either positive predictive scoring or antigen tests, the PPV was 92% (n = 55/60, 95% CI: 90% to 94%). Meanwhile, the sensitivity was 88% (n = 55/62, 95% CI: 87% to 89%), which was higher than that when using only antigen tests (n = 29/41, 71%, 95% CI: 69% to 73%). CONCLUSIONS: The symptom-based COVID-19 predictive score was validated in healthcare settings for its precision and sensitivity. However, an impact study is needed to confirm if this can balance detection and workload for the next COVID-19 surge.

Comparing the effect of tissue adhesive and suturing material on collagen I/III ratio in abdominal skin wounds: an experimental study.

Background: The skin closure procedure should be technically simple, acceptable, quick, and cost-effective. Sutures remain the technique's mainstay, however tissue adhesive is becoming more used in clinical practice. Collagen ratios of types I and III play a significant role as postoperative wound healing parameters. Here, the authors aim to examine the collagen I/III ratio of tissue adhesive vs. non-absorbable sutures for abdominal skin closure in Wistar albino rats. Material and methods: The authors allocated 20 rats into four experimental groups. Wounds in groups 1 and 3 were sealed with tissue adhesive (cyanoacrylate), while those in groups 2 and 4 were closed using suture material (monofilament non-absorbable nylon). Groups 1 and 2 were sacrificed on postoperative day (POD) 4, while those in groups 3 and 4 were euthanized on POD 7. Skin samples (1×0.5 cm) were collected for analysis, and the collagen I/III ratios were determined using immunohistochemistry staining techniques. Results: The levels of collagen I and III expression did not exhibit statistically significant differences between tissue adhesive and nylon suture groups at either POD 4 (P=0.052, P=0.513) or POD 7 (P=0.125, P=0.80). Similarly, the collagen I/III ratio did not significantly differ between the two groups at POD 4 (1.23±2.26 vs. 0.70±0.24; P=0.47) or POD 7 (0.68±0.96 vs. 0.77±1.22; P=0.857). Conclusions: There were no statistical significance difference in collagen I/III ratio between the tissue adhesive and suture material groups, suggesting that the choice of wound closure material may not influence the abdominal skin closure.

Prognostic factors for persistent obstructive symptoms in patients with Hirschsprung disease following pull-through.

BACKGROUND: Although most patients with Hirschsprung disease (HSCR) improve after pull-through, some patients still have persistent obstructive symptoms. Most previous studies reported persistent obstructive symptoms after pull-through in HSCR patients from developed countries. Our study determined the prognostic factors of persistent obstructive symptoms in patients with HSCR following pull-through from a particular developing country. METHODS: A cross-sectional study was conducted using medical records of patients with HSCR at our institution from January 2017 to January 2022. RESULTS: We ascertained 114 patients with HSCR: 79 males and 35 females. Most of them (90.4%) showed a short aganglionosis and underwent transanal endorectal pull-through (55.3%). Twenty-two percent of patients showed persistent obstructive symptoms following pull-through. Operative technique and age at definitive surgery were significantly associated with the persistent obstructive symptoms after pull-through (p = 0.011 and 0.019, respectively), while sex, aganglionic segment length, presence of global developmental delay, and Down syndrome were not (p = 0.873, 0.525, 0.647, and 0.301, respectively). Multivariate analysis revealed that age at pull-through was a significant independent factor for persistent obstructive symptoms after pull-through, with an odds ratio of 3.41 (95% CI = 1.18-9.91; p = 0.02). CONCLUSIONS: Our study shows a moderate frequency of persistent obstructive symptoms after pull-through in our institution. In addition, patients who underwent pull-throughs at a younger age might have persistent obstructive symptoms following a definitive surgery. Our study provides new data on persistent obstructive symptoms after pull-through from a particular population that might be beneficial for pediatric surgeons' consideration before performing definitive surgery on patients with HSCR.

Comparison and impact of associated anomalies on the anal position index in neonates with anorectal malformation.

OBJECTIVE: Some prognostic factors have affected the functional outcomes of patients with anorectal malformations (ARM) after definitive surgery, including the associated anomalies. Moreover, the anal position index (API) study in neonates from developing countries is minimal. We aimed to (1) compare the API between neonates with ARM and controls; and (2) determine the impact of associated anomalies on the API in neonates with ARM. RESULTS: We ascertained 68 subjects: 35 neonates with ARM and 33 controls. The API of neonates with ARM was similar to controls, either male or female neonates (p = 0.51 and 0.90, respectively). Interestingly, the API in ARM males with associated anomalies (0.42 ± 0.07) was significantly lower than in control males (0.48 ± 0.02) (p = 0.005). Moreover, the API of ARM neonates with vertebral anomalies (0.35 ± 0.04) was lower than ARM neonates without vertebral anomalies (0.47 ± 0.07) (p = 0.021). In conclusion, associated anomalies and sex might affect the API in neonates with ARM. These findings should be considered and informed during counseling to the parents regarding the prognosis of functional outcomes in ARM neonates, particularly with associated anomalies.

Measurement of Social Strain in People with Dementia: A Preliminary Study of the Reliability and Validity of the Negative Relationship Quality Questionnaire in Indonesia.

People with dementia (PWD) may exhibit symptoms that negatively affect their relationships with their families or friends which could cause social strain. The Negative Relationship Quality (NRQ) questionnaire can be used to measure social strain in PWD. There has never been an Indonesian adaptation of the NRQ. This preliminary study aimed to measure the validity and reliability of the NRQ among PWD in Indonesia (NRQ-INA). This study used a cross-sectional design. Forward−backward translation methods were conducted first. Pearson's correlation and factor analysis were employed for the validity test. Cronbach's alpha and test−retest were used to determine reliability. The NRQ-INA has four parallel items related to social strain that are divided into three subscales and asked to spouse/partner, family members, and friends, leading to a total of 12 questions. The results of validity testing from 60 respondents showed that all items in the NRQ-INA were strongly valid with correlation coefficients (r) of >0.8 (p < 0.01). Factor analysis showed a convergence with the variance explained of more than 50% for all items in each subscale, which also indicated that NRQ-INA had acceptable construct validity to measure social strain. Cronbach's alpha values (α) were 0.926, 0.942, and 0.938 for the subscales of spouse, friends, and family members, respectively. The correlations of test−retest reliability for all items were >0.7 (p < 0.01), demonstrating a reliable NRQ-INA measurement. In conclusion, NRQ-INA had a good validity and reliability to measure social strain in PWD. Further study of the concurrent validity among PWD is still needed.

Association between prognostic factors and the clinical deterioration of preterm neonates with necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) is responsible for most morbidity and mortality in neonates. Early recognition of the clinical deterioration in newborns with NEC is essential to enhance the referral and management and potentially improve the outcomes. Here, we aimed to identify the prognostic factors and associate them with the clinical deterioration of preterm neonates with NEC. We analyzed the medical records of neonates with NEC admitted to our hospital from 2016 to 2021. We ascertained 214 neonates with NEC. The area under the receiver operating characteristic (ROC) curve and cut-off level of age at onset, C-reactive protein (CRP), leukocyte count, and platelet count for the clinical deterioration of preterm neonates with NEC was 0.644 and 10.5 days old, 0.694 and 4.5 mg/L, 0.513 and 12,200/mm3, and 0.418 and 79,500/mm3, respectively. Late-onset, history of blood transfusion, thrombocytopenia, and elevated CRP were significantly associated with the clinical deterioration of neonates with NEC (p = < 0.001, 0.017, 0.001, and < 0.001, respectively), while leukocytosis, gestational age, and birth weight were not (p = 0.073, 0.274, and 0.637, respectively). Multivariate analysis revealed that late-onset and elevated CRP were strongly associated with the clinical deterioration of neonates with NEC, with an odds ratio of 3.25 (95% CI = 1.49-7.09; p = 0.003) and 3.53 (95% CI = 1.57-7.95; p = 0.002), respectively. We reveal that late-onset and elevated CRP are the independent prognostic factor for the clinical deterioration of preterm neonates with NEC. Our findings suggest that we should closely monitor preterm neonates with NEC, particularly those with late-onset of the disease and those with an elevated CRP, to prevent further clinical deterioration and intervene earlier if necessary.

The role of focused assessment sonography for trauma (FAST) on the outcomes in patients with blunt abdominal trauma following non-operative therapy: A cohort study.

Background: The non-operative management of blunt abdominal trauma had a high success rate and is expected to reduce the length of hospitalization and patients' morbidity. Here, we aim to evaluate the outcomes of patients with blunt abdominal trauma after non-operative management and associate them with prognostic factors. Methods: We performed a retrospective analysis on patients with blunt abdominal trauma who received non-operative management (NOM) at our institution from April 2018 to April 2021. Results: Two hundred eleven patients were included in this study who underwent non-operative management. Most of the subjects (73%) were males, with male to female ratio of 2.7:1. Most patients aged 20-29 years old (29.4%), FAST negative (62.1%), minor injured (45%), successfully managed nonoperatively (98.6%), received no transfusion (38.9%), and injured due to traffic accident (80.1%). ISS was significantly associated with FAST (p = 0.028), while male gender, NLR, PLR, and blood transfusion did not (p > 0.05). The presence of external injury was associated with FAST results (p = 0.039), while the head, facial, thoracic, pelvic, and skeletal injuries did not (p > 0.05). We also found a significant correlation between blood transfusion and patient survival with NOM outcomes (p = 0.047 and p = 0.041, respectively). Furthermore, external injury significantly correlated with NOM outcomes (p = 0.042). Multivariate analysis showed that external and pelvic injury was significantly associated with NOM outcomes (p < 0.0001 and p = 0.036, respectively). Conclusions: The results of the FAST examination were not associated with the outcome of non-operative therapy. Moreover, the successful outcome of NOM might be affected by blood transfusions, the presence of external injuries, and pelvic injury.

Dementia in a patient with autoimmune disease and hypercoagulable state worsened by COVID-19 vaccination: A case report.

Background: Systemic autoimmune disorders are associated with an increased risk of hypercoagulability. The hypercoagulable state in people with systemic autoimmune disorders has lately gained attention. Presentation of case: We presented a 44-year-old male with a chief complaint of progressive difficulty concentrating, memory impairment, and weakness in all limbs. Seven months before admission to our Memory Clinic, the patient began to have infrequent short-term memory loss and sometimes got lost when he went for a drive. Three months later, he complained of feeling dizzy when in a crowd, being unable to watch television for a long time, and easily forgetting. Computed tomography (CT) scan showed brain infarction. After receiving the first dose of COVID-19 vaccine (Sinovac), the patient had difficulty communicating verbally and could only point at objects, as well as tetraparesis. These conditions severely intervened in his daily activities. The patient was then referred to an immunologist and diagnosed with autoimmune disease. In our Memory Clinic, his performances of attention, memory, language, visuospatial, and executive function were very poor. We diagnosed him with autoimmune dementia. The administration of methylprednisolone, mycophenolate mofetil, vitamin D3, donepezil, and memantine could improve his condition. Discussion: Autoimmune disease can cause microvascular thrombosis and microembolism at the central nervous system level, which would cause vascular damage and cognitive impairment leading to brain infarction and dementia. Conclusion: There seems to be a link between autoimmune disease, hypercoagulable state, and dementia, although the magnitude of this link and the underlying processes are not fully understood.

Combination of simple advancement flap and fistulectomy to treat complex anal fistula as a complication of hemorrhoidectomy: Case report.

INTRODUCTION: After hemorrhoidectomy, anal stenosis occurs, which is an uncommon but severe consequence. The majority of severe cases require advancement flap anoplasty. PRESENTATION OF CASE: A 50-year-old female patient with a history of hemorrhoidectomy 10 months prior to admission complained of difficulty defecating, pain, and incomplete evacuation sensation, as well as a hole on the right side of the anal canal through which feces unintentionally passed. On the physical examination, we found that the anal lumen was partially obstructed, which did not allow the insertion of a finger. There was an impression of a perineal fistula at 5 and 7 o'clock, which was connected to the anal canal 3 cm from the edge of the anus. The patient was diagnosed with severe anal stenosis with perianal fistula. The patient underwent fistulectomy and advancement flap with perianal skin. In the outpatient follow-up clinic in the first and second weeks, the patient showed no complications, and no recurrence of her complaints was found. DISCUSSION: Several corrective surgical techniques have been applied to restore a healthy lining to the constricted portion of the anal canal. We performed a combination of simple cutaneous advancement flap and fistulectomy to manage the patient with severe anal stenosis following hemorrhoidectomy with concurrent anal fistula. CONCLUSION: A combination of fistulectomy and simple cutaneous advancement flap anoplasty is a simple, safe, and effective surgical option for the management of severe anal stenosis with concomitant anal fistula.

Outcomes and Prognostic Factors for Survival of Neonates With Necrotizing Enterocolitis.

Background: Due to the survival of preterm neonates being continually improved, the modifiable prognostic factors of necrotizing enterocolitis (NEC) are essential to be investigated and considered in making a suitable treatment to decrease the prevalence and effect of NEC. Many prognostic factors have been associated with the survival of neonates with NEC; however, the studies show conflicting results. Moreover, the study from developing countries regarding NEC outcomes is minimal. Here, we aimed to determine the survival of neonates with NEC and associate it with the prognostic factors. Methods: A retrospective study was conducted using medical records of neonates with NEC at our institution from January 2014 to December 2019. Results: Fifty-two neonates with NEC were involved with the overall survival of 44.2%. Log-rank analysis showed that NEC staging and birth weight were significantly associated with the survival of neonates with NEC with a p-value of 0.010 and 0.002, respectively, while sex, APGAR score, platelet count, and type of treatment were not (p = 0.068, 0.752, 0.087, and 0.343, respectively). Multivariate analysis revealed that sex and NEC staging were strongly associated with the survival of neonates with NEC with a p-value of 0.018 [HR = 3.10 (95% CI = 1.21-7.93)] and 0.019 [HR = 0.44 (0.22-0.87)], respectively. Conclusions: Our study shows that sex and NEC staging might affect the survival of neonates with NEC. It implies that NEC staging should be closely monitored and intervened as early as necessary to prevent further morbidity and mortality.

Effectiveness of tutorial videos combined with online classes in surgical knotting course during COVID-19 pandemic: A cohort study.

BACKGROUND: COVID-19 pandemic has changed medical education from offline courses to online formats. Nowadays, offline skill demonstration lessons becomes unfeasible. This study assess the effectiveness of tutorial videos and online classes in delivering knowledge and skill in basic surgical knotting to medical students. METHODS: A group of medical students (n = 95) was divided into two groups: the first group was allowed to watch the tutorial video that we have been made and uploaded into YouTube (https://www.youtube.com/watch?v=WyfOVGhAeVA) while the other group did not watch the video. All participants submitted a demonstration video to show their knotting skill. These videos were graded and made into the first evaluation. Then, all participants attended online classes for the surgical knotting skills via Zoom application. Participants submitted another demonstration video after the online classes. The videos were assessed, and the results were analyzed. RESULTS: The experimental group (n = 50) who watched the tutorial video prior to class scored higher in the first video than the control group (n = 39) with a meanscore of 10.850 versus 7.462, p = 0.000*, In the second video, the assessment showed no significant difference between the two groups with meanscore of 11.220 versus 10.897, p = 0.706. CONCLUSION: The combination of tutorial videos and online classes is the optimal teaching method for surgical knotting skills.

Gallbladder adhesion degree as predictor of conversion surgery, common bile duct injury and resurgery in laparoscopic cholecystectomy: A cross-sectional study.

BACKGROUND: The gold-standard treatment for cholecystectomy, laparoscopic cholecystectomy, has remarkably variable outcomes and conversion rates. We investigated the gallbladder adhesion degree as a predictor of conversion surgery, common bile duct injury, and resurgery. METHODS: We reviewed 157 medical records and video recordings of laparoscopic cholecystectomy on patients with cholelithiasis with or without cholecystitis at three hospitals in Yogyakarta, Indonesia from January 2016 to December 2018. The degree of gallbladder adhesion is classified into 4 categories: no adhesion, <50% adhesion, 50%-buried GB, and completely buried GB. RESULTS: One hundred fifty seven patients were involved in this study, of whom 58 were males and 99 females with average age 49.2. Eighty-one patients out of 157 patients (51.6%) had gallbladder adhesion comprising of 61/157 (38.9%) with <50% adhesion and 20/157 (12.7%) 50%-buried GB. There is one incidence each of conversion surgery, CBD injury, and resurgery. The degree of GB adhesion has low degree of correlation with conversion surgery, CBD injury, and resurgery wirh r value of 0.156, 0.041, and 0.156 respectively. There is significant correlation between the degree of GB adhesion and conversion surgery and resurgery with p value of 0.032, and 0.032 respectively. There is no significant correlation between degree of GB adhesion and CBD injury with p value of 0.453. CONCLUSION: The degree of GB adhesion has low degree of correlation with conversion, CBD injury and resurgery. This study also showed that patients with high degree of gallbladder adhesion are still eligible for laparoscopic procedure performed by an experienced surgeon.

TGF-ß expression on different suturing technique for abdominal skin wound closure in rats.

BACKGROUND: The method of closing the abdominal wall, as well as, the choice of material for stitching are important aspects of efficient incision closure. Generally, transforming growth factor-beta (TGF-ß) is involved in the wound healing process. Suturing procedures also play a part in the wound dehiscence occurrence. This study aimed to compare TGF-ß expressions in rats after using the large stitch vs. small stitch technique for abdominal skin wound closure. METHODS: A total of twenty Wistar rats (Rattus norvegicus) were used in this experiment. Small tissue bites of 5 mm were obtained by the small stitch group and the large stitch group received large bites of 10 mm. Abdominal skin incisions were closed by running sutures. On days 4 and 7, the animals were euthanized. For TGF-ß expressions, histological parts of the tissue-embedded sutures were analyzed. With significance set at p < 0.05, two-way ANOVA showed that on days 4 and 7, the TGF-ß expressions of the rats in the small stitch group were nearly identical to those in the large stitch groups. RESULTS: After including twenty rats in this study, results showed the TGF-ß expressions on days 4 and 7 in rats in the small stitch group were equivalent to those in the large stitch group. (p = 0.45). CONCLUSIONS: Between the small and the large stitch groups, the TGF-ß expressions are similar, suggesting that the suturing methods do not have any significantly different beneficial impact on the frequency of wound dehiscence.

Management of gallstone-induced severe acute cholecystitis and pancreatitis in the second trimester of pregnancy during covid-19 pandemic: A case report.

INTRODUCTION: Gallstone-induced severe acute cholecystitis with acute pancreatitis during pregnancy can be life-threatening both for the mother and fetus. Surgical approach is recommended in this complicated disease to prevent morbidity and mortality. During COVID-19 pandemic, additional precautions are needed when dealing with abdominal complaints. PRESENTATION OF CASE: We present a 37-year-old female patient, pregnant at 22 weeks gestational age, who complained of fever, diffuse abdominal pain, and shortness of breath. Laboratory examination results revealed anemia, leukocytosis and an increase in amylase level. SARS-CoV-2 antibody is non-reactive. Imaging strongly suggested cholelithiasis and cholecystitis. The patient was given antibiotics for three days but there was no significant improvement. Open cholecystectomy with subcostal (Kocher) incision was performed. Patient was released from the hospital without post-operative complications. DISCUSSION: Treatment of gallstone induced severe acute cholecystitis with acute pancreatitis during pregnancy is challenging with the surgical complications. In the second and third trimester of pregnancy, it is more difficult to perform laparoscopic cholecystectomy because of the size of uterus. Laparoscopic procedure is also not recommended in early Covid-19 pandemic period. Therefore, open cholecystectomy with Kocher incision becomes the surgery of choice to avoid preterm birth. CONCLUSIONS: Based on our case, open cholecystectomy with Kocher incision is a safe and effective procedure for pregnant patients with cholelithiasis, cholecystitis, and pancreatitis.

Molecular epidemiology of SARS-CoV-2 isolated from COVID-19 family clusters.

BACKGROUND: Transmission within families and multiple spike protein mutations have been associated with the rapid transmission of SARS-CoV-2. We aimed to: (1) describe full genome characterization of SARS-CoV-2 and correlate the sequences with epidemiological data within family clusters, and (2) conduct phylogenetic analysis of all samples from Yogyakarta and Central Java, Indonesia and other countries. METHODS: The study involved 17 patients with COVID-19, including two family clusters. We determined the full-genome sequences of SARS-CoV-2 using the Illumina MiSeq next-generation sequencer. Phylogenetic analysis was performed using a dataset of 142 full-genomes of SARS-CoV-2 from different regions. RESULTS: Ninety-four SNPs were detected throughout the open reading frame (ORF) of SARS-CoV-2 samples with 58% (54/94) of the nucleic acid changes resulting in amino acid mutations. About 94% (16/17) of the virus samples showed D614G on spike protein and 56% of these (9/16) showed other various amino acid mutations on this protein, including L5F, V83L, V213A, W258R, Q677H, and N811I. The virus samples from family cluster-1 (n = 3) belong to the same clade GH, in which two were collected from deceased patients, and the other from the survived patient. All samples from this family cluster revealed a combination of spike protein mutations of D614G and V213A. Virus samples from family cluster-2 (n = 3) also belonged to the clade GH and showed other spike protein mutations of L5F alongside the D614G mutation. CONCLUSIONS: Our study is the first comprehensive report associating the full-genome sequences of SARS-CoV-2 with the epidemiological data within family clusters. Phylogenetic analysis revealed that the three viruses from family cluster-1 formed a monophyletic group, whereas viruses from family cluster-2 formed a polyphyletic group indicating there is the possibility of different sources of infection. This study highlights how the same spike protein mutations among members of the same family might show different disease outcomes.

Clinical findings and management of diaphragmatic rupture with hernia caused by safety body harness: A case report.

INTRODUCTION: Acute blunt traumatic diaphragmatic rupture (BTDR) caused by falling from a height is rare. Transabdominal diaphragmatic repair in an acute setting following BTDR requires good clinical decision-making and diagnostic tests. CASE PRESENTATION: A 36-year-old male was involved in a work accident. He fell from a 30-m radio transmitter tower while wearing an attached safety body harness. He arrived in the emergency room with complaints of breathing difficulty, abdominal and pelvic pain. We discovered a diaphragmatic rupture with abdominal organ herniation based on the imaging. We decided to perform an emergency laparotomy. We discovered a 12cm diaphragmatic defect on the anteromedial side of the left during surgery. We carried out the evacuation by suction and controlled the bleeding in the wound at the edge of the diaphragm. On postoperative day 4 (POD), the patient complained of dyspnea, and chest radiology revealed a hemothorax in the left lung. We then installed a water-sealed drainage (WSD) until POD 6. On the following day, his complaint was resolved, the WSD was removed and the patient was discharged uneventfully. DISCUSSION: Abdominal CT scan can be helpful in determining early diagnosis of traumatic diaphragm rupture with abdominal organ herniation, allowing for prompt surgical intervention to minimize morbidity and mortality. Furthermore, reinforced sutures might be useful to prevent recurrence of the symptoms. CONCLUSION: In conclusion, injury due to wearing a safety body harness when falling can be a potential cause of BTDR. Management of BTDR transabdominally is a safe and effective procedure.

Spontaneous cystic biloma after laparoscopic cholecystectomy treated conservatively: A case report.

INTRODUCTION: Biloma forms due to common bile duct (CBD) injury as a laparoscopic cholecystectomy complication. Spontaneous localized biloma forming cysts in the biliary duct is rare. PRESENTATION OF CASE: We report a 47-year-old male with complaint of a painful lump in the upper abdomen two months after laparoscopic cholecystectomy. Magnetic resonance cholangiopancreatography (MRCP) found a large epigastric cyst mass, without any signs of CBD injury. Patient was managed with percutaneous drainage in the outpatient clinic and kept the contents of the drainage bag for evaluation. After two months follow-up the outcome was favorable. DISCUSSION: Biloma forming cysts is a very rare complication post laparoscopic cholecystectomy. Biloma most common occurs as free fluid in the abdominal cavity. Clinical diagnostics, intraoperative historical evaluation and support with MRCP may determine the treatment options. Decision to manage with non-operative procedures by percutaneous drainage and evaluations of the patient in the outpatient clinic had a favorable outcome. CONCLUSION: Post laparoscopic biloma cysts are a very rare case. Management with percutaneous drainage in an outpatient clinic and ambulatory drainage is an effective and safe procedure.

Outcomes and survival of infants with congenital duodenal obstruction following Kimura procedure with post-anastomosis jejunostomy feeding tube.

BACKGROUND: Several modifications of the Kimura procedure for congenital duodenal obstruction (CDO) have been reported, however, their effects on the outcomes show conflicting results. METHODS: We compared the CDO outcomes following the Kimura procedure with and without post-anastomosis jejunostomy feeding tube (JFT). RESULTS: A total of 52 CDO neonates were involved (JFT: 13 males and 2 females vs. non-JFT: 14 males and 23 females, p = 0.0019). Time to full oral feeding was significantly earlier in the JFT than non-JFT group (14 [interquartile range (IQR), 12-15] vs. 17 [IQR, 14-22.5] days; p = 0.04). Duration of parenteral nutrition given to infants with CDO after surgery was significantly shorter in the JFT than non-JFT group (12 [IQR, 10-15] vs. 17 [IQR, 13-23] days; p = 0.031). Moreover, enteral feeding was significantly earlier in the JFT than non-JFT group (2 [IQR, 1-3.5] vs. 5 [IQR, 4-6] days; p = < 0.0001). However, the length of stay following surgery was not significantly different between groups (16 [IQR, 14-22] vs. 20 [IQR, 17-28] days; p = 0.22). Also, overall patient survival did not significantly differ between JFT (66.7%) and non-JFT patients (59.5%) (p = 0.61). CONCLUSION: Jejunostomy feeding tube shows a beneficial effect on the time to full oral feeding, duration of parenteral nutrition and early enteral feeding in neonates with congenital duodenal obstruction after Kimura procedure.

Challenge in diagnosis of late onset necrotizing enterocolitis in a term infant: a case report.

BACKGROUND: Necrotizing enterocolitis (NEC) is a common devastating inflammatory gastrointestinal disease and frequently occurs in premature infants. Here, we reported a case of late-onset NEC in a term neonate with good outcome after surgery for long-term follow-up. CASE PRESENTATION: Ten-week-old male came to emergency unit due to prolonged diarrhea and abdominal distention. He was born at gestational age of 40 weeks with birth weight and Apgar score of 2800 g and 7/8, respectively. He had no history of formula feeding. Two weeks before admitted to the hospital, the patient had frequent diarrhea with fever. He was found lethargic with abdominal distention, absence of bowel sounds and abdominal tenderness. Plain abdominal x-ray and CT scan showed gastric and intestinal dilatation and gasless colon, suggesting a small bowel obstruction, and bowel wall thickening indicating peritonitis, without any free subdiaphragmatic air (pneumoperitoneum). Moreover, the patient did not have a congenital heart disease. While in intensive medical treatment, he showed a continuous clinical deterioration. All findings were suggestive of intestinal inflammation with clinical deterioration, and we decided to perform an emergency exploratory laparotomy and found an ischemia along the jejunoileal with a perforation at 25 cm above the ileocecal valve. Subsequently, we performed a double-barrel ileostomy through a separate incision from the laparotomy. Histopathological findings confirmed the diagnosis of NEC. We closed the stoma at postoperative day 43. The patient was discharged uneventfully a month after stoma closure. CONCLUSION: Abdominal CT scan might be useful to establish an early recognition of late-onset NEC; thus, immediate surgical intervention might be performed to decrease its morbidity and mortality. Moreover, late-onset NEC in term neonates might occur without any risk factors or significant co-morbidities.

Various radiological findings in patients with COVID-19: A case series.

INTRODUCTION: Radiological evaluation of suspected COVID-19 patients is required for early detection of thoracic involvement, particularly in emergency units, while waiting for definitive diagnosis by real-time reverse transcription polymerase chain reaction (RT-PCR). Here, we report a case series of CXR findings in Indonesian patients with COVID-19 in our institution. PRESENTATION OF CASES: We included 7 patients with COVID-19 confirmed by RT-PCR, including 4 females and 3 males, with ages ranging from 36 to 71 years. All patients showed abnormal findings on CXR when admitted to the hospital, except one, composed of ground glass opacity (GGO) (n = 1), consolidation (n = 3), and both (n = 2). Both and one side of the lung were affected in three and three (left side = 2; right side = 1) patients, respectively. Pneumonia degrees of mild, moderate and severe were observed in three, one, and two patients, respectively. All patients eventually recovered. DISCUSSION: CXR is the most common radiological examination for patients with respiratory disorders, including COVID-19, and it is readily available in almost all health care facilities. The imaging manifestation of COVID-19 is similar to viral pneumonia but also has its own characteristics, including GGO, consolidation, multiple plaque shadows, and interstitial changes that are mostly seen in peripherals and subpleural areas, as well as shadow infiltration in both lungs. CONCLUSION: CXR showed various abnormality findings in patients with COVID-19, including the type, location, and degree of pneumonia. Moreover, CXR is considered more effective and useful for initial screening and follow-up of the progress of patients with COVID-19.