Class 3A Research Articles

Physician awareness and attitudes regarding early warning score systems in mainland China: a cross-sectional study.

The purpose of this study was to assess the application of the early warning score system (EWS-S) and gauge physician awareness, perceptions of necessity and attitudes regarding these tools based on previously experienced unnoticed clinical deterioration (CDET). A cross-sectional survey was carried out via an online questionnaire at a large 3,500-bed Class 3A general hospital in China. A total of 299 physicians of adult general wards were asked to answer a translated questionnaire that was localised from the original version. Demographic profiles of patients were included as well as three other sections assessing awareness of CDET/EWS-S and gauging attitudes towards and perceptions of the necessity of EWS-S at our hospital. A high level of physician awareness of the CDET problem was observed. Most physicians knew about the existence of a systematic assessment tool for clinical application. Physicians with previous experience in reanimation, unplanned transfer to intensive care unit (UTICU) and/or death tended to consider EWS-S necessary in attentive and well-trained staff (p < 0.05). Physicians who had previous experience with UTICU were more likely to recommend implementing EWS-S in their wards compared with those without such experience (p < 0.05). Most physicians have positive attitudes towards EWS-S. However, their awareness should be further heightened. Physicians who had previous experience with CDET/UTICU were more likely to employ EWS-S in their clinical practices. To better facilitate the implementation of EWS-S in Chinese hospitals, existing facilities, policy supports, standardised managements and the development of information systems should be strengthened.

On the application of intelligent speech aids in English teaching under multimedia environment

In order to improve the effect of English Teaching in multimedia environment, this paper proposes an English teaching method based on intelligent language AIDS in multimedia environment. Firstly, an intelligent speech teaching assistant system is designed in the multimedia environment. The software mainly includes four modules: new words and sentences, Chinese and English reading, voice evaluation, tools and settings. Learners can learn independently through the software, and teachers can also use the software to make various audio teaching resources in the classroom. In addition, the system can promote vocabulary teaching and support sentence pattern teaching and situational teaching in English teaching. The experimental results show that the average score of class 3A is increased from 86.35 to 86.79, with an increase of 0.64, which proves that the application of this method can effectively mobilize the enthusiasm of students in learning English and achieve good teaching effect.

Study on Health Management and Service Model of Chifeng Class 3A General Public Hospital

This study investigates the construction of a health management service mode based on large-scale comprehensive hospitals by analyzing health management service modes at home and abroad, that is, taking the Affiliated Hospital of Chifeng University as an example, establish a health examination hospital, undertake core tasks such as health service operation process, system, monitoring, and system formulation, and take the best medical resources. Attract social medical resources to collaborate and give health service mode of health status monitoring, evaluation, and intervention to health service objects, aided by advanced medical technology. To extend the traditional health management service with the hospital as the protagonist to health management with participation from family and society beyond the hospital, forming a closed-loop, rapid, and efficient health service management system. Thus, through graded quality services, to lessen the difficulties of patients seeing a doctor and to solve the problem of overcrowding and minor ailments in major hospitals.

Energy consumption and building layouts of public hospital buildings: A survey of 30 buildings in the cold region of China

• Building layout and energy consumption of tertiary hospitals was surveyed. • The average energy consumption per unit area of Class 3A hospitals increased. • The comprehensive clinics layout mainly includes five types. • The inpatient departments mainly include three types. The energy consumption in hospitals is intensive owing to the complex building functions, high density of electrical equipment for diagnosis and treatment, and long hours of operation. This study focuses on the building layout patterns and energy efficiency of hospitals in the cold climate region of China. The building layout and energy consumption of 30 hospitals from 2015 to 2017 are collected and analysed. According to the survey data, the average energy consumption per unit area of Class 3A hospitals in the cold region increased by 5.3% from 2015 to 2017. The total energy consumption per unit area in summer was higher than that in winter, with remarkable heating and cooling demands. The building layout of comprehensive clinics can be categorised into the following five types: centralised arrangement, linear arrangement of multiple wings, linear arrangement of courtyards, grid courtyards, and mixed arrangement. Among these, the energy savings rate of the grid courtyard-type arrangement is the highest (16.3%). Three types of layouts are noted for inpatient buildings: ‘L’-shaped layout, ‘工’-shaped layout, and ‘一’-shaped layout. Among these, the ‘L’-shaped layout is the most energy efficient, with the energy savings rate reaching 5.9%. Corresponding energy-saving strategies are developed in the present investigation. These can provide guidance for architects in the early design stages.

Chromosome counts of eight Iranian endemic species of Nepeta L. (Lamiaceae)

In this survey, the chromosome counts of eight Nepeta L. species were investigated and the karyotypic diversity among these species was studied. The examined species belong to N. cephalotes Boiss. species group, namely N. eremokosmos Rech.f., N. gloeocephala Rech. f., cephalotes Boiss., N. pungens (Bunge) Benth., N. ispahanica Boiss., N. mahanensis Jamzad &amp; Simonds, N. hormozganica Jamzad and N. denudata Benth. collected from different habitats in Iran. The ploidy levels, karyotype formula, chromosome length range, total karyotype length, several karyotype asymmetries values and Stebbins classification were determined in this study. Results showed the same chromosome number, 2n = 2x= 18 for all studied species. The basic chromosome number for the above mentioned species are x = 9. Also, the smallest chromosome length is 1.02 μm in N. mahanensis. The largest chromosome length is 2.3 μm in N. ispahanica. The chromosomes of species were metacentric or submetacentric. According to the Stebbins classification, these species were located into three classes 1A, 2A and 3A. The chromosome numbers for six of studied species are reported here for the first time.

Reciprocal teaching approach towards mathematics learning outcome of elementary school teacher education students

The purpose of this paper is to describe the effectiveness of the reciprocal teaching approach towards mathematics learning outcomes of elementary school teacher education students, the effectiveness of group presentation learning towards mathematics learning outcomes and to compare the effectiveness of reciprocal teaching approaches and group presentation learning in terms of mathematics learning outcomes of towards mathematics learning outcomes of elementary school teacher education students. This type of research is a quasi-experimental quantitative research. This research was conducted at elementary school teacher education program in Universitas Sarjanawiyata Tamansiswa. The subjects of this study were students of the 3rd semester, namely classes 3A and 3C. Data Analysis technique of quantitative used one way anova and independent sample t-test. Based on the results of the research, it can be concluded that mathematics learning using a reciprocal teaching approach was more effective than mathematics learning using group presentations towards mathematics learning outcomes.

Specialized Medical Weight Management Intervention for High-Risk Obesity.

Background: Bundled payments are services rendered at pre-determined costs with the goal of providing high value care. Our institution’s Episodes of Care team partnered with its tertiary care obesity center to design a novel medical weight management bundle for employers that would collectively deliver high value obesity services.Objective: As a first step, we sought to evaluate short-term medical weight loss outcomes over 6 months at the obesity center.Methods: We retrospectively analyzed weight loss outcomes on 157 patients with commercial insurance coverage over a period of 6 months.Results: Patients ranged in age from 18-72 years, and 77.7% were female. Patients ranged in weight from 160-443 pounds, with a mean body mass index (BMI) of 42.7 kg/m2 (Class 3a severe obesity; BMI range 28.4-74.5). The prevalence of any obesity-related medical condition was 54.1%; at least a quarter of the patients had either prediabetes or Type 2 diabetes mellitus, approximately a third had hypertension, and over 8% had hyperlipidemia. Mean weight loss from the initial program start date was 6.28% (+/-0.48% standard error of mean [SEM]; 95% confidence interval [CI] 5.34-7.23%). Completers (defined as having at least 6 visits with a medical provider) achieved a higher percentage of weight loss (7.06%) from the initial program start compared to non-completers (4.68%; at least 4-5 visits with a medical provider; P<0.0158). Approximately 50% of patients were able to achieve >7% weight loss, with over 55% of patients achieving at least 3% weight loss or higher irrespective of BMI classification.Conclusions: Specialized medical weight intervention is effective in treating high-risk obesity with complications. This has implications for enhanced long-term cost savings related to employer coverage of such programs for their employees with obesity.

Specialized Medical Weight Management Intervention for High-Risk Obesity

Background: Bundled payments are services rendered at pre-determined costs with the goal of providing high value care. Our institution’s Episodes of Care team partnered with its tertiary care obesity center to design a novel medical weight management bundle for employers that would collectively deliver high value obesity services. Objective: As a first step, we sought to evaluate short-term medical weight loss outcomes over 6 months at the obesity center. Methods: We retrospectively analyzed weight loss outcomes on 157 patients with commercial insurance coverage over a period of 6 months. Results: Patients ranged in age from 18-72 years, and 77.7% were female. Patients ranged in weight from 160-443 pounds, with a mean body mass index (BMI) of 42.7 kg/m2 (Class 3a severe obesity; BMI range 28.4-74.5). The prevalence of any obesity-related medical condition was 54.1%; at least a quarter of the patients had either prediabetes or Type 2 diabetes mellitus, approximately a third had hypertension, and over 8% had hyperlipidemia. Mean weight loss from the initial program start date was 6.28% (+/-0.48% standard error of mean [SEM]; 95% confidence interval [CI] 5.34-7.23%). Completers (defined as having at least 6 visits with a medical provider) achieved a higher percentage of weight loss (7.06%) from the initial program start compared to non-completers (4.68%; at least 4-5 visits with a medical provider; P&lt;0.0158). Approximately 50% of patients were able to achieve &gt;7% weight loss, with over 55% of patients achieving at least 3% weight loss or higher irrespective of BMI classification. Conclusions: Specialized medical weight intervention is effective in treating high-risk obesity with complications. This has implications for enhanced long-term cost savings related to employer coverage of such programs for their employees with obesity.

Characteristics of hospitalized patients with depression and their relationship with the surrounding environment: A study in a class 3A hospital in Shanghai

The World Health Organization predicted that depression will become the second greatest disease burden after coronary heart disease by 2020. However, there are few quantitative studies on the spatial relationship between environmental factors and characteristics of patients with depression. In this paper, mathematical statistics, geographical information system and regression methods were used to conduct a quantitative analysis of the individual attributes of hospitalized patients with depression in a Class 3A hospital in Shanghai from 2013 to 2019 and to explore the relationship between individual attributes and circumjacent environmental factors. The results show that (1) the total number of patients with depression has increased in recent years, and the proportion of women was increased 2.5-fold compared with that of men. The risk was significantly increased in middle-aged and young adults aged 45–69 years compared with other age groups. The average hospitalization time was 20–30 days. The lower the level of education, the greater the risk of depression. (2) Within a certain spatial range, the closer to city parks and coffee shops, the lower the distribution density of depressed patients. (3) Medical insurance for patients with depression needs to implement a “people-oriented” differentiation policy. (4) Expanding urban public space, improving urban leisure and entertainment infrastructure, and introducing coffee shops into large-scale residential communities are three important strategies to prevent and treat depression.

Peritoneal cancer index predicts severe complications after ovarian cancer surgery

Introductionprediction and importance of severe postoperative complications after ovarian cancer surgery is a strong issue in patient selection and evaluation. Pre- and early peroperative predictors of severe 30-days postoperative complications (Clavien-Dindo class ≥3) after surgery for primary ovarian cancer are not fully established, neither their impact on patients’ survival. Materials and methodsA prospective observational study included 256 patients with primary ovarian cancer FIGO stages IIB-IV, operated during 2009–2018 in a primary or interval debulking surgery setting. Patient variables were analysed in relation to severe postoperative complications (Clavien-Dindo class ≥3) and overall survival. ResultsHigh-grade postoperative complications occurred in 24.2% patients. Class 3a complications were observed in 12.5% cases. High-grade complications class ≥3 were observed in 31.6% after primary debulking surgery compared to 12.2% after interval debulking surgery (p = 0.0004). Peritoneal cancer index ≥21 and preoperative albumin concentration ≤33 g/L were independent predictors of high-grade complications. Peritoneal cancer index correlated with the surgical complexity score and completeness of cytoreduction. Increased peritoneal cancer index was a negative predictor of overall survival, but high-grade complications did not influence survival negatively. ConclusionsPeritoneal cancer index ≥21 was an independent predictor of high-grade complications after ovarian cancer surgery. Increased peritoneal cancer index also impacted overall survival negatively, but high-grade complications did not influence overall survival.

Cellular antioxidant mechanisms control immunoglobulin light chain-mediated proximal tubule injury

A major cause of morbidity and mortality in multiple myeloma is kidney injury from overproduction of monoclonal immunoglobulin light chains (FLC). FLC can induce damage through the production of hydrogen peroxide, which activates pro-inflammatory and pro-apoptotic pathways. The present study focused on catalase, a highly conserved antioxidant enzyme that degrades hydrogen peroxide. Initial findings were that FLC increased hydrogen peroxide levels but also decreased catalase levels and activity in proximal tubule epithelium. In order to clarify, we showed that the phosphatidylinositol 3-kinase inhibitor, LY294002, inhibited FLC-induced Akt-mediated deactivation of Forkhead box O class 3a (FoxO3a) and increased catalase activity in proximal tubule cells. Augmented catalase activity decreased FLC-mediated production of hydrogen peroxide as well as the associated increase in High Mobility Group Box 1 (HMGB1) protein release and caspase-3 activity. Coincubation of cells with FLC and an allosteric activator of Sirtuin 1 (SIRT1) was also sufficient to increase catalase activity and promote similar cytoprotective effects. Our studies confirmed that the mechanism of downregulation of catalase by FLC involved deactivation of FoxO3a and inhibition of SIRT1. Mechanistic understanding of catalase regulation allows for future treatments that target pathways that increase catalase in the setting of proximal tubule injury from FLC.

Distal pancreatectomy with en bloc celiac axis resection (DP‐CAR) and arterial reconstruction: Techniques and outcomes

Ischemic complications are still prevalent after distal pancreatectomy with en bloc celiac axis resection (DP-CAR) despite the use of preoperative arterial embolization. We described our institutional experience with arterial reconstruction during DP-CAR. We retrospectively reviewed short- and long-term outcomes of all DP-CAR performed for pancreatic adenocarcinoma between January 1, 1995 and March 30, 2020. Outcomes were compared according to the presence of arterial reconstruction. Sixty consecutive DP-CARs were reviewed. Most patients underwent induction chemotherapy (85%) based on FOLFIRINOX protocol (80.3%). The hepatic artery was reconstructed in 50 patients (83.3%). The left gastric artery was reconstructed in 4 and preserved in 14 patients. A venous resection was associated during 44 DP-CARs (36 segmental venous resections/8 lateral venous resections). Ninety days mortality was 5.0% with 48.3% (n = 29) overall rate of morbidity. Postoperative outcomes in term of mortality, morbidity, and ischemic events between patients with and without arterial reconstruction were similar despite a higher rate of venous resection (81% vs. 40%; p = 0.005) and more complex cases (Mayo clinic DP-CARs class1B, 2A, and 3A) in the reconstructed group. Arterial reconstruction represents a safe surgical option during DP-CAR to lessen postoperative ischemic events. This technique, reserved to high volume centers expert in vascular resection during pancreatectomy, deserves further comparison with standard technique in a larger setting.

Emphysematous pyelonephritis: experience at a tertiary care hospital in Bangladesh.

Emphysematous pyelonephritis (EPN) is a necrotizing infection of the renal parenchyma, collecting system and/or perinephric tissues, characterized by gas accumulation. We describe clinical, laboratory and imaging characteristics and in-hospital outcomes of patients with EPN. This retrospective observational study was carried out at BIRDEM General Hospital, Dhaka, Bangladesh between 2014 and 2020. We followed 20 patients (mean age 49.4 years; females 70%). Risk factors for EPN were diabetes mellitus (in 100%) and renal stones (in 10%). Fever, loin pain, vomiting and dysuria were common. Complications included acute kidney injury (AKI, 70%; mostly stage 1, 78.6%), hyponatraemia (55%) and bacteraemia (15%). Escherichia coli was the most common (60%) urinary isolate. Most patients (80%) had class 2 EPN, with 15% class 3B and 5% class 3A. Besides medical management, four (20%) required surgery (nephrectomy in 3). Nephrectomised patients had a higher radiological class (p = 0.032) and incidence of AKI (p = 0.034). No deaths occurred. EPN occurred predominantly in female diabetic patients, who presented with fever, loin pain, vomiting and dysuria. Two-thirds of patients had AKI and one-fifth required surgery, and there were no deaths.

Emphysematous pyelonephritis (EPN): A prospective study on management modalities and outcome in a tertiary care hospital

Background: EPN was a rapidly progressive, fulminant, life threatening, necrotizing infection of kidneys and perinephric space. EPN was most commonly seen in patients with diabetes mellitus.Aim and Objective: To study the clinical features, radiological classification, risk factors, Prognostic factors and management Modalities of Emphysematous pyelonephritis. Methodology: 54 patients who were diagnosed to have Emphysematous pyelonephritis from various departments in Nizam’s institute of medical sciences from December 2016 to November 2019 were included in the study. The diagnosis of EPN was confirmed by plain CT KUB scan. Results: Of the 54 patients 16 were male and 38 were female. 40 patients with EPN had diabetes mellitus (DM). There was 4 patients who was diagnosed to have DM after admission. Left kidney involved in 51.80% (28) of patients. Right kidney in 37.03% (20) of cases. Out of 54 patients, 14 patients who were presented to us with EPN had a pre-existing CKD. Only 14 out of 54 patients with EPN had normal renal parameters. Thrombocytopenia was seen in 32 of these patients and 4 of patients with thrombocytopenia required platelet transfusion. Urine culture was sterile in 3 patients. E.coli was grown in 42 patients and klebsiella in 3patients. There were 14 patients with dry EPN and 40 patients with wet EPN. 21.8% (12) patients has class 1 EPN. 43.75% (24) of patients had Class 2 EPN (Commonest class in our study), 25% (13) of patients had class 3A EPN, 3.1% (2) had class 3B EPN, 6.25% (3) has Class 4 EPN. The mean follow up was 8 months, ranging from 3 months to 24 months. 40 patients are under regular follow up. Conclusion: Pre-existing CKD status, shock at presentation and altered sensorium are the poor prognostic factors in this study.

Effects of Lithium Combined with Second-Generation Antipsychotics for the Treatment of Manic Episodes in Patients with Bipolar Disorder: A Naturalistic Study in China.

ObjectiveTo explore the therapeutic effects of lithium combined with second-generation antipsychotics (SGAs) of quetiapine, clozapine, olanzapine, and risperidone for the treatment of manic episodes in patients with bipolar disorder (BD) to guide the selection of medications.MethodsWe examined the case data of patients with BD who experienced manic episodes and were hospitalized in a Class 3A Psychiatric Hospital in Anhui Province from January 2015 to October 2019. The enrolled patients were rated using the Bech–Rafaelsen Mania Rating Scale (BRMS) before and after treatment, and relevant adverse effects were monitored.ResultsAnalysis of the collected case data of 182 patients showed significant differences in the BRMS scores on admission and at discharge of patients treated with lithium combined with each SGA. The chi-square test showed no obvious difference in the final therapeutic effects of lithium combined with each of the four SGAs (χ2 = 7.365, P = 0.146). However, there were differences in the incidence of adverse effects (χ2 = 10.604, P = 0.014) and remission rate after 2 weeks of treatment (χ2 = 10.174, P = 0.017). Logistic regression analysis revealed that the incidence of adverse effects was related to the length of stay in hospital and clozapine treatment. The remission rate after 2 weeks was associated with the length of stay in hospital, clozapine treatment, and age of onset.ConclusionLithium combined with SGAs (quetiapine, clozapine, olanzapine, and risperidone) effectively improves the manic symptoms of patients with BD who experience manic episodes. Lithium combined with quetiapine for the treatment of bipolar manic episode has advantages with respect to the speed of effective and incidence of adverse effects.

Improving Student Creative Thinking Ability With Problem Based Learning Approach Using Hawgent Dynamic Mathematics Software

The main problem in this study is the lack of mathematical creative thinking abilities of elementary school students in Cimahi, Indonesia. This lack of mathematical creative thinking abilities is caused by an incorrect learning process. The teacher does not direct students to think creatively. In fact students still depend a lot on what is explained by the teacher in the class. The learning process with problem-based learning that is aided by hawgent dynamic mathematic software can direct students to think creatively. The population in this study were all elementary school students in Cimahi city. The samples were the students of elementary school Cimahi class 3A and 3B. The instrument in this study is descriptive test of students creative thinking abilities. This instrument was used to obtain data about students' creative thinking abilities with problem-based learning approach using hawgent dynamic mathematic software and by conventional learning. The data processed in this study was from the post-test score. These scores from both of the experimental class group and the control class group. Then, the data was processed by using SPSS 19.0 and Microsoft Excel. The data was analyzed using t-test statistic. The final result of this study concluded the achievement and improvement of creative thinking abilities of students whose learning problem-based approach using hawgent dynamic mathematic software.

The Biosynthetic Option as an Alternative in Complex Abdominal Wall Reconstruction.

Synthetic mesh and acellular dermal matrix reinforcement during complex abdominal wall reconstruction (CAWR) have significantly improved outcomes. In an attempt to further improve outcomes, we combined both into a single biosynthetic by suturing a synthetic mesh on top of porcine acellular dermal matrix. Our aim was to review our experience with this new technique. Patients undergoing CAWR with the biosynthetic mesh were reviewed from a prospective database from 2015 to 2018. A total of 39 patients were 56.3 ± 10.9 years old, white (59.0%), and female (74.4%), with 31.9 ± 7.4 kg/m of body mass index. Eight repairs were performed on patients classified as greater than or equal to modified Ventral Hernia Working Group (mVHWG) class 3a, and 41.0% followed a concurrent resection of previously placed mesh. The biosynthetic mesh was placed as an underlay (51.3%) or inlay (46.2%) with primary closure in 51.3% and component separation in 12.8%. Recurrence at 3 years of follow-up occurred in 3 patients (7.7%). Complications within 60 days occurred in 6 patients (15.4%), including 4 soft tissue infections-one requiring explantation, with a total of 2 patients (5.1%) requiring explantation overall. Type 2 diabetes, previous mesh removal, component separation, and mVHWG class 3b independently predicted noninfectious complications. Male sex and mVHWG class 3b independently predicted surgical site infection. No predictors were found for recurrence. Biosynthetic mesh does not seem to increase the risk of early complications and may reduce recurrences and improve long-term outcomes after CAWR.

Myasthenia Gravis Mimicking Acute Cerebrovascular Events

Background and Objective: Myasthenia gravis (MG) is an immune-mediated disorder that can sometimes present acutely with a focal neurological deficit and thus mimic a cerebrovascular event. The objective of this study was to describe the clinical characteristics in a large cohort of patients who were initially misdiagnosed with an acute vascular event and later diagnosed with MG.&#x0D; Methods: This is a retrospective chart review of patients who were initially diagnosed with an acute cerebrovascular event but subsequently found to have MG. The chart review was done for the period from January 2013 to December 2017, and patients with at least one-year follow-up included. Data are reported as means ± SEM, and the results reported using prevalence rates.&#x0D; Results: Twenty-one patients met our inclusion criteria. Among them, 13 (61.9%) were female with a mean age of 56.7 ± 4.07 years. Ten were MGFA class 3a; seven were MGFA class 2b, 3 were MGFA 3b. Eighteen patients were acetylcholine receptor antibody positive; one was MuSK positive, and the rest two seronegative. Slurred speech (8 patients, 38.1%) was the most common symptom that resulted in misdiagnosis, followed by hemibody weakness (7 patients, 33.3%) and dysphagia (3, 14.3%). Smoking (12, 57.1%) and hypertension (11, 52.4%) were common risk factors for cerebrovascular disease. Small vessel disease was suspected the most common etiology (15, 71.4%) of the vascular event. Ten patients had received thrombolytic therapy, and 16 patients were on antiplatelets. 4 patients who presented recurrent symptoms placed on anticoagulants. &#x0D; Conclusion: Acute presentation of bulbar symptoms and hemibody weakness resulted in the misdiagnosis of MG.

P0298EMPHYSEMATOUS PYELONEPHRITIS: SEVEN YEAR EXPERIENCE OF MANAGING CONSECUTIVE 22 PATIENTS IN A SINGLE CENTER OF BANGLADESH

Abstract Background and Aims Emphysematous pyelonephritis (EPN) is an uncommon, severe, necrotizing infection of the renoureteral unit and is recognized by accumulation of gas within the collecting system, renal parenchyma and/or perinephric tissue. Common risk factors for EPN are diabetes mellitus, renal stone, obstructive uropathy and immunosuppression. Principles of treatment include resuscitative measures, antibiotics, strict glycaemic control and interventions in selected cases. This study aimed to describe clinical, laboratory and imaging characteristics of EPN patients with special emphasis on in-hospital outcome. Method This cross-sectional study included consecutive 22 EPN patients, managed in the Department of Internal Medicine and the Department of Nephrology of a tertiary care hospital in Dhaka, Bangladesh from January 2013 to December 2019. Patients’ selected socio-demographic, clinical and laboratory parameters and in-hospital treatment-outcome were recorded in case record forms at the time of discharge or death, if were any. Results Total patients were 22 (mean age 46.8±12.5, range 34.0–55.0 years) including 16 (72.7%) females. All (22, 100%) were diabetic [one (4.5%) patient was newly detected as diabetic during EPN diagnosis]. Three (13.6%) patients had renal stones (bilateral in one), two (9.1%) had obstructive uropathy, six (27.3%) had chronic kidney disease, 12 (54.5%) had hyponatreamia and 16 (72.7%) were complicated by acute kidney injury (AKI). Patients presented with fever (22, 100%), loin pain/renal angle tenderness (19, 86.4%), vomiting (19, 86.4%) and dehydration (8, 36.4%). One (4.5%) patient had pneumaturia. One (4.5%) patient presented with uraemic encephalopathy and none had shock. One (4.5%) patient had tender ectopic (pelvic) right kidney. Patients had leukocytosis (mean total white cells 19917±7549, range 10250–37630/cmm of blood) and four (18.2%) patients had thrombocytopaenia. All patients had high erythrocyte sedimentation rate (mean 65.7±20.8, range 35–120 mm in 1st h) and C-reactive protein (mean 68.9±60.3, range 18–209 mg/L). Glycaemic status was poor [mean random blood glucose at admission 17.4±6.0, range 10.6–35.5 mmol/L and mean glycated haemoglobin (HbA1c) 9.8±2.1, range 6.9–15.5%]. Diagnosis of EPN was confirmed by abdominal ultrasonography and computed tomography scan. One patient had EPN in ectopic right kidney, one patient had EPN along with air in ureter, two patients had associated emphysematous cystitis and one had psoas abscess. Ten (45.5%) patients had EPN in right kidney (including pelvic kidney), 11 (50%) had EPN in left kidney, one (4.5%) had bilateral EPN and three (13.6%) patients had concomitant contralateral pyelonephritis. According to Huang and Tseng classification, one (4.5%) patient had class 4 EPN, three (13.6%) patients had class 3B, five (22.7%) patients had class 3A and thirteen (59.1%) patients had class 2 EPN. Escherichia coli was the most common (13, 59.1%) organism identified on urine culture [including four (4/13, 30.8%) cases with extended-spectrum beta-lactamase positive E. coli] and four (18.2%) patients were complicated by bacteraemia. Five (22.7%) patients required surgical interventions [nephrectomy in three (13.6%) and open drainage in two (9.1%)]. All patients were treated with intravenous antibiotics and other supportive measures. One patient required three sessions of haemodialysis. Mean hospital stay was 16.1±6.4 (range 7–31) days. AKI resolved in 3 (3/16, 18.8%) patients and in others renal function was improving at the time of discharge and there was no death. Conclusion Most EPN patients were successfully managed by conservative approach in this study, two-thirds had AKI, one-fourth required surgical interventions and there was no death. Though conservative approaches for managing EPN is becoming popular, we emphasize interventions should not be delayed, as and when indicated, and may appear life-saving.

Surgical site complications after parotid gland surgery for benign tumors in a centralized setting: A Clavien-Dindo class cohort analysis

BackgroundSurgical resection is the standard of care for parotid gland tumors. Comprehensive reports on the surgical complications of parotidectomy are lacking. This study focuses on surgical wound complications of parotid gland surgery. Patients and methodsIn the period 2002–2012, 390 consecutive patients (395 procedures) who underwent parotid gland surgery were selected for retrospective analysis. Based on subsequent management, the impact of surgical site complications was graded by the Clavien-Dindo Classification (CDC). ResultsIn 83 (21.0%) of the procedures, at least one complication was registered. In total, 118 complications were described. Rated to CDC, 61 patients (15.4%) were graded as class 2 or higher. This implies therapy was dictated. Fortyfive (11.4%) of the complications were surgical site infections (SSI). In 9 patients (2.3%) surgical complications required a surgical intervention under general anesthesia (CDC class 3b), and in 19 patients (4.8%) other invasive treatment (CDC class 3a) was needed. ConclusionsThe Clavien-Dindo Classification proved to be very useful for retrospective registration of surgical complications. Of the 61 patients, 33 were managed by conservative therapy. No risk profile was found for patients at risk for direct surgical complications.