Management Of High-risk Cases Research Articles

Factors predicting mortality among patients with COVID-19 associated hospital acquired pneumonia: insights from a tertiary care center.

Hospital acquired pneumonia (HAP) is a severe and dangerous complication in patients admitted with COVID-19, causing significant morbidity and mortality globally. However, the early detection and subsequent management of high-risk cases may prevent disease progression and improve clinical outcomes. This study was undertaken in order to identify predictors of mortality in COVID-19 associated HAP. A retrospective study was performed on all patients who were admitted to a tertiary care center with COVID-19 associated HAP from July 2020 till November 2020. Data was collected on relevant demographic, clinical and laboratory parameters to determine their association with in-hospital mortality; 1574 files were reviewed, out of which 162 were included in the final study. The mean age of subjects was 59.4±13.8 and a majority were male (78.4%). There were 71 (48.3%) mortalities in the study sample. Klebsiella pneumoniae (31.5%) and Pseudomonas aeruginosa (30.2%) were the most common organisms overall. Clinically significant growth of Aspergillus sp. was observed in 41 (29.0%) of patients. On univariate analysis, several factors were found to be associated with mortality, including male gender (p=0.04), D-dimers >1.3 mg/L (p<0.001), ferritin >1000 µg/mL (p<0.001), LDH >500I.U/mL (p<0.001) and procalcitonin >2.0 µg/mL (p<0.001). On multivariate analysis, ferritin >1000ng/mL, initial site of care in Special Care Units or Intensive Care Units, developing respiratory failure and developing acute kidney injury were factors independently associated with mortality in our patient sample. These results indicate that serum ferritin levels may be a potentially useful biomarker in the management of COVID-19 associated HAP.

STUDY OF THE PROPORTION AND VARIOUS INDICATIONS ASSOCIATED WITH PRIMARY CESAREAN SECTION IN MULTIPAROUS WOMEN IN TERITARY CARE HOSPITAL IN WESTERN MAHARASTRA

Background : World wide raise in cesarean section rate in the last three decades has been the cause of alarm and need for study in depth .cesarean section has been one of the most commonly performed surgical procedures . Primary caesarean section in the multipara means first caesarean section done in the patients who had previously delivered vaginally once or more(1). Aims and objectives of this study were to know the proportion and various indications of primary caesarean section in multipara. Methods : This was a prospective observational study of primary caesarean section in multipara women admitted at tertiary care hospital in western rural Maharashtra during the period of 1year from june2021 to june2022. Multipara with pregnancy of &gt;28 weeks gestation (gravida 2 and above), each of whom has had a previous vaginal delivery of &gt;20 weeks gestation were included(2). Women with previous abortions and previous section were excluded. Results:During the study period of one year, total 8124 deliveries occurred, out of which 3000 (37.39%) underwent caesarean section and 386 (12.61%) were primary caesarean section in multigravida. Out of these multigravida patients who underwent primary caesarean section- most of the patients were unbooked (77.72%). Majority of the cases were direct admission in the hospital (61.13%). Maximum number of the patients were in the age group of 22- 30 years (55.95%). Two third of the patients were literate (69.44%) Maximum number of patients were Gravida 2 (48.72%). Almost all of them (94.85%) underwent emergency caesarean section. The most common indication for primary LSCS in multigravida patients was fetal distress 120 (30.79%) followed by malpresentation in 76 (19.39%) patients, severe pre ecclamsia and ecclamsia in 82 (19.39%), Obstructed labour in 36 (9.55%), and antepartum hemorrage in 43 (12.1%), Twin pregnancy in 29 (6.44%). Most common maternal complication was pyrexia 40 (10.36%) Most common indication for caesarean section in multipara was fetal distress followed by mal-presentation and severe pre-ecclampsia Conclusion and interpretation:From the above study it is very clear that, many unforeseen complications occur in woman who previously had a normal vaginal delivery, Present studyalso concludes that Fetal distress is a major contributor to primary CS in multigravida. Proper antenatal evaluation with early detection and management of high risk cases can reduce the likelyhood of intrapartum fetal distress.

Outcome of dual mobility total hip arthroplasty in patients who are at high risk for dislocation

&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;Dislocation after total hip arthroplasty (THA) remains a major concern, because it is reported to range from 1% to 5%. The concept of dual mobility articulation was developed in 1970 by Bousquet to decrease dislocation risk. Several studies have looked at the outcome of dual mobility articulation in primary THA and in revision THA.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This is a prospective study of 33 patients undergoing dual mobility THA during 24 months period from October 2017 to September 2019. Patients undergoing total hip replacement (THR) to have dual mobility cup (DMC) were those at high risk of dislocation. Patients were followed up for a mean period of 18 months.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;33 patients (mean age 67 years) underwent DMC THA. 27 patients underwent primary hip replacement. The follow-up of our cases has ranged from 13 months to 3 years with a mean follow-up of 18 months. none of the patients had hip dislocation.&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions&lt;/strong&gt;: The DMC is an effective solution for the management of high-risk cases undergoing total hip replacement to reduce the incidence of postoperative instability.&lt;/p&gt;

Prevalence and Risk Factors of Glaucoma in Rural China (the Rural Epidemiology for Glaucoma in China [REG-China]): A National Cross-Sectional Study

Background: Glaucoma is the commonest cause of irreversible blindness worldwide. The Rural Epidemiology for Glaucoma in China (REG-China) was conducted to investigate the present status of glaucoma in rural China. Methods: The REG-China Study is a cross-sectional study in a nationally representative sample of population aged 6 years or older from ten provinces, autonomous regions, and municipalities in rural areas of China. All participants underwent a comprehensive eye examination, including visual acuity, intraocular pressure, slit-lamp microscopy, direct ophthalmoscopy, and further investigations. Findings: From June to October 2018, 52 041 individuals were invited to participate, of whom 48 398 were included in the final analysis. The overall prevalence of glaucoma was 1·6% (95% CI 1·52–1·77) among the population aged 6 years or older. The prevalence of all types of glaucoma in persons aged 40 years or older was 2·0% (95% CI 1·96–2·85); 58·2%, and 19·8% had primary angle-closure glaucoma (PACG) or primary open-angle glaucoma (POAG), respectively. Increasing age, marital status, history of cerebral infarction, location areas and family history of glaucoma were significant risk factors for both PACG and POAG. The overall blindness rate of glaucoma was 31·1% (95% CI 25·91%-34·82%). Those who were older, men, and divorced/separated were more likely to become blindness due to glaucoma. Interpretation: Glaucoma should be included in chronic disease-management programs in China for long-term care and continuous management of high-risk cases. Funding Statement: This research was supported by the National Natural Science Foundation of China (grant no. 81830026) and the Natural Science Foundation of Tianjin (grant no. 18ZXDBSY00030). Declaration of Interests: The authors declare there are no competing interests. Ethics Approval Statement: The study protocol was approved by the ethics review committee of Tianjin Medical University and other participating institutes. We obtained written informed consent from all study participants.

Incidence and factors associated with early neonatal near miss in a tertiary care hospital in Bengaluru

Background: Neonatal near miss is defined as, a neonate who has suffered a life-threatening condition but survived the first 28 days of life. As neonatal near miss is a predictor for early neonatal death, the lessons learned from near misses will be useful to help prevent early neonatal mortality. Objectives: The objectives of the study were to estimate the incidence of neonatal near miss and its associated factors in the early neonatal period in a tertiary hospital. Materials and Methods: This was a longitudinal study where all the cases of early neonatal near miss and early neonatal mortality were documented over a 1-year period. A face-validated structured questionnaire was used to collect information from mothers. The data were described using proportions, mean, and standard deviation. Regression analysis and adjusted odds ratio (aOR) were used to identify the determinants of early neonatal near miss. Results: The study was conducted among 210 neonates born to 197 mothers. The neonatal near miss rate in our study was found to be 75.43/1000 live births. The total live births during the study period were 2784. The most common cause of near miss was identified as birth weight of &lt;1750 g. The absence of antenatal ultrasound scans (aOR 6.124), anemia (aOR 3.945), preterm premature rupture of the membranes (aOR 3.136), presence of oligohydramnios (aOR 3.624), and malpresentation (aOR 5.581) was independent determinants of early neonatal near miss. Conclusion: These findings demonstrate the importance of better antenatal care including prevention of anemia, screening and management of high-risk cases, and antenatal complications to avoid the incidence of near miss.

Rural Glaucoma in China: Present Status and Future Directions

BACKGROUND: Glaucoma is the commonest cause of irreversible blindness worldwide. Factors associated with the development of glaucoma have been examined in several studies, but not in the Chinese rural population. The China Rural Glaucoma Cohort Study (China-RG Study) was conducted to investigate the present status of glaucoma in China. METHODS: The China-RG Study is a population-based study (June–October 2018) that included 22 rural areas from ten provinces in China and enrolled 52,041 individuals (age >6 years). Participants completed a comprehensive eye examination, including visual acuity, intraocular pressure (IOP), slit-lamp microscopy, direct ophthalmoscopy, and further investigations. Associations of demographics and medical factors with glaucoma were assessed using multiple logistic regression models. Disability (YLD) and quality-adjusted life-years (QALYs) were used to express adverse health outcomes of glaucoma; cost-effectiveness analysis was conducted to evaluate the superiority of glaucoma-screening program. FINDINGS: Overall prevalence of glaucoma was 1.6% (95% CI 1.52–1.77%); 58.2%, and 19.8% had primary angle-closure glaucoma (PACG) or primary open-angle glaucoma (POAG), respectively. Increasing age, history of cerebral infarction, marital status, location, and family history of glaucoma were significant risk factors for both PACG and POAG. Cost–benefit analysis indicated savings of approximately 286,56.57 million yuan in direct medical expenses nationwide by adopting the proposed screening mode. INTERPRETATION: Glaucoma should be included in chronic disease-management programs in China for long-term care and continuous management of high-risk cases. The scope and inclusions of basic public health services should be expanded, especially to include ophthalmic diseases. FUNDING STATEMENT: This research was supported by the National Natural Science Foundation of China (grant no. 81830026) and the Natural Science Foundation of Tianjin (grant no. 18ZXDBSY00030) DECLARATION OF INTERESTS: The authors declare there are no competing interests. ETHICS APPROVAL STATEMENT: Ethics approval for study conduct was obtained from the institutional ethics committee of Tianjin Medical University General Hospital; all participants provided written informed consent prior to study participation.

The Role of Anticoagulant Therapy in the Prevention of Preeclampsia Pharmacokinetic and pharmacodynamic mechanisms

Pregnancies complicated with preeclampsia associate a high incidence of intrauterine fetal death, intrauterine growth restriction, premature ruptures of membranes, abruption placentae and prematurity. Understanding the pathogenesis of preeclampsia is mandatory for a correct approach and prevention management of high risk cases. Placental hypoperfusion seems to be a key factor in developing systemic resounding. By placental necrosis and apoptosis, cell-free DNA is released in maternal circulation in early pregnancy, respectively prior 17 weeks of gestation. There is no test, useful in early pregnancy, accurate enough to predict preeclampsia. Various screening test have been proposed in order to predict the development of preeclampsia, but most of them are not sufficiently accurate for general screening. There is a continuous debate regarding the algorithm of administration, doses and timing of low dose aspirin. The initiation moment is crucial, as the administration after the development symptoms and signs of preeclampsia do not interfere with the progression and the severity of the disease. Early initiation of therapy with low dose aspirin, prior the end of the first trimester is important since the pathogenesis mechanisms of preeclampsia take place in the first trimester. The action of acetylsalicylic acid consists in inhibition of COX-1 and COX-2 (cyclooxygenase isoenzymes), necessary for prostaglandin biosynthesis. Preferential inhibition of Thromboxane A2 by low dose aspirin, counterbalance the increased production of thromboxanes characteristic to preeclampsia and modulate the inflammatory process, amplified in pregnant women with preeclampsia.

Defining and Assessing Geriatric Risk Factors and Associated Health Care Utilization Among Older Adults Using Claims and Electronic Health Records.

Using electronic health records (EHRs), in addition to claims, to systematically identify patients with factors associated with adverse outcomes (geriatric risk) among older adults can prove beneficial for population health management and clinical service delivery. To define and compare geriatric risk factors derivable from claims, structured EHRs, and unstructured EHRs, and estimate the relationship between geriatric risk factors and health care utilization. We performed a retrospective cohort study of patients enrolled in a Medicare Advantage plan from 2011 to 2013 using both administrative claims and EHRs. We defined 10 individual geriatric risk factors and a summary geriatric risk index based on diagnosed conditions and pattern matching techniques applied to EHR free text. The prevalence of geriatric risk factors was estimated using claims, structured EHRs, and structured and unstructured EHRs combined. The association of geriatric risk index with any occurrence of hospitalizations, emergency department visits, and nursing home visits were estimated using logistic regression adjusted for demographic and comorbidity covariates. The prevalence of geriatric risk factors increased after adding unstructured EHR data to structured EHRs, compared with those derived from structured EHRs alone and claims alone. On the basis of claims, structured EHRs, and structured and unstructured EHRs combined, 12.9%, 15.0%, and 24.6% of the patients had 1 geriatric risk factor, respectively; 3.9%, 4.2%, and 15.8% had ≥2 geriatric risk factors, respectively. Statistically significant association between geriatric risk index and health care utilization was found independent of demographic and comorbidity covariates. For example, based on claims, estimated odds ratios for having 1 and ≥2 geriatric risk factors in year 1 were 1.49 (P<0.001) and 2.62 (P<0.001) in predicting any occurrence of hospitalizations in year 1, and 1.32 (P<0.001) and 1.34 (P=0.003) in predicting any occurrence of hospitalizations in year 2. The results demonstrate the feasibility and potential of using EHRs and claims for collecting new types of geriatric risk information that could augment the more commonly collected disease information to identify and move upstream the management of high-risk cases among older patients.

Penile cancer: a case series in two tertiary care teaching hospitals with review of literature

Introduction Carcinoma of penis is a very rare disease most commonly affecting elderly men. This rare disease can have terrible and horrifying consequences on the social and emotional life of patients as well as their families. The objective of our case series is to describe the sociodemographic and clinical features, the standard investigations and treatment protocols and follow up of patients who presented to our hospitals. Methodology This is a prospective study of fourteen patients admitted in two tertiary care teaching institutions of Kolkata between January 2013 to December 2015 with a histopathological diagnosis of penile cancer. Results and discussion Age of patients varied between 45 to 82 years. Duration of disease varied between 3-13 months. Nine patients had palpable inguinal lymphadenopathy and 2 patients had liver metastases. Eight patients underwent partial amputation of penis and 4 patients underwent total amputation. Conclusion Penile cancer is a rare disease with devastating consequences. Patients often present late and the primary surgical treatment is often disfiguring. Aggressive surgical treatment of the primary disease and groin remains the cornerstone in the management of high-risk cases.

Predictors of prognosis in neonates with congenital diaphragmatic hernia: experience of 12 years

Introduction: Congenital diaphragmatic hernia (CDH) is a severe malformation, displaying relevant mortality and morbidity rates in newborns.Aim: To characterize clinically and demographically all neonatal cases of CDH admitted to a level III Neonatal Intensive Care Unit during a 12-year period and to evaluate the predictive value of baseline characteristics on mortality and morbidity at discharge.Methods: Maternal/infant clinical and electronic records were ret-rospectively reviewed. All neonates with posterolateral CDH admitted between January 2003 and December 2014 were included.Results: Fifty-three newborns were included. Overall mortality during hospitalization was 22/53 (41.5%). Clinical characteristics associated with mortality were the presence of intrathoracic liver (p = 0.005), intrathoracic stomach (p = 0.015), elevated arterial pCO2 or lower pH values at admission (respectively, p = 0.001 and p < 0.001), pre-ductal oxygen saturation < 85% at admission (p = 0.012) and surgical repair with prosthetic patch (p = 0.041). Morbidity at discharge was reported in 7 (22.6%) survivors. Stomach herniation and sepsis were associated with higher morbidity (respectively, p = 0.012 and p = 0.029). In a logistic regression, patch repair was the only variable with predictive value for death during hospitalization, with an odds ratio (OR) of 15 (95% CI 0.98-228.9), and intrathoracic stomach was a predictor of morbidity at discharge (OR = 15.7, 95% CI 1.4-174.2).Conclusion: Structural characteristics, namely defect size and presence of intrathoracic stomach, remain the primary determinants of neonatal prognosis in CDH. Although post-natal approaches have progressively proven their value in increasing survival and improving management of high-risk cases, future researches should continue focusing on the definition of foetal anatomical markers of severity and prenatal treatment of CDH.

Risk stratification in febrile neutropenic episodes in adolescent/young adult patients with cancer

BackgroundRisk-stratified management of febrile neutropenia (FN) allows intensive management of high-risk cases and early discharge of low-risk cases. Most risk stratification systems predicting severe infection from admission variables have been derived from childhood or adult populations and consequently their value in adolescents/young adults (AYA) may vary. Our objective was to determine their value in this population. MethodsData from the ‘predicting infectious complications in children with cancer’ (PICNICC) individual participant data collaboration were used to evaluate six previously described risk stratification schema in the AYA population. Complete case analyses were undertaken for five ‘paediatric’ rules, with imputation for specific missing variables of the ‘adult’ rule. The predictive performance of the rules or the outcome microbiologically defined infection (sensitivity, specificity and predictive values) were compared. ResultsAmong the 5,127 episodes of FN in 3,504 patients in the PICNICC collaboration data set, 603 episodes of FN from 478 patients in 20 studies were of patients 16–25 years old. The six rules demonstrated variable sensitivity (33–96%) and specificity (13–83%). Their overall discriminatory ability was poor (area under the receiver operator curve estimates 0.514–0.593). ConclusionsBoth paediatric and adult FN risk stratification schema perform poorly in AYA with cancer. An alternative rule or clinical recognition of their limitations is required.

Predicting microbiologically defined infection in febrile neutropenic episodes in children: global individual participant data multivariable meta-analysis.

Background: Risk-stratified management of fever with neutropenia (FN), allows intensive management of high-risk cases and early discharge of low-risk cases. No single, internationally validated, prediction model of the risk of adverse outcomes exists for children and young people. An individual patient data (IPD) meta-analysis was undertaken to devise one. Methods: The 'Predicting Infectious Complications in Children with Cancer' (PICNICC) collaboration was formed by parent representatives, international clinical and methodological experts. Univariable and multivariable analyses, using random effects logistic regression, were undertaken to derive and internally validate a risk-prediction model for outcomes of episodes of FN based on clinical and laboratory data at presentation. Results: Data came from 22 different study groups from 15 countries, of 5127 episodes of FN in 3504 patients. There were 1070 episodes in 616 patients from seven studies available for multivariable analysis. Univariable analyses showed associations with microbiologically defined infection (MDI) in many items, including higher temperature, lower white cell counts and acute myeloid leukaemia, but not age. Patients with osteosarcoma/Ewings sarcoma and those with more severe mucositis were associated with a decreased risk of MDI. The predictive model included: malignancy type, temperature, clinically 'severely unwell', haemoglobin, white cell count and absolute monocyte count. It showed moderate discrimination (AUROC 0.723, 95% confidence interval 0.711-0.759) and good calibration (calibration slope 0.95). The model was robust to bootstrap and cross-validation sensitivity analyses. Conclusions: This new prediction model for risk of MDI appears accurate. It requires prospective studies assessing implementation to assist clinicians and parents/patients in individualised decision making.

Predicting microbiologically defined infection in febrile neutropenic episodes in children: global individual participant data multivariable meta-analysis.

Background:Risk-stratified management of fever with neutropenia (FN), allows intensive management of high-risk cases and early discharge of low-risk cases. No single, internationally validated, prediction model of the risk of adverse outcomes exists for children and young people. An individual patient data (IPD) meta-analysis was undertaken to devise one.Methods:The ‘Predicting Infectious Complications in Children with Cancer' (PICNICC) collaboration was formed by parent representatives, international clinical and methodological experts. Univariable and multivariable analyses, using random effects logistic regression, were undertaken to derive and internally validate a risk-prediction model for outcomes of episodes of FN based on clinical and laboratory data at presentation.Results:Data came from 22 different study groups from 15 countries, of 5127 episodes of FN in 3504 patients. There were 1070 episodes in 616 patients from seven studies available for multivariable analysis. Univariable analyses showed associations with microbiologically defined infection (MDI) in many items, including higher temperature, lower white cell counts and acute myeloid leukaemia, but not age. Patients with osteosarcoma/Ewings sarcoma and those with more severe mucositis were associated with a decreased risk of MDI. The predictive model included: malignancy type, temperature, clinically ‘severely unwell', haemoglobin, white cell count and absolute monocyte count. It showed moderate discrimination (AUROC 0.723, 95% confidence interval 0.711–0.759) and good calibration (calibration slope 0.95). The model was robust to bootstrap and cross-validation sensitivity analyses.Conclusions:This new prediction model for risk of MDI appears accurate. It requires prospective studies assessing implementation to assist clinicians and parents/patients in individualised decision making.

Cutaneous SCC: identification and management of high risk cases

Cutaneous SCC: identification and management of high risk cases

149: The novel influenza virus H7N9 peptide activates the inflammasome

Background Influenza virus is the major cause of respiratory tract infections resulting in severe immunopathologies. Understanding the molecular basis for disease severity is vital for predicting potential emerging influenzas. The recently emerged H7N9 virus isolated from human disease cases are associated with increased risk of virulence and transmissibility. Understanding the elements of H7N9 induced disease severity during virus infection and pathophysiology is vital for clinical management of high-risk cases and providing valuable insights into the pathogenesis of H7N9 virus infection. Aim To examine whether differences between inflammatory and non-inflammatory PB1-F2 strains influences the degree of inflammasome activation and induces influenza pathophysiology. Methods Human peripheral blood mononuclear cells (hPBMCs) were primed with LPS (50 pg/mL) for 3 h then stimulated with PB1-F2 peptide strains (50 μg/mL) for 6 h. Immortalised wild-type bone marrow macrophages (iBMMs) were primed with LPS (100 ng/mL) for 3 h prior to stimulation with the H7N9 peptide at a range of doses (10–100 μg/mL) for 6 h. Supernatants were assayed via ELISA for levels of IL-1β protein expression as evidence of inflammasome activation. Cerulean-tagged ASC iBMMs were also stimulated with H7N9 peptide (100 μg/mL) and imaged as time-lapse for 2 h for the visual formation of cerulean ASC specks indicative of inflammasome activation. Results Stimulation of hPBMCs with the different PB1-F2 influenza peptides (50 μg/mL) for 6 h induced inflammasome activation as evidenced by the increased levels of IL-1β detected compared to control cells. H7N9 (10–100 μg/mL) stimulation of iBMMs induced inflammasome activation as evidenced by the increased levels of IL-1β detected compared to control cells. H7N9 (100 μg/mL) stimulation of cerulean-tagged ASC iBMMs increased ASC speck formation visually indicative of inflammasome activation compared to control cells. Conclusion Pandemic PB1-F2 strains potently activate the inflammasome in hPBMCs. The novel H7N9 influenza peptide potently activates the inflammasome in iBMMs. Understanding the regulation of inflammasome activation during influenza infection is essential for improving influenza disease therapeutics.

Re-Evaluation of the Role of Antifibrinolytic Therapy with Lysine Analogs in Liver Transplantation in The Post-Aprotinin Era

Purpose of review: Hemorrhage, blood and blood product transfusions and the need for surgical re-exploration for bleeding can have a detrimental effect on patient outcome during liver surgery. Following the suspension of aprotinin from the market only the antifibrinolytics tranexamic acid (TA) and epsilon-aminocaproic acid (EACA) are left as pharmacological options to reduce hemostatic activation and associated bleeding complications. Considering the apparent usefulnes of aprotinin in liver surgery and transplantation, its loss has left a void within the armamentarium of drugs available to reduce blood loss. The need for large independent safety studies has become evident. The current review focuses on the drugs that are available, the safety and efficacy data that supports their use and the indications warranting further trails. Recent findings: Both TA and EACA are effective in reducing blood loss and transfusion requirements in liver surgery. Analysis of data is complicated as the dosing regimens, especially for tranexamic acid, varies enormously and the agents are highly overdosed in most relevant trials. New data indicates that in a dose-dependent fashion, TA is associated with an increase in adverse events with transient renal failure highlighted as a particular problem. It appears that all the anti-fibrinolytics have side effects that may impact on morbidity and mortality and it may be that aprotinin is no worse. The use of these agents needs to be balanced against benefit especially in the management of high risk cases.

Expression of CD66c and CD25 in acute lymphoblastic leukemia as a predictor of the presence of BCR/ABL rearrangement

Expression of myeloid or T cell lymphoid in precursor B cell acute lymphoblastic leukemia (pre-B cell ALL), which is referred to as aberrant expression, is quite a common phenomenon. CD66c is a myeloid marker which has aberrant expression in pre-B cell ALL, with strong correlation with non-random genetic changes (BCR/ABL rearrangement). Another leukemia associated marker (CD25) is frequently expressed in pre-B cell ALL. The frequency of CD25-expressing lymphoblasts has been found to be significantly higher in BCR/ABL-positive vs. BCR/ABL-negative patients. In a cohort of 103 patients diagnosed with pre-B cell ALL or biphenotypic leukemia and studied for expression of CD66c and CD25 at presentation, we evaluated the frequency of expression of either or both in BCR/ABL positive cases. Surface CD66c was expressed by 70 cases (68%) and CD25 was expressed by 33 cases (32%) while both were expressed together on 29 cases (28%). BCR/ABL was positive in 18/103 patients. All BCR/ABL positive cases were positive for surface CD66c and CD25. Positivity for both leukemia-associated antigens CD66c and CD25 in combination can predict the presence of BCR/ABL rearrangement in pre-B cell ALL. While this finding does not replace the detection of BCR/ABL abnormality by cytogenetic or molecular techniques, it does provide an early and handy tool for prediction and management of high-risk cases of pre-B cell ALL, especially in centers with limited laboratory facilities.

FAMILICIDE AND FAMILY LAW: A STUDY OF FILICIDE–SUICIDE FOLLOWING SEPARATION*

This article is based on a qualitative study undertaken in Western Australia, which examined in depth seven cases of family homicide followed by suicide where disputed custody and/or access was identified as being an issue. These offenses typically consist of one or more young children being murdered by their father, the homicide being followed by the perpetrator's suicide. Common factors are identified and suggestions made for screening and proactive management of high-risk cases. Possible explanations of perpetrators’ motivation are proposed. Trauma effects on survivors are described. Recommendations for future policy, practice, and research are made.

Peptic ulcer perforation: Management of high-risk cases by percutaneous abdominal drainage

Sixty-six patients were selected as high-risk cases of duodenal ulcer perforation. After resuscitation with intravenous fluids and nasogastric suction, a widebore percutaneous intra-abdominal drain was put in under local anaesthesia. There were three (4.5%) deaths; 58 (87.8%) patients improved satisfactorily. High-risk peptic ulcer perforation patients can be managed by putting in an intra-abdominal drain supported by conservative treatment.

The effectiveness of high dependency unit in the management of high risk thoracic surgical cases.

To assess the effectiveness of high dependency unit (HDU) in the management of high-risk thoracic surgical cases at a single dedicated thoracic surgical unit. There is a strong drive to improve postoperative management in a cost-effective way. The number of high-risk thoracic surgical procedures undertaken is increasing rapidly. The HDU can be an effective weapon in the armoury of thoracic surgeons to treat these patients effectively without the need for managing in the extreme environment of expensive intensive care beds. Patients who had undergone lobectomy, pneumonectomy and oesophagectomy were included in the study, as they formed the bulk of the high risk thoracic surgical procedures undertaken by our unit. All data were collected retrospectively from case notes and computerised patient tracking system, for the period between April 2000 and March 2001. One hundred and ninety-one lobectomies (174 for malignancy), 86 pneumonectomies and 50 oesophagectomies were performed during the time period of the study. Of these, 189 (99%) lobectomies, 82 (95%) pneumonectomies and 47 (94%) oesophagectomies were electively admitted to HDU. The mean HDU stay was 21.8 h. Operation discharge time was 7.3 days for lung resections and 9.1 days for oesophagectomy. The overall 30-day mortality was 1.9% for lobectomy, 11% for pneumonectomy and 2% for oesophagectomy. Two oesophagectomies, one lobectomy and three pneumonectomies had to be transferred from HDU to ITU for either mechanical ventilation or more invasive monitoring. Four pneumonectomies, two lobectomies and two oesophagectomies had to be readmitted to HDU with respiratory failure or cardiac instability. Of all the readmitted patients, one pneumonectomy and one lobectomy died. The causes of death were myocardial infarction, pulmonary embolism, adult respiratory distress syndrome and septicaemia. The above results clearly demonstrate that a well-equipped and properly manned HDU can greatly facilitate management of high-risk cases with favourable outcome. It provides excellent pain control facilities, detects complications early and avoids unnecessary ITU admissions. It also provides an excellent training opportunity for both medical and nursing staff.