Peripheral Hospital Research Articles

Traumatic Brain Injury in Underage Motorcycle Drivers: Clinical Outcomes and Sociocultural Attitudes from a Lower-Middle-Income Country.

Poor societal attitudes and inadequate law enforcement have greatly contributed to the increase in underage motorcycle driving in Pakistan. This study reports the burden of traumatic brain injury (TBI), clinical characteristics/outcomes, and reason for driving in underage motorcyclists. A prospective study was conducted throughout 2021. Demographics, mechanism of injury, helmet use, number of passengers, clinical outcomes, reason for driving and parental awareness/consent status, referral pathway, and transport duration were documented. Of a total of 1052 motorcyclists with TBI, 112 were underage drivers. The mean age was 14.7 years (range, 10-17 years); 98.2% were male and 17% wore protective helmets. The most common reason for driving was recreational, followed by for domestic chores. In 66 patients, there was parental awareness and 30 of these patients had active parental consent. These patients reported domestic chores as the reason for their journey, whereas recreational purposes were a more prevalent reason in patients without parental awareness/consent (P < 0.001). Most patients were brought by provincial ambulance service (response time 12.8 minutes). Some patients came from peripheral hospitals (26.8%) and private hospitals (14.3%) that lacked neurosurgical cover, and these were associated with severer baseline injuries (P < 0.001). The average stay was 6.5 days, and 75.9% of patients were discharged with a good Glasgow Outcome Scale score. Most underage patients with TBI resulting from motorcycle driving are adolescent boys who do not use helmets. Trauma prevention systems and involvement of multiple stakeholders are needed to reduce underage driving. Efficient referral systems must transport patients to appropriate neurosurgical cover, which is lacking outside major cities.

A Co-diagnosis of Crohn Disease and Autoimmune Diabetes in an Adolescent Patient.

Inflammatory bowel disease (IBD) is a lifelong, immune-mediated disorder that often occurs in childhood and is becoming increasingly common worldwide. Diagnosis of IBD in children remains difficult due to the spectrum of symptoms, including gastrointestinal and extraintestinal manifestations. Type 1 diabetes mellitus (T1D) is one of the most common autoimmune diseases in children and adolescents. Classic manifestations of T1D in young people include polyuria, polydipsia, abdominal pain, weight loss, and ketoacidosis. However, children with autoimmunity of pancreatic β-cells may remain euglycemic and asymptomatic for many years. An accurate and prompt diagnosis of IBD and T1D is particularly important in children because they can negatively affect growth, psychosocial function and overall well-being. We present a case in which a previously healthy child was co-diagnosed with Crohn disease and T1D during a routine pediatric evaluation in the outpatient clinic of a peripheral secondary hospital.

Perforated diverticulitis leading to Fournier’s gangrene

Perforated diverticulitis is a rare cause of Fournier’s gangrene. Management for these conditions separately is well established, however no clear guidelines exist for operative management when they present in combination. This case provides a suggested management approach for managing the two conditions concurrently, in a peripheral hospital.

349 THE IMPACT OF INTER-HOSPITAL TRANSFER TO ENDOVASCULAR THROMBECTOMY (EVT) CENTRES ON THE INCIDENCE OF TENOUS THROMBOEMBOLISM (VTE) IN STROKE PATIENTS

Abstract Background The risk of VTE is increased following an ischaemic stroke with pulmonary emboli accounting for up to 25% of early deaths after stroke. Patients suitable for EVT have a higher NIHSS (average 16 in Ireland, 2020) and are more likely to have hemiplegia, potentiating the risk of VTE. Many VTE prophylaxis interventions that are provided to in-hospital stroke patients are not provided to those during the journey to thrombectomy centres. Our objective was to assess the incidence of VTE in acute ischaemic stroke patients transferred from a peripheral hospital to an EVT centre and estimate the potential national impact. Methods We reviewed the files of patients (n=35) transferred from a peripheral hospital to an EVT centre from January 1st 2019 until December 31st 2021 and included those who had a VTE confirmed on imaging during their admission. We calculated the incidence of VTE in these patients and the potential national figure. The sample size in this review is small, however 458 patents were transported to EVT centres from other hospitals in Ireland in 2020. Results VTE was confirmed in 8.57%(n=3/35) ; 1 out of 15, in 2019, 2 out of 10 in 2020, 0 out of 10 in 2021. The potential national rate using figures from 2020 equates to 39 VTEs. Conclusion We report a substantial risk of VTE risk in stroke patients during transit to EVT centres. Agreed national thrombectomy guidelines do not address the prevention of VTE in transit. A national audit of VTE in patients transferred from peripheral hospitals is needed with special focus on the role of mechanical preventative devices(pneumatic compression) in this preventable complication of stroke.

Intussusception of the distal bowel after ileostomy

Postoperative intussusception (POI) in preterm infants is very rare; intussusception at the distal end of the stoma is not seen. A 13-day-old premature infant was referred from peripheral hospital with history of necrotizing enterocolitis(NEC), which after the surgery of enterostomy. No typical symptoms appeared during treatment. Distal intestinal intussusception found during closed enterostomy. The patient recovered well after excision of the intussusception and intestinal anastomosis.

Appendicitis Inflammatory Response Score in Acute Appendicitis: A Study at a Tertiary Care Center in North India.

Appendicitis is a common cause of acute abdominal pain. The diagnosis is eminently clinical and the cause is surgically correctable. However, a decision of surgery based on the clinical presentation only has a 15%-30% chance of the removal of a normal appendix. Thus, the diagnosis involves a corroboration of clinical, laboratory, and radiological findings. Appendicitis scoring systems can be considered to expedite the diagnostic and decision-making process. The present study was conducted to study the efficacy of Appendicitis Inflammatory Response (AIR) score in the diagnosis of acute appendicitis and its correlation with the histopathological findings. A cross-sectional study was conducted at a tertiary care center in North India comprising patients who presented to the surgery department with a provisional diagnosis of acute appendicitis and required appendectomy. Appendicitis was histopathologically proven in 54 patients. Patients with an AIR score ≥5 were 2.18 times more likely to have appendicitis. The probability of having appendicitis with AIR score ≥5 was 92.16% (positive predictive value). The diagnostic accuracy of AIR score was 82.81%. AIR score has a high sensitivity and positive predictive value in the diagnosis of acute appendicitis. It is a quick and convenient system for clinical evaluation of patients in primary care or peripheral hospitals where advanced facilities such as USG scan or CT scan are not available all the time. The application of this scoring system definitely improves diagnostic accuracy and reduces negative appendectomy rate.

Delay in Diagnosis of Brain Tumors: A Dilemma For Neurosurgical Community Due To Spirituality and Quackery In A Developing Country

Objectives: Primary and metastatic brain tumors are a significant cause of mortality and morbidity. The complex pathway to a cancer diagnosis is not human error and the achievements of better outcomes solely depend on the early diagnosis and management of symptomatic tumors. The estimated time between the first presentation to any health care professional and diagnosis is approximately 3 times longer in the UK as compared to other developed countries.&#x0D; Material and Methods: It was a descriptive study and included 52 patients who were admitted to the Neurosurgery department at Jinnah hospital Lahore. The required data were collected either directly from the patients or from the hospital record of discharged patients. Our study compares the time interval difference of presentation of a patient to a local care provider (Quacks, Hakeem, and spiritual healers) and Neurosurgeon as well as delay in surgical intervention even after diagnosis and radiological investigations.&#x0D; Results: 54% of patients presented with supratentorial lesions and out of these, parietal lobe lesions were more common (39%) while 29% of lesions were infratentorial. Around 50% of patients presented to a Local Care Provider within 20 days. However, only 42% of patients presented to a neurosurgeon after 6-9 months of the onset of symptoms.&#x0D; Conclusion: Public awareness is the key to timely diagnosis, proper management, and better outcomes. The availability of specialists in peripheral hospitals can bring a change in this regard.

P490 Fatal secondary fungemia due to Trichosporon asahii onychomycosis in a diabetic patient

Poster session 1, September 21, 2022, 12:30 PM - 1:30 PM ObjectivesWe describe a fatal case of trichosporonosis caused by Trichosporon asahii. The aim was to molecularly characterize the T. asahii strains from blood and foot tissue samples to investigate their genetic relatedness.CaseAn 85-year-old morbidly obese female with a prior cerebrovascular accident, hypertension, and diabetes mellitus was admitted to a peripheral hospital with type II respiratory failure, metabolic acidosis, and chronic anemia. Three weeks post-hospitalization the patient remained febrile, physical examination showed that the patient had paronychia, nail pigmentation, subungual onychomycosis, and a diabetic foot ulcer. Blood culture, as well as nail and ulcer samples, became positive for Trichosporon yeasts.Methods Trichosporon yeasts were subjected to molecular identification by sequencing the intergenic spacer (IGS1) region. Minimal inhibitory concentrations (MICs) were determined by the EUCAST microdilution method. Long-read nanopore sequencing was performed for the three clinical strains, the type-strain of T. asahii (CBS2479), and two IGS-genotype 7 strains (CBS2936, CBS7632) using the native barcoding kit v12 (SQK-LSK112; Oxford Nanopore Technologies). Raw data were basecalled with Guppy v6, Flye v2.9 was used to de novo assemble the genome of CBS2479, this was used as a reference for variant calling using the genomic reads of all strains.ResultsThe three clinical strains were found to belong to the rare IGS-genotype 7 and had similar MICs for amphotericin B (4 µg/ml), 5-fluorocytosine and fluconazole (2 µg/ml), voriconazole (≤ 0.015 µg/ml), posaconazole (0.0625 µg/ml), itraconazole (0.125 µg/ml), caspofungin (8 µg/ml), anidulafungin and micafungin (> 16 µg/ml). Strains from the ulcer and nail were genetically very closely related with 10 836 SNPs differences, the blood-derived strain differed more from these two strains with 94 729 SNPs and 94 913 SNPs, respectively. Strains CBS2936 and CBS7632 were only distantly related to CBS2479 with 328 221, and 436 060 SNPs, respectively.ConclusionThe T. Asahii IGS-genotype 7 strain causing fatal fungemia was genetically nearly identical to that obtained from nail and foot ulcers, making it highly likely that this was the port d'entrée for T. asahii.

Impact of inter-hospital transfer on success of angioembolization for lower gastrointestinal bleeding.

Angioembolization is a useful therapeutic tool for lower gastrointestinal bleeding (LGIB) however is only available at centres with specialist interventional radiology departments. Delay in angioembolization of greater than 120-150 minutes is associated with higher rates of non-therapeutic angioembolization. This retrospective review analysed the impact of interhospital transfer on timing and success of angioembolization in adults with LGIB. Of the 121 patients who underwent CTMA at a peripheral hospital for LGIB, only 20.7% had positive CTMA (n= 25). Of the 24 patients who were transferred for the purpose of angioembolization, only five ultimately had successful embolisation (20.1%). Patients who had unsuccessful angioembolization had a significantly longer mean time from arrival at the tertiary hospital to angioembolization compared to patients who had successful angioembolization (mean 375 versus 175 min, P= 0.001). There was no association of patient haemodynamics, use of anticoagulant or antiplatelet therapy, and transfusion requirement with success of angioembolization. Interhospital transfer is associated with delay in angioembolization. Delay after arrival at the receiving hospital is associated with unsuccessful angioembolization.

Power of Tele-Radiology. Connecting Central Radiology Units to Peripheral Hospitals. Author's view on the Role of Tele-radiology in Modern Healthcare Systems

Power of Tele-Radiology. Connecting Central Radiology Units to Peripheral Hospitals. Author's view on the Role of Tele-radiology in Modern Healthcare Systems

Abdomino-Thoracic Impalement: Challenges and Management in Remote Set up in North-East India

: Penetrating abdominal injuries are common injuries faced by surgeons at peripheral hospitals. The prime source of morbidity and mortality of these injuries are bleeding and visceral perforation. These injuries demand instantaneous resuscitation, with shifting of the patient to tertiary care center with multimodality surgical facility in order to minimize the morbidity and mortality associated with the patient.

Fournier’s Gangrene: A Novel Approach and Pushing the Envelope to a Case of Abdominoperineal Necrotizing Soft Tissue Infection in Peripheral Hospital Setup and Review of Literature

Introduction: Fournier’s gangrene is a rapidly progressive necrotizing soft tissue infection with very high mortality and is due to evolving synergistic polymicrobial infections of aerobes and anaerobes in perineum and genital area. Multiple predisposing factors include diabetes mellitus, alcoholism, immunosuppression, renal and hepatic disease. In the vast majority of cases, scrotum is most commonly affected. Case Presentation: The prognosis of the disease is not limited to the patient’s age, disease extent, and comorbidities. Treating such cases is always challenging for a surgeon and requires high expertise and quick decision. Conclusions: The aim of this report is to share our experience of a multimodal and multidisciplinary approach to this disease in peripheral hospital with resource constraints.

Resistant Uropathogens in Gulmi Hospital: High Time to Take Action

Introduction: Recent study in Nepal showed 29.5% culture positive cases of Urinary Tract Infections (UTIs). Extensive consumption of broad-spectrum antibiotics leading to increased AMR rates amongst uropathogens. This study has been carried out to determine the proportion and types of uropathogens causing infections and their antibiotics susceptibility pattern based on WHO classification of antibiotics- access, watch and reserve ('AWaRe') categories. Methods: Record review of the urine isolates with antibiotic susceptibility testing reported from Laboratory of Gulmi Hospital from April 2019 to April 2021. Ethics approval was obtained from Nepal Health Research Council (NHRC). Calculation of frequencies and proportions and cross-tabulation was done. Results: Bacterial yield was found in more than one-third of the total 315 samples. Majorities (84.48%) of them were gram negative bacteria. More than three-fourth of the urine isolates were of female. Urinary isolates showed variable resistance to the 'access' and 'watch' group of antibiotics. There was high resistance to the conveniently prescribed antibiotics like cefixime, ciprofloxacin, ofloxacin, for UTIs. Among tested urine isolates, 75.7% were sensitive to Nitrofurantoin. Conclusion: The yield of urine culture was 36.83% in our study with higher proportions in female. The resistance was high for conveniently prescribed antibiotics. Sensitive antibiotics like Nitrofurantoin were incorporated in the empirical therapy for UTI in this hospital after the study. It is an awakening call to implement measures to strengthen antimicrobial surveillance with inclusion of the peripheral hospitals to the reporting by capacitating them for quality reporting of the antibiograms.

Impact of review of histopathology specimens at a tertiary oncology hospital in Eastern India-lessons learnt.

A central review of histopathology specimens at tertiary oncology hospitals is important for optimum patient care in the modern era of personalised medicine. The challenges of healthcare delivery and access to ancillary investigations faced by a pathologist from the Indian subcontinent are different from the western world. We undertook an audit to analyse the differences of opinion between the diagnosis offered at peripheral hospitals and a tertiary oncology hospital in Eastern India. By analysing the differences, common pitfalls and diagnostic discrepancies are identified which need to be addressed in future. This audit also highlights the need of setting up of tertiary oncology diagnostic centres to help both peripheral pathologists and cancer care clinicians like a hub and spoke model. This is most needed for haematopathology, soft tissue and gynaecologic oncology where the need of ancillary investigations is high.

Pinpoint accuracy: guided core biopsy diagnostic accuracy in musculoskeletal lesions

Core biopsy is integral in the work-up of diagnosis for musculoskeletal lesions. Prior to referral through Christchurch hospital-a tertiary referral centre for sarcomas/musculoskeletal lesions, many patients undertake guided core biopsy in peripheral hospitals. We wished to assess the accuracy of these biopsies undertaken in the peripheral centres and compare to those done in the tertiary setting. A retrospective analysis of image-guided core biopsies done in the South Island of New Zealand over a 5year period was performed. An electronic database enquiry was made, and electronic notes were then screened for core biopsy results including subsequent biopsies done of the same lesion. Results from guided core biopsy were then recorded as diagnostic if the pathologist was able to reach or a definitive diagnosis, or guide management sufficiently. 223 patients with 229 biopsies were analysed. Overall accuracy of core biopsies were 83% across all centres. There were similar results between CT and ultrasound as well as soft tissue and bone lesions. Between the regions, the peripheral centres showed high accuracy compared with the tertiary centres. The regional centres demonstrated high diagnostic yield, and the current practice of providing core biopsy locally where possible prior to referral to a tertiary sarcoma, remains valid.

Cytomorphological Patterns of Various Head and Neck Lesions- A Study in a Peripheral Hospital in North India

Introduction: Head and neck lesions are routinely encountered by the clinicians, irrespective of age, sex and demography. FNAC is a integral part of diagnosing these lesions as these lesions are quite accessible to aspiration. FNAC is easy OPD procedure with minimal complications and a good sensitivity and specificity. Aims: To assess the cytomorphological spectrum of various head and neck lesions diagnosed on FNAC according to site, age and sex in a peripheral hospital in north India where no previous such study has been done. Material and Methods: The present study is a retrospective study undertaken in the Department of Pathology, District hospital udhampur, a peripheral hospital in north India. Cases were studied from December 2020 to March 2021. Results: Out of 85 fine needle aspiration procedures 48.2% (40 cases) were of lymph node, 24.7%(21 cases) from skin and soft tissue swellings 17% (20 cases) were of thyroid, 7.05% from salivary gland(06 cases). The present study included 85 cases with the age ranging from 5 months to 72 years out of which 52(61.1%) were females and 33(38.8%) were males .Reactive lymphadenitis is the commonest inflammatory lesion. Colloid goitre is the commonest benign lesion. Conclusion: Skin and soft tissue lesions were second most common lesion in these areas as compared to other studies. No such previous study has been done in rural area. This will help us to know the trend of various head and neck lesions in these areas.

Occlusive Syndrome Revealing Hirschsprung's Disease in Two Pediatric Cases Seen in Emergency in a Peripheral Hospital Department of Pediatric Surgery Fousseyni Daou Hospital in Kayes

Hirschsprung's disease is a congenital anomaly of the innervation of the distal intestine, usually limited to the rectum and colon, resulting in partial or total functional occlusion. It is one of the most common causes of obstruction in children. It is a rare pathology, but the diagnosis of which is becoming increasingly easy because of dill Omo pathology. We report two cases treated urgently in the pediatric surgery department of the Fousseyni Daou hospital in Kayes. Our objectives were to describe the clinical aspects and the management of an occlusive syndrome secondary to Hirschsprung's disease.

Challenges of Management and Outcome of Neonatal Medical Emergencies in a Peripheral Hospital, Bangladesh

Background: Respiratory distress and desaturation remains a significant cause of neonatal intensive care admission ,althoughmanagement has evolved gradually over the years resulting in improving survival for the these neonates . Still 10% of neonatesrequire respiratory support immediately after delivery due to respiratory disorder, and up to 1% of neonates are in need ofresuscitation. Objectives: The aim of the study is to present some fundamental steps of emergency neonatal management which includerapid identification and admission , followed by assessment for respiratory distress, hypoxemia and hypoglycemia ,initialstabilization when required and early administration of medications. Methods: This hospital based retrospective study was conducted at Combined Military Hospital ,sylhet ,Bangladesh fromApril 2021 to September 2022 .A total 224 sick neonates shortly after delivery included for this study. Results: From April ,2021 to september 2022, 917 newborn were born, of which 224 neonates were identified and admitted as a emergency cases immediate after delivery at combined military hospital,sylhet .Immediately after admission around allcases were assessed for hypoxemia ,hypoglycaemia and hypothermia.Around 66% were hypoxemic (preterm 71.4% ,22.3%in full term and 6.2% in post term ).There was male predominance 55% .Respiratory distress syndrome (RDS ) was found to bethe commonest 35.7% causes followed by persistent pulmonary hypertension with large patent ductus arteriosus(PPHN withPDA) 17.8% ,septicemia 16.9% ,meconium aspiration syndrome (MAS) 8.9%, transient tachypnea of newborn (TTN) 8%,congenital pneumonia 4.9% ,perinatal asphyxia (PNA) 3.5% , large atrial septal defect (ASD) with ventricular setal defect(VSD) 2.6% and 1.75% was hypoglycemic .All babies received immediately oxygenation . Bubble CPAP was required in 90(40.1%) cases. Vascular access was established in all cases and 2.6% neonates received medications bycentral (femoral) line.Mortality was 2( 0.8%) in neonates with respiratory distress due to respiratory distress syndrome with multiple congenitalanomalies . 2(0.8%) cases referred to tertiary hospital (Combined Military Hospital,Dhaka ) requiring mechanical ventilation. Conclusion: Early and appropriate treatment seeking is one of the most important aspects for interrupting the pathways to neonatal deaths due to severe illness. In developing countries, the role of Paediatrician is multidimensional . paediatrician by early detection of risk factors and timely intervention can reduce significantly neonatal mortality rate.

Emergent craniotomy in rural and regional settings: recommendations from a tertiary neurosurgery unit: diagnosis and surgical decision-making.

Largely attributed to the tyranny of distance, timely transfer of patients with major traumatic brain injuries (TBI) from rural or regional hospitals to metropolitan trauma centres is not always feasible. This has warranted emergent craniotomies to be undertaken by non-neurosurgeons at their local hospitals with previous acceptable results reported in regional Australia. Our institution endorses this ongoing potentially life-saving practice when necessary and emphasize the need for neurosurgical units to provide ongoing TBI education to peripheral hospitals. In this first of a two-part narrative review, the authors describe the recommended diagnostic pathway for patients with a suspected TBI presenting to rural or regional hospitals and discuss local surgical management options in the presence or absence of a CT scanner.

An Unusal Case of Acute Uterine Inversion

Abstract Uterine inversion is a rare case in obstetrics and gynecology field ,but the incident can be life threatening event. In the present case, a 19 year old women presented with total and acute uterine inversion after the delivery in peripheral hospital. She presented with fourth degree uterine inversion with the severe degree of hypovolemic shock with active vaginal bleeding. Immediate resuscitation along with simultaneous successful manual repositioning of uterus was done in the labour room. Medical management for atonic uterus was done. Despite of medical management uterus was atonic so uterine packing done. In view of persistent atonicity of uterus decision for emergency laporotomy were taken and patient was reffered to higher centre were she underwent subtotal hysterectomy with right internal iliac artery ligation. Postoperatively broad spectrum antibiotic and blood and blood product transfusion were done according to investigations. These findings suggest that proper management of 3rd stage of labour and early diagnosis and proper management will save the life of patient. Keywords: Uterine inversion; Atony; Hypovolemic shock; Manual uterine repostion. Abstract Uterine inversion is a rare case in obstetrics and gynecology field ,but the incident can be life threatening event. In the present case, a 19 year old women presented with total and acute uterine inversion after the delivery in peripheral hospital. She presented with fourth degree uterine inversion with the severe degree of hypovolemic shock with active vaginal bleeding. Immediate resuscitation along with simultaneous successful manual repositioning of uterus was done in the labour room. Medical management for atonic uterus was done. Despite of medical management uterus was atonic so uterine packing done. In view of persistent atonicity of uterus decision for emergency laporotomy were taken and patient was reffered to higher centre were she underwent subtotal hysterectomy with right internal iliac artery ligation. Postoperatively broad spectrum antibiotic and blood and blood product transfusion were done according to investigations. These findings suggest that proper management of 3rd stage of labour and early diagnosis and proper management will save the life of patient. Keywords: Uterine inversion; Atony; Hypovolemic shock; Manual uterine repostion.