Requiring Emergency Treatment Research Articles

The impact of COVID-19 on colorectal cancer in regional Northern Australia and changes to treatment related to distance to care: A retrospective cohort study

Background: The COVID-19 pandemic has created challenges in the diagnosis and management of colorectal cancer (CRC). It was proposed in regional Northern Australia that the distance to services could further impact cancer outcomes, leading to delayed diagnosis. We compared the outcomes of patients prior and during the pandemic; with a focus on whether patients were presenting in the emergency setting with more advanced disease. The distance to treatment was also analysed to see if there was any impact to the management of patients with colorectal cancer. Methods: A retrospective analysis of 444 patients that underwent treatment for colorectal cancer over 2 time periods were examined. Time period 1 (prior to COVID-19); March 2017-July 2019 and time period 2 (during COVID-19); March 2020-July 2022. Only patients with colorectal adenocarcinoma were included if they were primarily treated at a hospital in northern Australia; those with benign pathologies or recurrent disease were also excluded. Data was collected in terms of treatment and outcomes and compared between the two groups. A separate analysis of whether locality affected outcomes and referral times was also performed. Results: In the time period prior to COVID-19 174 patients’ required invasive management, while in the second time period during COVID-19 there were 188 patients managed surgically or endoscopically. Of the patients managed prior to COVID-19 17/174 (9.8%) patients required emergency interventions, during COVID-19 this number increased to 37/188 (19.7%). This difference was deemed to be statistically significant (P =0.008). No substantial difference in cancer staging at presentation was found between the two groups. There was an increase in complication rate found during COVID-19 34.6% vs 25.5% prior to COVID-19 (P =0.046). During COVID-19 the median time between General Practitioner (primary care physician) referral and colonoscopy was actually lower than prior to covid 26.5 vs 36 days (P=0.047). When comparing local to distant patients we found locally based patients had lower rates of neoadjuvant treatment 18.9% vs 30.4% (P=0.018) and higher rates of open surgery 39.1% vs 26.5%, P =0.012. An increase in time between colonoscopy and outpatient department review (OPD) was seen in patients not from the local area 13 vs 18 days (P =0.006). Conclusion: We found during the COVID-19 pandemic a greater proportion of patients were presenting with colorectal cancer that required emergency intervention. This may be due to decreased presentations to general practitioners due to lockdown causing potential delays in diagnosis. We did not see more advanced disease in these patients presenting emergently, between the two groups. Further assessment of local patients’ vs patients from distant sites, showed difference in how patients were managed but similar outcomes. Our large catchment area with distance to treatment in Northern Australia may further impact the management of colorectal cancer in the future.

1047 Umbilical Hernia Emergency Care: A Scoping Review

Abstract Aim Umbilical hernias may become acutely symptomatic, strangulated, or obstructed, requiring emergency treatment. Robust evidence is required for high-quality care in this field. This study presents a scoping review on emergency care of umbilical hernias. Method The study is reported in line with PRISMA-ScR guidance. EMBASE, MEDLINE & CENTRAL databases were searched using a predefined strategy. A secondary hand-search was also performed. Eligible studies were primary research, reporting any aspect of emergency umbilical hernia care, published in the English language. Where emergency umbilical hernia care was not the primary focus, subsets of relevant data should be extractable. Two authors screened s and full texts, disagreement resolved by discussion and third author. Data were charted according to core concepts addressed by each study. A narrative synthesis was performed. Results The search generated 299 s, with 32 full texts for assessment and 15 included for final review. This encompassed 52,089 patients undergoing emergency umbilical hernia care. Most were retrospective cohort designs (11/15), equally split between single (7/15) and multi-centre (8/15) studies with only one RCT. Most multi-centre studies were from national databases (7/8). Themes arising included risk profile (n=4), timing of surgery (n=5), investigations (n=2), repair method (n=9, 5 mesh vs suture; 4 laparoscopic vs open), and outcomes (n=12). Most common outcomes reported were mortality (n=10), morbidity (n=8), and length of hospital stay (n=6). Conclusions This scoping review demonstrates paucity of high-quality data for this condition. There is a need for randomised trials addressing timing and technical aspects of repair, with umbilical hernia-specific patient reported outcomes measures.

Outcome of Obstructing vs Nonobstructing Colorectal Carcinomas: Comparative Study at Tertiary Care Hospital in Kashmir.

Colorectal cancer (CRC) is the commonly diagnosed malignancy presenting either in obstruction or without obstruction. Bowel obstruction (BO) is usually a complication of advanced cancer, significantly reducing the quality of life. We aimed to study the outcomes of these obstructed colorectal cancers requiring emergency intervention and compare it with nonobstructed cancers. In our observational comparative study, patients were divided into groups on basis of their presentation and site of lesion: nonobstructing colon group/obstructing colon group nonobstructing rectum group/obstructing rectum group. A total of 232 patients with known modes of presentation between 2015 and 2018 were included; 144 colonic, 88 rectal carcinomas with 71 being completely obstructive ones. Our study showed higher recurrence in obstructive groups with local recurrence being more common. The median interval for recurrence was early in obstructive group (p < 0.001*). The overall 5-year survival rates were better in Nonobstructing colon group, (p = -0.046* in OR vs NOR) (p = -0.031* in OC vs NOC). 5-year disease-free survival rates statistically insignificant (p = 0.203 in NOC and OC groups), (p = 0.307 in NOR and OR groups). Immediate post-op, complications except for SSI, there was no significant difference between the two groups. Our study showed higher proportion of R0 resection in NOC groups as compared with obstructive groups (p = 0.021* in in OC vs NOC and p = 0.037* in OR vs NOR) with better lymph node retrieval in NOC groups. On comparing outcome of patients who had completed multi-modal therapy in both groups, there was significantly better outcome for patients who have presented without obstruction. Ul Haq MF, Bhat GA, Wani MA, et al. Outcome of Obstructing vs Nonobstructing Colorectal Carcinomas: Comparative Study at Tertiary Care Hospital in Kashmir. Euroasian J Hepato-Gastroenterol 2024;14(1):75-80.

A guide to mycetisms: A toxicological and preventive overview.

Fungi are often considered a delicacy and are primarily cultivated and harvested, although numerous species are responsible for intoxication due to toxin content. Foodborne diseases are a significant public health concern, causing approximately 420000 deaths and 600 million morbidities yearly, of which mushroom poisoning is one of the leading causes. Epidemiological data on non-cultivated mushroom poisoning in individual countries are often unrepresentative, as intoxication rarely requires emergency intervention. On the other hand, the lack of specialist knowledge among medical personnel about the toxicological manifestations of mushroom consumption may result in ineffective therapeutic interventions. This work aims to provide an easy-to-consult and wide-ranging tool useful for better understanding the variability of mushroom intoxications, the associated symptoms, and the main treatments for the most severe cases, given the absence of a complete species mapping tool toxic. Moreover, we establish an effective collection network that describes the incidence of mushroom poisonings by reporting the species and associated toxicological manifestations for each case. In conclusion, we highlight the need to establish appropriate primary prevention interventions, such as training the affected population and increasing consultancy relationships between mycological experts and specialised healthcare personnel.

Epidemio-Clinical and Therapeutic Aspects of Digestive Surgical Emergencies at Fousseyni Daou Hospital in Kayes

Introduction: According to the WHO, digestive surgical emergencies are abdominal pain lasting a few hours or days (les s than three) and which are related to a surgical pathology requiring emergency treatment. Digestive surgical emergencies are pathologies which occupy an important place in surgery due to their high frequency, their difficult management, and their high mortality and morbidity rate. Objective: Study the epidemio-clinical and therapeutic aspects of digestive surgical emergencies à the Fousseyni Daou in Kayes Hospital. Patients et Method: This was a prospective and descriptive study from March 2022 to March 2023 in the general surgery department of Fousseyni Daou Hospitol in Kayes. We included in this study all patients operated on for a digestive surgical emergency without distinction of sex or age. Results: The frequency of digestive surgical emergencies was 42.53%. The 10-20 year old age group was most represented with 37%. Abdominal pain was the most fréquent reason for admission with 87%. The site of pain was the right iliac fossa in 35% of cases. Acute appendix was the most common preoperative diagnosis with 37%. In our series, 54% of patients were operated on in les s than 24 hours. Therapeutically, 47% of patients benefited from an appendectomy. In our series, 30% of patients presented with a postoperative complications. We observed 3 cases of death. Conclusion: Digestive surgical emergencies occupy an important place in digestive pathology due to their high frequency at the Fousseyni Daou Hospitol in Kayes. The etiologies are multiple and varied, hence the need for close multidisciplinary collaboration for treatment.

Direct geocoding of street intersections in text message analysis tasks

Discussing various kinds of events on social networks is an integral part of everyday life. Users often publish and discuss information about traffic accidents, emergencies, utility accidents, and situations that do not require emergency intervention. Such information can be used to identify situations of a certain type, for example, to create statistics or timely involve certain services to eliminate emergency situations. The paper proposes a way to solve the problem associated with geocoding intersections when processing and analyzing text messages.

A STUDY TO ASSESS THE KNOWLEDGE ABOUT BASIC LIFE SUPPORT AMONG 1ST YEAR GNM STUDENTS(2022-2023) AT SMT NAGARATHNAMMA SCHOOL OF NURSING IN BENGALURU

Statement of the problem: A study to assess the knowledge about Basic life support among 1st year GNM students (2022-2023) at Smt Nagarathnamma school of Nursing in Bengaluru. Background of the Study: Cardiac Arrest is a major emergency situation faced by the people and it requires emergency intervention in terms of resuscitation by using basic life support. As people grow they must learn not only to cope with current demands but also to prepare for many unexpected event to facing tomorrows needing future. Method: The research design used was quasi experimental i.e one group pre test and post test design. The sample size was 50 1 st year GNM nursing students at Smt Nagarathnamma school of nursing in Bengaluru. The tool develop and selected for the data collection were structured teaching method. The data were collected, analyzed and interpreted. Result:Finding revealed the highest 70% of the students were in age Group of 19-20 years, 56% of the total students were female students, 40% were belongs to Hindu religion, 84% were not having hereditary cardiac disease. For pre test 24% of respondents have inadequate knowledge level, 46% of respondents have moderate knowledge level and 30% of respondents have adequate knowledge level regarding basic life support. For post test 2% of respondents have inadequate knowledge level, 28% of respondents have moderate knowledge level and 70% respondents have adequate knowledge level regarding basic life support. The obtained t- value in the area of general information is 5.30(P= 0.001) regarding the knowledge level on basic life support is 8.22(P= 0.001) and overall value of t is 6.21(P= 0.001) was highly significant. Therefore null hypothesis was rejected. The study finding reveal that there was highly significant enhancement in knowledge level after structured teaching programme among basic life support students. Conclusion: This chapter gives a summary of the study salient features, implications and recommendations of nursing practice, nursing education and nursing research also gives addition to the limitation of the study.

DEPRESSION AMONG OLDER ADULTS WITH ACUTE CORONARY SYNDROME ASKING FOR EMERGENCY HELP

Abstract Acute coronary syndrome (ACS) has been associated with urgent cardiac symptoms, which require an emergent medical care by the healthcare providers (HCPs), including nurses. These cardiac emergency events may cause disturbance to daily life for older adults with ACS. The purpose of this study was to identify the occurrence of depression and examine its correlates among those patients with ACS asking for emergency help. This is secondary data analysis of data collected from a convenient sample of 300 older adults with ACS asking for emergency help. Correlation and multivariate analyses were utilized in this study. Depression was found to be significantly, positively associated with each of hospital length of stay (LOS), intensive care unit (ICU) LOS, and frailty. The level of depression among older adults with ACS asking for emergency help was 65.7%. The level of depression among older adults asking for emergency help had significant predictors, as follows: Age (t=3.06), troponin (t=2.98), hemoglobin alpha 1C (HbA1c) (t=3.18), and frailty (t=5.77). These factors utilized in the linear regression model explained 56.6% (Adjusted R²=0.566, p=0.017) of the variation in the level of depression. The rate of depression is high among older adults asking for emergency help. Thus, the HCPs, including nurses, should pay a high attention to those at-risk patients for the occurrence of depression, as well as be well-prepared to manage correspondingly. Depression among older adults with ACS asking for emergency help requires emergency intervention protocol to combat depression among those patients by HCPs, including nurses.

Flare Frequency and Duration in Patients with Generalized Pustular Psoriasis (GPP)

Introduction: Generalized pustular psoriasis (GPP) is a rare, neutrophilic, chronic skin disease in which an overactivation of inflammatory pathways causes widespread erythema and eruption of sterile pustules that may coalesce into ‘lakes of pus’. GPP flares are heterogeneous, and there is no standard clinical definition. GPP flares are painful; severe cases may require emergency treatment and can lead to life-threatening complications such as sepsis. The objective of this study was to characterize the frequency, number, and duration of flares in patients with GPP.&#x0D; Methods: We conducted a retrospective chart review including patients of all ages with a confirmed diagnosis of GPP after 2011 receiving care at 27 sites in France, Malaysia, and Tunisia.&#x0D; Results: Data from 175 patients were included (France: 58.9%, Malaysia: 31.4%, Tunisia: 9.7%). Mean (SD) follow-up was 5.0 (3.1) years. Flare-related care was the second most common reason for patient visits, accounting for 200 of 1378 follow-up visits after GPP diagnosis, surpassed only by routine follow-up. The mean (SD) annual number of flare episodes was 2.3 (2.0); the total number of flare episodes since the initial flare leading to diagnosis ranged from 0 to 9. Eighty-three (47.4%) patients experienced ≥1 flare episode after diagnosis, though individual country data suggested a higher flare burden in Tunisia (70.6%) and Malaysia (54.5%) versus France (39.8%). Twenty-eight patients (16.0%) had ≥2 flare episodes (60 visits); median (min, max) time between episodes was 11.6 (0.1, 52) months. The mean (SD) duration of flares was 34.3 (41.3) days during follow-up. Of 254 hospitalizations, 128 (50.4%) were flare-related inpatient admissions. Overall, 37.5% of GPP flares required inpatient care. The mean (SD) duration of flare-related admissions was almost twice as long as non-flare admissions at 19.2 (23.1) days versus 10.5 (8.1) days. Mean (SD) time between flare-related hospitalizations among 66 patients (128 hospitalizations) was 14.1 (17.1) months, with a median of 9.5 months indicating a skew distribution.&#x0D; Conclusion: Flare episodes are a heavy burden for patients with GPP, with flares recurring as often as once a year and lasting up to 2 weeks or more. Flares account for &gt;50% of hospitalizations for patients with GPP and are an important cause of follow-up care visits. The frequency of flares varied between patients, with some individuals experiencing up to 10 episodes over the study period. Heterogeneity of flares and rarity of GPP make diagnosis and clinical study challenging, while the severity of acute episodes and the burden of flare reoccurrence demonstrate the need for more effective treatment options.

Results of the surgical treatment of patients with traumatic injuries to the cervical trachea at Viet Duc University Hospital in the period 2017-2022

Background: Tracheal trauma is one of the increasingly common airway injuries in Vietnam and requires emergency treatment due to the risk of severe and acute respiratory failure, threatening the patient's life. Treatment of tracheal trauma depends on the extent of the injury; surgery plays an important role in saving the patient's life in emergencies, and surgery also solves the complications caused by trauma to the trachea. This study was conducted to describe some important features of the diagnosis and outcome of surgical treatment of tracheal trauma.&#x0D; Patients and methods: This is a descriptive, cross-sectional, retrospective study of all patients who were diagnosed with cervical tracheal trauma and treated by surgery at Viet Duc University Hospital from January 2017 to December 2022.&#x0D; Results: There were 23 patients, mainly male, who accounted for 83%. The average age was 37 ± 17.8 (31 - 59) years old. Traffic accidents was the main cause, accounting for 73.9%. The likely location of injury was the Tracheo-Laryngeal junction, accounting for 73.9%. The disease was often associated with multiple traumas. Shortness of breath and subcutaneous emphysema were the most frequent symptoms. X-rays, tracheobronchoscopy, and computed tomography were valuable imaging diagnostic tools. 78.3% of patients were discharged with good results. One patient died during a hospital stay because of multiple traumas. One case had a complication of stenosis of the trachea. The results show that early surgery gives better results than late treatment.&#x0D; Conclusion: Initial management of tracheal injury should be done quickly at the first emergency facility, where ensuring airways open is a top priority. The correct indication and early surgery gives good results and reduces complications.&#x0D; Keywords: Cervical tracheal injury, tracheal trauma surgery, Viet Duc University Hospital

Infectious Complications of Contact Lenses: A Review of the Literature

The use of contact lenses is very common, they are prescribed for the correction of refractive errors that cannot be treated by glasses such as aphakia, keratoconus and strong anisometropia, or as alternatives to glasses. Contact lenses can cause serious complications that are not always easy for patients to manage [1]. Infectious complications in contact lens wearers are a real diagnostic and therapeutic emergency. These infections can be bacterial, amoebic (due to wearing contact lenses in swimming pools, rinsing lenses with tap water or saliva), fungal (due to wearing therapeutic, cosmetic or aphakic lenses, diabetes, alcoholism, immunosuppression, corticosteroids). Infectious complications require emergency treatment. The first line of treatment consists of removing the contact lens and sending it, along with the lens case and lens care product, to the laboratory along with corneal samples and appropriate medical treatment. Infectious keratitis related to contact lens wear is serious and can permanently affect the visual prognosis. The prevention requires a fitting under medical supervision and an awareness of the patients with potential risks of infection.

Perspective: Postoperative spinal epidural hematomas (pSEH) should be treated, not ignored.

Patients with postoperative spinal epidural hematomas (pSEH) typically require emergency treatment to avoid paralysis; these hematomas should not be ignored. pSEH patients need to undergo immediate MR studies to document the location/extent of their hematomas, and emergent surgical decompression with/ without fusion if warranted. The frequencies of symptomatic pSEH ranged in various series from 0.1%-4.46%. Major predisposing factors included; perioperative/postoperative coagulation abnormalities/disorders, multilevel spine surgeries, previous spine surgery, and intraoperative cerebrospinal fluid (CSF) leaks. For surgery at all spinal levels, one study observed pSEH developed within an average of 2.7 postoperative hours. Another series found 100% of cervical/thoracic, and 50% of lumbar pSEH were symptomatic within 24 postoperative hrs., while a third series noted a 24-48 postoperative window for pSEH to develop. Early recognition of postoperative symptoms/signs of pSEH, warrant immediate MR examinations to diagnose the local/extent of hemorrhages. Subsequent emergent spinal decompressions/fusions are critical to limit/avert permanent postoperative neurological deficits. Additionally, patients undergoing open or minimally invasive spinal procedures where pSEH are suspected, warrant immediate postoperative MR studies. Patients undergoing spinal surgery at any level typically become symptomatic from pSEH within 2.7 to 24 postoperative hours. Early recognition of new neurological deficits, immediate MR studies, and emergent surgery (i.e., if indicated) should limit/minimize postoperative neurological sequelae. Thus, pSEH should be treated, not ignored.

Association of carbon monoxide poisonings and carboxyhemoglobin levels with COVID-19 and clinical severity.

Coronavirus disease 2019 (COVID-19), which recently spread throughout the entire world, is still a significant health issue. Additionally, the most common cause of risky poisoning in emergency services is carbon monoxide (CO) poisoning. Both disorders seem to merit more research as they have an impact on all bodily systems via the lungs. To determine how arterial blood gas and carboxyhemoglobin (COHb) levels affect the clinical and prognostic results of individuals requiring emergency treatment who have both COVID-19 and CO poisoning. Between January 2018 and December 2021, 479 CO-poisoning patients participated in this single-center, retrospective study. Patients were primarily divided into two groups for analysis: Pre-pandemic and pandemic periods. Additionally, the pandemic era was divided into categories based on the presence of COVID-19 and, if present, the clinical severity of the infection. The hospital information system was used to extract patient demographic, clinical, arterial blood gas, COVID-19 polymerase chain reaction, and other laboratory data. The mean age of the 479 patients was 54.93 ± 11.51 years, and 187 (39%) were female. 226 (47%) patients were in the pandemic group and 143 (30%) of them had a history of COVID-19. While the mean potential of hydrogen (pH) in arterial blood gas of all patients was 7.28 ± 0.15, it was 7.35 ± 0.10 in the pre-pandemic group and 7.05 ± 0.16 in the severe group during the pandemic period (P < 0.001). COHb was 23.98 ± 4.19% in the outpatients and 45.26% ± 3.19% in the mortality group (P < 0.001). Partial arterial oxygen pressure (PaO2) was 89.63 ± 7.62 mmHg in the pre-pandemic group, and 79.50 ± 7.18 mmHg in the severe group during the pandemic period (P < 0.001). Despite the fact that mortality occurred in 35 (7%) of all cases, pandemic cases accounted for 30 of these deaths (85.7%) (P <0.001). The association between COHb, troponin, lactate, partial arterial pressure of carbon dioxide, HCO3, calcium, glucose, age, pH, PaO2, potassium, sodium, and base excess levels in the pre-pandemic and pandemic groups was statistically significant in univariate linear analysis. Air exchange barrier disruption caused by COVID-19 may have pulmonary consequences. In patients with a history of pandemic COVID-19, clinical results and survival are considerably unfavorable in cases of CO poisoning.

Paraconduit hernia following esophagectomy: Is it safe to watch and wait?

ObjectivesWe hypothesized that emergency complications related to asymptomatic paraconduit hernias may occur less often than generally believed. Therefore, we assessed the occurrence and timing of paraconduit hernia diagnosis after esophagectomy, as well as outcomes of these asymptomatic patients managed with a watch-and-wait approach. MethodsFrom 2006 to 2021, 1214 patients underwent esophagectomy with reconstruction at the Cleveland Clinic. Among these patients, computed tomography scans were reviewed to identify paraconduit hernias. Medical records were reviewed for timing of hernia diagnosis, hernia characteristics, and patient symptoms, complications, and management. During this period, patients with asymptomatic paraconduit hernias were typically managed nonoperatively. ResultsParaconduit hernias were identified in 37 patients. Of these, 31 (84%) had a pre-esophagectomy hiatal hernia. Twenty-one hernias (57%) contained colon, 7 hernias (19%) contained pancreas, and 9 hernias (24%) contained multiple organs. Estimated prevalence of paraconduit hernia was 3.3% at 3 years and 7.7% at 10 years. Seven patients (19%) had symptoms, 4 of whom were repaired electively, with 2 currently awaiting repairs. No patient with a paraconduit hernia experienced an acute complication that required emergency intervention. ConclusionsThe risk of paraconduit hernia increases with time, suggesting that long-term symptom surveillance is reasonable. Emergency complications as a result of asymptomatic paraconduit hernias are rare. A small number of patients will experience hernia-related symptoms, sometimes years after hernia diagnosis. Our findings suggest that observation of asymptomatic paraconduit hernias (watch and wait) may be considered, with repair considered electively in patients with persistent symptoms.

Treatment strategy for acute myocarditis in pediatric patients requiring emergency intervention

BackgroundPatients with acute myocarditis present with a wide range of symptoms. Treatment strategies for pediatric patients with circulatory failure comprise extracorporeal membrane oxygenation (ECMO), emergency temporary pacing, and pharmacotherapy. However, they remain controversial. ECMO is an effective treatment but gives rise to several complications; the goal is therefore to avoid excessive treatment as much as possible. We aimed to evaluate the importance of electrocardiogram findings in differentiating severity and establish an appropriate treatment strategy in pediatric patients with acute myocarditis who required emergency interventions.MethodsThis retrospective study enrolled pediatric patients admitted to and treated in our hospital for acute myocarditis between April 1983 and December 2021. Patients were retrospectively divided into whether circulatory failure occurred (ECMO or temporary pacing was needed; emergency intervention group) or not (pharmacotherapy alone).ResultsOf the 26 pediatric patients, 11 experienced circulatory failure while 15 did not. In the circulatory failure group, six patients were treated with ECMO (ECMO group) and five patients with temporary pacing (pacing group). In the pacing group, all patients were diagnosed with complete and/or advanced atrioventricular block (CAVB and/or advanced AVB) and narrow QRS. Furthermore, these patients improved only with temporary pacing and pharmacotherapy, without requiring ECMO. Wide QRS complexes (QRS ≥ 0.12 ms) with ST-segment changes were detected on admission in five of six patients in the ECMO group and none in the pacing group (P = 0.015). Although all patients in the ECMO group experienced complications, none did in the pacing group (P < 0.008).ConclusionsRegarding emergency intervention for acute myocarditis, ECMO or temporary pacing could be determined based on electrocardiogram findings, particularly wide QRS complexes with ST-segment changes on admission. It is important to promptly introduce ECMO in patients with wide QRS complexes with ST-segment changes, however, patients with CAVB and/or advanced AVB and narrow QRS could improve without undergoing ECMO. Therefore, excessive treatment should be avoided by separating ECMO from temporary pacing based on electrocardiogram findings on admission.

Multi-modality treatment approach for paediatric AVMs with quality-of-life outcome measures.

Despite the potentially devastating and permanently disabling effects of paediatric arteriovenous malformations (pAVMs), there is a paucity of studies reporting long-term quality-of-life (QoL) outcomes in AVM patients. We aim to evaluate the management strategies for paediatric intracranial pAVMs in the UK and long-term QoL outcomes using a validated paediatric quality-of-life outcome measure. In this single-centre case-series, we retrospectively reviewed a prospectively maintained database of all paediatric patients (i.e. 0-18years old) with intracranial AVMs, who were managed at Alder Hey Children's Hospital from July 2007 to December 2021. We also collected the PedsQL 4.0 score for these patients as a measure of QoL. Fifty-two AVMs were included in our analysis. Forty (80%) were ruptured, 8 (16%) required emergency intervention, 17 (35%) required elective surgery, 15 (30%) underwent endovascular embolisation, and 15 (30%) patients underwent stereotactic radiosurgery. There was an 88% overall obliteration rate. Two (4%) pAVMs rebled, and there were no mortalities. Overall, the mean time from diagnosis to definitive treatment was 144days (median 119; range 0-586). QoL outcomes were collected for 26 (51%) patients. Ruptured pAVM presentation was associated with worse QoL (p = 0.0008). Location impacted psychosocial scores significantly (71.4, 56.9, and 46.6 for right supratentorial, left supratentorial, and infratentorial, respectively; p = 0.04). This study shows a staged multi-modality treatment approach to pAVMs is safe and effective, with superior obliteration rates with surgery alone. QoL scores are impacted by AVM presentation and location regardless of treatment modality.

Redirection of non-critical patients in the Emergency Department of Hospital Tuaran to the Primary Care Unit (Klinik Kesihatan)

The Emergency Department (ED) provides treatment for acutely ill patients in need of urgent medical attention. Despite the availability of the primary care unit ‘Klinik Kesihatan’, where non urgent patients should be treated, Malaysia’s public hospitals still need to deal with overcrowding of non-urgent patients in ED. The main aim of the study was to assess the willingness of non-urgent patients to be redirected to Klinik Kesihatan. This was a cross-sectional study conducted at Hospital Tuaran Emergency Department, Sabah. Non-urgent patients were interviewed using a questionnaire, to find out the purpose of their visit to Emergency Department. A total of 318 non-urgent patients out of 457 patients were interviewed during the study duration. 41 respondents (12.9%) were willing to be redirected towards a Klinik Kesihatan. No associated factors were found when compared with the unwilling to be redirected group. Among 277 respondents who rejected redirection to Klinik Kesihatan, 70.4% agreed to pay a surcharge to be treated in the Emergency Department and there was no association found with the employment status (p= 0.391). Most patients were not willing to accept redirection to a Klinik Kesihatan and would prefer to visit the Emergency Department despite knowing that their condition or illness is one that does not require emergency treatment. Social media, advertisements and pamphlets must be made available to educate patients on the proper use of the Emergency Department.

Understanding and Managing Hepatic Disease, Portal Hypertension and Stomal Varices

Scarring (cirrhosis) from advanced liver diseases can block normal hepatic circulation of blood through the liver, causing increased pressure in the venous portal system (portal hypertension). This can result in pressurised veins (varices), usually in the gastro-oesophageal region, which are liable to bleed. Variceal bleeding is dangerous, leading to haemodynamic destabilisation and death, and thus requires emergency intervention. Treatments include medications and endoscopic suturing, sclerotherapy, ligation or embolisation. Transjugular intrahepatic portosystemic shunt (TIPS) is a high-risk option that can relieve the underlying portal hypertension. People with a stoma and cirrhosis may develop peristomal varices (caput medusae), which are at risk of copious bleeding. These require immediate treatment, followed by the stoma care nurse reconsidering the stoma management routine and appliance use to reduce the risk of rebleeding.

Clinical Study of a New Modified Early Warning Scoring System for Rapidly Evaluating Shock in Adults.

Shock is one of the most common severe syndromes requiring emergency treatment. Acute myocardial infarction guidelines, the surviving sepsis campaign, and low blood volume resuscitation guidelines indicate the prioritization ofearly identification of shock. APACHE II(Acute Physiology and Chronic Health Evaluation II), SOFA (Sequential Organ Failure Assessment), and MEWS (Modified Early Warning System) scores are used to predict mortality in ICU (intensive care unit) patients. However, similar to APACHE II, SOFA cannot be used forrapid assessment. Hence the need for a new scoring system that is simple, faster, and efficacious in predicting and preventing mortality among shock patients. The present study was conducted to evaluate a new MEWS scoring system for early identification and estimate mortality risk in patients with shock. A total of 170 patients with shock meeting the inclusion criteria who presented to the ICU of Ramaiah Hospitals from November 2019 to August 2021 were included in the study. Baseline variables, laboratory parameters, APACHE II score, SOFA score, MEWS score, and new MEWS score were compared between the two groups. Patients were followed up till mortality or discharge from ICU. Among the 170 patients included in the studyseptic shock (69.4%) was the most common type of shock followed by cardiogenic(7.64%) and hypovolemic shock (7.64%). The requirement of inotropic support and mechanical ventilation was associated with significantly higher mortality (55.6% and 52.6% respectively). The AUROC (area under the curve) for SOFA in predicting mortality was 0.738 (p<0.001). The AUROCfor APACHE II score in predicting mortality was 0.758 (p<0.001). The AUROC for MEWS score in predicting mortality was 0.655 (p=0.0002). The AUROC for the new MEWS score in predicting mortality was 0.684 which is more than that of the conventional MEWS score (p <0.001). New MEWS score is better than the MEWS score in predicting mortality. The new MEWS score is a simple, entirely clinical, inexpensive scoring system that can be done within a short time as a patient contact in an emergency. Hence, the new MEWS score can help in the quick identification of patients who are at high risk for developing shock and can be used as a better predictor of mortality.

Timing of Colonoscopy for Hemodynamically Stable Patients With Acute Lower Gastrointestinal Bleeding.

The detection rate of the etiology of the lower gastrointestinal system (GIS) hemorrhage has been low, although urgent colonoscopy has been performed. Even if the etiology has been specified, the possibility of rebleeding is uncertain. Furthermore, adequate bowel cleansing required for colonoscopy cannot be achieved in emergency situations, so the procedure may fail. The aim of this study is to compare the etiological diagnoses of patients with lower GIS bleeding after bowel preparation at their first hospitalization and after discharge. Patients who were hemodynamically stable after upper GIS bleeding were identified and divided into 2 groups. Colonoscopy was performed in the first group of patients at their first hospitalization. The second group of patients was called again for colonoscopy within 2 weeks after discharge. Patients were classified according to their age, gender, bleeding etiology, whether complete colonoscopy procedure was possible (The cecum was intubated, and the bowel cleansing was sufficient to evaluate the intestinal mucosa), and whether the colonoscopic intervention was performed. The rate of patients who are hemodynamically stable and require emergency intervention at their first hospitalization is 5%. The colonoscopy repeat rate is 70% for the first hospitalization group, and the patients with no findings despite the second colonoscopy at a rate of 50% are re-evaluated electively. Our study suggests that colonoscopy should be performed in elective conditions after a complete bowel cleansing in hemodynamically stable patients.