Prehospital Trauma Scoring Systems for Evaluation of Trauma Severity and Prediction of Outcomes.

INTRODUCTION: Trauma scoring systems in prehospital settings are supposed to ensure the most appropriate in-hospital treatment of the injured. AIM OF THE STUDY: To determine the sensitivity and specificity of the CRAMS scale (circulation, respiration, abdomen, motor and speech), RTS score (revised trauma score), MGAP (mechanism, Glasgow Coma Scale, age, arterial pressure) and GAP (Glasgow Coma Scale, age, arterial pressure) scoring systems in prehospital settings in order to evaluate trauma severity and to predict the outcome. MATERIALS AND METHODS: A prospective, observational study was conducted. For every trauma patient, a questionnaire was initially filled in by a prehospital doctor and these data were subsequently collected by the hospital. RESULTS: The study included 307 trauma patients with an average age of 51.7 ± 20.9. Based on the ISS (injury severity score), severe trauma was diagnosed in 50 (16.3%) patients. MGAP had the best sensitivity/specificity ratio when the obtained values indicated severe trauma. The sensitivity and specificity were 93.4 and 62.0%, respectively, for an MGAP value of 22. MGAP and GAP were strongly correlated with each other and were statistically significant in predicting the outcome of treatment (OR 2.23; 95% Cl 1.06-4.70; p = 0.035). With a rise of one in the MGAP score value, the probability of survival increases 2.2 times. CONCLUSION: MGAP and GAP, in prehospital settings, had higher sensitivity and specificity when identifying patients with a severe trauma and predicting an unfavorable outcome than other scoring systems.

Clinical Hematochemical Parameters in Differential Diagnosis between Pediatric SARS-CoV-2 and Influenza Virus Infection: An Automated Machine Learning Approach.

BACKGROUND: The influenza virus and the novel beta coronavirus (SARS-CoV-2) have similar transmission characteristics, and it is very difficult to distinguish them clinically. With the development of information technologies, novel opportunities have arisen for the application of intelligent software systems in disease diagnosis and patient triage. METHODS: A cross-sectional study was conducted on 268 infants: 133 infants with a SARS-CoV-2 infection and 135 infants with an influenza virus infection. In total, 10 hematochemical variables were used to construct an automated machine learning model. RESULTS: An accuracy range from 53.8% to 60.7% was obtained by applying support vector machine, random forest, k-nearest neighbors, logistic regression, and neural network models. Alternatively, an automated model convincingly outperformed other models with an accuracy of 98.4%. The proposed automated algorithm recommended a random tree model, a randomization-based ensemble method, as the most appropriate for the given dataset. CONCLUSIONS: The application of automated machine learning in clinical practice can contribute to more objective, accurate, and rapid diagnosis of SARS-CoV-2 and influenza virus infections in children.

Hemogram-based decision tree models for discriminating COVID-19 from RSV in infants.

OBJECTIVE: Decision trees are efficient and reliable decision-making algorithms, and medicine has reached its peak of interest in these methods during the current pandemic. Herein, we reported several decision tree algorithms for a rapid discrimination between coronavirus disease (COVID-19) and respiratory syncytial virus (RSV) infection in infants. METHODS: A cross-sectional study was conducted on 77 infants: 33 infants with novel betacoronavirus (SARS-CoV-2) infection and 44 infants with RSV infection. In total, 23 hemogram-based instances were used to construct the decision tree models via 10-fold cross-validation method. RESULTS: The Random forest model showed the highest accuracy (81.8%), while in terms of sensitivity (72.7%), specificity (88.6%), positive predictive value (82.8%), and negative predictive value (81.3%), the optimized forest model was the most superior one. CONCLUSION: Random forest and optimized forest models might have significant clinical applications, helping to speed up decision-making when SARS-CoV-2 and RSV are suspected, prior to molecular genome sequencing and/or antigen testing.

Platelet indices in children with type 1 diabetes mellitus: a simple glucoregulation monitoring tool.

Introduction: Long-term hyperglycemia can lead to changes in the function and morphology of platelets. Objective: This study aimed to test the potential glucoregulation monitoring properties of platelet indices, mean platelet volume (MPV) and platelet distribution width (PDW), in children with type 1 diabetes mellitus (T1DM). Methods: The study included 453 patients below the age of 18 with T1DM treated at the Institute for Child and Youth Health Care of Vojvodina. Children were divided into two groups, according to their glucoregulation quality, i.e., glycated hemoglobin (HbA1c) levels. Descriptive and inferential statistical analyses were performed. Results: MPV and PDW were found to be important in predicting poor glucoregulation, both in independent and conjoint analysis. Proposed cut-off values for MPV and PDW in the glucose control monitoring of children with T1DM were 7.6 fL and 14.4%, respectively. Conclusion: Our study showed that MPV and PDW have monitoring properties in terms of glucose control in children with T1DM. Additionally, our study emphasizes the importance of selecting the most convenient control group in order to avoid misleading conclusions.

Could platelet indices have diagnostic properties in children with COVID-19?

INTRODUCTION: Viral infections are often accompanied by reactive thrombocytosis, that is, increased activity of platelets, which is especially common in infants and children. OBJECTIVE: This study aimed to test the diagnostic properties of platelet indices, plateletcrit (PCT), mean platelet volume (MPV) and platelet distribution width (PDW), in children with beta corona virus 2 (SARS-CoV-2) infection. METHODS: The study included 232 patients below the age of 18 admitted to the coronavirus disease (COVID-19) isolation wards at the Institute for Child and Youth Health Care of Vojvodina. PCT, MPV and PDW values on the day of admission were recorded. In total, 245 controls were selected from those treated for SARS-CoV-2 negative respiratory infections. Descriptive and inferential statistical analyses were performed. RESULTS: MPV and PDW were found important as independent predictors for COVID-19 in children. Furthermore, the joint effect of MPV and PDW for predicting COVID-19 was confirmed. The parameters showed better sensitivity than specificity. CONCLUSION: Our study showed that PCT is not clinically significant, while MPV and PDW have diagnostic value in predicting COVID-19 in children. In perspective, these parameters could be implemented in the various learning algorithms in order to achieve earlier diagnosis and treatment.

Predictive Value of Red Blood Cell Distribution Width, Mean Platelet Volume and Platelet Distribution Width in Children with Acute Appendicitis.

BACKGROUND AND OBJECTIVES: Acute appendicitis in pediatric patients is one of the most common surgical emergencies, but the early diagnosis still remains challenging. The aim of this study was to determine the predictive value of Red blood cell distribution width (RDW), Mean platelet volume (MPV) and Platelet distribution width (PDW) in children with acute appendicitis. MATERIALS AND METHODS: This study was a retrospective assessment of laboratory findings (RDW, MPV, PDW) of patients who underwent surgical treatment for acute appendicitis from January 2019 to December 2020. RESULT: During this period, 223 appendectomies were performed at our Institute. In 107 (43%) cases appendicitis was uncomplicated, while in 116 (46.6%) it was complicated. WBC and RDW/MPV ratio were significant parameters for the diagnosis of acute appendicitis with cut-off values of 12.86 (susceptibility: 66.3%; specificity: 73.2%) and 1.64 (susceptibility: 59.8%; specificity: 71.9%), respectively. WBC and RDW/RBC ratio were independent variables for the diagnosis of complicated appendicitis. The cut-off values were 15.05 for WBC (sensitivity: 60.5%; specificity: 70.7%) and 2.5 for RDW/RBC ratio (sensitivity: 72%; specificity: 52.8%). CONCLUSIONS: WBC is an important predictor of appendicitis and complicated appendicitis. RDW, MPV and PDW alone have no diagnostic value in pediatric acute appendicitis or predicting the degree of appendix inflammation. However, the RDW/MPV ratio can be an important predictor of appendix inflammation, with higher values in patients with more severe appendix inflammation. RDW/RBC ratio may be an important predictor of complicated appendicitis.

[Effects of caudal block in pediatric surgical patients: a randomized clinical trial]. / Efeitos do bloqueio peridural caudal em pacientes cirúrgicos pediátricos: estudo randomizado.

BACKGROUND: Surgery generates a neuroendocrine stress response, resulting in undesirable hemodynamic instability, alterations in metabolic response and malfunctioning of the immune system. OBJECTIVES: The aim of this research was to determine the effectiveness of caudal blocks in intra- and postoperative pain management and in reducing the stress response in children during the same periods. METHODS: This prospective, randomized clinical trial included 60 patients scheduled for elective herniorrhaphy. One group (n = 30) received general anesthesia and the other (n = 30) received general anesthesia with a caudal block. Hemodynamic parameters, drug consumption and pain intensity were measured. Blood samples for serum glucose and cortisol level were taken before anesthesia induction and after awakening the patient. RESULTS: Children who received a caudal block had significantly lower serum glucose (p < 0.01), cortisol concentrations (p < 0.01) and pain scores 3 hours (p = 0.002) and 6 hours (p = 0.003) after the operation, greater hemodynamic stability and lower drug consumption. Also, there were no side effects or complications identified in that group. CONCLUSIONS: The combination of caudal block with general anesthesia is a safe method that leads to less stress, greater hemodynamic stability, lower pain scores and lower consumption of medication.

The association of early postoperative lactate levels with morbidity after elective major abdominal surgery.

Lactate levels are widely used as an indicator of outcome in critically ill patients. We investigated the prognostic value of postoperative lactate levels for postoperative complications (POCs), mortality and length of hospital stay after elective major abdominal surgery. A total of 195 patients were prospectively evaluated. Lactate levels were assessed on admission to the intensive care unit (ICU) [L0], at 4 hours (L4), 12 hours (L12), and 24 hours (L24) after the operation. Demographic and perioperative clinical data were collected. Patients were monitored for complications until discharge or death. Receiver operating characteristic (ROC) curves were used to determine the predictive value of lactate levels for postoperative outcomes. The best cut-off lactate values were calculated to differentiate between patients with and without complications, and outcomes in patients with lactate levels above and below the cut-off thresholds were compared. Univariate and multivariate analyses were used to identify variables associated with POCs and mortality. Seventy-six patients developed 184 complications (18 deaths), while 119 had no complications. Serum lactate levels were higher in patients with complications at all time points compared to those without complications (p < 0.001). L12 had the highest predictive value for complications (AUROC12 = 0.787; 95% CI: 0.719-0.854; p < 0.001) and mortality (AUROC12 = 0.872; 95% CI: 0.794-0.950; p < 0.001). The best L12 cut-off value for complications and mortality was 1.35 mmol/l and 1.85 mmol/l, respectively. Multivariate analysis revealed that L12 ≥ 1.35 mmol/l was an independent predictor of postoperative morbidity (OR 2.58; 95% CI 1.27-5.24, p = 0.001). L24 was predictive of POCs after major abdominal surgery. L12 had the best power to discriminate between patients with and without POCs and was associated with a longer hospital stay.

TRANEXAMIC ACID IN SURGICAL TREATMENT OF SCOLIOSIS IN CHILDREN: A CASE REPORT.

INTRODUCTION: Children who are subjected to surgical treatment for scoliosis usually end up receiving a lot of blood transfusions since they tend to lose one or more blood volumes during the surgery. Tranexamic acid is an antifibrinolytic agent, increasingly used in children to reduce perioperative blood loss in various settings, including corrective surgery of scoliosis. CASE REPORT: A 12-year-old girl, weighing 44 kg, was admitted to our hospital for scoliosis correction. She had congenital scoliosis caused by congenital malformation of vertebrae. The surgery was performed under balanced general anesthesia. Two central and one peripheral line were cannulated in case massive transfusion would be required. Invasive monitoring was used, as well as prevention of hypothermia. Since massive blood loss was expected, bolus of tranexamic acid had been administered prior to the surgery. Tranexamic acid was given continuously in an intravenous infusion during the surgery. Blood loss was only 10 ml/kg, and since the hemoglobin value was orderline (89 g/l) during the surgery, the patient received 10 ml/kg of packed red blood cells. The child was hemodynamically stable throughout the surgery. After the completion of surgery, which lasted for 5 hours, the patient was extubated in the operating room. Postoperatively, the patient was transferred to the surgical ward. Hemoglobin values were stable and there was no need for additional blood replacement. CONCLUSION: Extensive blood loss is common in pediatric scoliosis correction surgery, transfusion being unavoidable in the majority of cases. In our patient, tranexamic acid proved safe and effective in reducing perioperative blood loss and transfusion requirement.

Infections associated with the central venous catheters.

Central venous catheters are of an essential importance to critically ill patients who require long-term venous access for various purposes. Their use made the treatment much easier, but still they are not harmless and are prone to numerous complications. Catheter infections represent the most significant complication in their use. The frequency of infections varies in different patient care settings, but their appearance mostly depends on the patient's health condition, catheter insertion time, localization of the catheter and type of the used catheter. Since they are one of the leading causes of nosocomial infections and related to significant number of morbidity and mortality in intensive care units, it is very important that maximal aseptic precautions are taken during the insertion and the maintenance period. Prevention of infection of the central venous catheters demands several measures that should be applied routinely.

[Ondansetron, alfentanil and nitrous oxide in the prevention of pain on injection of propofol].

INTRODUCTION: Propofol is a widely used intravenous anesthetic with a number of advantages over intravenous anesthetics used so far.The leading side effect is pain on injection. OBJECTIVE: Aim of the study was to determine the impact of ondansetron, nitrous oxide and alfentanil on reducing pain during propofol application. METHODS: The paper presents a prospective, randomized, single blind study. The study included 120 patients of ASA class I and II, who underwent elective surgery under general anesthesia using propofol for the induction of anesthesia. The patients were divided into four equal groups of 30 patients.The control group received a few milliliters of saline, N group the mixture of nitric oxide and oxygen, O group ondansetron and group A received alfentanil. In all patients, venous occlusion was performed for 60 seconds. Pain assessment was based on the criteria and the score by McCrirrick and Hunter. RESULTS: Pain after the application of propofol was present in 47 (39.2%) patients. The highest frequency of pain was recorded in the control group (18, 60%), and significantly lower (p = 0.009) in the patients who received ondansetron (8; 26.7%) and (p = 0.020), alfentanil (9; 30%).The statistical analysis proved that there was a significant relationship between the groups and the scale of pain (Chi2 = 13.849, p = 0.031). CONCLUSION: Based on the results of our study we can conclude that intravenous ondansetron and alfentanil with venous occlusion can effectively prevent pain during IV use of propofol.

[Complications of mechanical ventilation].

Mechanical ventilation of the lungs, as an important therapeutic measure, cannot be avoided in critically ill patients. However, when machines take over some of vital functions there is always a risk of complications and accidents. Complications associated with mechanical ventilation can be divided into:1) airway-associated complications; 2) complications in the response of patients to mechanical ventilation; and 3) complications related to the patient's response to the device for mechanical ventilation. Complications of artificial airway may be related to intubation and extubation or the endotracheal tube. Complications of mechanical ventilation, which arise because of the patient's response to mechanical ventilation, may primarily cause significant side effects to the lungs. During the last two decades it was concluded that mechanical ventilation can worsen or cause acute lung injury. Mechanical ventilation may increase the alveolar/capillary permeability by overdistension of the lungs (volutrauma), it can exacerbate lung damage due to the recruitment/derecruitment of collapsed alveoli (atelectrauma) and may cause subtle damages due to the activation of inflammatory processes (biotrauma). Complications caused by mechanical ventilation, beside those involving the lungs, can also have significant effects on other organs and organic systems, and can be a significant factor contributing to the increase of morbidity and mortality in critically ill of mechanically ventilated patients. Complications are fortunately rare and do not occur in every patient, but due to their seriousness and severity they require extensive knowledge, experience and responsibility by healthcare workers.