Profile of and risk factors for early unplanned readmissions in patients with acute necrotizing pancreatitis.

INTRODUCTION: Acute necrotizing pancreatitis (ANP) complicates up to 15% of acute pancreatitis cases. ANP has historically been associated with a significant risk for readmission, but there are currently no studies exploring factors that associate with risk for unplanned, early (<30-day) readmissions in this patient population. METHODS: We performed a retrospective review of all consecutive patients presenting to hospitals in the Indiana University (IU) Health system with pancreatic necrosis between December 2016 and June 2020. Patients younger than 18 years of age, without confirmed pancreatic necrosis and those that suffered in-hospital mortality were excluded. Logistic regression was performed to identify potential predictors of early readmission in this group of patients. RESULTS: One hundred and sixty-two patients met study criteria. 27.7% of the cohort was readmitted within 30-days of index discharge. The median time to readmission was 10 days (IQR 5-17 days). The most frequent reason for readmission was abdominal pain (75.6%), followed by nausea and vomiting in (35.6%). Discharge to home was associated with 93% lower odds of readmission. We found no additional clinical factors that predicted early readmission. CONCLUSION: Patients with ANP have a significant risk for early (<30 days) readmission. Direct discharge to home, rather than short or long-term rehabilitation facilities, is associated with lower odds of early readmission. Analysis was otherwise negative for independent, clinical predictors of early unplanned readmissions in ANP.

The associations between cigarette smoking behavior and the use of heated tobacco products among Arab cigarette smokers: Findings from Saudi Arabia, Egypt, Kuwait, and Yemen.

As the availability of tobacco forms has evolved, emerging products known as heated tobacco products (HTPs) are increasingly being consumed worldwide and are claimed to be less harmful than tobacco cigarette smoking. To date, it is unknown whether Arab cigarette smokers are using or susceptible to HTPs. Therefore, this study aimed to assess the association between cigarette smoking behavior and the use of and susceptibility to HTPs in the Eastern Mediterranean region. Arab cigarette smokers (n = 628) from Saudi Arabia, Egypt, Kuwait, and Yemen were recruited using a convenience sampling technique. A cross-sectional survey comprised questions related to sociodemographic characteristics, cigarette smoking behavior characteristics (quitting attempts and desire to quit cigarette smoking, nicotine dependence, and consideration of switching to nicotine products with reduced health risks), and awareness of, use of, and susceptibility to use of HTPs. Descriptive and logistic regression models were used for analysis. The participants indicated a high frequency of past quitting attempts and a desire to quit smoking cigarettes. They were also considering switching to a nicotine product with reduced health risks. However, their awareness of HTPs was relatively low (24.2%), and the proportion of participants who had ever used HTPs or were currently using them was quite low as well (10.7% and 5.0%, respectively). A history of quit attempts was associated with more likely lifetime use of HTPs (adjusted odds ratio [AOR] = 2.63, 95% confidence interval [CI] [1.21-5.71]). Nicotine-dependent cigarette smokers were more likely to be susceptible to HTP use (AOR = 1.12, 95% CI [1.01-1.24]). Moreover, those who would consider switching to a product that provided nicotine and could reduce health risks by 99% were more likely to be susceptible to using HTPs (AOR = 2.17, 95% CI [1.05-4.51]). Awareness of HTPs is relatively low among Arab cigarette smokers. Attempts to quit cigarette smoking, nicotine dependence, and the consideration of switching to a product that delivers nicotine with reduced health risks were significantly associated with using HTPs. The findings of this study provide potential for evidence-based treatment for smokers and will help prevent the use of tobacco industry tactics in marketing HTPs.

Respiratory Care Profession in Yemen: Past, Present, and Future.

The respiratory care (RC) discipline in Yemen emerged 15 years ago. Although there have been significant advancements in the domain, no documented history is available regarding its development and progress over the years. This paper highlights the history and development of the RC field in Yemen and highlights the major events that took place during these times that shaped the development of the RC discipline. A detailed, comprehensive review and assessment were conducted through direct communication, personal interviews, and the review of existing documents in the hospital's archives, academic institutes, Ministry of Public Health and Population, and other relevant resources. The gathered data were evaluated for relevance and grouped on a thematic basis. So far, this is the first paper on the comprehensive history and development of the RC discipline in Yemen. How to cite this article: Hamilah SN, Ahmari MAI, Alsabri MA, Alrubaiee GG. Respiratory Care Profession in Yemen: Past, Present, and Future. Indian J Crit Care Med 2021;25(8):890-895.

Early extubation failure in very low birth weight infants: Clinical outcomes and predictive factors.

OBJECTIVE: To identify the clinical outcomes and the potential predictive factors of early extubation failure (EEF) in very low birth weight (VLBW) infants. METHODS: A retrospective study of VLBW infants admitted to the neonatal intensive care unit (NICU) over fifteen years. Neonates were intubated and mechanically ventilated on the first day of life, and early extubated within the first 3 days. EEF was defined as the need for re-intubation within 3 days of the first extubation. A composite outcome of mortality or any major morbidity (grade 3-4 intraventricular hemorrhage or periventricular leukomalacia; stage 3-4 retinopathy of prematurity, moderate-severe bronchopulmonary dysplasia or stage 2-3 necrotizing enterocolitis) was assessed. RESULTS: In total, 394 infants were extubated early. Of those, 347 (88%) had early extubation success (EES), whereas 47 (12%) had EEF. Incidence of the composite outcome was significantly higher in the EEF group than the EES group, even after adjusting for confounding factors. Logistic regression indicated that birth weight < 1000 g (p < 0.01), administration of≥2 doses of surfactant (p < 0.01) and administration of≥2 inotropic agents (p < 0.01) were all significantly associated with EEF. The area under the curve (AUC) for the combination of these three factors (AUC = 0.77) indicated significantly higher predictive value (p < 0.01) for EEF in VLBW infants, compared with individual factors (AUC = 0.59 for≥2 inotropic agents, AUC = 0.64 for birth weight≤1000 g and AUC = 0.66 for≥2 doses of surfactant). CONCLUSION: EEF is associated with poor clinical outcomes in VLBW infants. The combination of birth weight and the requirement for surfactants and inotropic agents can predict EEF.

Utility of additional abdominopelvic CT in detecting occult cancer in patients with unprovoked venous thromboembolism.

AIM: To analyse the positive rate for cancer on additional abdominopelvic computed tomography (CT) in patients with unprovoked venous thromboembolism (VTE), evaluate the subsequent emergence of a cancer diagnosis in the clinical follow-up period, and identify any possible predictive factors of cancer in this cohort, which may allow better selection of patients for additional imaging. MATERIALS AND METHODS: Consecutive adult patients with VTE were retrospectively identified in two large teaching hospitals between January 2013 and June 2014, including a subset of those with unprovoked VTE. Relevant demographic data were extracted and analysed. All patients had a minimum of 12 months clinicoradiological follow-up. RESULTS: One thousand four hundred and forty-six patients with VTE were deemed eligible, of which 699 (48%) were male; the median age (range) was 66 (16-102) years. The prevalence of pre-existing cancer in these patients was 343/1446 (24%), and 388/1446 (27%) were classified as unprovoked VTE. In 12/1446 (0.8%), cancer was diagnosed synchronously with VTE on the initial imaging investigation. Additional screening imaging was performed in 232/388 (60%) including abdominopelvic CT in 205 (53%) patients with unprovoked VTE. Only five additional cancers were identified, all of these occurring in patients with clinical symptoms suspicious for cancer. None of the additional CT examinations identified any clinically occult cancer in asymptomatic patients, and subsequent mean follow-up of 22 (SD=6) months also failed to reveal any further cancer diagnosis. CONCLUSION: Contrary to the National Institute of Health and Care Excellence (NICE) guidance, the yield of performing additional abdominopelvic CT as a screening tool for occult cancer in asymptomatic patients with unprovoked VTE is negligible. A more selective and clinically-driven assessment of these patients is recommended.

Mixed glioneuronal tumour of the fourth ventricle with prominent rosette formation.

We describe three unusual tumours characterized by a mixture of glial and neuronal differentiation, involvement of the posterior fossa and formation of rosettes. Mixed glial-neuronal tumours of the posterior fossa are rare and poorly described neoplasms. However, several distinctive entities have appeared in the literature over recent years under a variety of different names. Our cases demonstrate the morphological features of the 'rosette-forming glioneuronal tumour of the fourth ventricle', a recently identified tumour characterised by its unique location, neurocytic pseudo-rosette formation and the presence of a low grade astrocytoma component. The long term prognosis of these tumours remains unclear. However, the clinical data available including the cases presented here, along with the histological features, suggest that these are low grade tumours with a good prognosis after surgical resection.

Factors influencing the results of surgery for hypospadias: experience at NICH.

OBJECTIVE: To evaluate the factors that may influence the results of surgery after hypospadias repair at National Institute of Child Health, Karachi. METHODS: It was a retrospective observational study. Files of all patients who had Hypospadias repair were retrieved and analysed with a view to identify the factors which may influence the results of surgery for Hypospadias. Patients with complete record available were included in the study, whereas those with incomplete data were excluded. For most patients who had penile or distal hypospadias TIP (Tubularised Incised Plate) urethroplasty was performed. Patients with severe chordee had Duckett Island flap urethroplasty as a two stage procedure. Patients having moderate chordee were subjected to the Mustardee Procedure. Some underwent MAGPI and Mathieu's repairs. RESULTS: One hundred four patients were operated. Files of only 46 patients with a mean age of 4 years could be retrieved and these were included in the study. Twenty five patients had TIP urethroplasty, 5 had island flap urethroplasty, 2 had Mustardee repair, 6 had MAGPI, 5 had Mathew's repair and 3 had Byers Staged Urethroplasty. Over all incidence of fistula formation was 26%. The frequency of fistula formation was less with TIP urethroplasty (16%) compared to those who received no dartos pedicle flap. Mathieu's repair gave good results with 20% incidence of fistula formation. Highest numbers of complications (60%) were seen in patients who had Island flap urethroplasty for proximal hypospadias with chordee. CONCLUSION: TIP urethroplasty is a safe and reliable method of hypospadias repair. The results of surgery can however be improved by using dartos pedicle flap to protect the repair, meticulous surgical techniques, use of monofilamentous absorbable suture material and soft waterproof dressing.

Is there a correlation between degree of viremia and liver histology in chronic hepatitis C?

OBJECTIVE: To determine the correlation between degree of histological liver damage and serum HCV RNA level in patients of chronic hepatitis C, in order to evaluate the usefulness of HCV RNA estimation as an alternate to liver biopsy. METHODS: This non-interventional descriptive study, was carried out at the department of Pathology, Army Medical College, Rawalpindi, Pakistan between April and September 2002. Core needle liver biopsies of fifty five patients of chronic hepatitis C were evaluated according to Knodell's histological activity index system. The patients were categorized into four subgroups depending upon the grade and stage of disease according to Desmet's classification, and into three groups according to degree of viremia. RESULTS: Five patients had mild viremia, 43 moderate and 7 had severe viremia. Seven patients had minimal disease, 9 mild, 22 moderate and 17 had severe chronic hepatitis. Eight patients had no fibrosis, 20 had fibrous portal expansion, 19 bridging fibrosis, and 8 patients had cirrhosis. No significant correlation was found between serum HCV RNA levels and grade or stage of the disease, with correlation coefficients of rs = -.054 and rs = .034 respectively. Moreover, no individual component of the HAI correlated with serum HCV RNA levels. CONCLUSION: Serum HCV RNA level does not determine the degree of hepatic injury precisely and liver biopsy is necessary to accurately evaluate the extent of liver damage.

Morphological study of liver biopsy in Thalassaemia major.

OBJECTIVE: To see the morphological changes in liver in transfusion dependent Thalassaemia major children undergoing bone marrow transplantation. METHODS: This retrospective cross-sectional survey was conducted at Pathology department of Army Medical College and Paediatric department of Military Hospital, Rawalpindi from Jul 2000 to Aug 2003. Liver biopsies were done in 40 thalassaemic major children and histological changes including Knodell Histological activity index (HAI); grade, stage and score along with degree of haemosiderosis were noted. Serum ALT levels, ferritin assays and screening for HBsAg and Anti- HCV antibody were also carried out in these cases. RESULTS: Forty children 1.5-10.5 years of age (mean 6.1 years) with a male to female ratio of 1.2:1 were included in the study. According to Knodell HAI scoring, 24 (60%) cases had Knodell HAI score between 13/22 to 18/22 and 18 patients (45%) in grade 9-12/18. Six children had fully developed cirrhotic changes whereas 22 and 12 patients showed stage 3 and 1 respectively. Twenty eight (70%) patients had grade 3-4 haemosiderosis. HBsAg was positive in 6 and anti- HCV antibody in 14 patients. Serum ferritin and ALT levels were markedly raised in most of the patients. CONCLUSION: Seventy percent patients had moderate to severe haemosiderosis and high Knodell HAI score was found in children with severe haemosiderosis, raised ALT and Ferritin levels and with positive serology for HBsAg and anti- HCV antibody. Liver biopsy is useful in thalassaemic children to assess the stage of liver disease and selection of suitable cases for bone marrow transplantation (BMT).

Efficacy of bronchial wash cytology and its correlation with biopsy in lung tumours.

OBJECTIVE: To evaluate bronchial wash cytology with histology in our set up. METHODS: Seventy three specimens were obtained by flexible fiberoptic bronchoscope at pulmonology department of Military Hospital Rawalpindi. All the preserved samples were processed under standard conditions. The slides were stained with Papanicolaou and Haematoxylin and Eosin stains. RESULTS: A total of 73 patients were studied. The age range was 21 to 80 years. Male to female ratio was 8:1. Complete cytological and biopsy consensus was found in 55 (77.4%) cases. Cytology revealed 24 cases as malignant and nine as atypical/suspicious. Benign and inadequate were 29 and 2 respectively. Histopathology of these cases confirmed 24 (32.9%) as malignant and 29 (39.8%) as benign. True positive alongwith suspicious/atypical were 33 and true negative cases were 29. False positive was one case only whereas false negative cases were eight. The bronchial wash cytology showed sensitivity (80.5%), specificity (96.6%) and accuracy (87.3%). Positive predictive value and negative predictive value were 97% and 78.4% respectively. The commonest types of tumours were squamous cell carcinoma and small cell carcinoma. CONCLUSION: It is concluded that bronchial wash cytology is a valuable tool and yields almost same information as biopsy. It is useful in patients with evidence of obstruction or risk of haemorrhage.

Expert systems as computer assisted instruction systems for nursing education and training.

The ever-increasing specialization of nursing care may require nursing professionals to provide nursing care outside of their specialty. Nurses will have to familiarize themselves with a new specialization area at short notice. Fortunately, expert-systems technology can prove particularly helpful in achieving this familiarity. As such, this technology can prove a valuable tool for education and training of nursing professionals and students. This article describes the unique edge that expert systems technology provides in this context. Using VP-Expert, an expert system shell, the authors present two examples to illustrate the development of a computer aided instruction system and the unique benefits such a system offers.

Isoniazid acetylation and polymorphism in humans.

Phenotypes of slow and fast acetylators of isoniazid (INH) were determined in 157 subjects (80 normals and 77 patients with tuberculosis) from the twin cities of Rawalpindi and Islamabad. Plasma INH concentrations were determined chemically six hours after the drug ingestion. The findings indicate that 31.8% subjects were fast acetylators of the drug.

Bone marrow cellularity and iron stores in chronic renal failure.

Bone marrow biopsies of 15 patients with chronic renal failure (CRF) were compared with those of a control group matched for age and sex. Using a point-counting method for assessing cellularity, there was no significant difference in marrow cellularity between the CRF patients and the control group. There was a significant difference in the myeloid-erythroid ratio (p < 0.05) between the control group and the CRF patients, the latter group having a lower ratio. A point-counting method was used for the assessment of iron stores. Of 8 CRF patients who had not been given intravenous iron, oral iron or blood transfusion, 2 had greater iron stores than the control group.