Clinical study to determine the predictability of significant rebound hyperbilirubinemia in neonates after phototherapy and conditions likely to be associated with it: Prospective observational study in a teaching hospital in Eastern India.

Aim: Neonatal hyperbilirubinemia is defined as yellowish discoloration of the skin, conjunctive, and sclera from the elevated serum or plasma bilirubin in the newborn. The standard of care for the management of neonatal hyperbilirubinemia is phototherapy to prevent long-term neurological sequelae. The aim of this study was to ascertain the predictability of significant rebound hyperbilirubinemia (SRH) in neonates after phototherapy and the factors associated with it. Materials and Methods: Neonates ≥ 35 weeks of gestation, who received treatment for hyperbilirubinemia and admitted in our hospital from 15th of March 2019 to 15th of September 2020 were enrolled after taking parental consent. SRH was defined as bilirubin levels crossing the treatment threshold within 72 hours of phototherapy termination. Logistic regression analysis was used to identify the predictability of SRH. Results: Out of 400 neonates treated with phototherapy, 10% developed SRH. Prematurity (Gestational age < 37 weeks), low birth weight (Birth weight < 2000 gram), ABO and Rh incompatibility, Glucose-6-phophate dehydrogenase deficiency (G6PD) deficiency, sepsis, and longer duration of primary phototherapy were found to be significantly associated with rebound hyperbilirubinemia. The probability of SRH increases for all American Academy of Paediatrics (AAP) risk categories as the gestational age decreases and total serum bilirubin at the stoppage of phototherapy increases. Conclusions: The presence of risk factors should be taken into account while planning discharge and follow-up of neonates admitted for neonatal hyperbilirubinemia to prevent long-term complication of bilirubin neurotoxicity.

Molecular epidemiology of lumpy skin disease outbreak in Odisha, India.

Lumpy skin disease virus (LSDV) is the causative agent of lumpy skin disease (LSD) which is a member of Capripoxvirus. It is an economically critical transboundary disease affecting cattle. This study records an LSD outbreak in Ganjam district of Odisha, India during August 2020. The epidemiological data were analysed and LSDV was genetically characterized. Out of the 452 animals clinically examined (59 farms), 63 animals were clinically affected with LSD, with a total morbidity rate of 13.93%. The morbidity rates in the surveyed villages (n = 10) varied from 5.55 to 21.62%. The multivariable logistic regression analysis showed that grazing of animals (P = 0.013; OR: 2.04; 95% CI: 1.16-3.57) and age of cows > 3 years old (P = 0.001; OR: 2.90; 95% CI: 1.65- 5.07) were potential risk factors for the presence of LSD. Out of the 53 clinically suspected animals' samples, 18 samples (33.96%) were found positive for both the P32 and F genes of Capripoxvirus by PCR. Phylogenetic analysis of the P32 gene of LSDV (MW147486) showed 100% similarity with other isolates from India, Bangladesh, Egypt and Saudi Arabia. Additionally, phylogenetic analysis of the F gene of LSDV (MW147485) revealed a similarity of 97.99%, with Odisha India (MT074110) isolate and located in the same cluster with other Indian isolates.

Evaluation of participatory learning approach for developing competency of human immunodeficiency virus risk assessment skills among MBBS undergraduate students.

BACKGROUND: An Indian medical graduate needs to be competent in the diagnosis and management of human immunodeficiency virus (HIV) patients. This is crucial in terms of occupational safety. A participatory learning approach could be a possible way to change behavior and improve HIV risk assessment skills among medical students for better occupational safety and health care. The present study was planned to identify the need, provide different learning experiences for acquiring competency, and compare the effectiveness of participatory learning over traditional in developing HIV risk assessment skills. MATERIALS AND METHODS: An educational interventional (randomized controlled trial) was carried out at GEMS and Hospital. Needs assessment survey was conducted, which identified HIV risk assessment as a key competency. For which the outcome-specific learning objectives were defined, two different learning experiences were employed. A pretest was conducted to assess the baseline knowledge and attitude (n = 92); they were then divided into two equal groups (A and B). "A" group was taught by participatory approach, whereas "B" by traditional techniques followed by posttest and objective structured clinical examination (OSCE) to assess their HIV risk assessment skills. Statistical analysis: Paired t-test for assessing knowledge and attitude within the same group and unpaired t-test for assessing skills between the two groups were used in this study. RESULTS: Statistically significant improvement (P < 0.001) in knowledge and attitude scores was noticed that OSCE scores were significantly higher in the intervention group "A" (P < 0.001) as compared to "B" taught by traditional techniques. CONCLUSION: Participatory learning effectively builds upon existing knowledge and attitude to develop better HIV risk assessment skills.

Peri-Operative Anaesthetic Documentation: A Report of Three Sequential Audits on the Quality of Outcomes, with an Insight Into Surrounding Legal Issues.

OBJECTIVE: The aim of the audits was to assess contemporary performance, with comparison of the same against previous outcomes, to gauge trends in clinical practice. This allowed for completion of the audit cycle, as well as the ability to analyse and consistently improve the quality of care delivered to our patients. METHODS: We undertook three prospective audits on the quality of peri-operative anaesthetic documentation in the years 2009, 2011 and 2014, respectively. Anaesthetic records for patients undergoing elective as well as emergency surgical procedures were assessed for 'adequacy of peri-operative documentation' based on a combination of select criteria outlined by the Royal College of Anaesthetists and the Australian and New Zealand College of Anaesthetists. RESULTS: A total of 1000 anaesthetic records were analysed in 2009, followed by a review of 412 records and 376 documents in 2011 and 2014 respectively. In the year 2014, 43.8% of pre-operative anaesthetic records were 'appropriately' documented. This was in stark comparison to 16.3% and 25.9% in the years 2009 and 2011, respectively. The quantity of 'adequately' documented intra-operative records increased to 35.1% in 2014, in comparison to 25.5% and 22.7% in 2009 and 2011, respectively. There was an overall improvement in the standards of peri-operative documentation in consecutive audits. CONCLUSION: We propose that regular audits on 'anaesthetic record keeping' can lead to an improvement in the standards of this often overlooked, but essential scope of our practice.

Continuous transversus abdominis plane block vs intermittent bolus for analgesia after abdominal surgery: a randomized trial.

BACKGROUND: Continuous and intermittent bolus techniques of transversus abdominis plane (TAP) blocks have been used for analgesia after abdominal surgery. Although both are effective, there are no studies comparing them. The aim of this study is to compare analgesia and cost-effectiveness between these groups. METHODS: After obtaining ethical approval, 20 American Society of Anesthesiologists ASA grade I to III patients undergoing elective abdominal surgery were recruited with 10 patients allocated to each arm. Bilateral ultrasound-guided TAP blocks were performed with an initial bolus of 0.5% ropivacaine 20 mL per side, followed by catheter insertion. After surgery, the continuous infusion group received 0.2% ropivacaine 8 mL/hour on each side and the intermittent bolus group received doses of 0.2% ropivacaine 20 mL per side every 8 hours for 48 hours. Both groups received intravenous fentanyl patient-controlled analgesia and regular oral paracetamol. Parameters recorded included numerical rating scores for pain and post-operative analgesic consumption at baseline (time 0) and at 1 hour, 1 day and 2 days post-operatively. The duration of catheter insertion, complications, patient satisfaction and information regarding costs were also recorded. Patient satisfaction was assessed utilizing a 4-point "Likert" scale on day 2 and on day 30. Pain and Likert scores were analysed by non-parametric sum rank test and all two-sampled t-tests assumed unequal variances. RESULTS: There was no difference between duration of TAP block, anesthetic and surgical technique and length of stay (p=0.23). Primary outcomes: pain scores at rest and cough were not significantly different (p=0.20) between the groups. Satisfaction scores were similar at day 2 and 30 (p=0.77). However, the bolus group was more cost-effective (AU$347.98 vs AU$429.43). CONCLUSION: Continuous or bolus TAP blocks are effective analgesic techniques in abdominal surgery, with bolus technique being more economical.

Tracheal extubation under deep sevoflurane anesthesia: A novel strategy for weaning difficulties in intensive care.

Various criteria for weaning patients from ventilators in intensive care have been widely published. These criteria are increasingly incorporated into guidelines, protocols, and more recently, care pathways. We present a case where a patient's lungs were ventilated for 4 days with an infective exacerbation of chronic obstructive pulmonary disease (COPD). We successfully weaned off mechanical ventilation and rapidly extubated the patient's trachea utilizing deep sevoflurane anesthesia. Published weaning indices suggest that this would have been an inappropriate course of action at the time. However, our patient clearly benefited and avoided the need for tracheostomy and prolonged ventilation.

Multiple myeloma: clinical review and diagnostic imaging.

Multiple myeloma (MM) is a malignant clonal neoplasm of plasma cells of B-lymphocyte origin that commonly results in overproduction of large amounts of monoclonal immunoglobulins. Important advances in the therapeutic management of this disease in the past decade have resulted in higher rates of durable complete remission, prolonged event-free survival, and improved overall survival. Clearer understanding of the effects of abnormal plasma cells on bone has led to therapeutic approaches that help prevent vertebral body fractures. Current imaging technologies and, in particular, survey marrow studies with magnetic resonance (MR) imaging have improved detection of the extent and location of disease in MM patients. In newly diagnosed cases, MR surveys of the axial skeleton accurately demonstrate the extent of disease-diffuse or focal involvement-and the presence of associated compression fractures and cord compression. After treatment, MR images show the effects of treatment and the presence of residual disease. Multiple sites of focal bone lesions detected on MR studies allow a more appropriate choice of biopsy site than the usual random iliac marrow biopsy. Use of MR to determine biopsy sites and computed tomographic guidance for biopsy performance have increased the safety and accuracy of sampling. These biopsies have resulted in increased identification of cytogenetic abnormalities, particularly the presence of chromosome 13 deletion, which is a grave prognostic indicator in MM.

Infection--an underappreciated cause of bone pain in multiple myeloma.

Bone pain, especially back pain, is a common presenting feature of myeloma patients. We report three multiple myeloma patients with exacerbations of back pain and referred shoulder pain resulting from vertebral infections. Two patients were treated with surgery, and one patient had computerized tomography-guided percutaneous needle aspiration for diagnostic purposes. All three patients received a prolonged course of antibiotics. Vertebral infection resolved with this treatment in all three patients without any recurrence. Previous dexamethasone therapy, together with an episode of bacteraemia, appears to be a predisposing factor for vertebral infection. Magnetic resonance imaging enabled the diagnosis in all three patients.

Myeloma of the central nervous system: association with high-risk chromosomal abnormalities, plasmablastic morphology and extramedullary manifestations.

Involvement of the central nervous system (CNS) by multiple myeloma, as defined by the detection of malignant plasma cells in the cerebrospinal fluid in the presence of suggestive symptoms, is considered extremely rare. We report on the characteristics of 18 such patients diagnosed and treated at the University of Arkansas over the last 10 years for an overall incidence of approximately 1%. Their evaluation revealed association of CNS involvement with unfavourable cytogenetic abnormalities (especially translocations and deletion of the chromosome 13), high tumour mass, plasmablastic morphology, additional extramedullary myeloma manifestations and circulating plasma cells. The presence of these features should alert clinicians to the possibility of CNS involvement. The outcome of these patients was extremely poor despite the use of aggressive local and systemic treatment including autologous stem cell transplants. Given this universally poor prognosis, the application of allogeneic transplants should be studied in this clinical setting.