Journal articles: 'Chester County Hospital' – Grafiati (2024)

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Introduction: Human immunodefi ciency virus infection damages the immune system making those affected more susceptible to opportunistic infections and malignancies which are common in the chest. This study sought to determine the pattern of chest X-ray lesions and the corresponding CD4 counts of HIV positive patients reporting in the antiretroviral clinic of this teaching hospital for the fi rst time. Methodology: Consecutive HIV positive patients that attended the antiretroviral clinic of the Lagos State University Teaching Hospital, (LASUTH) from September 2009 to January 2011 were recruited. Their chest x-rays were assessed for the presence of pulmonary lesions and baseline CD 4 counts were done to assess their degree of immunosuppression. Data were analyzed using the Statistical Package for Social Sciences, version 16.0. Results: There were 211 subjects, 151 females and 60 males with a M:F ratio of 1:2.5 The mean age of participants was 36.5±11.9. Mean baseline CD4 count for the subjects was 279±220.7 cells/mm3. Almost two thirds (64.9%) cases had normal chest x-rays with their mean CD4 count as 277.65±228.54 cells/mm3. The commonest lesions seen in the lungs include pulmonary infi ltrations, 55 (26.1%), cardiomegaly, 24 (11.4%), pulmonary consolidation, 21 (10%) and lymphadenopathy, 14 (6.6%). The commonest radiological diagnosis made were Atypical pneumonitis, 39 (18.5%), pulmonary TB, 13 (6.2%), pneumonia 13 (6.2%) and cardiomegaly13 (6.2%) respectively.Patients with chest findings had lower mean CD4 counts, 239 cells/mm3 when compared to those without, 244 cells/mm3. Conclusion: Pulmonary infiltration was the commonest lesion, while the commonest diagnosis was atypical pneumonitis. Patients with chest x-ray lesions were found to have lower CD4 counts with probable worse destruction of their immune system. SAARC Journal of Tuberculosis, Lung Diseases & HIV/AIDS; 2013; X(2); 27-34 DOI: http://dx.doi.org/10.3126/saarctb.v10i2.9710

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This study aimed to assess the effect of the county-level medical centre policy on the health outcomes of trauma patients transported by emergency medical service (EMS) system in rural China. The methodology involved the use of electronic health records (EHRs, after 2016) of patients with trauma conditions such as head injury (n = 1931), chest (back) injury (n = 466), abdominal (waist) injury (n = 536), and limb injury (n = 857) who were transported by EMS to the county-level trauma centres of Huining County and Huan County in Gansu, China. Each patient was matched with a counterpart to a county-level trauma centre hospital by propensity score matching. Cox proportional hazard models were used to estimate the hazard ratios (HRs) of such patients in different hospitals. The HRs of all patients with the abovementioned traumatic conditions transported by EMS to county-level trauma centre hospitals were consistently higher than those transported by EMS to traditional hospitals after adjusting for numerous potential confounders. Higher HRs were associated with all patients with trauma (HR = 1.249, p < 0.001), head injury (HR = 1.416, p < 0.001), chest (back) injury (HR = 1.112, p = 0.560), abdominal (waist) injury (HR = 1.273, p = 0.016), and limb injury (HR = 1.078, p = 0.561) transported by EMS to the county-level trauma centre hospitals. Our study suggests that the construction of county-level medical centre provides an effective strategy to improve the health outcomes of EMS-transported trauma patients in Gansu, China. Policy makers can learn from the experience and improve the health outcomes of such patients through a personalised trauma treatment system and by categorizing the regional trauma centre.

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Abstract Introduction: Venous thromboembolism (VTE) is a leading cause of death and disability of the adverse outcomes associated with a hospital stay among low, middle, and high income countries evaluated by the WHO Patient Safety Program. Objective: Compare characteristics and risk factors for hospital associated and non-hospital associated cases of VTE in Oklahoma County from April 1, 2012 to March 31, 2014. Methods: In collaboration with the Centers for Disease Control and Prevention (CDC), a population-based surveillance system for VTE was established in Oklahoma County, OK between April 1, 2012-March 31, 2014 to estimate the incidences of first-time and recurrent VTE events. The Commissioner of Health made VTE a reportable condition and delegated surveillance-related responsibilities to the University of Oklahoma, College of Public Health. Active surveillance involved reviewing imaging studies (e.g., chest computed tomography and compression ultrasounds of the extremities) from all inpatient and outpatient facilities in the county and collecting demographic, treatment and risk factor data on all VTE case-patients. Hospital associated VTE is defined as a VTE diagnosis made either during the hospital stay or within 90 days of hospital admission, regardless of the reason for hospitalization. Odds ratios and 95% confidence intervals (CI) were calculated. Those age 80+ years were used as the referent age group. Comparisons between hospital associated and non-hospital associated VTE cases were made by using two-sided χ2tests. Results: We identified 2,737 patients with imaging-confirmed VTE. Of these, 1,223 (44.7%) cases were identified as hospital associated and 1,514 (55.3%) cases as non-hospital associated VTE. Of the hospital associated VTE cases, 863 (70.6%) had VTE diagnosed while hospitalized and 360 (29.4%) were diagnosed VTE as outpatients after hospital discharge; of these 360 cases, 239 (66.4%) were re-admitted to the hospital and 121 (33.6%) were managed as outpatients. Of the non-hospital associated VTE cases, 776 (51.3%) were admitted to the hospital after diagnosis and 738 (48.7%) were treated as outpatients. The median length of stay for hospital-associated cases was 8 days (range 1-206 days). The distribution of PE (p = 0.17) and DVT (p = 0.07) were similar in hospital associated cases and non-hospital associated cases. The distributions of race (p = 0.34) and sex (p = 0.17) were similar for patients with and without hospital associated VTE; however, hospital associated cases of VTE tended to be older than non-hospital associated cases (p<0.01; 18-39 years OR = 1.7, 95% CI 1.2-2.2, 40-49 years OR = 1.8, 95% CI 1.3-2.4, 50-59 years OR = 1.3, 95% CI 1.0-1.7, 60-69 years OR = 1.1, 95% CI 0.84-1.4, 70-79 years OR = 1.2, 95% CI 0.91-1.5). Venous catheterization in the last 6 months (OR= 4.4, 95% CI 3.4-5.7), surgery (OR = 3.4, 95% CI 2.8-4.0) and trauma (OR = 3.0, 95% CI 2.3-3.9) in the last 12 months, and histories of: congestive heart failure (OR = 2.6, 95% CI 2.0-3.3), stroke (OR = 2.6, 95% CI 1.9-3.6), myocardial infarction (OR = 2.2, 95% CI 1.6-3.1), superficial vein thrombosis (OR = 1.8, 95% CI 1.3-2.5), and cancer (OR = 1.5, 95% CI 1.3-1.8) were risk factors for hospital associated cases of VTE. Hospital associated VTE cases had 3.5 times the odds of death (95% CI 2.4-5.0) than non-hospital associated cases. Discussion: A significant proportion (45%) of the total VTE burden continues to be hospital associated. A substantial proportion of hospital associated cases are diagnosed after discharge and result in re-admission, with the potential for significant financial penalties under Medicare value-based payment programs. Hospital associated cases of VTE were older, had more risk factors, and were more likely to die than non-hospital associated cases. Disclosures Raskob: Bayer Healthcare: Consultancy; BMS: Consultancy; Daiichi Sankyo: Consultancy; Janssen Pharmaceuticals: Consultancy; Pfizer: Consultancy; ISIS Pharmaceuticals: Consultancy.

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INTRODUCTION: Erdheim-Chester Disease (ECD) is a rare histiocytic neoplasm with a heterogenous clinical course with asymptomatic localized course or systemic compromise involving multiples organs causing significant morbidity and mortality. There are few cohorts published however mainly from North America and Europe. Given the scarcity of data on ECD in Latin America, we have established a local registry in the city of São Paulo to collect clinical and biological material of ECD patients. METHODS: We retrospectively collected clinical data on biopsy-proven ECD patients diagnosed and treated at two reference centers for histiocytic disorders (Hospital das Clínicas da Universidade de São Paulo e Hospital Sírio-Libanês, Brazil) from January 2006 to February 2020. RESULTS: Sixteen patients with confirmed diagnosis of ECD were included with median age of 53 years. 75% were males and a median follow-up time of 50 months (7-163). Median time from onset of symptoms to diagnosis was 13 months (0.1-142). Immunohistochemistry (IHC) findings showed positivity for CD68 in 15/16 (94%) and for S100 in 3/16 (19%) patients, no case had CD1a positivity. The most frequent organs involved were: bone (75%), skin (44%), central nervous system (CNS) (44%), lymph nodes (31%), lung (13%), liver (6%), spleen (6%), and gastrointestinal tract (6%) of cases. CNS lesions involvement occurred mostly in the pituitary gland (86%). Twelve of 16 (75%) patients presented disease in more than one organ. Xanthelasma and xanthoma were the most common skin lesions (44%). The most frequent histiocytosis-related clinical manifestations were bone pain (44%) and diabetes insipidus (38%). The most frequent radiologic findings were osteosclerosis in 12/16 (75%) patients, retroperitoneal fibrosis around the kidneys in 6/16 (38%), the coated aorta sign and orbital infiltration were found in 4/16 (25%) of cases. 18FDG/PET-CT was performed in all patients, of whom 13 (81%) had hypermetabolic lesions. BRAF status at diagnosis was available in 13/16 patients using the technique of Sanger in 5/13, pyrosequencing in 3/13, IHC in 3/13 and polymerase chain reaction (PCR) in 2/13. Mutations were detected in only 3/16 (19%) cases. All patients received treatment due to symptomatic disease with a median of two lines of therapy (1-7). Median time between diagnosis and the first treatment was one month. First-line treatments were interferon in 12/16 patients, steroids in 5/16, and each one of thalidomide, vemurafenib and tumoral resection in one patient. Beyond first-line therapy, the most conventional chemotherapy regimens used were cladribine (4/16 patients) and LCH-like etoposide-containing vinblastine, methotrexate and mercaptopurine (2/16 patients). Other treatments included radiotherapy (4/16 patients) and a single patient used cobimetinib, imatinib and infliximab. Median progression free survival (PFS) after the first line treatment was 7.5 months (95% CI 5-10), and median overall survival (OS) was not reached to this date. Time to next treatment was 9 months in patients who did not achieved at least partial response after first line, and 15 months in those who attained it. PFS at 2 years was 45% (95% CI 0.17-0.71), and OS at 2 years was 100%. One patient died due to infection complication after the first cycle of cladribine after 50 months of follow-up. CONCLUSION: To our knowledge, despite the low number of patients, this is the largest Latin American cohort of patients with ECD reported to date. Our findings resemble demographic characteristics, sites of involvement and treatment choices reported by other groups. However, it is noteworthy that the proportion of ECD patients bearing a BRAF mutation (18.8%) was pretty lower than previously reported (approximately 50%). This needs to be taken cautiously due to the small number of subjects and due to technical issues, since all samples analyzed by PCR or Sanger were negative for BRAF mutation. A national registry of histiocytosis is needed to confirm these preliminary data. Disclosures No relevant conflicts of interest to declare.

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Displacement patterns of rib fractures (RF) and their association with thoracic coinjuries and outcomes are unknown. This is a retrospective review of adult patients with blunt closed RF who underwent chest CT at a Level I trauma center (2007–2012). Displacement patterns of RF were compared among the three-dimensional planes using CT images. An analysis of receiver operating characteristic (ROC) curves was performed to identify displacements in each plane most strongly associated with chest coinjuries. Univariate analysis was used to find association of displaced RF with hospital course and outcome. There were 1127 RF (245 patients, most in ribs 3–9, 45 per cent displaced). Axial displacement was the most common, with odds ratios 7.20 and 2.13 compared with cranio-caudal, and impaction-separation (along rib axis) movement, respectively. Axial displacement thresholds performed well with hemothorax (2.8 mm, ROC = 0.74), pneumothorax (2.6 mm, ROC = 0.70), hemopneumothorax (3.1 mm, ROC = 0.77), flail chest (3.4 mm, ROC = 0.80), and chest tube placement (2.8 mm, ROC = 0.75). RF displacement was associated with increased days on mechanical ventilation and hospital length of stay. In conclusion, even minimal RF displacement is associated with increased risk of chest coinjuries and chest tube placement, and displacements correlated with increased days on mechanical ventilation and hospital length of stay. Future studies are required to investigate these associations, especially in relationship to the indications for rib plating.

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Background: Patients presented with respiratory distress along with bilateral lung opacities, like infections, Neoplasia, primary abnormality of the airways, pulmonary edema, pulmonary haemorrhage, acute respiratory distress syndrome, and interstitial lung diseases is a common scenario in our hospitals. The chest radiograph remains the basic radiological tool in many rural hospitals in our country. Thus, we aimed to study the patients presenting with respiratory distress having bilateral opacities in chest radiograph admitted in a tertiary care centre.Methods: This study was cross sectional study conducted in the department of respiratory medicine, New Medical College and Hospital, Kota for a period of one year on indoor patients. Fifty patients were studied by detailed clinical history, thorough physical examination, chest x-ray, routine haematological, sputum, electrocardiogram and relevant investigations.Results: Amongst 50 patients we found tuberculosis in 32% cases, pneumonia in 28%, pulmonary edema in 16%, silicosis (ILD) in 8 %, fungal pneumonia in 8 %, malignancy in 4% and aspiration pneumonia in 4% cases.Conclusions: Patients presenting with respiratory distress and bilateral lung opacities can have different diagnosis, most of them can be diagnosed by thorough history, clinical examinations and basic investigations. Proper diagnosis is essential in these patients for their management.

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Introduction: The aim of this study was to evaluate how altitude difference affects complete blood count (CBC) in patients with stable Chronic Obstructive Pulmonary Disease (COPD). Study Design: Cross-sectional study. Setting: Department of Pulmonology, Kars Harakani State Hospital (Group 1) and Samsun Chest Diseases and Thoracic Surgery Hospital (Group 2), Turkey. Period: Six months i.e. from March to September 2018. Material and Methods: A total of 400 patients (200 female, 200 male) with stable COPD were included. For each group, 100 female and 100 male patients were randomly selected from hospitals. Age, BMI (kg/m2), comorbidity, smoking status, CBC were evaluated. Hemoglobin, hematocrit, WBC, MPV, platelet, lymphocyte count and percentage, platelet/lymphocyte rate (PLR), neutrophil count and percentage, neutrophil /lymphocyte rate (NLR), eosinophil count and percentage, PDW, PCT were recorded. Results: Patients living at high altitude were significantly older, had lower weight and had lower FEV1 levels. COPD stages of Group 1 patients were more severe (p<0.001). There were no moderate COPD patients in this group and the patients had fewer comorbidities (43%). Hemoglobin, hematocrit, MPV, WBC, neutrophil count and percentage, NLR and PLR were significantly higher in Group 1 (p<0.001). PDW, PCT, lymphocyte count and percentage, eosinophil count and percentage were significantly higher in Group 2 patients (p<0.001). Conclusion: Hemoglobin, hematocrit, MPV, WBC, neutrophil count and percentage, NLR and PLR were higher in patients living at high altitude. PDW, PCT, lymphocyte count and percentage, eosinophil count and percentage were significantly higher in patients living at low altitude.

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BACKGROUND Globally the number of people living with human immunodeficiency virus/ acquired immunodeficiency syndrome (HIV/AIDS) has been rising steadily since 2011 nearing more than 33 million whereas in developing countries like India it is 2.4 million with a prevalence of 0.3%. The purpose of this study was to assess the association of CD4 counts with cardiovascular dysfunction among HIV/AIDS patients. METHODS This was a hospital-based study conducted at the Vijayanagara Institute of Medical Sciences, Bellary. Convenience sampling was used and patients admitted to the wards of the internal medicine as well as those attending anti-retroviral therapy (ART) centre out-patient department (OPD) were included in the study. A total of 200 cases of seropositivity of HIV patient diagnosed by Elisa technique were assessed after obtaining informed consent. Clinical profile and laboratory investigations were carried out on the patients such as CD4 counts and analyzed with various cardiac dysfunction. RESULTS Commonest affected with HIV infection were young male (26 – 40 years) 77.5 % followed by young female 60 % Commonest symptoms were fever, cough 82 % each and breathlessness 44 %. Commonest clinical findings were pallor 80 %, pedal oedema 68 %, and lymphadenopathy 32 %. 26 % of patients had electrocardiography (ECG) abnormalities with commonest being sinus tachycardia 18 %, low voltage complex 4 %, IHD (ischemic heart disease) 2 %, LVH (left ventricular failure) 2 %. 34 % had chest x-ray abnormalities such as cardiomegaly 14 %, pleural effusion 12 % and PTB (pulmonary tuberculosis) 2 %. Abnormal CD4 counts were noted in 94 % of patients, with 12 % having very low CD4 counts that is less than 50. Statistically significant pericardial effusion was noted with low CD4 counts on 2D ECHO cardiography. CONCLUSIONS The study concludes that decrease in CD4 count is statistically associated with increased pericardial effusion among HIV/AIDS patients. KEYWORDS CD4 Counts, HIV/AIDS Patients, Cardiovascular Dysfunction, Pericardial Effusion

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Objectives: To document the pattern of chest radiographic findings in coronavirus disease 2019 (COVID-19) patients with moderate to severe disease. Design: Retrospective cross-sectional study. Setting: The study site was Komfo Anokye Teaching Hospital (KATH) located at Bantama in Kumasi, the capital town of the Ashanti Region. It is the second largest hospital in the country and the major referral site for Ashanti region and the northern part of the country. The hospital hosts a highly infectious isolation unit (HIIU) for COVID19 patients with moderate to severe infections and receives referred cases from the region and within the hospital. Participants: The study involved 27 patients admitted to the HIIU at KATH with COVID-19 infection who underwent chest X-ray as part of their investigations. Results: The study enrolled 12 males and 15 females. The common comorbidities were hypertension and diabetes. Chest x-ray findings in most of the patients (81.5%) revealed ground-glass opacities while a few of them (18.5%) had lung consolidations without ground-glass opacities. For those with ground-glass opacities, eight (29.6%) had superimposed consolidation. All the participants had positive chest x-ray findings. Conclusion: The chest x-ray findings in the 27 COVID-19 positive patients with moderate to severe disease on admission at the KATH HIIU enrolled in this study showed significant pulmonary abnormalities. The predominant pulmonary abnormalities were bilateral peripheral ground-glass opacities with the lower lung zones being mostly affected.

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Background: Diagnosis of cough variant asthma is very important. Objectives: The purpose of the present study was to measure the diagnostic value of eosinophil counts in sputum for the diagnosis of cough variant asthma patients. Methodology: This descriptive type of cross-sectional study was carried out in the Department of Respiratory Medicine at National Institute of Diseases of the Chest and Hospital (NIDCH), Dhaka, Bangladesh from September 2014 to August 2015 for a period of one year. Patients presented with cough variant asthma attending in NIDCH were selected as study population. Methacholine challenge test was performed to diagnosis of cough variant asthma. After Methacholine test, patient was encouraged to produced sputum. Sputum was collected in a plastic container and labeled accordingly and was sent to microbiology department of NIDCH for sputum eosinophil counts. Result: A total number of 50 patients were recruited for this study. The mean age±SD was found 19.1±7.6 years. 20 patients had leucocytosis. 96% patients had sputum eosinophil, 90% patients had >3% sputum eosinophil and 10% patients had ?3% sputum eosinophil count. All patients had trigger factor with negative CFT for Filaria and increased serum IgE.Conclusion: In conclusion increased eosinophil count in sputum is diagnostic tool in cough variant asthma.Bangladesh Journal of Infectious Disease 2015;2(2):37-41

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Background: This is the first report of Heparin induced thrombocytopenia (HIT) presenting as bilateral carotid thrombi and multiple cerebral infarcts. Methods: 54 year old woman presented with sudden onset of right arm numbness and weakness two days after discharge from hospital. During her hospitalization 9 days prior, she underwent colovesicular fistula repair, received heparin subcutaneously for DVT prophylaxis and had normal platelet counts. Results: On this admission, MRI Brain showed scattered multiple acute infarcts within the cortex of bilateral cerebral hemispheres. CT angiography head /neck showed non-occlusive thrombi at the carotid bifurcations bilaterally. Platelet count on admission was 267 K/uL q which decreased to 125 K/uL the next day, after which heparin was started for the carotid thrombi. The platelet count rapidly decreased further to 79 K/uL leading to suspicion for HIT and switching to Argatroban. HIT and serotonin release assay were positive confirming the diagnosis of HIT. CT chest and tranthoracic echocardiogram was normal. Venous Duplex of bilateral upper and lower extremities were negative for DVTs.Hypercoaguable evaluation was negative. Conclusions: This case highlights the importance of identifying HIT as a cause of arterial thrombosis and stroke even with normal platelet counts in the clinical setting of recent heparin use.

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Birth weight is not enough to evaluate growth of the newborn. Around the globe, growth charts at birth as percentiles for various gestational ages are available both in developed and developing countries. This study aimed to develop such growth chart in Bangladesh, to exactly evaluate an individual newborn’s growth pattern by comparing growth of its different parts with that of a standard one. A cross sectional observational study conducted at fifteen non-government maternity centers located in different parts of Dhaka, Narayanganj and Narsingdi. Birth weight, birth length, head and chest circumferences of five thousand one hundred and five singleton newborns’ with gestational ages ranging from 35 to 42 weeks were recorded during June 2014 to July 2015. Trained Physicians and paramedics of respective centers recorded data. Gestational age specific percentile charts were constructed for birth weight, birth length, head circumference and chest circumference. Mean birth weight, birth length, head and chest circumferences were found to be respectively 2966g, 47.1, 33.2 and 32.3 cm which were more or less comparable to some other studies in the country and also higher than some of the studies. Most strikingly, prevalence of low birth weight was found to be 11 percent which is significantly lower than any other study conducted in the country. The 10th, 50th and 90th percentile values of birth weight at 40th weeks of gestation were respectively found to be 2600g, 3000g and 3600g. The linear and circumference growth at 40th weeks of gestation match with the percentile values of birth weight. Constructed growth charts are more or less comparable to some South Asian countries but also significantly differ from some other studies. Country specific standard growth chart is required for clinical assessment and identifying high risk newborns for providing special care. The growth charts constructed in this study, will guide policy makers and programme personnel to take necessary interventions for ensuring potential growth of every future newborn. Furthermore, this study has made the opportunity to compare the charts with other South Asian countries and developed world.

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The results of introducing the ‘kangaroo method’ (constant nursing of the baby skin to skin on the mother's chest), as the exclusive means of treating low birth weight (LBW) babies is reported, in the context of a mission hospital in a developing country without incubators and standard equipment for care of LBW neonates. Details of the method developed are described. The survival of babies born under 1500g improved from 10% to 50%, whereas that of babies 1500–1999 g improved from 70% to 90%. The method is well accepted by the community, and easily grasped by all hospital staff. Staff expectations concerning survival have dramatically improved, and a considerable saving in workload is experienced. The kangaroo method as described is strongly recommended to all units in developing countries treating LBW babies without modern equipment.

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Objectives and study design: Zambia is a high tuberculosis burden country. Antituberculous medicines are the mainstay of tuberculosis management. There have been several reports of antituberculous drug-related haematological and hepatic adverse effects noted in other settings. Adverse events have healthcare cost and morbidity implications. Prevalence and severity of these adverse effects are understudied in patients at University Teaching Hospitals hence the purpose of this study was to identify haematological and hepatic abnormalities and compare parameters before treatment and after completion of the intensive phase among the patients. Factors associated with abnormalities were also determined. A prospective longitudinal study was undertaken at Chest Clinic between April 2018 and July 2018. Study patients were followed up for 2 months. Full blood count and liver function tests were recorded at baseline and at follow-up. Abnormalities were defined according to the 2017 Department of AIDS Table for Grading the Severity of Adult and Paediatric Adverse Events. Data were analysed using SPSS version 22.0. Paired t-test and Wilcoxon matched-pairs signed-rank test were used to compare parameters. Logistic regression was performed to determine factors that were predictive of abnormalities. A p< 0.05 was considered statistically significant. Results: A total of 37 patients were involved in the study. 56.8% of patients were male. The mean age of patients was 36.2 years (19 – 57 years) while body mass index was 21.9 kg/m2. Only 37.8% of patients were sputum smear-positive at baseline. 56.8% of patients had HIV co-infection. 45.9% of patients were on antiretroviral therapy.45.2% of patients had grade 1-3 aspartate transaminase derangements at follow-up compared to 29.7% at baseline. 5.4% of the patients had grade 1-3 alanine transaminase derangements at baseline while 9.7% of patients had grade 1 at follow-up. Fewer patients (16.1%) had grade 1-2 anaemia at follow-up while 62.2% of patients at baseline had grade 1-4 anaemia. More patients (46.2%) had platelet derangements at follow-up compared to 25.8% at baseline. Fewer patients had differential white cell count derangements at follow-up compared to baseline. Statistically significant differences in haematological parameters: haemoglobin concentration, haematocrit, red, and white cell, eosinophil and neutrophil counts at baseline and follow-up were found. However, no statistically significant differences in red cell indices were observed. Changes in alanine transaminase levels at baseline and follow-up were statistically significant. Logistic regression was performed to determine the effects of age, gender, body mass index, HIV infection, antiretroviral therapy, sputum smear status, and appropriate baseline full blood count/liver function test parameters on the likelihood of study patients having deranged haemoglobin concentration, white cell count and alanine transaminase at follow-up. Logistic regression models to predict deranged haemoglobin concentration and white cell count were statistically insignificant. None of the predictor variables were associated with the likelihood of derangements in alanine transaminase. Conclusion: Findings of this study show that haematological and hepatic adverse effects were relatively fewer at follow-up and were mostly grades 1-3 in severity. Antituberculous therapy is relatively safe for patients during the initial phase.

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There is little UK data on hospital admission rates for childhood pneumonia, lobar pneumonia, severity or risk factors. From 13 hospitals serving the catchment population, demographic and clinical details were prospectively collected between 2001 and 2002 for children aged 0–15 years, seen by a paediatrician with community-acquired pneumonia (CAP) and consistent chest X-ray changes. From 750 children assessed in hospital, incidence of CAP was 14·4 (95% CI 13·4–15·4)/10000 children per year and 33·8 (95% CI 31·1–36·7) for <5-year-olds; with an incidence for admission to hospital of 12·2 (95% CI 11·3–13·2) and 28·7 (95% CI 26·2–31·4) respectively. Where ascertainment was confirmed, incidence of CAP assessed in hospital was 16·1 (95% CI 14·9–17·3) and 41·0 (95% CI 37·7–44·5) in the 0–4 years age group, whilst incidence for hospital admission was 13·5 (95% CI 12·4–14·6) and 32 (95% CI 29·1–35·1) respectively. In the <5 years age group incidence of lobar pneumonia was 5·6 (95% CI 4·5–6·8)/10000 per year and severe disease 19·4 (95% CI 17·4–21·7)/10000 per year. Risk of severe CAP was significantly increased for those aged <5 years (OR 1·50, 95% CI 1·07–2·11) and with prematurity, OR 4·02 (95% CI 1·16–13·85). It also varied significantly by county of residence. This is a unique insight into the burden of hospital assessments and admissions caused by childhood pneumonia in the United Kingdom and will help inform future preventative strategies.

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Abstract Background In 2017, Harris County had a total of 281 cases of newly diagnosed tuberculosis (Mtb), which was the highest incidence in Texas, United States. Lyndon B. Johnson (LBJ) hospital is one of the two HarrisHealth county hospitals which serve a wide population including immigrants and an indigent population. GeneXpert® MTB/RIF (GeneXpert) was implemented in our hospital since 4/2016. However, pulmonary Mtb cases with negative GeneXpert/AFB smears carry significant challenges in the initiation of therapy and hospital infection control. Our aim was to describe how Infectious diseases (ID) consultations helped to identify the cases of both GeneXpert and AFB smear-negative pulmonary Mtb cases without delaying therapy and unnecessary exposures. Methods The patients with newly diagnosed pulmonary Mtb in LBJ hospital were identified between January 2017 and December 2018. The patient’s characteristics, GeneXpert results, AFB smear results, and the presence of ID consultation were retrospectively collected. Delayed therapy is defined as the initiation of active four-drug Mtb therapy until the positive culture results. Results A total of 52 cases with newly diagnosed pulmonary Mtb confirmed by positive culture were identified, of which 44 cases who had GeneXpert on at least one sputum specimen were included in the final analysis. 7 out of 44 (20%) had negative GeneXpert on the first specimen and all three or more AFB smears were negative. The patients were the median age of 51 years and predominantly female (57%). 5 cases were Hispanic and 2 had HIV/AIDS. In 6 out of the 7 cases, ID consultation was made and anti-tuberculous therapy was empirically initiated without delay and all remained in the isolation. Only one case had delayed therapy despite ID consultation, three consecutive AFB sputum samples, and one GeneXpert was properly performed. The patient had newly diagnosed AIDS (CD4 of 2 cells/µL) and 3 weeks of chronic cough with normal lung parenchyma and minimal right pleural effusion on CT chest at his presentation. Conclusion We had 7 cases (20%) of GeneXpert and AFB smear-negative pulmonary Mtb. ID consultation properly identified 6 cases without delayed therapy. Early involvement of ID should be considered when pulmonary Mtb is suspected. Disclosures All authors: No reported disclosures.

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Abstract In general, the use of granulocyte colony-stimulating factor (G-CSF) has been relatively safe with only occasional reports of inducing adult respiratory distress syndrome.1 The mechanism for this complication is relatively unknown. A possible mechanism include the superoxide production by G-CSF causing neutrophil leakage resulting in pulmonary epithelial damage. We are reporting a 63 year old woman with a medical history of severe psoriasis and chronic thrombocytopenia with splenomegaly who presented to the emergency room with epistaxis and excessive bruising with a platelet count of 5 x 109/L. She received weekly injections of efalizumab (Raptiva) for six months for treatment of severe psoriasis and was stopped five weeks prior to presentation. Methotrexate and dexamethasone were started approximately one week prior to admission for continued refractory psoriasis. G-CSF was started at 480 mcq subcutaneous once a day on day 4 of admission for neutropenia induced by either efalizumab or methotrexate. When her white blood cell (WBC) count rose from 1.9 x109/L to 6.3 x109/L the G-CSF was stopped on hospital day 8. Her absolute monocyte count also rose from 0 to 3.78 x 109/L (normal range from 0.1 x109/L to 0.9 x109/L) with a left shift in the peripheral blood. The WBC and monocyte counts continued to rise and she was transferred to our hospital for further care on hospital day 11. The WBC count peaked at 147.9 x 109/L on hospital day 12, with a differential of 17% monocytes, 16% metamyelocytes, 4% myelocytes, and 1% promyelocytes. The patient gradually became short of breath at rest, requiring 2–4 liters of oxygen and developed bibasilar crackles on exam. Bibasilar infiltrates were detected on chest radiographs at the outside hospital. Upon arrival to our hospital a CT of thorax showed diffuse bilateral ground glass attenuation. WBC count decreased to 119 x109/L on hospital day 15, with a differential of 47% monocytes, 2% metamyelocytes, 3% myelocytes, and 1% blasts. A bone marrow examination showed morphologic findings consistent with acute monocytic leukemia with monocytoid cells greater than 50%. Since the WBC count continued to decrease with improvement of her respiratory symptoms no chemotherapy was given. When the WBC reached 7.4 x 109/L another bone marrow examination showed a hypercellular marrow with full maturation and no excess of blasts and no evidence of acute leukemia. A background of mature monocytes (12%) and increased reticulin fibers were noted. Chronic myelomonocytic leukemia was her final diagnosis. The laboratory and bone marrow studies while under the effects of G-CSF mimicked those of acute myeloid leukemia. The use of G-CSF in this patient appeared to have unmasked an underlying CMML from an undifferentiated myeloproliferative disorder. Her development of pulmonary infiltrates, hypoxia, leukocytosis and monocytosis after receiving G-CSF appeared to be a differentiation-like syndrome. This resolved after stopping G-CSF and without high dose steroid therapy. Physicians should be aware that G-CSF can cause a syndrome that mimics AML and should refrain from starting cytotoxic chemotherapy based on bone marrow findings under the influence of growth factors.

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Background: Osteoporosis is one of the most common systemic features of Chronic obstructive pulmonary disease (COPD). But there had been no data regarding osteoporosis in COPD patients in Bangladesh. Objectives: To determine the frequency of osteoporosis in COPD patients.Materials & Methods: This was a cross sectional observational study. COPD patients were recruited from Sarkari kormachari hospital. Patients were excluded if they had asthma, any disease affecting bones and calcium homeostasis or were receiving drugs related to bone metabolism. Demographic data were collected including age, smoking history, inhaled corticosteroid use, body mass index, treatment history hospital admission. Chest x-ray was done to exclude any infection or malignancy. Blood was obtained for complete blood count, renal function test, CRP. Bone mineral density (BMD; g/cm2) was conducted by using dual energy x-ray absorptiometry scan (DXA scan) at second to fourth lumbar spines (L2-4) and femoral neck.Results: The overall prevalence of osteoporosis according to the lowest T-score at either L2-4 or femoral neck were 56.7%. This is very high than other country. BMI and CRP were significantly associated with osteoporosis.Conclusion: The frequency of osteoporosis in Bangladeshi COPD patients was higher than others. Osteoporosis was associated with low BMI and high level of CRP.J MEDICINE JUL 2018; 19 (2) : 114-118

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Background: Community acquired pneumonia refers to pneumonia contracted by a person with little or no contact with health care system. Following endotoxemia the number of circulating neutrophils increases while lymphocyte counts decrease. Combining both parameters seems a logical step and the ratio of neutrophil and lymphocyte counts is increasingly used in several clinical circ*mstances. Initially, this so-called neutrophil-lymphocyte count ratio (NLCR) was studied as an infection marker in ICU patients and found to correlate well with disease severity and outcome, according to APACHE-II and SOFA scores. In the current study, we explored the value of the NLCR in patients admitted with Community acquired pneumonia. Aims and Objectives: 1) To find out the value of Neutrophil-Lymphocyte Count Ratio (NLCR)in Community Acquired Pneumonia (CAP). 2) To study Neutrophil-Lymphocyte Count Ratio (NLCR) as prognostic indicator in Community Acquired Pneumonia (CAP). Materials and Methods: This prospective study was conducted on minimum of 100 patients admitted to hospitals from November 2015 to September 2017 from Bangalore. After admission of cases based on CURB-65 scores, a detailed history and clinical examination was done along with chest x-ray to establish the diagnosis. Before taking into the study all patients had signed the informed consent. Routine haematological investigations done on day 1,3 & 7 were carried out. Serum c-reactive protein levels, Urea nitrogen levels, Sputum for culture and sensitivity and Acid-fast bacilli (AFB) was done on the same day of admission. ANC (Absolute neutrophil count), ALC (Absolute lymphocyte count) and NLCR were calculated. Results: Our study included age groups above 18yrs. Majority of the patients in the study were between 58-67 years (30%) followed by 48-57 years (27%). As the CURB-65 score increased from score 0 to score 4–5, the NLCR consistently increased, while the lymphocyte counts consistently decreased. In patients who died there was a significantly higher NLCR at presentation compared to patients that survived (15.18±3.55 versus 11.73±3.01, p-value,0.003). Conclusion: In our study increased NLCR carried poor prognosis which correlated with high CURB65 score and ICU admission. In patients who died there was a significantly higher NLCR at presentation compared to patients those survived.

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Background: One potential strategy to increasing physical activity after surgery is to use an ambulation orderly (AO), a dedicated employee who assures frequent patient walking. However, the impact of an AO on physical and functional recovery from surgery is unknown. Methods: We randomized postoperative cardiac surgical patients to receive either the AO or usual care. We measured average daily step count, changes in 6-min walk test (6MWT) distance, and changes in functional independence (Barthel Index). Our primary goal was to test protocols, measure variability in activity, and establish effect sizes. Results: Thirty-six patients were randomized (18 per group, 45% bypass surgery). Overall, patients exhibited significant recovery of physical function from baseline to discharge in the 6MWT (from 83 to 172 meters, p &lt; 0.001) and showed improvement in independent function (Barthel Index, 67 to 87, p &lt; 0.001). Moreover, each additional barrier to ambulation (supplemental oxygen, intravenous poles/fluid, walkers, urinary catheters, and chest tubes) reduced average daily step count by 330 steps/barrier, p = 0.04. However, the AO intervention resulted in only a small difference in average daily step counts (2718 versus 2541 steps/d, Cohen's d = 0.16, 608 patients needed for larger trial), which we attributed to several trial factors that likely weakened the AO intervention. Conclusion: In this pilot study, we observed significant in-hospital physical and functional recovery from surgery, but the addition of an AO made only marginal differences in daily step counts. Future studies should consider stepped-wedge or cluster trial designs to increase intervention effectiveness. Clinical Trials Registration: Clinicaltrials.gov unique identifier: NCT02375282.

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Abstract Background This study aimed to investigate the usefulness of inflammatory biomarkers such as white blood cell (WBC) count, C-reactive protein (CRP) and procalcitonin (PCT) for differentiating cryptogenic organising pneumonia (COP) from community-acquired pneumonia (CAP). Methods COP patients hospitalised in Kurashiki Central Hospital between January 2010 and December 2017 whose WBC counts and CRP and PCT levels were measured were investigated retrospectively, and their results were compared with those of hospitalised CAP patients who were prospectively enrolled between October 2010 and November 2017. Definite COP was defined by specific histopathological findings, and possible COP was defined as a consolidation shadow on chest computed tomography and lymphocyte dominance in bronchoalveolar lavage fluid in the absence of specific histopathological findings or lung specimens. The discriminatory abilities of WBC counts, CRP and PCT were evaluated by receiver operating characteristic (ROC) curve analysis. Results There were 56 patients in the entire COP group, 35 (61.4%) with definite COP, and 914 CAP patients. All three biomarkers were significantly lower in COP than in CAP. The AUC value of PCT in all COP patients was 0.79, significantly higher than of both CRP (AUC 0.59, p < 0.001) and WBC (AUC 0.69, p = 0.048). In definite COP patients, the AUC value of PCT was 0.79, which was also significantly higher than of both WBC (AUC 0.64, p = 0.006) and CRP (AUC 0.64, p = 0.001). Conclusions PCT is a more useful biomarker for differentiating COP from CAP than WBC count or CRP. However, PCT should be used as an adjunct to clinical presentation and radiological findings.

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Background: In developing countries, Ischemic heart diseases (IHD) is one of the leading causes of morbidity and mortality. The underlying pathology of CAD is atherosclerosis. When this atherosclerotic plaque ruptures, platelets play a crucial role in the prothrombotic events and forms a thrombus on this plaque and as a result coronary artery gets occluded causing ischemia and infarction. Platelet contains many chemokines, cytokines and growth factors. Release of these factors along with interaction with endothelial cells and leukocytes promotes inflammation and progression of atherosclerosis. We aimed to investigate the association between platelet volume indices in patients with diagnosis of Ischemic heart disease in comparison with control group.Methods: By using automated cell counter platelet count and platelet volume indices - were compared with Normal healthy or non-cardiac chest pain patients with the use of unpaired t test.Results: In the present study, we demonstrated that platelet count is significantly low and MPV and PDW are significantly high in Ischemic heart disease as compared to patients with noncardiac chest pain or healthy subjects. The correlation of MPV with PC revealed an inverse correlation between the patients of IHD and healthy or non-cardiac chest pain patients which is statistically significant.Conclusions: The platelet volume indices are an important, simple, effortless and a cost-effective tool useful in predicting the development of an acute coronary event sometimes in the near future and therapeutic modification for improved patient’s cardiovascular care.

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I am currently caring for a child named Priscilla who is ventilator-dependent and whose care confronted me with questions of justice. Priscilla was born at the County Hospital after a normal pregnancy to a 17-year-old single mother. At birth, she was noted to have some dysmorphic features: widely spaced eyes, low-set ears, and a cleft palate. Her chest X-ray showed hypoplastic ribs and scapulae. Her chromosome studies were normal. Eventually, a diagnosis of a rare dwarfing syndrome campomelic dysplasia – was made.

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Background: Children suffering from cancer are more vulnerable than others. This study performed to outline the clinical characteristics and outcome of children with cancer with severe acute respiratory syndrome corona virus 2 (SARS-CoV-2) infection in Dhaka Medical College Hospital, Dhaka. Methods: Clinical data and epidemiologic history of 24 children with cancer with laboratoryconfirmed COVID-19 infection by real-time reverse transcription-PCR (RNA-PCR) were admitted in the Dhaka Medical College Hospital, Dhaka from May, 2020 to June, 2020. Clinical data and epidemiologic history of these patients were restrospectively collected and analyzed. Results: Among the 24 cases, 16 (67%)were males and 8 (33%) were females. The median age was 5 years (range 0.11–12 years). The most common symptoms were fever (11 cases, 45%) and runny nose (8 cases, 33%), cough (8 cases, 33%), 6 (24%) were asymptomatic. Acute Lymphoblastic Leukemia were the most common (50%) and second most were Wilms tumor (17%). Among the 24 cases, on admission, 17 (71%) had normal white blood cell counts, while only 2 (8%) more than 10x109/L and 5 (21%) less than 4x109/L, respectively. 16 cases (67 %) had normal neutrophil count and 7 cases (29%) had neutropenia. Lymphocyte counts were normal in 50% cases, lymphocytopenia in 10 (42%). C Reactive protein and serum ferritin raised in 19(79%) cases, D-dimer raised, prothrombin time, activated partial thromboplastin time raised in 8(33%) cases. X-ray chest was abnormal in 6 cases (25%). 16 cases (66%) received intravenous antibiotics, 5 cases (21%) needed oxygen therapy and 4 cases (17%) needed corticosteroid. Ninteen (79%) patients were discharged from hospital, 3cases (13%) were discharged on request and death was 2 cases (8%). Conclusions: Children at all ages appeared susceptible to COVID-19 and there was significant gender difference. Clinical manifestations of children’s COVID-19 cases were generally less severe than those of adult patients. Death rate is more in children with cancer than others. J Dhaka Medical College, Vol. 29, No.2, October, 2020, Page 165-170

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ObjectivesTo describe contemporary characteristics and diagnoses in prehospital patients with chest pain and to identify factors suitable for the early recognition of high-risk and low-risk conditions.DesignProspective observational cohort study.SettingTwo centre study in a Swedish county emergency medical services (EMS) organisation.ParticipantsUnselected inclusion of 2917 patients with chest pain contacting the EMS due to chest pain during 2018.Primary outcome measuresLow-risk or high-risk condition, that is, occurrence of time-sensitive diagnosis on hospital discharge.ResultsOf included EMS missions, 68% concerned patients with a low-risk condition without medical need of acute hospital treatment in hindsight. Sixteen per cent concerned patients with a high-risk condition in need of rapid transport to hospital care. Numerous variables with significant association with low-risk or high-risk conditions were found. In total high-risk and low-risk prediction models shared six predictive variables of which ST-depression on ECG and age were most important. Previously known risk factors such as history of acute coronary syndrome, diabetes and hypertension had no predictive value in the multivariate analyses. Some aspects of the symptoms such as pain intensity, pain in the right arm and paleness did on the other hand appear to be helpful. The area under the curve (AUC) for prediction of low-risk candidates was 0.786 and for high-risk candidates 0.796. The addition of troponin in a subset increased the AUC to >0.8 for both.ConclusionsA majority of patients with chest pain cared for by the EMS suffer from a low-risk condition and have no prognostic reason for acute hospital care given their diagnosis on hospital discharge. A smaller proportion has a high-risk condition and is in need of prompt specialist care. Building models with good accuracy for prehospital identification of these groups is possible. The use of risk stratification models could make a more personalised care possible with increased patient safety.

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Background: A pleural effusion represents the disruption of the normal mechanisms of formation and drainage of fluid from the pleural space. Pleural effusions are associated with diseases of varied etiologies and often carry a grave prognosis.Objective: To evaluate the common cause of pleural effusion in developing country and also to compare to that of developed countries.Methods: This is a prospective observational study. Fifty four patients, diagnosed with pleural effusion on admission were randomly selected from I April 2016 to 30 September 2016 in Medicine ward of Khulna medical college hospital. Etiologic diagnosis was established by sequential clinical history and findings on physical examination, laboratory tests, chest radiograph, CT Scan of chest and pleural fluid analysis. Patients who remained undiagnosed were subjected to fibre-optic bronchoscopy, thoracoscopic pleural biopsy, and histopathology.Results : Etiologic diagnosis of pleural effusion was established in 50 (92.59%); tuberculosis 25 (46.29%), parapneumonia 10 (18.52%) malignancy 7 (12.96%) nephrotic syndrome 3 (5.55%),cirrhosis of liver disease 2 (3.71%) congestive cardiac failure 2 (3.71%), systemic lupus erythematosus I (1.85%). 4 patients (7.41%) remain undiagnosed. Among subjects, exudative pleural effusion was 43 (79.63%) and transudative 11 (21 57%). Among exudative pleural effusion sputum for AFB positive 15 (34.88%), FNAC 10 (23%), fibreoptic bronchoscopy was positive 2 (4.6%), gene expart test for tuberculosis positive in 5 (11.62%).Conclusions: Most of the pleural effusion cases are diagnosed as tuberculosis, Early and adequate treatment results in complete recovery of the patient.Bang Med J (Khulna) 2016; 49 : 27-30

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IntroductionThe COVID-19 pandemic has been characterised by significant in-hospital virus transmission and deaths among healthcare workers. Sources of in-hospital transmission are not fully understood, with special precautions currently reserved for procedures previously shown to generate aerosols (particles <5 μm). Pleural procedures are not currently considered AGPs (Aerosol Generating Procedures), reflecting a lack of data in this area.MethodsAn underwater seal chest drain bottle (R54500, Rocket Medical UK) was set up inside a 60-litre plastic box and connected via an airtight conduit to a medical air supply. A multichannel particle counter (TSI Aerotrak 9310 Aerosol Monitor) was placed inside the box, allowing measurement of particle count/cubic foot (pc/ft3) within six channel sizes: 0.3–0.5, 0.5–1, 1–3, 3–5, 5–10 and >10 μm. Stabilised particle counts at 1, 3 and 5 L/min were compared by Wilcoxon signed rank test; p values were Bonferroni-adjusted. Measurements were repeated with a simple anti-viral filter, designed using repurposed materials by the study team, attached to the drain bottle. The pressure within the bottle was measured to assess any effect of the filter on bottle function.ResultsAerosol emissions increased with increasing air flow, with the largest increase observed in smaller particles (0.3–3 μm). Concentration of the smallest particles (0.3–0.5 μm) increased from background levels by 700, 1400 and 2500 pc/ft3 at 1, 3 and 5 L/min, respectively. However, dispersion of particles of all sizes was effectively prevented by use of the viral filter at all flow rates. Use of the filter was associated with a maximum pressure rise of 0.3 cm H2O after 24 hours of flow at 5 L/min, suggesting minimal impact on drain function.ConclusionA bubbling chest drain is a source of aerosolised particles, but emission can be prevented using a simple anti-viral filter. These data should be considered when designing measures to reduce in-hospital spread of SARS-CoV-2.

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AbstractA 20-year-old male was impaled through the chest, abdomen, and right upper thigh by three 1.5 cm (0.59 in) diameter rods, each 2 m (6.56 ft) in length. The first rod entered below his right nipple, the second through the right hypochondrium, and the third through the right upper thigh. He was transported to the hospital with the rods in situ. This paper provides insight as to how these unusual injuries were managed in a limited-resource environment. Even in a developing country, the challenges posed by multiple impalement injuries can be managed successfully by rapid prehospital transfer, along with an adequate and coordinated hospital team effort.

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Background Acute respiratory infections (ARIs), primarily pneumonia, are the leading infectious cause of under-5 mortality worldwide. Manually counting respiratory rate (RR) for 60 seconds using an ARI timer is commonly practiced by community health workers to detect fast breathing, an important sign of pneumonia. However, correctly counting breaths manually and classifying the RR is challenging, often leading to inappropriate treatment. A potential solution is to introduce RR counters, which count and classify RR automatically. Objective This study aims to determine how the RR count of an Automated Respiratory Infection Diagnostic Aid (ARIDA) agrees with the count of an expert panel of pediatricians counting RR by reviewing a video of the child’s chest for 60 seconds (reference standard), for children aged younger than 5 years with cough and/or difficult breathing. Methods A cross-sectional study aiming to enroll 290 children aged 0 to 59 months presenting to pediatric in- and outpatient departments at a teaching hospital in Addis Ababa, Ethiopia, was conducted. Enrollment occurred between April and May 2017. Once enrolled, children participated in at least one of three types of RR evaluations: (1) agreement—measure the RR count of an ARIDA in comparison with the reference standard, (2) consistency—measure the agreement between two ARIDA devices strapped to one child, and (3) RR fluctuation—measure RR count variability over time after ARIDA attachment as measured by a manual count. The agreement and consistency of expert clinicians (ECs) counting RR for the same child with the Mark 2 ARI timer for 60 seconds was also measured in comparison with the reference standard. Results Primary outcomes were (1) mean difference between the ARIDA and reference standard RR count (agreement) and (2) mean difference between RR counts obtained by two ARIDA devices started simultaneously (consistency). Conclusions Study strengths included the design allowing for comparison between both ARIDA and the EC with the reference standard RR count. A limitation is that exactly the same set of breaths were not compared between ARIDA and the reference standard since ARIDA can take longer than 60 seconds to count RR. Also, manual RR counting, even when aided by a video of the child’s chest movements, is subject to human error and can result in low interrater reliability. Further work is needed to reach global consensus on the most appropriate reference standard and an acceptable level of agreement to provide ministries of health with evidence to make an informed decision on whether to scale up new automated RR counters. Trial Registration ClinicalTrials.gov NCT03067558; https://clinicaltrials.gov/ct2/show/NCT03067558 International Registered Report Identifier (IRRID) RR1-10.2196/16531

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Objective: To determine the frequency of bacterial infection in children less than five years of age presenting with respiratory wheeze to Tertiary care centre. Study Design: Descriptive Case Series study. Setting: Department of Pediatrics, The Children’s Hospital and The Institute of Child Health, Multan. Period: November 2019 to April 2020. Material & Methods: A total of 130 children, presenting with respiratory symptoms were examined for presence of respiratory wheeze. After confirmation of chest auscultation, patients were enrolled. Information regarding duration of wheeze, axillary temperature, presence of chest in drawing and respiratory rate were recorded. Appropriate blood sample were drawn for total leukocyte count and differential leukocyte count from which absolute neutrophils count was calculated. Children were evaluated for the presence of bacterial infection as per operational definition. Results: There were 38 (29.23%) female and 92 (70.76%) male patients. Overall, mean age was13.17±5.49 with age range of 1-57 months. Bacterial infection was noted in 33 (25.38%) patients. Out of 130 patients presenting with wheeze, 50 patients (38.46%) had temperature range of 98.1-990F. Absolute neutrophil count was more than 5000/dl in 42(32.30%) patients, out of these 33(78.6%) had bacterial infection. Chest X-rays were showing infiltrates in 110 (84.6%) patients. Conclusion: Children suffering from wheeze have bacterial infection if age is less than five years and there is fever, crepitations, elevated absolute neutrophil count and radiographic evidence of pneumonia.

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A 24-year-old Hispanic male came into the emergency room of a large public teaching hospital with acute cardiac failure and chest pain. He was admitted and diagnosed with rheumatic heart disease and regurgitation and stenosis of both mitral and aortic valves. Medical judgment concluded that the patient needed to be medically stabilized and then undergo cardiac surgery to repair heart valves. The patient spoke only Spanish. Investigation through an interpreter revealed that he was an illegal alien from a Central American country who has lived in this country for five to seven years. He came to the United States so that he could receive treatment for his heart condition, evidently fearing that he would not receive treatment in his home country. The patient entered this country through the assistance of some distant relatives. He did not have a strong support system.

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Background Coronavirus disease 2019 (COVID-19) has quickly spread throughout the country and the world since first broke out in Wuhan, China. The outbreak that started from January 22, 2020, in Fujian Province has been controlled as the number of indigenous cases has not increased since March. We aimed to describe the clinical characteristics of patients with COVID-19 in Fujian Province, China. Methods In this retrospective, multicenter study, we collected and analyzed the epidemiological, clinical, and laboratory data of all cases confirmed by nucleic acid tests in five designated hospitals in Fujian Province between January 22 and February 27, 2020. All patients were followed up until discharge. COVID-19 severity was classified as mild, moderate, severe, or critical. Results Of 199 discharged patients with COVID-19, 105 patients were male, with a median age of 46.3 years, and 17 patients were severe, and 5 patients were critical on admission. Hypertension and diabetes were the most common comorbidities. The symptoms at illness onset were mainly fever (76.4%), cough (60.8%), and myalgia or fatigue (27.6%). A total of 96.5% of patients had abnormal imaging findings on chest computed tomography. Lymphopenia (37.2%) and hypoxemia (13.6%) were observed. Acute respiratory distress syndrome and respiratory failure occurred in 9 patients (4.5%) and 8 patients (4.0%) respectively. One patient died and the others were cured and discharged with the median hospital stay of 19 days. Old age was negatively correlated with lymphocyte count (r = - 0.296, p < 0.001) and oxygenation index (r = - 0.263, p = 0.001). Bivariate regression analysis revealed that old age (≥ 75 years), hypertension, diabetes, and lymphopenia were correlated with the severity of COVID-19. Conclusions Patients in Fujian Province were mostly nonsevere cases with mild or moderate symptoms, and had a lower mortality than patients in Wuhan (4.3%-15%). Older age, hypertension, diabetes, and lymphopenia were risk factors for severity of COVID-19.

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Introduction:Platelet counts in peripheral blood could possibly be used as prognostic markers in sickle cell disease (SCD), since these blood elements play an important role in the phenomena of vessel occlusion. In this context, the mean platelet volume (MPV) may also reflect the level of platelet activation, a parameter that is already used in the stratification of thrombotic processes in situations such as acute coronary syndromes. Thus, the aim of this study was to evaluate platelet counts and MPV in SCD as possible prognostic markers for the occurrence of clinical complications and their relation with laboratory markers of inflammation and hemolysis. Methods:A retrospective chart review was performed on two hundred and sixty-six adult SCD patients (median age 40 years, ranging from 14 to 66), followed from 2002 to 2019, distributed as follows: 156 HbSS, 16 HbSβ0, 15 HbSβ+ and 79 HbSC. Medical records were reviewed for laboratory data at baseline (first visit); clinical data and hospital admissions were recorded for sickle related complications throughout follow-up: acute chest syndrome, retinopathy, avascular bone necrosis, stroke, priapism, leg ulcers and venous thromboembolism. Results:The median platelet count was significantly different between the different genotypes (Kruskal-Wallis rank sum test, p &lt; 0.001), with SS: 420 (95-1043) x 103/uL, Sβ0: 406.5 (206 -713), Sβ+: 362 (87-925) and SC: 295 (84 -927). This difference may be related to the degrees of inflammation and hyposplenia in each genotype. Regardless of the genotypes, platelet counts in peripheral blood tend to decrease with age (Rô = -0.201, p &lt; 0.001). Interestingly, higher platelet counts are associated with the presence of leg ulcers (Wilcoxon rank sum test with continuity correction, p = 0.03), acute chest syndrome (p= 0.047), higher levels of microalbuminuria (p &lt;0.001) and transfusion load accumulated throughout life (p = 0.03), pointing to a marker of disease severity in this specific cohort. In addition, patients with higher platelet counts tend to have lower hemoglobin (Rô = -0.252, p &lt;0.001) and hematocrit levels (Rô = -0.229, p &lt;0.001), as well as higher RDW (Rô = 0.131, p = 0.032), which could be related to the higher reticulocyte count (Rô = 0.333, p &lt;0.001) suggesting higher levels of hemolysis, corroborated by the higher levels of unconjugated bilirubin (Rô = 0.227, p &lt;0.001). There was also a positive relationship between platelet counts and number of total leukocytes (Rô = 0.343, p &lt;0.001), neutrophils (Rô = 0.272, p &lt;0.001), monocytes (Rô = 0.28, p &lt;0.001) and lymphocytes (Rô = 0.257, p &lt;0.001), probably reflecting an association with exacerbated inflammation and hematopoietic response. MPV index was above normal values in only 10 patients (3.75%) and there were no significant variations between the different genotypes. However, MPV seems to predict the occurrence of retinopathy in SC individuals (Wilcoxon rank sum test with continuity correction, p = 0.05). Moreover, there is an inverse relationship between MPV value and hemoglobin levels (Rô = -0.125, p = 0.041) and hematocrit (Rô = -0.156, p = 0.011), though no correlation with any other laboratory marker or clinical complication. Discussion: In this cohort of Brazilian patients, we observed that, despite the difference in platelet counts between the genotypes, the increase in platelet counts was related to a greater chance of leg ulcers, Acute Chest Syndrome, microalbuminuria and high transfusion load. Furthermore, platelet number was inversely correlated with hemoglobin and hematocrit levels, and was associated with changes in hemolysis and inflammation markers. MPV was related to the presence of retinopathy in HbSC individuals and MPV elevation was also associated with low levels of hemoglobin and hematocrit. Thus, it is important to evaluate the baseline platelet counts of SCD patients as possible predictor of clinical complications and more severe phenotypes. This simple measure has the potential to raise awareness in the care of these specific patients and to direct greater efforts in the prevention of chronic complications, especially in situations of fewer resources, as this is a cheap and easily available marker. Disclosures Costa: Novartis:Consultancy.

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Background: Malnutrition is a common consequence notably in patients admitted to the intensive care unit. Aim of the study: was to assess the Impact of hospitalized nutritional formula on anthropometric, clinical and biochemical indices among Egyptian adult cardio-thoracic Critically Ill Patients on admission and discharge days. Methods: Totally, A convenient sample of 100 cardiothoracic patients was evaluated from admission to discharge in ICUs at Damietta Chest Disease Hospital in Egypt. The patients' anthropometric measurements, clinical data and biochemical indices were assessed As well, hospital diet prescription and intake was also evaluated. Results: High significant statistical difference patients' clinical data on admission and after one week such as body built (X2 = 52.6; p = 0.0), skin color (X2= 12.9; p = 0.02), skin turgor (X2= 13.19; p = 0.0), and occurrence of bed sore (X2= 27.7; p = 0.0). On the other hand, no significant statistical differences were found in the patients' weight and body mass index on admission and discharge (one week). Moreover, significant statistical differences were found in patients biochemical indices such as albumin (t= 3.03; p=0.003) and lymphocyte counts (3.74; p=0.000). So, the 88 % of patients showed decreased albumin after one week when compared to admission time. While, 10 % of patients showed increased lymphocytic count after one week of admission when compared to admission time. Conclusion and Recommendations: Clinical assessment, anthropometric, and biochemical indices are essential for evaluation, follow-up and management of cardiothoracic critically ill patients

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BACKGROUND Tuberculosis (TB) remains a major public health problem in India. TB worsens glycaemic control in patients with diabetes mellitus (DM), complicating the treatment for each condition leading to poor treatment outcomes and increase in morbidity / mortality. Human immunodeficiency virus - tuberculosis (HIV-TB) coinfections are on the rise. The objectives of the study were to describe various comorbidities in patients with tuberculosis, determine expected radiological presentations in these patients and to determine prognosis altering metabolic indicators in patients with TB. METHODS A prospective cross-sectional study using data of 40 microbiologically diagnosed TB patients admitted in wards of C.G. Hospital, JJM Medical College, Davangere, from January to March 2020 was done. Chest x-rays, clinical and haematological tests were analysed. RESULTS TB patients with DM, kidney disease, HIV presented with higher count of fibrosis, cavities and infiltrates on chest radiographs, and was worse with renal function. Hospitalisation was prolonged in patients with anaemia, multidrug-resistance tuberculosis (MDR-TB), urosepsis, and HIV as compared to patients with no comorbidities. MDR-TB showed more fibrosis. Patients with urosepsis had higher incidence of multiple lesions and effusion by 4 times. CONCLUSIONS Increased HbA1c and sugar levels lead to increase in lesions on chest x-ray in tuberculosis. Good glycaemic control in TB is a must to achieve good control of DM and reduce hospitalisation. KEYWORDS Tuberculosis, Diabetes Mellitus, HbA1c, Chest X-Ray

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Background: Cough variant asthma (CVA) is a subset of asthma where the only symptom is chronic persistent cough. Many cases go unrecognized due to lack of proper evaluation. Response to asthma medication with features supportive of airway hypersensitivity helps in management of this disease. Objective: To find out the proportion of cough variant asthma among the patients attending medicine outpatient department of Enam Medical College, Savar, Dhaka. Materials and Methods: This cross sectional study was conducted in Enam Medical College Hospital, Savar, Dhaka over a period of two years from July 2009 to July 2011. Cough variant asthma was diagnosed mainly on clinical ground as chronic cough without wheezing, fever, weight loss, shortness of breath or sputum or any other apparent cause that persisted for more than eight weeks with absolutely normal physical examination of chest, normal chest radiography and blood count except raised eosinophil count and IgE level. Patients who met these criteria were given 2 weeks course of inhaler beclomethasone propionate and were assessed for improvement. Those who improved after steroid inhalation were categorised as having cough variant asthma. Results: Out of purposively selected 148 patients complaining only of chronic dry cough for more than eight weeks, 92 patients met the primary selection criteria for cough variant asthma. These 92 patients were given 2 weeks trial of 250 ìgm beclomethasone inhalation twice daily. Seventy nine patients reported almost complete recovery from chronic cough after 2 weeks and were categorized as having CVA. Thirteen patients did not improve and were not categorized as CVA. Conclusion: These findings suggest that cough variant asthma is the most common among the patients with chronic cough not due to any apparent cause. The efficacy of inhaled corticosteroid suggests that early intervention is effective in the treatment of this disease. DOI: http://dx.doi.org/10.3329/jemc.v3i1.13871 J Enam Med Col 2013; 3(1): 29-31

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Introduction: Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted to the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results: The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, RSV isolation, and C-reactive protein were independent predictors of LOS Conclusions: Our results show that in infants with bronchiolitis, RSV isolation, age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.

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Introduction: Bronchiolitis is the leading cause of hospitalization in children. Estimate potentially preventable variables that impact the length of hospital stay are a priority to reduce the costs associated with this disease. This study aims to identify clinical variables associated with length of hospital stay of bronchiolitis in children in a tropical middle-income country Methods: We conducted a retrospective cohort study in 417 infants with bronchiolitis in tertiary centers in Colombia. All medical records of all patients admitted to the emergency department were reviewed. To identify factors independently associated we use negative binomial regression model, to estimate incidence rate ratios (IRR) and adjust for potential confounding variables Results: The median of the length of hospital stay was 3.68 days, with a range of 0.74 days to 29 days, 138 (33.17%) of patients have a hospital stay of 5 or more days. After modeling and controlling for potential confounders age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, RSV isolation, and C-reactive protein were independent predictors of LOS Conclusions: Our results show that in infants with bronchiolitis, RSV isolation, age <6 months, comorbidities (CHD or neurological), BPD, chest indrawing, and C-reactive protein were independent predictors of LOS. As a potentially modifiable risk factor, efforts to reduce the probability of RSV infection can reduce the high medical cost associates with prolonged LOS in bronchiolitis.

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<p><strong>BACKGROUND:</strong> Helicopter emergency medical services (HEMS) are considered as a standard component of advanced pre-hospital emergency care system. We assessed the clinical presentation and outcomes of trauma patients transported by HEMS versus ground emergency medical services (GEMS).</p><p><strong>METHODS:</strong> A retrospective analysis of prospectively collected trauma registry data at a level I trauma center was conducted for patients transported by GEMS and HEMS between 2011 and 2013. Patients’ data were categorized and analyzed based on the mode of transportation (MOT).</p><p><strong>RESULTS:</strong> A total of 4596 trauma patients were admitted to the hospital with a mean age of 31±15 years. Injured patients were transported to the trauma centre by GEMS (93.3%) and HEMS (6.7%). The common mechanisms of injury were motor vehicle crash (37%) and fall (25%). MVC victims were transported to the hospital by HEMS, whereas, patients with fall and pedestrian injuries (P=0.001 for all) were more likely to be transported by GEMS. Moreover, patients in the HEMS group had a higher frequency of head (p=0.001) and chest (p=0.001) injuries and required prolonged ICU and overall hospital stay (p=0.001). When compared with GEMS, HEMS group were more likely to sustain severe injuries (ISS&gt;15; p=0.001) and needed frequent on-scene intubation (P=0.001). Hospital mortality was grater in HEMS patients (10% vs 4%, p=0.001) in comparison to GEMS. Multivariate analysis, after adjusting for the confounding factors demonstrated that polytrauma and lower scene GCS were the independent predictors of mortality.</p><p><strong>CONCLUSIONS: </strong>Patients transported by HEMS are characterized by greater injury severity, traumatic brain injury and on-scene intubation. Moreover, the mortality is 2.5 fold greater in patients transported by GEMS, however, the impact of MOT on mortality disappear after adjusting for potential confounders. Institutional guidelines that focus on clinical triage criteria, key environmental factors and reducing transport time may be informed by this study. Further investigations are needed to better quantifyestimate the pre-hospital time intervals and to identify the sub-groups of trauma patients who will clearly benefit from the use of HEMS.</p>

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Background: Among all flaviviruses, Dengue is the most common fever. Every year 2-5 lakh cases of Dengue hemorrhagic fever occur. The objective of the study was to evaluate the clinical profile of patients with Dengue fever at a hospital in Kerala. Subjects and Methods: Patients with more than 12 years of age and those admitted with fever, headache, and myalgia were assessed with other clinical characteristics (warning signs of dengue fever, signs of hemorrhage, signs of plasma leakage and signs of shock). Laboratory examinations such as Hb, total count, differential count, platelet count, packed cell volume, peripheral smear for the malarial parasite, and liver function test (including S. protein) and renal function test were carried out. Blood coagulation profiles such as Bleeding Time, Clotting Time, Prothrombin Time and aPTT were performed. Radiological findings like X-ray chest and USG abdomen were also performed. Results: Consequently dengue fever is ordinary in young adults. In the current study, males were more pretentious than females. Males were affected by 63.7% while females are affected by 36.3%. The most usual indication was fever (94.8%) experienced in all patients followed by headache (41.3%), Generalized weakness (77.5%), myalgia (51.7%), vomiting (57.7%). Predominant organ involvement was hepatic (transaminases, jaundice) followed by gastrointestinal (abdominal pain, distension, loose stools, vomiting, ascites) systems. The total survivors are 86(74.1%) whereas 30(25.8%) were non-survivors. Conclusion: Dengue fever usually affects male and young populace. Headache, fever, myalgia are ordinary at hand grumble however in the recent few years, the world has observed the diverse experimental appearance of the dengue fever in dissimilar epidemics, even in the same regions and even with the period of times.

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Abstract Introduction: There is little data on the incidence and consequences of hospital-acquired (HA) platelet count drops and no consensus on how to define HA-thrombocytopenia. We evaluated the incidence of relative and absolute HA-drops in platelet count among medical patients (general medicine, cardiology, and intensive care unit) to determine their association with mortality, HA-venous thromboembolism (VTE), and HA-bleeding. Methods: Data was abstracted from the electronic medical record at the University of Vermont Medical Center, a 540-bed tertiary care hospital in Burlington, VT for admissions between 2009-12. Exclusion criteria were age &lt;18, pregnant, admitted to a non-medical service or to the oncology service, and platelet count &lt;150 thousand (k) at admission. HA-platelet count drops were defined as listed in the table (absolute nadir, relative drop, absolute platelet count). We used logistic regression to evaluate the association of various definitions of platelet count drops with HA-VTE, HA-bleeding (based on the International Society of Thrombosis and Haemostasis definition), and in-hospital mortality. Models were adjusted for age, sex, service, admission platelet count, and for known risk factors for HA-VTE, HA-bleeding, and mortality (Table). Results: Of 11,863 admissions without thrombocytopenia on admission, 1,905 (16.1%) patients developed a platelet count &lt;150k, 6,971 (58.8%) had at least a 10% drop in their platelet count, and 6,737 (56.8%) at least a 25k drop (Table). There were 939 (7.9%) deaths, 48 (0.4%) HA-VTE, and 106 (0.9%) HA-bleeding events. HA-platelet count drops were associated with increasing age, male sex, and admission to an intensive care unit (all p &lt; 0.05). All definitions of platelet count drops were associated with mortality, HA-VTE, and HA-bleeding (Table). A 10% platelet count drop was associated with increased mortality (OR 1.52, CI: 95% 1.30-1.79), HA-VTE (OR 5.19, CI: 95% 1.83-14.74), and HA-bleeding (OR 8.83, CI: 95% 3.20-24.36) and an absolute 25k drop was associated with increased mortality (OR 1.60, CI: 95% 1.36-1.88), HA-VTE (OR 4.27, CI: 95% 1.64-11.11), and HA-bleeding (OR 5.22, CI: 95% 2.38-11.49). Conclusion: Platelet count drops, even those considered clinically insignificant, identify a large number of hospitalized medical patients at increased risk for mortality, HA-VTE, and HA-bleeding. Our findings are not driven by severe HA-thrombocytopenia as only 2% of admissions developed platelet counts &lt;100,000. HA-platelet count drops are likely a good marker of illness severity in this population and could identify patients at increased risk for mortality, HA-VTE and HA-bleeding allowing targeted interventions to improve patient outcomes. Table 1. Association of Hospital-Acquired Platelet Count Drops with Mortality, HA-VTE and HA-Bleeding in Medical Patients Platelet Drop Admissions = 11,863 Odds Ratio (95% Confidence Interval) N, % Mortality N = 939 HA-VTE N = 48 HA-Bleeding N = 106 Absolute Nadir &lt;150k 1,905 (16.1%) 2.0 (1.7, 2.5) 4.3 (2.3, 7.9) 2.7 (1.8, 4.2) &lt;100k 235 (2.0%) 4.4 (3.0, 6.3) 5.4 (2.3, 12.5) 3.2 (1.8, 5.8) Relative Drop 50% 371 (3.1%) 3.8 (2.8, 5.2) 6.3 (3.1, 12.8) 5.0 (3.1, 8.0) 30% 1,748 (14.7%) 2.5 (2.1, 3.0) 4.2 (2.2, 7.9) 3.6 (2.3, 5.6) 10% 6,971 (58.8%) 1.5 (1.3, 1.8) 5.2 (1.8, 14.7) 8.8 (3.2, 24.4) Absolute Drop 100k 1,186 (10.0%) 2.7 (2.2, 3.3) 6.4 (3.2, 12.8) 4.3 (2.8, 6.8) 75k 2,019 (17.0%) 2.4 (2.0, 2.3) 5.0 (2.6, 9.9) 4.8 (3.1, 7.7) 50k 3,594 (30.3%) 1.9 (1.7, 2.3) 3.3 (1.7, 6.6) 5.5 (3.2, 9.4) 25k 6,737 (56.8%) 1.6 (1.4, 1.9) 4.3 (1.6, 11.1) 5.2 (2.4, 11.5) Mortality - Adjusted additionally for: Respiratory Rate, Respiratory Dysfunction (intubated or oxygen saturation &lt;90%), Heart Rate, Temperature, Diabetes, Cancer, and HIV (Brabrand, PLoS ONE 2015) HA-VTE - Adjusted additionally for: Anticoagulation (prophylactic and full dose), Cancer, Heart Failure, Respiratory Dysfunction, Rheumatologic or Inflammatory Disease, and Tachycardia (Zakai, JTH 2013) HA-Bleeding - Adjusted additionally for: Anticoagulation (prophylactic and full dose), Cancer, Renal Function, Heart Failure, Respiratory Dysfunction, Rheumatologic or Inflammatory Disease, and Tachycardia (Decousis, Chest 2011) Disclosures No relevant conflicts of interest to declare.