Autopsy study of febrile deaths during monsoon at a tertiary care institute in India: Is malaria still a challenge?

Background:

To utilise an autopsy-based approach to study the febrile deaths and deaths due to malaria during monsoon period of three years at a tertiary care teaching hospital in Mumbai, India.

Materials and Methods:

All autopsies done at the hospital during monsoon period from 2005 to 2007 when fever was the main presenting symptom were included in the study. Monsoon period was defined from June to September. A study on the duration of hospital stay of malaria deaths was also attempted.

Results:

There were 202 autopsies of febrile illness during the study period. Malaria resulted in 20.8% of the deaths besides other causes. A majority of deaths had intrapulmonary haemorrhages as the only pathological finding. Incidence of malaria deaths was more during monsoon period than the non-monsoon period. Plasmodium falciparum was the most common species responsible for malaria deaths while cerebral malaria was the most common mode of death. In 27% of the cases, post-mortem examination helped to arrive at the correct final diagnosis. In 88.1% of the cases, malaria deaths occurred within the first 24 hours of admission to the hospital.

Conclusion:

The study reiterates the fact that malaria remains a preventable but major cause of death in India, predominantly during the monsoon period. The study also emphasises the importance of developing treatment protocols for malaria during such crucial times besides reinforcing the existing preventive measures.     

Field hypotension in patients who arrive at the hospital normotensive: a marker of severe injury or crying wolf?

INTRODUCTION: Trauma patients with hypotension in the field who arrive at a hospital with a normal blood pressure (BP) may not be recognized as significantly injured. METHODS: Over a 5-year period, demographic, injury severity, and disposition data were retrospectively analyzed for patients > or =16 years of age with documented hypotension in the field (systolic BP < or =90 mm Hg) and normal BP (systolic BP >90 mmHg) on hospital arrival (hypotensive group). This group was compared to patients with normal BP in the field and on hospital arrival (normotensive group). RESULTS: During the study, 2207 patients with documented BP were transported directly from the scene. Of this number 44 (2%) were assigned to the hypotensive group, 2086 (94%) were assigned to the normotensive group, and 77 (4%) patients were hypotensive on hospital arrival. The hypotensive group had a systolic BP in the field of 70 +/- 26 mmHg compared to 140 +/- 26 mmHg in the normotensive group (p < 0.0001). Arrival BP at the hospital was normal in both groups. Compared to the normotensive group, the hypotensive group had higher Injury Severity Scores (22.0 vs. 11.1, p < 0.0001), lower Glasgow Coma Scores (10.8 vs. 14.0, p < 0.0001), lower Revised Trauma Scores (65 vs. 7.4, p < 0.0O01), more emergency department deaths (7% vs. 0%, p < 0.001), longer lengths of stay in the intensive care unit (8.6 vs. 7.0 days, p < 0.0001) and hospital (14.0 vs. 7.0 days, p < 0.0001), and increased hospital mortality (18% vs. 4%, p < 0.001). LIMITATIONS: The retrospective design and exclusion of patients without documentation of BP in the field may have resulted in selection bias. CONCLUSION: Despite these limitations, field hypotension is a marker of significant injury in patients arriving at the hospital normotensive.     

Characteristics of distractions in the intensive care unit: how serious are they and who are at risk?

INTRODUCTION

Distractions and interruptions of doctor’s work, although common and potentially deleterious in the intensive care unit (ICU), are not well studied.

METHODS

We used a simple observational method to describe the frequency, sources and severity of such distractions, and explore at-risk situations in the ICU. Independent paired observers separately shadowed eight residents and three fellows for 38 sessions (over 100 hrs) in a 20-bed medical ICU.

RESULTS

In total, 444 distractions were noted. Interobserver agreement was excellent at 99.1%. The mean number of distractions/doctor/hr was 4.36 ± 2.27. Median duration of each distraction was 2 mins (interquartile range 2–4 mins; range 1–20 mins). The top three initiators of distractions were other doctors (35.1%), nurses (30.4%) and oneself (18.7%). Of the 444 distractions, 107 (24.1%) were prolonged (lasting ≥ 5 mins), 210 (47.3%) led to a complete pause of current activity and 85 (19.1%) led to complete abandonment of the current activity. On multivariate analysis, physician seniority, time of session and day of week did not predict frequency of distraction. After adjusting for time of session, day of week and type of current activity, urgent distractions (to see another patient, perform immediate procedures or administer medications) and physician juniority were associated with major distractions (complete interruption or termination of current activity), while only urgent distractions were associated with prolonged distractions.

CONCLUSION

Distractions are common in the ICU and junior doctors are particularly susceptible to major distractions.     

When is a maternal death a maternal death? A review of maternal deaths at the Mercy Maternity Hospital, Melbourne

The limiting of the reporting of maternal deaths to those that are included in the criteria of the World Health Organization excludes deaths which yield useful information for further improvements in clinical performance. In this series of 22 maternal deaths, six deaths would have been excluded from reporting: one "direct" obstetric death of pre-eclampsia; one "indirect" death as a result of renal and cardiac failure; two deaths as a result of postnatal depression which led to suicide three and four months postpartum, respectively; and two deaths of cancers, where diagnostic delay may have been a result of the coexistent pregnancy. The importance of primary pulmonary hypertension, cardiomyopathy and psychiatric illness is emphasized. We endorse the recent recommendation of the International Federation of Gynaecology and Obstetrics (FIGO) that all maternal deaths that occur more than 42 days after the end of a pregnancy should be assessed for possible relationships with childbirth, and suggest that a time limit of one year would include all deaths that are worthy of scrutiny.     

The Guillain-Barré syndrome at two hospitals in Trinidad, West Indies: a review of 26 patients

Over a four-year period, 26 consecutive patients with Guillain-Barrd syndrome (GBS) were seen. Their ages ranged from 18 months to 68 years. Fifteen were male and 11 female. The crude annual incidence was estimated to be 1.5 per 100,000 population. East Indians made up the majority of the patients. An antecedent infection was reported in 65% of patients. Significant pain was present in halfofthe cohort. F-wave abnormalities were the commonest electrophysiological disturbance. Twenty-nine per cent of patients required ventilation. Intravenous immunoglobulin (IVIG) treatment was beneficial in 88% of patients. Eighty-four per cent made a complete or near complete recovery. One patient died.     

Use of Gamma locking nail® in tri-planar osteotomy in bilateral severe slipped upper femoral epiphysis: a case study and literature review

Introduction

Slipped upper femoral epiphysis (SUFE) is a common condition affecting adolescent boys and girls. It is classified as acute, chronic or acute on chronic. The slip can be mild, moderate or severe.

Materials and methods

We present a case of chronic severe SUFE in a 16-year-old male with significant fixed bilateral deformities requiring osteotomy of proximal femur and stabilisation with short locking Gamma nail^®. To our knowledge, this device has not been used in stabilisation of osteotomies in chronic SUFE.

Conclusion

The purpose of this paper is to describe the results of our fixation method and also to increase the awareness in orthopaedic surgeon about the usefulness of Gamma locking nail^® in these difficult situations.     

What are appropriate rates of invasive procedures following acute myocardial infarction? A systematic review

OBJECTIVE: To assess the evidence that higher rates of coronary angiography (CA) and revascularisation (RV) in the subacute phase of acute myocardial infarction (AMI) improve patient outcomes. DATA SOURCES: MEDLINE 1990 - December 1999, Current Contents 1990-1999, Cochrane Library (Issue 4, 1999), HealthSTAR 1990-1999, selected websites and bibliographies of retrieved articles. STUDY SELECTION AND DATA EXTRACTION: Studies selected were (1) randomised trials comparing outcomes of "invasive" versus "conservative" use of CA and RV following AMI; (2) observational studies with formal methods comparing outcomes of high versus low rates of use of these procedures; and (3) clinical practice guidelines (CPGs), expert panel statements and decision analyses which met critical appraisal criteria, and which specified procedural indications. Outcome measures were rates of mortality, re-infarction and limiting or unstable angina. DATA SYNTHESIS: 56 articles were identified; 24 met inclusion criteria. Pooled data from nine RCTs of "invasive" (CA rate 96%; RV rate 66%) versus "conservative" (CA rate 28%; RV rate 19%) strategies showed no significant differences in mortality or re-infarction rates. Pooled results from 12 observational studies showed no mortality differences, but an excess reinfarction rate (8.0% vs 6.4%; P<0.001) in high- versus low-rate populations. Evidence of survival benefit from procedural intervention was strongest for patients with recurrent ischaemia combined with left ventricular dysfunction. CONCLUSIONS: In the subacute phase of AMI, rates of CA and RV in excess of 30% and 20%, respectively, may not confer additional benefit in preventing death or re-infarction. However, variability between studies in design, patient selection, and extent of cross-over from medical to procedural groups, as well as limited data on symptom status, limits generalisability of results.     

Iodine status in pregnant women and their newborns: are our babies at risk of iodine deficiency?

OBJECTIVES: To determine whether pregnant women and their newborns show evidence of iodine deficiency, and to examine the correlation between maternal urine iodine concentration (UIC) and newborn thyroid-stimulating hormone (TSH) level. DESIGN: A cross-sectional study. SETTING: Hospital antenatal care services (March-May 2004) and private obstetrician clinics (June 2004) in the Central Coast area of New South Wales. PARTICIPANTS: 815 pregnant women (> or = 28 weeks' gestation) and 824 newborns. MAIN OUTCOME MEASURES: World Health Organization/International Council for the Control of Iodine Deficiency Disorders criteria for assessing severity of iodine deficiency (recommended levels: < 20% of urine samples in a population with UIC < 50 microg/L; and < 3% of newborns with whole-blood TSH level > 5 mIU/L). RESULTS: The median UIC for pregnant women was 85 microg/L, indicating mild iodine deficiency. Almost 17% of pregnant women had a UIC < 50 microg/L, and 18 newborns (2.2%) had TSH values > 5 mIU/L. There was no statistically significant linear correlation between neonatal whole-blood TSH level and maternal UIC (r = - 0.03; P = 0.4). Mothers with a UIC < 50 microg/L were 2.6 times (relative risk = 2.65; 95% CI, 1.49-4.73; P = 0.01) more likely to have a baby with a TSH level > 5 mIU/L. CONCLUSION: The pregnant women surveyed were mildly iodine deficient. TSH values for their newborns were mostly within acceptable limits. Ongoing surveillance of the iodine status of NSW communities to establish trends over time is recommended.     

The swollen leg: is it deep vein thrombosis? The experience of a tertiary referral center in Sri Lanka

INTRODUCTION: The role played by deep vein thrombosis (DVT) as a cause of leg swelling in Sri Lanka is unknown. PURPOSE: To study the prevalence of proximal DVT, value of risk factors and clinical features and attitudes of clinicians towards diagnosis and treatment of DVT among those presenting with leg swelling as the main complaint. DESIGN: Prospective consecutive referrals to the University Surgical Unit, Colombo, over 10 months starting in January 1998. INCLUSION CRITERIA: DVT suspects with swollen legs. EXCLUSION CRITERIA: Varicose veins, leg ulceration and generalized oedema. METHODS: Color duplex scanning of the proximal deep veins and the superficial veins to detect occlusion and reflux. Information on previous diagnoses and treatment were obtained from the medical records. RESULTS: 63/137 (45%) had deep venous causes for oedema. Fever with rigors and inguinal lymphaedenopathy were strongly predictive of non DVT causes. Filariasis is the first diagnosis and DVT is considered late among the outpatients. CONCLUSIONS: DVT is a common cause of leg swelling among those referred.