A Delphi study to identify prehospital and emergency department trauma care modifiers for older adults

Background:Older patients (age ≥ 65 yr) with trauma have increased morbidity and mortality compared to younger patients; this is partly explained by undertriage of older patients with trauma, resulting in lack of transfer to a trauma centre or failure to activate the trauma team. The objective of this study was to identify modifiers to the prehospital and emergency department phases of major trauma care for older adults based on expert consensus.Methods:We conducted a modified Delphi study between May and September 2019 to identify major trauma care modifiers for older adults based on national expert consensus. The panel consisted of 24 trauma care professionals from across Canada from the prehospital and emergency department phases of care. The survey consisted of 16 trauma care modifiers. Three online survey rounds were distributed. Consensus was defined a priori as a disagreement index score less than 1.Results:There was a 100% response rate for all survey rounds. Three new trauma care modifiers were suggested by panellists. The panel achieved consensus agreement for 17 of the 19 trauma care modifiers. The prehospital modifier with the strongest agreement to transfer to a trauma centre was a respiratory rate less than 10 or greater than 20 breaths/min or need for ventilatory support. The emergency department modifier with the strongest level of agreement was obtaining 12-lead electrocardiography following the primary and secondary survey.Conclusion:Using a modified Delphi process, an expert panel agreed on 17 trauma care modifiers for older adults in the prehospital and emergency department settings. These modifiers may improve the delivery of trauma care for older adults and should be considered when developing local and national trauma guidelines.     

Pediatric Sepsis Guidelines: Summary for resource-limited countries

Justification:

Pediatric sepsis is a commonly encountered global issue. Existing guidelines for sepsis seem to be applicable to the developed countries, and only few articles are published regarding application of these guidelines in the developing countries, especially in resource-limited countries such as India and Africa.

Process:

An expert representative panel drawn from all over India, under aegis of Intensive Care Chapter of Indian Academy of Pediatrics (IAP) met to discuss and draw guidelines for clinical practice and feasibility of delivery of care in the early hours in pediatric patient with sepsis, keeping in view unique patient population and limited availability of equipment and resources. Discussion included issues such as sepsis definitions, rapid cardiopulmonary assessment, feasibility of early aggressive fluid therapy, inotropic support, corticosteriod therapy, early endotracheal intubation and use of positive end expiratory pressure/mechanical ventilation, initial empirical antibiotic therapy, glycemic control, and role of immunoglobulin, blood, and blood products.

Objective:

To achieve a reasonable evidence-based consensus on the basis of published literature and expert opinion to formulating clinical practice guidelines applicable to resource-limited countries such as India.

Recommendations:

Pediatric sepsis guidelines are presented in text and flow chart format keeping resource limitations in mind for countries such as India and Africa. Levels of evidence are indicated wherever applicable. It is anticipated that once the guidelines are used and outcomes data evaluated, further modifications will be necessary. It is planned to periodically review and revise these guidelines every 3–5 years as new body of evidence accumulates.     

Indian patients with nonalcoholic fatty liver disease presenting with raised transaminases are different at presentation

We read with great interest the article, ＂Non-alcoholic fatty liver disease may not be a severe disease at presentation among Asian Indians＂ by Madan et at in the recent issue of WJG. Twenty-eight （55%） out of 51 patients with nonalcoholic fatty liver disease （NAFLD） who presented with abnormal transaminases had histological evidence of nonalcoholic steatohepatitis （NASH）. The majority of patients had grade 1 [32 （63%）] or grade 2 [16 （31%）] inflammation and either had no [23 （45%）] fibrosis or stage I [19 （37%）] fibrosis. None of the patients had cirrhosisf11. We agree with Madan et al that Asian Indians with NAFLD who present with unexplained increase in transaminases may have mild disease at presentation on the basis of similar observations made by us. NAFLD has a spectrum which includes patients with only steatosis and NASH that can progress to cirrhotic and hepatocellular carcinoma.     

An uncommon cause of abdominal pain in an adolescent

Imperforate hymen is a rare congenital anomaly which emergency physicians often forget to include in the differential diagnosis of lower abdominal pain in a pubescent girl. These patients often remain asymptomatic until puberty and present in early adolescence with cyclic abdominal pain. This case report reviews the presentation and treatment of an 11-year-old girl with imperforate hymen.     

Imaging of nonspecific (nonherpetic) acute viral infections

Encephalitis is an acute infection of brain parenchyma characterized clinically by fever, headache, and an altered level of consciousness. In the twenty-first century several outbreaks of encephalitis have been reported. Urbanization and encroachment on natural environments, the ease of world travel, and global trade have led to the spread of vectors and viruses.     

Effects of mental relaxation and slow breathing in essential hypertension

OBJECTIVES: To compare mental relaxation and slow breathing as adjunctive treatment in patients of essential hypertension by observing their effects on blood pressure and other autonomic parameters like heart rate, respiratory rate, peripheral skin temperature, electromyographic activity of the frontalis muscle and skin conductance. METHODS: One hundred patients of essential hypertension either receiving antihypertensive drugs or unmedicated were selected randomly. Various parameters were recorded during the resting state and then during mental relaxation and slow breathing for 10 min each, separated by a quiet period of 15 min. All parameters were recorded again after mental relaxation and slow breathing. Changes in various parameters observed after mental relaxation and slow breathing were analyzed and compared. RESULTS: Both mental relaxation and slow breathing resulted in a fall in systolic blood pressure, diastolic blood pressure, heart rate, respiratory rate and electromyographic activity with increase in peripheral skin temperature and skin conductance. Slow breathing caused a significantly higher fall in heart rate (p<0.05), respiratory rate (p<0.001), systolic blood pressure (p<0.05) and diastolic blood pressure (p<0.01). Increase in peripheral skin temperature (p<0.05) and reduction in electromyographic activity (p<0.05) occurred more with mental relaxation. No significant differences were seen between increases in skin conductance (p>0.2) observed with both the modalities. CONCLUSIONS: Even a single session of mental relaxation or slow breathing can result in a temporary fall in blood pressure. Both the modalities increase the parasympathetic tone but have effects of different intensity on different autonomic parameters.     

The accuracy of statistical shape models in predicting bone shape: A systematic review

Background

This systematic review aims to ascertain how accurately 3D models can be predicted from two-dimensional (2D) imaging utilising statistical shape modelling.

Methods

A systematic search of published literature was conducted in September 2022. All papers which assessed the accuracy of 3D models predicted from 2D imaging utilising statistical shape models and which validated the models against the ground truth were eligible.

Results

2127 papers were screened and a total of 34 studies were included for final data extraction. The best overall achievable accuracy was 0.45 mm (root mean square error) and 0.16 mm (average error).

Conclusion

Statistical shape modelling can predict detailed 3D anatomical models from minimal 2D imaging. Future studies should report the intended application domain of the model, the level of accuracy required, the underlying demographics of subjects, and the method in which accuracy was calculated, with root mean square error recommended if appropriate.