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   Table of Contents - Current issue
October-December 2017
Volume 7 | Issue 4
Page Nos. 185-257

Online since Tuesday, December 5, 2017

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What's new in critical illness and injury science? The quest for decisional objectivity and clinical precision in critical care: A neurosurgeon's perspective p. 185
Steven M Falowski
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A comprehensive framework for international medical programs: A 2017 consensus statement from the American College of Academic International Medicine p. 188
Manish Garg, Gregory L Peck, Bonnie Arquilla, Andrew C Miller, Sari E Soghoian, Harry L Anderson III, Christina Bloem, Michael S Firstenberg, Sagar C Galwankar, Weidun Alan Guo, Ricardo Izurieta, Elizabeth Krebs, Bhakti Hansoti, Sudip Nanda, Chinenye O Nwachuku, Benedict Nwomeh, Lorenzo Paladino, Thomas J Papadimos, Richard P Sharpe, Mamta Swaroop, Stanislaw P Stawicki, On behalf of the ACAIM Consensus Group on International Medical Programs
The American College of Academic International Medicine (ACAIM) represents a group of clinicians who seek to promote clinical, educational, and scientific collaboration in the area of Academic International Medicine (AIM) to address health care disparities and improve patient care and outcomes globally. Significant health care delivery and quality gaps persist between high-income countries (HICs) and low-and-middle-income countries (LMICs). International Medical Programs (IMPs) are an important mechanism for addressing these inequalities. IMPs are international partnerships that primarily use education and training-based interventions to build sustainable clinical capacity. Within this overall context, a comprehensive framework for IMPs (CFIMPs) is needed to assist HICs and LMICs navigate the development of IMPs. The aim of this consensus statement is to highlight best practices and engage the global community in ACAIM's mission. Through this work, we highlight key aspects of IMPs including: (1) the structure; (2) core principles for successful and ethical development; (3) information technology; (4) medical education and training; (5) research and scientific investigation; and (6) program durability. The ultimate goal of current initiatives is to create a foundation upon which ACAIM and other organizations can begin to formalize a truly global network of clinical education/training and care delivery sites, with long-term sustainability as the primary pillar of international inter-institutional collaborations.
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The American College of Academic International Medicine 2017 Consensus Statement on International Medical Programs: Establishing a system of objective valuation and quantitative metrics to facilitate the recognition and incorporation of academic international medical efforts into existing promotion and tenure paradigms Highly accessed article p. 201
Gregory L Peck, Manish Garg, Bonnie Arquilla, Vicente H Gracias, Harry L Anderson III, Andrew C Miller, Bhakti Hansoti, Paula Ferrada, Michael S Firstenberg, Sagar C Galwankar, Ramon E Gist, Donald Jeanmonod, Rebecca Jeanmonod, Elizabeth Krebs, Marian P McDonald, Benedict Nwomeh, James P Orlando, Lorenzo Paladino, Thomas J Papadimos, Robert L Ricca, Joseph V Sakran, Richard P Sharpe, Mamta Swaroop, Stanislaw P Stawicki, On behalf of the ACAIM Consensus Group on International Medical Programs
The growth of academic international medicine (AIM) as a distinct field of expertise resulted in increasing participation by individual and institutional actors from both high-income and low-and-middle-income countries. This trend resulted in the gradual evolution of international medical programs (IMPs). With the growing number of students, residents, and educators who gravitate toward nontraditional forms of academic contribution, the need arose for a system of formalized metrics and quantitative assessment of AIM- and IMP-related efforts. Within this emerging paradigm, an institution's “return on investment” from faculty involvement in AIM and participation in IMPs can be measured by establishing equivalency between international work and various established academic activities that lead to greater institutional visibility and reputational impact. The goal of this consensus statement is to provide a basic framework for quantitative assessment and standardized metrics of professional effort attributable to active faculty engagement in AIM and participation in IMPs. Implicit to the current work is the understanding that the proposed system should be flexible and adaptable to the dynamically evolving landscape of AIM – an increasingly important subset of general academic medical activities.
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Phosphorylated neurofilament heavy: A potential blood biomarker to evaluate the severity of acute spinal cord injuries in adults p. 212
Ajai Singh, Vineet Kumar, Sabir Ali, Abbas Ali Mahdi, Rajeshwer Nath Srivastava
Aims: The aim of this study is to analyze the serial estimation of phosphorylated neurofilament heavy (pNF-H) in blood plasma that would act as a potential biomarker for early prediction of the neurological severity of acute spinal cord injuries (SCI) in adults. Settings and Design: Pilot study/observational study. Subjects and Methods: A total of 40 patients (28 cases and 12 controls) of spine injury were included in this study. In the enrolled cases, plasma level of pNF-H was evaluated in blood samples and neurological evaluation was performed by the American Spinal Injury Association Injury Scale at specified period. Serial plasma neurofilament heavy values were then correlated with the neurological status of these patients during follow-up visits and were analyzed statistically. Statistical Analysis Used: Statistical analysis was performed using GraphPad InStat software (version 3.05 for Windows, San Diego, CA, USA). The correlation analysis between the clinical progression and pNF-H expression was done using Spearman's correlation. Results: The mean baseline level of pNF-H in cases was 6.40 ± 2.49 ng/ml, whereas in controls it was 0.54 ± 0.27 ng/ml. On analyzing the association between the two by Mann–Whitney U–test, the difference in levels was found to be statistically significant. The association between the neurological progression and pNF-H expression was determined using correlation analysis (Spearman's correlation). At 95% confidence interval, the correlation coefficient was found to be 0.64, and the correlation was statistically significant. Conclusions: Plasma pNF-H levels were elevated in accordance with the severity of SCI. Therefore, pNF-H may be considered as a potential biomarker to determine early the severity of SCI in adult patients.
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Clinical study to assess the outcome in surgically managed patients of spontaneous intracerebral hemorrhage p. 218
Yashwanth S Sandeep, M Raja Guru, Ranjan Kumar Jena, Veldurti Ananta Kiran Kumar, Amit Agrawal
Introduction: Spontaneous intracerebral hemorrhage (SICH) subtype of stroke is characterized by bleeding into brain parenchyma which is not accompanied by trauma. Emergency surgical evacuation of large size SICH increases the chances of survival but does not help in functional recovery of the patients. The present study was conducted to assess the outcome of surgical management in patients with SICH. Materials and Methods: All patients who were diagnosed with SICH and underwent surgical evacuation of the hematoma included in the study. The outcome at 1 month was obtained through follow-up visits/telephonic interview when the former is not available. The primary outcome measure was in hospital mortality/condition at the time of discharge/neurological deficit/modified Rankin Scale (mRS) at 1 month follow-up. Results: Out of 87 patients, 49 patients (63%) were male and 38 patients (37%) were females, male to female ratio was 1.2:0.8. Nearly 42% patient had systolic blood pressure with in normal range; however, in almost 50% of the cases, the systolic blood pressure at the time of admission was more than 140 mmHg. mRS was assessed for the patients at the time of admission, 39% patients had slight disability, 15% patients had moderate disability, 11% patients had moderately severe disability, and 33% patients had severe disability. Mortality was relatively higher in patients who had admission systolic blood pressure more than 140 mmHg (51% vs. 43%). mRS was assessed for the patients at the time of discharge after completion surgery and the severity of scale. Conclusions: Hypertension was found to be most common comorbid illness followed by smoking, alcohol intake, and diabetes mellitus. Hematoma was evacuated in 58% of the cases; it was supplement with decompressive craniectomy in 12% of the cases. Morality was relatively higher in patients who had admission systolic blood pressure more than 140 mmHg. Mortality was highest in <40 years age group in age group of 40–65 years, the mortality was 30.6%, and in >65 years age group, mortality was 15.4%; however, this was not statistically significant. Only 10% of patients can recover and live independently at 1 month, and only 20% of the survivors were independent at 6 months.
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Factors delaying management of acute stroke: An Indian scenario p. 224
Siju V Abraham, S Vimal Krishnan, Fazil Thaha, Jayaraj Mymbilly Balakrishnan, Tom Thomas, Babu Urumese Palatty
Background and Purpose: The purpose of this study was to assess factors causing delay in treatment of acute stroke in a tertiary care institute in South India. Methods: All clinically suspected cases of acute stroke presenting to the emergency department over a period of 1 year were prospectively followed up and data collected as per a preset pro forma. The various time intervals from stroke onset to definitive management and other pertinent data were collected. The time delays have been evaluated in the decision tree model: Chi-squared Automatic Interaction Detection. Significance was assessed at 5% level of significance (P < 0.05). Results: The mean prehospital time delay for all clinically suspected stroke (n = 361) in our institute was 716 min and the median time 190 min. The mean total in-hospital delay was 94.17 ± 54.5 min and median time being 82 min. The onset of symptoms to first medical contact was the main interval that influenced the prehospital delay. Computed tomographic (CT) diagnosis to stroke unit admission influenced the in-hospital delay the most. Conclusions: Lack of awareness regarding stroke leads to delayed seeking of treatment for the same. The factors that contribute to the in-hospital delay included patient admission procedure delay, lack of staff to transport the patient, and the distance between the stroke unit and CT room. Educating the community with regard to “stroke” and implementation of a better pre- and in-hospital stroke care system is a need of the hour in the country.
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Otorhinolaryngological manifestations in head trauma: A prospective study of the epidemiology, clinical presentations, management, and outcomes p. 231
Adeyi A Adoga, Kenneth N Ozoilo, Andrew A Iduh, Joyce G Mugu
Background: Otorhinolaryngological injuries following head trauma may be missed, overlooked, or forgotten in the acute phase resulting in worsened management outcomes. This study aims to report the epidemiology, clinical presentations, management, and outcomes of otorhinolaryngological injuries in head trauma with a view to creating awareness for early recognition and prompt treatment. Patients and Methods: Head injured patients consecutively presenting over a 5-year period were prospectively studied for age, gender, otorhinolaryngological presentations, interventions, and outcome of interventions. Data obtained were statistically analyzed. Results: There were 91 (1.3%) otorhinolaryngological presentations among 7109 head injured patients. Mean age of 34 years, standard deviation = ±15.6 with a male:female ratio of 2.4:1. Severe head injury (Glasgow coma scale <9) occurred in 46 (50.5%) patients. Patients aged 30–39 years were mostly affected (n = 30; 32.9%). Most injuries were from motor vehicular accidents (n = 61; 67%) and assaults (n = 23; 25.3%). The most common otorhinolaryngological presentations were cerebrospinal fluid (CSF) rhinorrhea (n = 26; 28.6%) and CSF otorrhea (n = 25; 27.5%). Conservative management was achieved in 59.3% of patients. Mean time of hospital presentation was 13.8 h. There was no statistical correlation between outcomes and each of etiology and time of presentation (P values 0.18 and 0.9, respectively). Seventy-five (82.4%) were discharged without neurological deficits. A case fatality rate of 6.6% was recorded. Conclusion: Frontal skull base and temporal bone fractures with CSF rhinorrhea and otorrhea are the most common injuries occurring mostly in young active males with favorable outcomes following conservative management.
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Maxillofacial injuries among trauma patients undergoing head computerized tomography; A Ugandan experience p. 236
Ullas Chandrika Krishnan, Rosemary Kusaba Byanyima, Ameda Faith, Adriane Kamulegeya
Aim: The aim of this study was to investigate epidemiological features of maxillofacial fractures within trauma patients who had head and neck computed tomography (CT) scan at the Mulago National referral hospital. Methods: CT scan records of trauma patients who had head scans at the Department of Radiology over 1-year period were accessed. Data collected included sociodemographic factors, type and etiology of injury, and concomitant maxillofacial injuries. Results: A total of 1330 trauma patients underwent head and neck CT scan in the 1-year study period. Out of these, 130 were excluded due to incomplete or unclear records and no evidence of injury. Of the remaining 1200, 32% (387) had maxillofacial fractures. The median age of the patients with maxillofacial fractures was 28 (range = 18–80) years and 18–27 age group was most common at 47.5%. Road traffic accidents constituted 49.1% of fractures. The single most affected isolated bone was the frontal bone (23%). The number of maxillofacial bones fractured was predicted by age group (df = 3 F = 5.358, P = 0.001), association with other fractures (df = 1 F = 5.317, P = 0.03). Conclusions: Good matched case–control prospective studies are needed to enable us tease out the finer difference in the circumstances and pattern of injury if we are to design appropriate preventive measures.
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A competency-based simulation curriculum for surgical resident trauma resuscitation skills p. 241
Matthew L Moorman, Tony R Capizzani, Michelle A Feliciano, Judith C French
Background: Evidence-based curricula for nonprocedural simulation training in general surgery are lacking. Residency programs are required to implement simulation training despite this shortcoming. The goal of this project was the development of a simulation curriculum that measurably improves milestone performance and replaces traditional experienced-based training with a competency-based model. Materials and Methods: SimMan 3G® (Laerdal Medical, Wappingers Falls, NY, USA) was utilized for simulation. Needs assessment targeted trauma and shock resuscitation. Scenario design applied deliberate practice methodology. Learner performance data included items such as identification of shock physiology, resuscitation products used, volume delivered, use of resuscitation end-points, and knowledge of massive transfusion. Characteristics essential for a successful program were tabulated. Results: Forty-eight residents in postgraduate year (PGY) 2–5 participated representing 100% of the 48 eligible for the training. Senior residents (PGY 4 and 5) demonstrated near universal improvement. Junior residents (PGY 2 and 3) improved in some areas but showed more skill decay between sessions. Overall, milestone performance improved with each training session, and resident feedback was universally positive. Conclusions: This prototype curriculum improved surgical resident competency in shock resuscitation in a simulated patient care environment. It can be modified to accommodate centers with fewer resources and can be implemented by clinical faculty. The essential characteristics of a successful program are identified.
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Accuracy of emergency transfusion score in prediction need for blood transfusion among multiple trauma patients: A cross-sectional study from Iran p. 248
Hossein Alimohammadi, Yalda Kianian, Farahnaz Bidari Zerepoosh, Hojjat Derakhshanfar, Mostafa Alavi-Moghadam, Hamid Reza Hatamabadi, Seyed-Mostafa Hosseini-Zijoud
Objective: Prediction of blood transfusion requirement in trauma patients is a dilemma in most trauma centers. The aim of the current study was assessing the accuracy of emergency transfusion score (ETS) in detecting patients' need for blood transfusion in ED. Methods: In this cross-sectional study, all multiple trauma patients referred to the emergency department (ED) of Imam Hossein Hospital, Tehran, Iran, from March to August 2014, were enrolled. ETS parameters including low blood pressure, free fluid on ultrasound, clinical instability of the pelvic ring, age, admission from the scene, and trauma mechanism were recorded for all patients. ETS was calculated for all patients and compared with patients who received blood transfusion to estimate the accuracy of ETS. Results: Of the 793 patients included in the study, 54 (6%) received blood in the ED. The mean of ETS for all patients was 3.91 ± 0.93. There was a significant correlation between ETS more than 3 and amount of blood transfusion (P = 0.004). The sensitivity, specificity, positive, and negative predictive value of ETS was 98.1%, 13.8%, 7.7%, and 99%, respectively. Conclusion: ETS may be considered as a useful instrument for prioritizing multiple trauma patients' need for blood transfusion in Iran. Therefore, by implementing this score, it may be prevented from inappropriate requests for blood transfusion.
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Delta model for end-stage liver disease and delta clinical prognostic indicator as predictors of mortality in patients with viral acute liver failure p. 252
Ashok Kumar Pannu, Ashish Bhalla, Chelapati Rao, Charanpreet Singh
Objective: The objective of the study is to compare the model for end-stage liver disease (MELD) with clinical prognostic indicators (CPI) specifically the change in these parameters after 48 h of admission in predicting the mortality in patients with acute liver failure (ALF) due to acute viral hepatitis. Materials and Methods: An open label, investigator-initiated prospective study was conducted that included 41 patients with acute viral hepatitis with ALF. The cases were followed prospectively till death or discharge. The MELD and CPI were calculated at admission and 48 h of admission. Results: Patients having no change or worsening in CPI score, i.e., delta CPI more negative had a higher mortality over the next 48 h compared to patients having an improvement in their respective CPI score. Delta CPI predicted adverse outcome better than the presence of any three CPI on admission (P = 0.019). Patients having no change or a worsening in MELD score, i.e., delta MELD more negative, had a higher mortality in the next 48 h compared to the patients having improvement in their respective MELD score. However, MELD >33 on admission was superior to delta MELD in predicting the adverse outcome (P = 0.019). Conclusion: Among the patients with ALF due to viral hepatitis, delta CPI was found to be superior to delta MELD in predicting the adverse outcome in patients with viral ALF (P < 0.0001).
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Leaking stent leading to a venous-bronchial fistula p. 256
Raghav Gupta, Andre Jared, James Mahoney
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