What is thalassemia?

Thalassemia is an inherited blood disorder in which the body makes an abnormal form of haemoglobin – the protein molecule in red blood cells that carries oxygen.

The disorder results in an excessive destruction of red blood cells, leading to anemia. Anemia is a condition in which one’s body doesn’t possess enough normal, healthy red blood cells.

Thalassemia is inherited, meaning that at least one of your parents must be a carrier of the disease. It’s caused by either a genetic mutation or a deletion of certain key gene fragments.

Thalassemia minor is a less serious form of the disorder. There are two main forms of thalassemia which are more serious. In alpha thalassemia, at least one of the alpha globin genes has a mutation or abnormality. In beta thalassemia, the beta globin genes are affected.

Each of these forms of thalassemia has different subtypes. The exact form you have will affect the severity of your symptoms and your outlook.

What are the symptoms of thalassemia?

The symptoms of thalassemia can vary. Some of the commonest ones include:

l    bone deformities, especially in the face 

l    dark urine

l    delayed growth and development

l    excessive tiredness

l    yellowish or pale skin.

Not everyone has visible symptoms of the disease. Signs of the disorder also tend to show up later in childhood or adolescence.

Causes of thalassemia?

Thalassemia occurs when there’s an abnormality or mutation in one of the genes involved in hemoglobin production. The inheritance of this genetic defect is from the parents.

If only one of the parents is a carrier for thalassemia, it may develop into a form of the disease known as thalassemia minor. If this occurs, there probably no symptoms develop, and one becomes a carrier of the disease. Some people with thalassemia minor do develop minor symptoms.

If both the parents are carriers of thalassemia, there is a greater chance of inheriting a more serious form of the disease.

According to the Centre for Disease Control and Prevention (CDC), thalassemia is the commonest amongst the people from Asia, the Middle East, Africa, and Mediterranean countries such as Greece and Turkey.

What are the different types of thalassemia?

There are three main types of thalassemia (and four subtypes) :

l    Beta thalassemia: which includes the subtypes major and intermedia;

l    Alpha thalassemia: which includes the subtypes Hemoglobin H and Hydrops fetalis

l    Thalassemia minor

All of these types and subtypes vary in symptoms and severity. The onset may also vary.

Beta thalassemia:

Beta thalassemia occurs when your body can’t produce beta globin. Two genes, one from each parent, are inherited to make beta globin. This type of thalassemia comes in two serious subtypes: thalassemia major (Cooley’s anemia) and thalassemia intermedia.

Thalassemia major is the most severe form of beta thalassemia. It develops when beta globin genes are missing. The symptoms of thalassemia major generally appear before a child’s second birthday. The severe type of anemia related to this condition can be life-threatening. Other signs and symptoms include:

Fussiness, paleness, frequent infections, a poor appetite, failure to thrive, jaundice – yellowing of the skin and/or the whites of the eyes and enlarged organs.

This form of thalassemia is usually so severe that it requires regular blood transfusions.

Thalassemia intermedia is a less severe form. It develops because of alterations in both beta globin genes. People with thalassemia intermedia don’t need blood transfusions.

Alpha thalassemia

Alpha thalassemia occurs when the body can’t make alpha globin. In order to make alpha globin, it needs to have four genes, two from each parent.

This type of thalassemia also has two sub types :Hemoglobin H  and Hydrops fetalis.

Hemoglobin H develops when a person is missing three alpha globin genes or experiences changes in these genes. This disease can lead to bone issues. The cheeks, forehead, and jaw may all overgrow. Additionally, hemoglobin H disease can cause :

Jaundice, an extremely enlarged spleen and malnourishment

Hydrops fetalis is an extremely severe form of thalassemia that occurs before birth. Most individuals with this condition are either stillborn or die shortly after birth. This condition develops when all four alpha globin genes are altered or missing.

Thalassemia minor

People with thalassemia minor don’t usually have any symptoms. If they do, it’s likely to be a minor anemia. The condition is classified as either alpha or beta thalassemia minor. In alpha minor cases, two genes are missing. In beta minor, one gene is missing.

The lack of visible symptoms can make thalassemia minor difficult to detect. It’s important to get tested if one of your parents or a relative has some form of the disease.

How is thalassemia diagnosed?

If the doctor is trying to diagnose thalassemia, they’ll likely take a blood sample. They’ll send this sample to a lab to be tested for anemia and abnormal hemoglobin. A lab technician will also look at the blood under a microscope to see if the red blood cells are oddly shaped. Abnormally shaped red blood cells are a sign of thalassemia. The lab technician may also perform a test known as hemoglobin electrophoresis. This test separates out the different molecules in the red blood cells, allowing them to identify the abnormal type.

Depending on the type and severity of the thalassemia, a physical examination might also help your doctor make a diagnosis. For example, a severely enlarged spleen might suggest to your doctor that you have hemoglobin H disease.

What are the treatment options for thalassemia?

The treatment for thalassemia depends on the type and severity of the disease involved. Your doctor will give you a course of treatment that will work best for your particular case.

Some of the treatments include : blood transfusions; bone marrow transplant; medications and supplements and possible surgery to remove the spleen or gallbladder.

The doctor may instruct one not to take vitamins or supplements containing iron. This is especially true if one needs blood transfusions. People, who receive blood transfusions, require extra iron that the body can’t easily get rid of. Iron can build up in the tissues, which can be potentially fatal.

If one receives a blood transfusion, there may also be a need for chelation therapy. This generally involves receiving an injection of a chemical that binds with iron and other heavy metals. This helps to remove the extra iron from your body.

How does thalassemia affect pregnancy?

Thalassemia also brings up different concerns related to pregnancy. The disorder affects reproductive organ development. Because of this, women with thalassemia may encounter difficulties in fertility.

To ensure the health of both the mother and her baby, it’s important to plan ahead of time as much as possible. If a female wants to have a baby, a discussion with the doctor is mandatory to make sure that the concerned person is in the best of health possible. The iron levels will need to be carefully monitored. Pre-existing issues with major organs are also to be considered.

Pregnancy carries the following risk factors in women with thalassemia :

A higher risk for infections; gestational diabetes; heart problems; hypothyroidism; increased number of blood transfusions and low bone density.

What is the long-term outlook for thalassemia?

If one has thalassemia, the outlook depends on the type of the disease. People who have mild or minor forms of thalassemia can typically lead normal lives.

In severe cases, heart failure is a possibility.

The doctor can give a person more information about one’s outlook. They will also explain how the treatments can help improve one’s life or increase one’s lifespan.

How do one manage thalassemia?

Since thalassemia is a genetic disorder, there’s no way to prevent it. However, there are ways to manage the disease and help prevent complications. In addition to hepatitis vaccines and ongoing medical care, diet and exercise may also be helpful.

A low-fat, plant-based diet is the best choice for most people, including those with thalassemia. However, there’s a need to limit iron-rich foods if one has already high iron levels in one’s blood. Fish and meat are rich in iron, so there’s a need to limit these in the diet. There might be a consideration in avoiding fortified cereals, breads, and juices as they contain high iron levels too. One must be sure to discuss any dietary changes with the doctor ahead of time.

A person may ask the doctor for tips on exercising if one’s not currently physically active. Moderate-intensity workouts are best since heavy exercise can make the symptoms worse. Walking and bike riding are examples of moderate-intensity workouts. Swimming and yoga are other options; and they’re also good for the joints. The key is to find something one enjoys and keeps moving.

Mindfulness meditation- related pain relief:

An age-old concept revisited

Dr. Debjani Gupta 

Professor, Dept. of Anaesthesiology

VIMS, RKMSP

The advent of contemporary neuroimaging techniques has contributed greatly to our understanding of the neural mechanisms underlying pain perception and, importantly, how pain can be modulated. Increases in experienced pain are reliably associated with increased brain activity in a set of regions including the anterior cingulate cortex (ACC), anterior insula and sensory areas such as primary and secondary somatosensory cortices (SI/SII), thalamus and posterior insula.

A variety of factors are now known to either increase or decrease pain-related brain activation, including: predictive cues , distraction , attention , expectation , beliefs, placebo, hypnosis , stress, anxiety, mood and emotional state. Many of these factors, however, are difficult for an individual to engage in a self-directed and volitional fashion. By contrast, there is growing evidence that mindfulness meditation,a volitionally initiated cognitive act, can significantly attenuate the subjective experience of pain. Although mindfulness meditation has only recently been the subject of scientific investigation, the emerging data indicate that it shares important common neural substrates engaged by other cognitive factors known to modulate pain. Nevertheless, some facets of mindfulness meditation-related pain relief appear to engage brain mechanisms distinct from those engaged by other cognitive factors and thus may provide novel insights into how the subjective experience of pain is produced and modulated.

What is mindfulness?

Mindfulness has been described as a “non-elaborative, non- judgmental awareness” of present moment experience. Operational definitions of mindfulness expand on this description by regarding it as including: (a) regulated, sustained attention to the moment-to-moment quality and character of sensory, emotional and cognitive events, (b) the recognition of such events as momentary, fleeting and changeable , and (c) a consequent lack of emotional or cognitive appraisal and/or reactions to these events. This latter aspect highlights the assumption that our normal experiences are typically, but perhaps unnecessarily, framed as enduring due to insufficient mindfulness and thus augmenting mindfulness could have significant positive effects. Taken together, mindfulness is simultaneously a process of cognitive control, emotional reappraisal or reduced judgment, and existential insight. Although there are individual differences in trait mindfulness, this characteristic can be developed by mental training such as meditation.

Mindfulness meditation practices: focused attention and open monitoring

There are a variety of different meditative practices that are together called “mindfulness”. This ambiguity has led to confusion within the literature because the specific meditation technique being employed is not always adequately defined . Because the mechanisms involved in meditation-induced pain-related changes may be dependent on the specific technique being used, it is critical that the specifics of the practice being taught or employed be known. In general, mindfulness techniques can be divided into two styles, namely, focused attention and open monitoring .

Focused attention (FA), also known as Samatha or Shamatha (from Sanskrit), is associated with maintaining focus on a specific object, often the changing sensation or flow of the breath or an external object . When attention drifts from the object of focus to a distracting sensory, cognitive or emotional event, the practitioner is taught to acknowledge the event and to disengage from it by gently returning the attention back to the object of meditation. Along with training stability and flexibility of one’s attention, the FA practitioner  engages in cognitive reappraisal by repeatedly reinterpreting distracting events as fleeting or momentary and doing so with acceptance.

By contrast, open monitoring (OM), or Vipassana (Sanskrit translation), is associated with a non-directed acknowledgement of any sensory, emotional or cognitive event that arises in the mind. Zen meditation is considered to be one form of OM practice . While practicing OM, the practitioner experiences the current sensory or cognitive ‘event’ without evaluation, interpretation, or preference. OM practice is associated with a non-evaluative and non-elaborative mental stance whereas FA practice places less emphasis on refraining from appraisal or elaboration. Unlike FA, which likely involves reappraisal, OM ultimately would involve a complete lack of higher order appraisal. Traditionally it is taught that training in focused attention, prior to open monitoring, stabilizes one’s attention and emotions allowing insight into the changeability of experience to occur during OM practice.

Mindfulness meditation and health :

Mindfulness meditation has been found to improve a wide spectrum of cognitive and health outcomes .Training in mindfulness meditation improves anxiety, depression, stress, and cognition. Mindfulness- related health benefits are associated with enhancements in cognitive control, emotion regulation, positive mood, and acceptance, each of which have been associated with pain modulation.

Thus, it seems reasonable to hypothesize that mindfulness meditation itself would attenuate pain through some of these mechanisms.

Mindfulness meditation and pain :

For thousands of years, practitioners have reported that the practice of mindfulness meditation attenuates the experience of pain by modulating expectations, the nature and orientation of attention toward the experience, and the corresponding emotional response . In 1980, Clark and Clark reported that “devout Buddhist” porters from Nepal exhibited higher pain tolerance and lower subjective pain reports when compared to other, age-matched, eth- nic groups . Although these researchers suggested that religious practices (i.e., meditation) were associated with greater pain tolerance, it was not clear if mindfulness-based practice itself could reduce pain .

In the early 1980s, clinical studies of mindfulness began with Jon Kabat-Zinn’s seminal work with chronic pain patients. It was hypothesized that training in mindfulness would attenuate pain by altering emotional responses to pain and enhancing acceptance- related coping strategies . Over the course of a five year study, it was found that chronic pain patients who completed an eight-week Mindfulness-Based Stress Reduction (MBSR) program significantly improved their pain symptoms and overall quality of life, even up to four years after completion of this initial training. In other work, eight weeks of mindfulness training was shown to improve pain acceptance in lower back pain patients. Taken together, these findings provide evidence for the effectiveness of mindfulness meditation in the treatment of clinical pain. However, the degree to which these effects are due to the meditation practices themselves (i.e., the efficacy of mindfulness to reduce pain) is less clear.

Behavioral studies of meditation-related pain relief :

 Grant and Rainville noted that long-term Zen meditation practitioners required higher temperatures to report moderate pain .  During a mindful attention condition, both sensory and affective pain ratings were reduced in experienced practitioners, whereas no effect was seen in meditation-naive controls. Importantly, the largest pain reductions were observed in the most advanced practitioners. 

 Different meditative traditions (i.e., Zen, Vipassana) employing mindfulness practice, particularly the OM style of mindfulness, are associated with pain reduction. Kingston et al. found that six, 1-h mindfulness meditation training sessions (twice weekly) effectively increased pain tolerance on the cold pressor test as compared to a control group that underwent 2 h of visual imagery training .

Mindfulness-related pain reduction may also involve divided attention, distraction or non-specific changes in relaxation or mood.

The neural substrates of mindfulness meditation-related pain relief :

The subjective experience of pain is constructed by interactions among sensory, cognitive, and affective processes. Mindfulness meditation is associated, via enhanced cognitive control and emotion regulation, with the modulation of sensory representations. This raises the question, which of these specific mechanisms are involved, if any, in mindfulness-related pain relief? Secondly, we might ask, to what extent are these mechanisms unique to meditative practices and to what extent are they shared by other cognitive/affective modulators of pain?

Trait effects of prior meditation practice on pain :

Studies of long-term meditation practitioners on pain processing have necessarily employed case–control designs to assess differences in pain sensitivity during basal states (i.e., non- meditation). Using electroencephalography (EEG) and noxious laser stimulation, Brown and Jones examined the influence of long-term mindfulness practice on pain and pain anticipation and postulated that mindfulness meditators would have reduced electrophysiological [event related potentials (ERP)] markers of anticipation. They determined that greater meditation experience was associated with lower pain unpleasantness ratings . When compared to controls, the meditation group exhibited smaller anticipation- evoked potentials in right inferior parietal cortex and mid-cingulate cortex, indicating less anticipation to the noxious stimuli. Lower mid-cingulate cortex activation during anticipation further predicted lower pain unpleasantness ratings in the meditation group but not in controls.These findings are noteworthy, as the meditation group was not formally meditating, thereby suggesting that practitioners have undergone persistent changes that allow them to process nociceptive information in a unique manner. The authors postulated that mindfulness meditation-related pain reduction is associated with increased cognitive and emotional control produced by cultivating an attitude of acceptance towards impending stimuli. 

In a follow up to their behavioral study of Zen meditators, Grant et al. investigated the brain mechanisms involved in mindfulness-related pain reduction using functional and structural MRI . It was hypothesized that even during a non-meditative state, Zen practitioners would differ from controls in a manner reflective of open monitoring meditation .During pain, meditators exhibited greater activation in brain areas responsible for encoding sensory aspects of noxious stimulation [insula, thalamus, mid- cingulate cortex] At the same time, brain activity decreases were observed for meditators in regions involved in emotion, memory and appraisaL,eg. amygdala and hippocampus.Within these areas, the most advanced practitioners had the largest activation decreases, accompanied by the lowest pain ratings.These results were interpreted as reflecting a mental state wherein the meditators were fully attentive to the sensory properties of the stimuli (highly activated pain areas) but simultaneously inhibiting appraisal, elaboration and emotional reactivity (deactivated amygdala, hippocampus). The authors postulated that Zen practitioners learn to adopt such a mental stance following extensive training.

The studies summarized in this section extend the preceding behavioral studies by demonstrating that the effects of meditation are not limited to a meditative state. Further, they provide the first potential neural mechanisms underlying mindfulness-related pain reduction. Even then,because of some contrasting results,more research is needed.

 State effects of active meditation during pain :

While the results discussed above suggest that meditation- related effects are not necessarily dependent upon a meditative state, little is actually known about the effects of active mindful- ness meditation on pain. Gard et al. have recently examined the influence of Vipassana meditation on pain perception with fMRI. They found that during meditation, long-term mindfulness practitioners had significant reductions in pain unpleasantness ratings to noxious electrical stimulation compared to a control group.While meditating during pain, the meditation group exhibited greater activation of contralateral SII and posterior insula , regions implicated in the sensory dimension of pain processing. 

The results described thus far provide strong confirmatory evidence for an influence of mindfulness practice on pain processing.

Given these differences, a critical question that must be addressed is how much mindfulness training is necessary to have an influence on pain perception? Surprisingly, the answer appears to be very little. Zeidan et al.recently examined the brain mechanisms involved in meditation-related pain relief with a brief mindfulness training protocol in previously meditative-naïve participants.They examined the effects of four days (20 min/day) of mindfulness meditation training on pain- related brain processing. Training consisted of a combination of FA and OM techniques. In session 1 (before training), subjects were stimulated with noxious heat for 6 min at 49 ◦C (12 s OFF/ON) in a rest condition and an attention to breath condition (ATB) where subjects were instructed to “focus on the changing sensations of the breath.” The ATB condition served as a divided attention control. Prior to meditation training, although ATB did not reduce pain intensity ratings, there was a trend towards significance in reducing pain unpleasantness ratings (p = .06). After meditation training, subjects were reassessed in a rest and meditation condition. Meditating in the presence of noxious heat stimulation significantly reduced pain intensity (average reduction 40%) and pain unpleasantness (average reduction 57%) ratings compared to rest. Regression analyses revealed that mindfulness meditation reduced pain through multiple brain mechanisms. . Interestingly, greater activity in the right anterior insula during meditation and noxious heat stimulation was associated with greater reductions in pain intensity ratings.  Taken together, these findings contribute to the existing literature  by demonstrating that brief mindfulness-based mental training reduces pain through multiple mechanisms including cortico- cortical and cortico-thalamic interactions.

An integrated perspective on meditation-based pain relief :

OM meditations seem more suited to analgesia than FA when taking into account meditation experience. That is, OM is more effective at reducing pain after extensive meditation training, as compared to FA. On the other hand, approaches combining elements of both FA and OM are effective at reducing behavioral and neural mechanisms of pain after brief mental training 

 Common final pathway to the cognitive modulation of pain :

The data indicate that, like other cognitive factors that modulate pain, prefrontal and cingulate cortices are intimately involved in the modulation of pain by mindfulness meditation. Mindfulness meditation, like other cognitive manipulations, alters the contextual evaluation of pain but is likely to do so dynamically over time and experience, such that beginners reappraise events and the most advanced practitioners may refrain from elaboration/appraisal entirely.Nonetheless, mindfulness-related pain reduction promises to be an important tool for understanding how our awareness of sensory events occurs as well as a potentially impor- tant adjunct to current treatment options for acute and chronic pain. 

Further reading :

J.A. Astin, Stress reduction through mindfulness meditation. Effects on psychological symptomatology, sense of control, and spiritual experiences, Psychotherapy and Psychosomatics 66 (1997) 97–106.

S.J. Bantick, R.G. Wise, A. Ploghaus, S. Clare, S.M. Smith, I. Tracey, Imaging how attention modulates pain in humans using functional MRI, Brain 125 (2002) 310–319.

L.E. Carlson, M. Speca, K.D. Patel, E. Goodey, Mindfulness-based stress reduction in relation to quality of life, mood, symptoms of stress, and immune parameters in breast and prostate cancer outpatients, Psychosomatic Medicine 65 (2003) 571–581.

86. Dunne, Toward an understanding of non-dual mindfulness, Contemporary Buddhism 12 (2011) 69–86.

J.A. Grant, P. Rainville, Pain sensitivity and analgesic effects of mindful states in Zen meditators: a cross-sectional study, Psychosomatic Medicine 71 (2009) 106–114.

43. Grossman, L. Niemann, S. Schmidt, H. Walach, Mindfulness-based stress reduction and health benefits. A meta-analysis, Journal of Psychosomatic Research 57 (2004) 35–43.

B.K. Holzel, J. Carmody, K.C. Evans, E.A. Hoge, J.A. Dusek, L. Morgan, R.K. Pitman, S.W. Lazar, Stress reduction correlates with structural changes in the amygdala, Social Cognitive and Affective Neuroscience 5 (2010) 11–17.

47. Kabat-Zinn, An outpatient program in behavioral medicine for chronic pain patients based on the practice of mindfulness meditation: theoretical considerations and preliminary results, General Hospital Psychiatry 4 (1982) 33–47.
48. Kabat-Zinn, L. Lipworth, R. Burney, The clinical use of mindfulness meditation for the self-regulation of chronic pain, Journal of Behavioral Medicine 8 (1985) 163–190.

D.M. Perlman, T.V. Salomons, R.J. Davidson, A. Lutz, Differential effects on pain intensity and unpleasantness of two meditation practices, Emotion 10 (2010) 65–71.

S.L. Shapiro, L.E. Carlson, J.A. Astin, B. Freedman, Mechanisms of mindfulness, Journal of Clinical Psychology 62 (2006) 373–383

605. Zeidan, S.K. Johnson, B.J. Diamond, Z. David, P. Goolkasian, Mindfulness meditation improves cognition: evidence of brief mental training, Consciousness and Cognition 19 (2010) 597–605.
606. Zeidan, K.T. Martucci, R.A. Kraft, N.S. Gordon, J.G. McHaffie, R.C. Coghill, Brain mechanisms supporting the modulation of pain by mindfulness meditation, Journal of Neuroscience 31 (2011) 5540–5548.

Pediatric Blunt Abdominal Trauma: 

Wait or operate?

Dr. Debasish Mitra

Senior Consultant Pediatric Surgeon Apollo Gleneagles Hospital, Kolkata

Trauma is the most common cause of death in children, and most pediatric trauma is blunt rather than penetrating.

Before discussing the management options of blunt trauma abdomen, a short discussion is made on the preliminary approach to a child with blunt trauma.

The primary assessment can be divided in three steps: Prehospital care, Initial assessment and resuscitation or Primary Survey and Secondary Survey.

Prehospital Care

Emergency medical technicians (EMTs) must be trained in rapid pediatric cardiorespiratory assessment, prompt establishment of effective ventilation (airway), oxygenation (breathing), and perfusion (circulation) as well as in stabilization and transport of injured children to a tertiary care facility. EMTs are the first medical contact that children have following an injury. The resuscitation should be tailored to each child and should begin in the field. Time should be dedicated in the field to secure the airway and time should not be extended with multiple attempts to establish intravenous access. If direct transport to a designated pediatric trauma facility is not possible because of great distance or a child’s instability, the child should be taken to the nearest emergency department for a stabilization.

Initial assessment and resuscitation

The primary survey or initial phase of resuscitation  should address life-threatening injuries that compromise oxygenation and circulation. Airway control is the first priority. Once a patent airway is established, the child’s breathing should be carefully assessed. If respiration is inadequate, ventilatory assistance has to be provided.

Making vascular access is the next priority once adequate airway and breathing is established. Recognizing hypovolemic  shock in pediatric trauma patients is essential to ensure a positive outcome. Techycardia is usually the earliest measurable response to hypovolemia. In addition, mental status change, respiratory compromise, absence of peripheral pulses, delayed capillary refill, skin pallor, and hypothermia are all possible early signs of shock that must be immediately recognized. Children are known to have an amazing cardiovascular reserve, so the initial normal vital sings should not impart any sense of security with regard to the status of the child’s circulating volume.

Obvious signs of shock, such as hypotension or a decrease in urinary output, may not occur until more than 30% of blood volume has been lost. Initial fluid resuscitation should consist of warm isotonic crystalloid solution (Ringer lactate or isotonic sodium chloride solution) at a bolus of 20 mL/kg. The goals of the initial resuscitation should be to achieve hemodynamic normality and to restore adequate tissue perfusion as soon as possible. Children with evidence of hemorrhagic shock who fail to respond to fluid resuscitation should also receive blood (10 mL/kg) and be evaluated by a pediatric surgeon for possible operative intervention.

Accidental hypothermia should be avoided during the initial phase of resuscitation. Hypothermia result in vasoconstriction, Low-flow state, acidosis, and consumptive coagulopathy.

Hypothermia can be prevented by using warm intravenous fluids, warm blanket, connective air rewarmers, warmed humidified ventilation, and by using warm saline for peritoneal lavage if required.

Once the primary survey has been completed, the issue of pain control needs to be assessed.

Secondary survey

Definitive treatment can be accomplished safely once hypoxia, tachycardia, hypotension, and hypothermia have been managed. The secondary survey involves a more detailed systemic evaluation and initiation of diagnostic studies.

Early surgical evaluation is important for high risk patients. The NPTR database was examined by Tepas et al to evaluate the risk of death or disability from a significant injury that required surgical evaluation. Those at risk with a surgical diagnosis had mortality of 6.6% compared with 0.9% of those at risk without a surgical diagnosis. Of those at risk with a surgical diagnosis requiring operative procedure, mortality climbed to 12.1% compared with 5.1% of those requiring no operation. Surgical pathology is the major determinant of outcome in pediatric trauma.

The data emphasize the importance of early surgical evaluation of high-risk injured pediatric patients.

Surgical evaluation of blunt abdominal trauma in children

Blunt trauma is responsible for most intra-abdominal injuries. Also the mortality rate for children from severe blunt trauma is higher than the rate from penetrating injuries because of concurrent CNS, chest, and skeletal injuries. In blunt trauma of abdomen, injuries of solid organs predominate, particularly injuries of the spleen, followed by the liver and kidney. Fortunately non-operative management has a 90% success rate and has become the standard of care.

Blunt trauma abdomen in pediatric patient, when to operate is the question often faced by the physicians who deal with accident and emergency.

In children, the abdomen begins at the level of the nipple. children’s small, pliable rib cages and underdeveloped abdominal muscles provide little protection to the major organs. Solid organs (e.g., spleen, liver, kidneys) are particularly vulnerable to injury by direct impact. On the other hand hollow viscera are more prone to injury in deceleration type injury.

We will divide the specific organs in two categories. A) Hollow viscus and B) solid organ

1. A) Hollow viscus

    Bruising of the abdominal wall after a motor vehicle collision an important finding. This is usually the result of a lap seat belt or a restraint device. A seat belt syndrome has been described as the concurrent findings of abdominal wall bruising, intra-abdominal injury, and vertebral fracture. About 11.11% children with abdominal wall bruising have significant intra-abdominal injury. The finding of fluid in the abdomen on CT scan without associated solid organ injury should raise suspicion for bowel injury. The most common intra-abdominal injury associated with abdominal wall bruising is a hollow viscus. In the setting of abdominal wall bruising and unexplained fluid in the abdomen, serial abdominal examination and further investigation are indicated.

    The great majority of stomach injuries are secondary to blunt trauma, and blunt injuries to the stomach occur more frequently in children than in adults, because stomach is less covered by rib cage in children. The greater curvature is usually involved with either a blow out or a perforation. Children who are stuck by a vehicle or who fall across bicycle handlebars shortly after eating a meal are at greater risk. Stomach injury should be considered if the child has peritoneal signs and/or blood in the nasogastri aspirate. Surgery is the absolute treatment option in stomach injury

    Small intestinal injury

    The incidence of intestinal injury in children with blunt trauma is estimated to be 1-15%. Because of the mesentery and high mobility of small gut, deceleration tear is more in small intestine than colon. With blunt trauma, a high index of suspicion should be maintained for small intestine injury, because a delay in diagnosis or an unrecognized injury can result in substantial morbidity. Fewer than 50% of children with blunt intestinal perforation have peritonitis on initial examination. Abdominal tenderness is a consistent finding. Management of small intestinal injury is always surgical.

1. B) Solid organ

    Conservative management is considered the standard care for most children with blunt solid organ injury who are critically stable. The fact is, this approach was initially started in children and has led to a dramatic change in the management of adult patients with solid organ injury.

    Splenic Injury

    Splenic injuries are relatively common in pediatric trauma. Successful conservative management of splenic injury was reported in 1968 by Upadhyaya et al. Because of the risk of overwhelming sepsis following splenectomy (OPSS), the current philosophy is to manage splenic injuries conservatively unless the patient is hemodynamically compromised. OPSS occurs slightly more frequently after splenectomy in the splenectomy. Age younger than 5 years at the time of splenectomy also increases the risk. A child’s spleen stops bleeding spontaneously; therefore, most patients with splenic injuries respond to conservative management. CT scanning, ultrasound, or isotope imaging needs to be performed to define the site and the extent of injury in every child with splenic injury. Conservative treatment can be used, provided the child is in a pediatric intensive care unit for at least 48 hours, with an experienced surgical team who are prepared to intervene if needed, and adequate anesthesia and transfusion services are immediately available. In adults, the presence of a splenic arterial blush is a risk factor for failure of conservative management. Contrast blush is rare in children, and according to a small review by Cloutier et al, its presence does not predict conservative treatment failure. A role for splenic artery embolization in the management of pediatric splenic injury has yet to be clarified.

    Hepatic Injury

    Isolated hepatic injury, without disruption of the portal vein, hepatic vein, or suprarenal inferior vena cava, behaves clinically like a splenic injury. Most patients with these injuries respond to conservative management. The same criteria for selecting conservative or operative treatment for patients with splenic injury are now being selectively used for patients with documented hepatic injuries. The success rate for conservative management of blunt hepatic injury is about 85-90%.

    Delayed bleeding after liver injury may occur in 1-3%, and mortality from this injury has been reported as high as 18%. Delayed bleeding has been reported from 3 days to 6 weeks after injury. Hemodynamic Instability should prompt surgical treatment; however, a role for angiographic embolization may exist.

    Hepatosplenic injury occurred in 2.9% of children registered in the NPTR database having sustained blunt abdominal injury. Mortality rate for isolated splenic injury was the lowest at 0.7% followed by isolated hepatic injury at 2.5% and hepatosplenic injury was the highest at 8.6%. Most deaths (89%) occurred during the first 48 hours after injury hepatosplenic was the most common cause of death for each group. Clearly, combined hepatosplenic injury portends a higher risk and requires vigilance.

    Pancreatic injury

    CT scanning is a useful diagnostic modality in evaluating most pancreatic trauma. It is through, insufficient to evaluate pancreatic ductal injury. Operative exploration may be required to fully evaluate pancreatic injury. Endoscopic retrograde pancreatography (ERP) can reliable evaluate pancreatic duct injury. A few reports have described using this technique to provide definitive treatment of pediatric blunt injury associated pancreatic ductal injury with ERP and stent placement.

    Timely diagnosis of major pancreatic injuries and prompt surgical treatment are essential to decrease mortality and morbidity rates in pediatric patients

    Renal injury

    Blunt abdominal trauma involves renal injury in 10-12% of causes. Renal trauma comprises 1.6% of total injuries and 90% of these injuries are from a blunt mechanism of injury. The fat and decreassed protection from incompletely ossified ribs. Contusion is the most common renal injury encountered in children. The concept of conservative management has been expanded to include renal injuries as well. Conservative management is standard for low-grade renal injury (grades I-III). A treatment strategy adopted by some level I trauma centers includes bed rest for 24 hours, serial hematocrit, heart rate monitoring, and frequent physical examinations.

    Management of high-grade renal injury is more controversial (grades IV-V). Absolute indications for renal exploration are an expanding or pulsatile renal hematoma. A recent experience reported by Rogers et at demonstrated successful management of most grade IV injuries with a blunt mechanism. Management consisted of bed rest, catheter drainage, and documentation of the resolution of extravasations or urine leak via CT scan or ultrasound. A trial of ureteral stenting and catheter drainage should be used for urinary extravasation or renal fracture. All grade V inuries required operative management and only 30% achieved long-term renal salvage.

    A recent review by Holmes et al sought to identify factors predicting failure of conservative management. Data was collected from a 5-year multi institutional review of 1,818 pediatric patients who sustained splenic, hepatic, pancreatic, or renal trauma. Overall incidence of conservative management failure was 5%. The reasons for declaration of failure were shock, peritonitis, persistent hemorrhage, pancreatic injury, associated hollow viscus injury, and reputed diaphragm. Overall mortality for this cohort was 0.8%. Time to failure was 59% by 4 hours and 87% by 24 hours. A significantly increased risk of failure was associated with bicycle-related mechanism of injury, isolated pancreatic injury, and isolated grade 5 injury. Multiple solid organ injuries were associated with a higher risk of failure as well.

    The data emphasize the importance of early vigilance in the care of the child with a solid organ injury. Those who will fail conservative management will likely do so early, within the first 12 hours. An important finding is that pancreatic injuries do not behave like other injured solid organs and are associated with a higher need for operative intervention. A key distinction between adult and pediatric conservative management of solid organ injury is that adults are more prone to late failure (e.g., 5> d), whereas 98% of pediatric failure is within 72 hours.

    Thus to conclude, majority of blunt trauma of abdomen in pediatric patients can be managed by conservative approach, provided the patient is monitored by an efficient trauma team in a well equipped centre with an experienced surgical team ready to operate on the child if indicated.

MEDICAL ETHICS – Incredibly Important, 

Inevitably Overlooked

Tirna Halder

Director, CEO

Orcivita Sciences & Research Pvt. Ltd.

Medical ethics has a long history, from the days of Hippocrates to the present. The concept of ethics is very dynamic and the same ethical principles are not necessarily followed everywhere around the world. 

A lot of world religions teach us ethical codes that are accepted as moral norms, such as don’t steal, don’t kill, don’t be an adulterer, honour your parents, etc. These ethical codes are accepted by most without question but unfortunately, they are not encompassing enough when it comes to the world of medicine. 

Simply being of moral character does not provide enough framework for the doctor to know how to act and make appropriate decisions. Having a system of medical ethics that is widely accepted gives you a starting point for tackling the difficult dilemmas put forward by medicine. It is worth remembering that medical ethics is not just the domain for clinical trials, but forms part of the daily life of every doctor. 

Many great physicians and philosophers, such as Hippocrates, Aristotle and Immanuel Kant have tried to define such a framework. Most Western medicine follows the “four principles” approach, put forward by Tom Beauchamp and James Childress in their book “Principles of biomedical ethics”. This is popularly becoming known as principlism.

This system of ethics follows four main principles, or four pillars of medical ethics, which can be applied to biomedical ethics: Autonomy, Beneficence, Non-maleficence and Justice.

Autonomy

This ethical principle of autonomy relates to the patient’s right to choose. It comes from the Greek language and literally means self-rule or self-governance. It is a concept that is relatively modern and until recently, there was often a paternalistic doctor-patient relationship, with “the doctor knows best” mentality and patients putting their lives in their doctor’s hands. Some of your patients still often ask for this approach and will ask you to make the decision, so we must be careful to make sure we respect their autonomy.

Beneficence

Beneficence is a principle that says that our actions should contribute to or improve our patients’ welfare, or essentially do good.

It is closely linked with non-maleficence and there isn’t a sharp cut-off between the two principles since lots of medical interventions are both beneficial, but carry some risk or side effect that may be detrimental. In certain ethical systems, non-maleficence and beneficence are one ethical principle covering a spectrum between doing no harm and doing only good.

Non-maleficence

Non-maleficence is the aim of not inflicting harm on others. Harm in medicine usually refers to physical or psychological harm. There was a similar statement in the Hippocratic oath. This is often a tricky concept for medical doctors, because certainly some of our procedures have harm as a foreseen side effect, yet we still do the procedures.

Justice

The concept of justice relates to fairness. The formal principle of justice is often attributed to Aristotle, who is alleged to have said: “Equals must be treated equally and unequal must be treated unequally”. This takes a bit of getting your head around to start with, but essentially it means that not everybody in society needs to be treated the same, but we must treat people of a similar demographic the same way.

Medical ethics has developed over centuries. In the allopathic system of medicine, such developments commenced from the time of Hippocrates (the Hippocratic oath) and over time has several “codes” have been developed. These include the Helsinki Declaration, World Medical Code and Belmont Report.