Publications by authors named "Bhavesh Jarwani"

10 Publications

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Associations of On-arrival Vital Signs with 24-hour In-hospital Mortality in Adult Trauma Patients Admitted to Four Public University Hospitals in Urban India: A Prospective Multi-Centre Cohort Study.

Injury 2021 May 26;52(5):1158-1163. Epub 2021 Feb 26.

Trauma Research group, WHO Collaborating Centre for Research in Surgical Care Delivery in LMICs, Mumbai, India; Affiliate, Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden; Adjunct Professor (Research), School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic, Australia. Electronic address:

Introduction: In India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India.

Methods: We performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality.

Results: A total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP<90mm Hg), tachycardia (HR>100bpm) and bradycardia (HR<60bpm), hypoxia (SpO2<90%), Tachypnoea (RR>20brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality.

Conclusion: The routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.
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http://dx.doi.org/10.1016/j.injury.2021.02.075DOI Listing
May 2021

Cardiovascular Disease and Antiretroviral Therapy.

Authors:
Bhavesh Jarwani

J Glob Infect Dis 2019 Jul-Sep;11(3):91-92

Department of Emergency Medicine, Trauma Center, VS General Hospital, Ahmedabad, Gujarat, India.

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http://dx.doi.org/10.4103/jgid.jgid_4_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733197PMC
September 2019

Consensus statements on the approach to patients in a methanol poisoning outbreak.

Clin Toxicol (Phila) 2019 12 22;57(12):1129-1136. Epub 2019 Jul 22.

The Norwegian CBRNE Centre of Medicine, Department of Acute Medicine, Oslo University Hospital, Oslo, Norway.

Methanol poisoning is an important cause of mortality and morbidity worldwide. Although it often occurs as smaller sporadic events, epidemic outbreaks are not uncommon due to the illicit manufacture and sale of alcoholic beverages. We aimed to define methanol poisoning outbreak (MPO), outline an approach to triaging an MPO, and define criteria for prioritizing antidotes, extracorporeal elimination treatments (i.e., dialysis), and indications for transferring patients in the context of an MPO. We convened a group of experts from across the world to explore geographical, socio-cultural and clinical considerations in the management of an MPO. The experts answered specific open-ended questions based on themes aligned to the goals of this project. This project used a modified Delphi process. The discussion continued until there was condensation of themes. We defined MPO as a sudden increase in the number of cases of methanol poisoning during a short period of time above what is normally expected in the population in that specific geographic area. Prompt initiation of an antidote is necessary in MPOs. Scarce hemodialysis resources require triage to identify patients most likely to benefit from this treatment. The sickest patients should not be transferred unless the time for transfer is very short. Transporting extracorporeal treatment equipment and antidotes may be more efficient. We have developed consensus statements on the response to a methanol poisoning outbreak. These can be used in any country and will be most effective when they are discussed by health authorities and clinicians prior to an outbreak.
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http://dx.doi.org/10.1080/15563650.2019.1636992DOI Listing
December 2019

Establishing a Multicentre Trauma Registry in India: An Evaluation of Data Completeness.

World J Surg 2019 10;43(10):2426-2437

Emergency and Trauma Centre, The Alfred Hospital, Melbourne, Australia.

Background: The completeness of a trauma registry's data is essential for its valid use. This study aimed to evaluate the extent of missing data in a new multicentre trauma registry in India and to assess the association between data completeness and potential predictors of missing data, particularly mortality.

Methods: The proportion of missing data for variables among all adults was determined from data collected from 19 April 2016 to 30 April 2017. In-hospital physiological data were defined as missing if any of initial systolic blood pressure, heart rate, respiratory rate, or Glasgow Coma Scale were missing. Univariable logistic regression and multivariable logistic regression, using manual stepwise selection, were used to investigate the association between mortality (and other potential predictors) and missing physiological data.

Results: Data on the 4466 trauma patients in the registry were analysed. Out of 59 variables, most (n = 51; 86.4%) were missing less than 20% of observations. There were 808 (18.1%) patients missing at least one of the first in-hospital physiological observations. Hospital death was associated with missing in-hospital physiological data (adjusted OR 1.4; 95% CI 1.02-2.01; p = 0.04). Other significant associations with missing data were: patient arrival time out of hours, hospital of care, 'other' place of injury, and specific injury mechanisms. Assault/homicide injury intent and occurrence of chest X-ray were associated with not missing any of first in-hospital physiological variables.

Conclusion: Most variables were well collected. Hospital death, a proxy for more severe injury, was associated with missing first in-hospital physiological observations. This remains an important limitation for trauma registries.
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http://dx.doi.org/10.1007/s00268-019-05039-2DOI Listing
October 2019

Emergency Departments need Psychiatric Emergency Protocols!

Authors:
Bhavesh Jarwani

J Emerg Trauma Shock 2017 Oct-Dec;10(4):169-170

Department of Emergency Medicine, VSGH, Smt. NHLM Medical College, Ahmedabad, Gujarat, India. E-mail:

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http://dx.doi.org/10.4103/JETS.JETS_1_17DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5663133PMC
November 2017

The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emergency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India.

J Emerg Trauma Shock 2017 Apr-Jun;10(2):74-81

Deapartment of Emergency Medicine, Sir H. N. Reliance Foundation Hospital, Mumbai, Maharashtra, India.

There have been no published recommendations for the management of low-risk chest pain in emergency departments (EDs) across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in EDs. Risk stratification of patients utilizing an accelerated diagnostic protocol has been shown to decrease hospitalizations by approximately 40% with a low 30-day risk of major adverse cardiac events. The experts group of academic leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with academic experts in emergency medicine and cardiology from leading institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in EDs across India.
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http://dx.doi.org/10.4103/JETS.JETS_148_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5357871PMC
April 2017

Ultrasound guided Deep Vein cannulation: "Perpendicular Insertion Technique (PIT)", an edge over "Conventional Insertion Technique (CIT)".

J Emerg Trauma Shock 2015 Jul-Sep;8(3):149-53

Department of Emergency Medicine, Smt. NHL Municipal Medical College, Vadilal Sarabhai General Hospital, Ahmedabad, Gujarat, India.

Introduction: The use of ultrasound imaging before or during vascular cannulation greatly improves first-pass success and reduces complications, but this skill must then be combined with manual dexterity to perform the three dimensional (3D) procedure of placing a catheter into the deep veins while analyzing the 2D images. Hence this study is an attempt to still decrease the above mentioned limitation of guided deep vein cannulation by slight modification in the insertion technique.

Aims And Objectives: Aims to compare the ultrasound guided deep vein cannulation by conventional insertion technique(CIT) v/s ultrasound guided perpendicular insertion technique (PIT). Main comparison parameters here are number of attempts required, time taken for successful insertion, vessel counter puncture, arterial puncture and other known mechanical complications of deep venous cannulation.

Material And Method: Prospective, non randomized cross sectional study, done over 200 patients in two arms. Data-analysed by epi2k and state-9 software.

Results: Total number of insertions were 64 by CIT v/s 136 by the PIT. Mean of number of attempts required were 1.918 with the CIT v/s 1.106 for the PIT method. Mean of time of cannulation was 78.62 + 18 sec with CIT while it was 66.98 + 12 sec for PIT and this was statistically significant(P = 0.041). Incidence of vessel counter-puncture was much lower in PIT as compared to CIT (6.1 % v/s 16.2%). 5.9% cannulation done by CIT had arterial puncture v/s 0.8% with the PIT. Not a single episode of any other mechanical complications with either of the method.

Conclusion: USG guided perpendicular method is less time consuming, less number of attempts are required and there are less chances of arterial picture or vessel counter puncture.
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http://dx.doi.org/10.4103/0974-2700.160720DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4520028PMC
August 2015

Demographic, epidemiologic and clinical profile of snake bite cases, presented to Emergency Medicine department, Ahmedabad, Gujarat.

J Emerg Trauma Shock 2013 Jul;6(3):199-202

Department of Emergency Medicine, Smt. NHL M Medical College, VS General Hospital, Ahmedabad, Gujarat, India.

Aim: Snake bite is a common medical emergency faced mainly by the rural populations in tropical and subtropical countries with heavy rainfall and humid climate. Although India is a single largest contributor of snake bite cases, reporting is very poor. There is hardly any publication of the same from Gujarat state that is developing at a good pace. Hence, we aimed to study the snake bite cases with particular attention to demography, epidemiology, and clinical profile.

Settings And Design: The present descriptive, observational study was carried out at the Emergency Medicine Department of a tertiary care center in Ahmedabad, Gujarat. This department is one if the firsts to get recognized by the Medical Council of India.

Materials And Methods: This is a cross-sectional single-center study. Cases were entered into the prescribed form, and detailed information regarding demographic, epidemiologic, and clinical parameters was entered.

Statistical Method: Data were analyzed using Epi2000. Means and frequencies for each variable were calculated.

Results: Majority (67.4%) of the snake bite victims were in the age group between 15 and 45 years. Majority were male victims (74.2%). 71% victims of snake bite lived in rural areas. Farmers and laborers were the main victims. 61.2% incidents took place at night time or early morning (before 6 a.m.). 64% patients had bite mark on the lower limb. 40% victims had seen the snake. Eight patients had snake bite, but were asymptomatic. 52% had neuroparalytic manifestation, 34% were asymptomatic, and 9.6% had hemorrhagic manifestation. 14% cases received treatment within 1 h of the bite and 64.84% within 1-6 h after the bite. First aid given was in the form of application of tourniquet (16.2%), local application of lime, chillies, herbal medicine, etc., (1%). 2.20% cases were sensitive to anti-snake venom. Only three patients died.

Conclusion: In this region (Gujarat), neuroparalytic manifestation of snake bite is more prevalent. Cobra and krait are the commonest types of poisonous snakes. The time of seeking treatment has reduced because of awareness about snake bite treatment and better transport and ambulance facility. Mortality is very less in well-equipped hospitals due to early initiation of treatment with anti-snake venom.
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http://dx.doi.org/10.4103/0974-2700.115343DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3746443PMC
July 2013

Study of various clinical and laboratory parameters among 178 patients affected by hooch tragedy in Ahmedabad, Gujarat (India): A single center experience.

J Emerg Trauma Shock 2013 Apr;6(2):73-7

Department of Medicine and Emergency Medicine, Smt. NHL Municipal Medical College, VS General Hospital, Ahmedabad, Gujarat, India.

Introduction/purpose: The outbreak of methanol poisoning described in this paper occurred in Ahmedabad, Gujarat, India in July 2009. Our intention is to share the experience of clinical features, laboratory investigations and their relation during this tragedy.

Materials And Methods: Single center, retrospective study of clinical features and laboratory parameters of 178 cases of methanol toxicity treated at tertiary care hospital in Ahmedabad, Gujarat.

Results: Maximum patients (39.8%, n = 45) were received in 48 h; Mean age of presentation was 41.9 ± 10.2 years. Most of them were men (175 out of 178). On presentation, 83% patients had gastro-intestinal symptoms, 46% had neurological symptoms, 73% had visual symptoms and 32% had dyspnoea. 62% had blurred vision, 10.5% had blindness. Patients with visual symptoms had high mean level of methanol (120.12 ± 23.12 vs. 55.43 ± 29.24, P = 0.014). On fundus examination 52.8% (n = 62) had bilateral hyperaemia of discs, 8.4% (n = 12) had bilateral disc pallor and 4.5% had papilledema (n = 5). Patients with hyperaemia of discs, discs pallor or papilledema, had higher mean methanol level (121.1 ± 32.2 mg% v/s 70.1 ± 23.2 mg%, P = 0.032). Mean of pH values was 7.17 ± 0.22 and bicarbonate was 12.3 ± 7.3 mmol/L. Both pH and bicarbonate levels correlated well with mortality and serum methanol level. Mean serum methanol level was 87.1 mg/dL, and correlated significantly with the mortality (53.1 ± 41 mg/dL v/s 121 ± 92 mg/dL, P value < 0.05).

Conclusion: GI symptoms, neurological symptoms and breathlessness are important clue to ED physician for diagnose methanol poisoning. Visual symptoms and fundus findings correlate well with the methanol level. Arterial Blood Gas derived pH and bicarbonate levels correlate significantly with the methanol level and mortality.
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http://dx.doi.org/10.4103/0974-2700.110745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665074PMC
April 2013

Study of various clinical and laboratory parameters among 178 patients affected by hooch tragedy in Ahmedabad, Gujarat (India): A single center experience.

J Emerg Trauma Shock 2013 Apr;6(2):73-7

Department of Medicine and Emergency Medicine, Smt. NHL Municipal Medical College, VS General Hospital, Ahmedabad, Gujarat, India.

Introduction/purpose: The outbreak of methanol poisoning described in this paper occurred in Ahmedabad, Gujarat, India in July 2009. Our intention is to share the experience of clinical features, laboratory investigations and their relation during this tragedy.

Materials And Methods: Single center, retrospective study of clinical features and laboratory parameters of 178 cases of methanol toxicity treated at tertiary care hospital in Ahmedabad, Gujarat.

Results: Maximum patients (39.8%, n = 45) were received in 48 h; Mean age of presentation was 41.9 ± 10.2 years. Most of them were men (175 out of 178). On presentation, 83% patients had gastro-intestinal symptoms, 46% had neurological symptoms, 73% had visual symptoms and 32% had dyspnoea. 62% had blurred vision, 10.5% had blindness. Patients with visual symptoms had high mean level of methanol (120.12 ± 23.12 vs. 55.43 ± 29.24, P = 0.014). On fundus examination 52.8% (n = 62) had bilateral hyperaemia of discs, 8.4% (n = 12) had bilateral disc pallor and 4.5% had papilledema (n = 5). Patients with hyperaemia of discs, discs pallor or papilledema, had higher mean methanol level (121.1 ± 32.2 mg% v/s 70.1 ± 23.2 mg%, P = 0.032). Mean of pH values was 7.17 ± 0.22 and bicarbonate was 12.3 ± 7.3 mmol/L. Both pH and bicarbonate levels correlated well with mortality and serum methanol level. Mean serum methanol level was 87.1 mg/dL, and correlated significantly with the mortality (53.1 ± 41 mg/dL v/s 121 ± 92 mg/dL, P value < 0.05).

Conclusion: GI symptoms, neurological symptoms and breathlessness are important clue to ED physician for diagnose methanol poisoning. Visual symptoms and fundus findings correlate well with the methanol level. Arterial Blood Gas derived pH and bicarbonate levels correlate significantly with the methanol level and mortality.
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http://dx.doi.org/10.4103/0974-2700.110745DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3665074PMC
April 2013
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