General Surgical Emergencies Research Articles

AN OBSERVATIONAL CLINICAL STUDY OF ASSOCIATION OF LINTULA SCORE IN SUSPECTED CASE OF ACUTE APPENDICITIS IN TERTIARY CARE HOSPITAL

Acute appendicitis is the most common general surgical emergency. About 8% of people have appendicitis at some time during their life. (1) Early surgical intervention improves outcomes. (1) Lintula scoring system is based solely on clinical examination. This might improve the clinical outcomes in adults with suspected appendicitis. A study was conducted on 50 patients suspected of having acute appendicitis were admitted in surgery department. The variables of the Lintula score were recorded and the sum of the score for each patient was calculated. Patients were treated according to standard protocol decided by consultant. The result of the score will be compared to intraoperative diagnosis using chi square test.After comparing positive and negative appendicitis with positive and negative Lintula scores, sensitivity and specificity of Lintula scoring system in diagnosis of acute appendicitis were found to be 55% and 90% respectively. The positive predictive value and diagnostic accuracy of the test has been found to be 95.65% and 80% respectively. (p value <0.05).

Laparoscopic Treatment of Perforated Appendicitis

The most frequent general surgical emergency worldwide is acute appendicitis. Because to its potentially fatal complications, including perforation, it could put patients at danger of death. An appendix that has ruptured frequently results in serious infectious complications as abdominal sepsis, pelvic abscess, and others. Laparoscopic appendectomy for perforated appendicitis raises several questions. In many nations today, laparoscopic treatment of perforated appendicitis is the preferred surgical technique. Aim: This prospective study's objective was to assess the efficacy of laparoscopy in the treatment of complicated appendicitis (perforation). Methods: The study was conducted prospectively during the period from September 2020 to August 2022. The study included 50 individuals who underwent peritoneal lavage after laparoscopic appendicectomy of perforated appendix in the department of Surgery, Lady Reading Hospital, Peshawar. The traditional method, three ports technique was used. Sometimes a fourth port is needed. Telescopic ports are 10 mm in size. The other two ports are 3/5 mm and 5/10 mm, respectively. Unipolar diathermy is a source of energy. Hemostasis and ligation of the appendicular stump are achieved via intra-corporeal knotting, endo-loop, and hemo-clip. Results: The study's age range is 5-70 years, with a mean age of 19 with male predominance. The duration of surgery varies from 30 to 120 minutes, with a mean duration of 65 minutes. Hospital stays range from 48 to 96 hours on average. There were 12 patients with complications, including paralytic ileus was seen in 1(2%), diarrhea in 2(4%), multiple or single (4% and 8%) port infections, and port TB in (4%). Open conversion was seen in 1 (2%) patient due to appendicitis burst haemorrhage. Every complication was treated carefully. Conclusion: Laparoscopy is an excellent method for treating perforated appendicitis. Thus, it is practical, achievable and may be carried out by skilled hands in any centre. That is now regarded as regular operating procedure. Keywords: Laparoscopic appendicectomy, Perforation (burst)

Social Media, Misinformation, and Online Patient Education in Emergency General Surgical Procedures

IntroductionPatients use the internet to learn about diagnoses and treatment options. These sources vary in quality and accuracy of medical information. Thus, utilization of social media may lead to misinformation regarding treatment for patients in need of emergent general surgery procedures. MethodsYouTube was searched with keywords “cholecystectomy,” “cholecystitis,” and “gallbladder surgery” and “appendectomy,” “appendicitis,” and “appendix surgery.” For each procedure, the 100 videos with the greatest views were reviewed. Videos were assessed by four surgical trainees using validated instruments, DISCERN and the Patient Education Materials Assessment Tool (PEMAT), and Likert scales for patient education and misinformation. After appendectomy or cholecystectomy, patients completed a survey assessing use of social media preoperatively. ResultsThe median DISCERN score was 28.0 of 75. The median PEMAT scores were 66.7% for understandability and 0% for actionability. Nearly half (49%) of videos provided no patient education and only 22% provided moderate or more. More than a third (35%) of videos contained misinformation. Doctors, medical education, and healthcare systems published videos with less misinformation, whereas patients, health/wellness groups published more misinformation (P < 0.001). Videos discoverable with colloquial terms “appendix surgery” and “gallbladder surgery” were more likely to contain misinformation (45.3%) compared to 20.5% of videos with misinformation discoverable using medical search terms only (P < 0.001). ConclusionsThere is a range of video quality online with most videos of poor quality and provide little patient education. Understanding information available to patients online can tailor surgeon-patient discussions to combat misinformation and improve the informed consent process for patients.

Retrospective analysis of outcome of COVID positive patients undergoing emergency surgeries for acute general surgical conditions

Background: There is a significant impact of COVID-19 disease on medical and surgical community. Acute surgical emergencies had to be addressed inspite of several hardships to save the lives of patients. There is a need to understand the impact of COVID-19 disease on outcome of surgical emergencies. This study aimed to analyse the outcomes of COVID-19 patients with general surgical emergencies. Methods: This retrospective study was conducted on 50 patients undergoing emergency surgeries for acute general surgical pathologies in department of general surgery, Government General Hospital, Guntur from January 2021 to October 2021. Patients were divided into two groups, 25 patients who were COVID positive and 25 patients who were COVID negative. The outcomes assessed were mortality, multi organ dysfunction syndrome, surgery related complications and number of days of hospital stay. Results: Mortality was higher in COVID group when compared to non COVID group (32% vs. 8%). Average number of hospital stay was higher in COVID group than non Covid group (11.78 days vs. 8.43 days). COVID-19 patients developed MODS 2.88 times greater than non COVID patients (20% vs. 8%). Surgery related complications were higher in COVID-19 patients (28% vs. 8%). Conclusions: COVID positivity was associated with higher complications rate, higher mortality and increased duration of hospital stay.

International guidelines on management of general surgical emergencies in the pregnant or breastfeeding woman.

International guidelines on management of general surgical emergencies in the pregnant or breastfeeding woman.

Dr Google - assessing the reliability and readability of information on general surgical procedures found via search engines.

The most common general surgical emergency operations are laparoscopic appendicectomy, laparoscopic cholecystectomy, hernia repair, hemorrhoidectomy and colectomy. Patients commonly perform an internet search for more information prior to undergoing surgery, which can lead to an inappropriate understanding of their procedure. The aim is to assess the quality of information available on three of the most used search engines. A search was conducted on Google.com, Bing.com and Yahoo.com using the terms related to laparoscopic appendicectomy, laparoscopic cholecystectomy, hemorrhoidectomy, hernia repair and colectomy. First 20 results from each search engine were collected for evaluation. Results were excluded if they were sponsored, duplicates, academic publications, advertisements, forums, audiovisual tools, social media or any non-English information. Included results were assessed for reliability using DISCERN and JAMA benchmark score. Readability was assessed using Flesch Reading Ease (FRE) Score and Simple Measure of Gobbledygook (SMOG). Hundred and ninety-seven websites were analysed, 44.7% were published by institutions, 34.5% by health websites and 20.8% by independent surgeons. Mean DISCERN scores for Institutions was 54.6 ± 11.3, independent surgeons 45.9 ± 11.4 and health websites 58.7 ± 10.3. Mean JAMA score for Institutions was 1.0 ± 1.0, independent surgeons 0.1 ± 0.4 and health websites 1.7 ± 1.1. FRE scores for institutions was 51.6 ± 10.3, independent surgeons 40.9 ± 10.2, and health websites 45.7 ± 12.3. SMOG scores were 9.8 ± 1.5 for institutions, 11.4 ± 1.6 for independent surgeons and 10.6 ± 1.7 for health websites. Health information on common general surgical procedures found on search engines are generally fair to good quality but still above the suggested reading level of the population. Information on surgical procedures should be written at recommended reading level of 13-14 years old.

Alvarado or RIPASA? Which one do you use to diagnose acute appendicitis?: A cross-sectional study.

Acute appendicitis is one of the most common causes of lower abdominal pain, which is considered a general surgical emergency worldwide. The present study aimed to compare the diagnostic value of Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) and Alvarado score systems in diagnosing acute appendicitis. A prospective cross-sectional study was conducted at Shahid Sadoughi and Shahid Rahnemoon Hospitals in Yazd between September 2020 and February 2020. The statistical population consisted of all of the patients referred to the Accident and Emergency department with right iliac fossa (RIF) pain. All patients were scored using Alvarado and RIPASA scoring system. sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were computed by using SPSS statistical software. An receiver operating characteristic curve were plotted. In present study, one hundred suspected patients with appendicitis who underwent appendectomy were evaluated. The mean age of our study population was 25.2 ± 12.1 years, and the gender distribution was 57% males and 43% females. The sensitivity, specificity, PPV and NPV of RIPASA were 86.6%, 66.7%, 92.2%, and 52.2%, respectively. The sensitivity, specificity, PPV and NPV of Alvarado score were 67.1%, 72.2%, 91.7%, 32.5%, respectively. The diagnostic accuracy was 68% for Alvarado score and 83% for RIPASA. The area under the curve for RIPASA (0.87) was more than that for Alvarado score (0.77). The RIPASA score system had higher sensitivity, PPV, NPV, and accuracy than the Alvarado one. It is recommended for the physician and surgeon to evaluate patients with RIF pain using the RIPASA score.

Acute Intestinal Obstruction: A 1-Year Prospective Audit into Causes.

Intestinal obstruction is a common general surgical emergency with high morbidity and mortality. Its aetiology varies widely between and within geographic regions, with gender, age, and time. Obstructed inguinal hernia is still considered the most common cause of intestinal obstruction in Sub-Saharan Africa and other low-income countries, but its incidence appears to be on the decrease as other causes of intestinal obstruction become more common in a particular society. To examine the spectrum of causes of intestinal obstruction in a tertiary hospital in southern Nigeria and compare the results with earlier studies in the region and Nigeria. A cross sectional, single-hospital study of adults diagnosed with and having clinical and radiological features of acute intestinal obstruction. Seventy patients were enrolled in the study, comprising of 35 (50%) males and 35 (50%) females, M:F = 1:1. The mean patient age was 44.8 years. Two peak age incidences of intestinal obstruction were observed in the 36-45 and 56-65 years age groups. Post-operative adhesion 13 (18.5%), obstructed external abdominal hernia 13 (18.5%), colonic cancer 11 (16%), and intussusception seven (10%) were the primary causes of intestinal obstruction. Obstructed inguinal hernia was commonly encountered in males while adhesions and colonic cancers were common in females. Obstructed external abdominal hernias and post-operative adhesion are at par as the main primary causes of intestinal obstruction. Colon cancer and intussusception are increasingly causing more obstructions.

A PROSPECTIVE COMPARATIVESTUDY OF OPEN VERSUS LAPAROSCOPIC APPENDECTOMY: A SINGLE UNIT STUDY

Introduction: Acute appendicitis is the most common general surgical emergency. Appendicectomy is the treatment of choice for acute appendicitis and the most commonly performed emergency abdominal operation. Open appendectomy is found safe and effective operation with low morbidity but found to be associated with post operative pain, wound infection and complications like intestinal obstruction which may delay recovery. Laparoscopic appendectomy emerged as a good option for treatment of appendicitis. The purpose of this study was to compare the laparoscopic versus open approach among patients with appendicitis in our centre. Materials And Methods: This study was a prospective study of 100 patients with clinically diagnosed as appendicitis admitted in the department of General Surgery, Unit II, Zoram Medical College for a period of two years during November 2019 to October 2021. They were divided into two groups - Open Appendectomy (OA) group and Laparoscopic Appendectomy (LA) group of 50 patients each. Age ranges from 10yrs to 75yrs. Exclusion criteria were pregnant female, chronic medical problems, haemodynamically unstable or psychiatric illness, cirrhosis, coagulation disorders, patients on steroid, immuno-compromised patients, patients on chemotherapy for malignancy and those who are not willing to participate. OA was performed through standard Mc Burney incision. LA was performed through a standard 3 ports technique. Results: The most common presentation of appendicitis is abdominal pain followed by nausea/vomiting and common in younger age group of 10-20 years. Laparoscopic Appendectomy was found as safe and effective as Open Appendectomy. LA has more acceptable cosmetic result, shorter hospital stay and less postoperative pain. The pain score was significantly reduced in LA group (3.2+-1.4) and in OA (4.1+-1.8). Conclusion: LA was found as safe and effective as OA. LA has more acceptable cosmetic result, shorter hospital stay and less postoperative pain.

The role of imaging in the diagnosis of acute appendicitis during the COVID-19 pandemic: a retrospective cohort study.

Acute appendicitis is one of the most common general surgical emergencies worldwide; however, its diagnosis remains challenging, with a high proportion of negative appendicectomies. The purpose of this study was to investigate the benefit of routine use of pre-operative imaging for the evaluation of suspected appendicitis. This retrospective cohort study included all cases of appendicectomies performed for suspected acute appendicitis during the first and second peaks of the COVID-19 pandemic, between March 2020 and February 2021. The control group included all cases of appendicectomies performed for suspected acute appendicitis in the previous 12months (March 2019-February 2020). One hundred and four patients underwent appendicectomy in the study group, compared to 209 in the control group, with similar gender distribution but a significantly higher median age in the study group (33 vs. 28, p = 0.001). The two groups had similar rates of perforation and similar median white cell count (WCC) and CRP. Imaging was used in 80.77% of the patients in the study group, compared to 61.72% in the control group (p = 0.001), with 55.77% of patients in the study group undergoing CT scans. Despite this, the negative appendicectomy rate (NAR) in the two groups did not differ significantly (11.54% vs. 15.79%, p = 0.320). The increase in the use of imaging for the diagnosis of acute appendicitis during the COVID-19 pandemic did not lead to a significantly lower negative appendicectomy rate. Registration: The study was pre-registered at ClinicalTrials.gov (NCT05205681).

Potential Access to Emergency General Surgical Care in Ontario.

Limited access to timely emergency general surgery (EGS) care is a probable driver of increased mortality and morbidity. Our objective was to estimate the portion of the Ontario population with potential access to 24/7 EGS care. Geographic information system-based network-analysis was used to model 15-, 30-, 45-, 60-, and 90-min land transport catchment areas for hospitals providing EGS care, 24/7 emergency department (ED) access, and/or 24/7 operating room (OR) access. The capabilities of hospitals to provide each service were derived from a prior survey. Population counts were based on 2016 census blocks, and the 2019 road network for Ontario was used to determine speed limits and driving restrictions. Ninety-six percent of the Ontario population (n = 12,933,892) lived within 30-min's driving time to a hospital that provides any EGS care. The availability of 24/7 EDs was somewhat more limited, with 95% (n = 12,821,747) having potential access at 30-min. Potential access to all factors, including 24/7 ORs, was only possible for 93% (n = 12,471,908) of people at 30-min. Populations with potential access were tightly clustered around metropolitan centers. Supplementation of 24/7 OR capabilities, particularly in centers with existing 24/7 ED infrastructure, is most likely to improve access without the need for new hospitals.

Prospect of food bolus obstruction in a tertiary care hospital

Background: Small bowel obstruction (SBO) is a common general surgical emergency usually caused by adhesions, bands or hernias. Food bolus impaction or bezoars remain an uncommon cause, albeit well reported in literature. The objective was to outline the frequency, demographic features, etiopathogenesis and management patterns of acute SBO due to ingested food bolus.Methods: An observational retrospective study was conducted whereby patients admitted to the surgical emergency of the associated hospital of Government Medical College, Jammu, Jammu and Kashmir, India as cases of acute SBO, who underwent laparotomy, over a period extending from August 2020 to June 2022 were selected and their records reviewed for history of ingestion/intra-operative finding of food bolus obstruction. Demographic, etiological and management patterns were noted. Descriptive analysis was done using Jamovi (version 1.6) (computer software).Results: A total of 100 patients of food bolus obstruction were admitted and operated upon during the study period with a median age of 14 years, with 40% patients belonging to 11 to 20 years age group, with a male to female ratio of 3:1. Majority belonged to rural areas (86%). 97% cases were due to ingestion of date plum or persimmons (vernacular: “amlook”). Ileum was the most common site of impaction (63%). 90% cases were managed by fragmentation of bolus and milking of gut, whereas enterotomy and resection-anastomosis were performed in 5 patients each.Conclusions: Food bolus obstruction especially due to phytobezoars of Diospyros lotus (date plum or “Amlook”) is often encountered in our setup, especially in rural populations, predominantly affecting male children and adolescents.

398 Acute Paediatric Appendicitis (AA)- Decreasing the Negative Rate of Appendicectomy in a District General Hospital

Abstract Aim Globally Acute appendicitis (AA) is the most common general surgical emergency. A recent consensus study has proposed a negative appendicectomy rate of 10%. Our aim is to monitor and reduce the negative rate of paediatric appendicectomy and optimise the acute paediatric management following the newly introduced workflow. Method Retrospective patient data collection via electronic sources (Evolve discharge summary, Operation notes) for all paediatric patients (0–16 years old) admitted with AA between March 23rd and October 31st, 2020. Results We separated our audit in three different periods of time. In the first period, 5 out 20 (25%) who underwent an appendicectomy had a normal appendix on histological analysis. In the second period (from June to August) we introduced a paediatric assessment workflow and managed to decrease the negative rate of appendicectomy from 25% to 19%. During the third period (from September to October 2020) the negative rate of appendicectomy decreased to 11%, 14% less than our initial result. More patients underwent an US prior CT as part of routine screening in order to avoid a negative appendicectomy. The initial percentage of US scanning was 72% and was increased to 90% after the end of the third period. Additionally, conservative management was 20% and was increased to 24% after the end of the third period. Conclusions Due to the results of this study, the paediatric appendicitis workflow in daily practice has resulted in more patients being treated conservatively.

WE3.10 The Impact of Simulation Training on Junior Doctors Managing Surgical Emergencies

Abstract Aim The use of simulation for the training of junior doctors in surgery usually involves either practicing technical skills or exercising communication skills. We have identified a gap in crisis resource management training of junior surgical trainees with scenario-based simulation. We have developed a one-day simulation course on general surgical emergencies and evaluated its impact. Methods The course included a human factors presentation and several scenarios of acute surgical emergencies. It was aimed at core surgical trainees, but other junior doctors were invited. High fidelity human simulator (SimMan®) was used and controlled by faculty. Surgical scenarios were selected in order to provide insight for the appropriate resuscitation for acute surgical patients. The impact of the course was evaluated with a post course questionnaire. Results Ten courses were completed between 2015 and 2021. A total of 58 doctors attended, 45 were core surgical trainees. All 51 participants who responded to the questionnaire rated the course “Good (4/5)” or “Excellent (5/5)”. Following the course, of 51 participants, 50 felt better prepared and 51 were confident in recognising unwell surgical patients; 42 felt better prepared and 50 confident in providing resuscitation; 46 felt better prepared and 51 confident in escalating care. During debriefs and on free text feedback, participants frequently reported the course helped develop their non-technical skills. Conclusion The General Surgical Emergencies simulation courses were rated useful by the learners. The course has positively impacted on the preparedness and confidence of junior surgical trainees in recognising unwell surgical patients, providing initial resuscitation and escalating care.

TH6.7 Direct Streaming of Acute Surgical Patients to an Advanced Nurse Practitioner-led Service: A Prospective Audit of a Pilot Service to Improve Patient Flow

AimsThe ongoing uncertainty of the COVID-19 pandemic and recovery to re-establish elective services presents a major challenge to the NHS. Patient flow and bed capacity is now a priority for acute hospitals. We have implemented a new service model aimed at improving patient flow from A&E, where acute surgical patients are triaged and referred directly to the Advanced Nurse Practitioner (ANP) team for assessment and management. A criterion based on the presenting complaint and clinical observations was developed to identify suitable patients. The utilisation of this service was audited for its safety and impact on the Emergency General Surgical provision.MethodsThe setting is a busy University Teaching Hospital with a diverse catchment population of 75,000. A prospective audit identified the number of patients utilising the new care pathway and details of any adverse events or delays in treatment identified. All patients presenting with a General Surgical condition were included.ResultsBetween August and December 2021, 361 patients were referred directly from A&E (81% within first 2 hours of presentation) to the surgical ANP team for assessment. Of these, 85 (24%) were admitted for emergency treatment and 276 (76%) were discharged the same day for either ambulatory or outpatient follow-up, or back to Primary Care. There were no adverse events identified during the audit period.ConclusionDirect streaming of acute surgical patients within a defined criteria to an ANP-led service is safe and effective in helping to improve patient flow and experience within an acute care model.

SP10.1.8 Acute uncomplicated diverticulitis: to scope or not to scope?

AimsTo investigate whether endoscopic follow up after a CT proven diagnosis of acute uncomplicated diverticulitis detected additional pathology, specifically colorectal cancer, and if our findings support the European Society of Coloproctology's consensus statement that “a single episode of CT verified uncomplicated diverticulitis endoscopic follow-up remains controversial and may not be necessary”.MethodsA retrospective study evaluated every General Surgical emergency admission with acute uncomplicated diverticulitis to our unit in a 5 year period (2015–2020) to assess for radiological diagnosis and endoscopic follow up.ResultsOver the 5 years there were 685 admissions with acute uncomplicated diverticulitis affecting 547 individuals. 74.3% of admissions and 80.3% of individuals underwent a Computerised Tomography (CT) during admission. 244 admissions (48%) went on to have an endoscopic examination, with 12.3% of these being inpatient investigations. 50% (122) of patients undergoing endoscopy had confirmed uncomplicated diverticulitis. Of the remaining patients undergoing endoscopy, 79.5% had no pathology detected. Only 1 malignant polyp was discovered on endoscopy with no tumours detected.ConclusionsCT has a high sensitivity and specificity in the diagnosis of acute uncomplicated diverticulitis. We suggest that it is reasonable not to utilise endoscopy as a screening tool after uncomplicated diverticulitis and the risks versus benefits must be carefully considered, especially in the era of Covid-19 where resources are tight and waiting lists ever growing. An endoscopic procedure is a costly, uncomfortable procedure that puts the patient at risk of morbidity and mortality.Our findings support the European Society of Coloproctology's statement regarding endoscopic follow-up.

EP-383 Correlation between delays to emergency laparotomy and outcomes at a large District General Hospital (DGH)

Abstract Aims Significant morbidity and mortality are associated with emergency laparotomies. Delays to theatre inevitably increase the risk of sepsis, deterioration, failure to rescue and death. The aim of our study was to determine the outcomes associated with delays of non-vascular emergency laparotomies at a large DGH. Methods A retrospective review of a prospectively maintained database was performed of all patients who underwent general surgical emergency laparotomy over a 10 week period from 10th June 2021 to 25th September 2021. Outcomes of patients were compared between delayed and non delayed surgery as per NCEPOD classification. Results 76 patients were included in the study, 46.05% were males. 15 (19.74%) patients had a delay to surgery. The most common indication for surgery was obstruction (63.16%), followed by perforation (27.63%). The patients requiring urgent surgery were least likely to arrive in theatre within the correct timeframe. 18.34% of patients experienced a delay if a decision is made for surgery during the day (0800–2000) compared to 30% at night (0000–0800). Severe complications, (Grade 3 and 4 on Clavien Dindo classification) occurred in 13% of those who had a delay to surgery, compared to 16% in those without delays. Total 30-day mortality was 9.2%. There was no significant difference in the outcomes of patients who had a delay and those who did not. Conclusion Delay in arrival to theatre was more amongst patients requiring urgent surgery. The time of day or week did not affect the time to theatre. Delay did not result in significant difference in outcomes.

Shock Index in Patients Undergoing Elective and Emergency General Surgical Procedures: A Predictor of Morbidity Risk and Outcomes

Introduction: Shock index (SI) has gained popularity as a quick and inexpensive screening tool for patients of trauma or obstetric hemorrhage to predict risk of mortality and morbidity especially transfusion requirement. It has further been studied for sepsis in recent times. Though not specific the shock index has been shown to be a sensitive tool in alerting physicians of patients that may require greater medical attention. It has not been studied in patients undergoing general surgical procedures either elective or emergency.&#x0D; Aims &amp; Objectives: To assess the utility of shock index in patients undergoing both elective and emergency general surgical procedures and to assess outcomes of these patients.&#x0D; Place and duration of study: It was a retrospective cohort study of in-patient records of the Department of General Surgery, Sir Ganga Ram Hospital, Lahore. The duration of study was from 1st September 2021 till 30th November 2021. Material &amp; Methods: From the medical records information was retrieved and the shock index was calculated by ‘heart rate divided by systolic blood pressure’ and was recorded for the following instances: (i)At admission (ii) Prior to induction of anesthesia (iii) In the immediate post-operative phase in the recovery unit (iv) post-operative Day 1 (v) at discharge. Patient’s outcomes and investigations were also recorded. SPSS version 24 was used for data entry and analysis&#x0D; Results: SI at admission and on post-operative Day 1 for emergency vs elective surgery was 0.82 and 0.72 vs 0.69 and&#x0D; 0.68. Shock index prior to induction was higher in the emergency surgery group and this was statistically significant. A shock index value of 0.81 was 71.7% and 72% specific for post-operative morbidities. The optimum value for shock index in ER and Elective surgery varies for each morbidity.&#x0D; Conclusion: This is a simple tool and may increase appropriate resource allocation and increased observation for certain patients who are screened to be at higher risk of developing a specific morbidity post-operatively, especially in resource- limited countries like Pakistan.

COVID-19 Diagnosis in Patients With Acute Abdominal Pain Without Respiratory Symptoms: A UK Emergency General Surgical Unit Experience.

BackgroundRecent evidence has emerged reporting atypical clinical symptoms of the novel coronavirus (COVID-19). There is a sparsity of existing studies examining COVID-19-related abdominal pain and the role of investigative imaging for the virus in these patients. Study aims were to determine COVID-19 incidence in those with acute abdominal pain in the absence of respiratory symptoms and to assess the diagnostic performance of CT thoracic imaging in such patients.MethodsRetrospective analysis of all consecutive patients admitted to our emergency general surgical unit between 1st March 2020 and 31st May 2020 was performed. In adherence with national guidelines, all patients underwent nasal and oro-pharyngeal COVID-19 RT-PCR swabs as well as thoracic and abdominal computed tomography (CT) on admission.ResultsFrom 112 patients admitted with acute abdominal pain in the absence of respiratory symptoms, 16 (14.3%) tested positive for COVID-19 on RT-PCR swab testing. Overall, 50% (8/16) of these patients had no intra-abdominal pathology on CT. The sensitivity and specificity of CT thoracic imaging for diagnosing COVID-19 was 43.8% and 91.7%, respectively. Patients with positive COVID-19 swabs had higher C-reactive protein levels, lower potassium levels and a higher proportion of those with a low lymphocyte count.DiscussionOne in seven patients with abdominal pain without any respiratory symptoms tested positive for COVID-19. Half of these patients represented COVID-19 manifesting primarily as acute abdominal pain. Combined swab testing and CT imaging should be performed in all abdominal pain presentations due to the varying diagnostic performance of thoracic CT in diagnosing COVID-19.

Does Mistreatment and Perceived Stress Impact Career Choice for LGBTQ+ US Medical Students?: An Analysis of AAMC Data

Introduction The impact of psychosocial stressors on specialty choice among sexual minority vs sexual majority medical students remains unclear. Past studies have suggested that sexual minority individuals are less likely to pursue specialties considered to have more intensive postgraduate training. We explored how sexual orientation, Perceived Stress Scale (PSS), and cumulative experience of mistreatment (ie, mistreatment experience variable [MEV]) during medical school influences specialty selection using longitudinal data from the Association of American Medical Colleges matriculation (2014) and graduation (2018) questionnaires. Design, Setting, and Participants A multinomial logistic regression model evaluated the association of sexual orientation, PSS, and MEV on specialty choice, adjusting for age, gender, race, US geographical region of medical school, and 2 interaction terms. Interactions between sexual orientation and PSS and MEV were not significant. The sample included 12 128 participants. Results Compared with heterosexual students, homosexual students were less likely to choose general surgery or surgical subspecialties (P = .004) and orthopedics (P = .002) over internal medicine. Homosexual students with a PSS score of 7 or greater were less likely to choose general surgery or surgical subspecialty (P = .03), orthopedics (P = .02), and emergency medicine (P &lt; .001) than internal medicine. Additionally, homosexual students who reported an MEV score of 3 or greater were less likely to choose orthopedics (P = .007) over internal medicine. Conclusions These data suggest that stress and mistreatment during medical school significantly impact specialty choice, particularly for homosexual students. To correct these disparities and broaden LGBTQ+ representation across all specialties, institutions need to explore early career advising for students with greater perceived stress and increase efforts to eradicate mistreatment of sexual minority students during medical training.