Surgical Illness Research Articles

The Glucocorticoid Taper: A Primer for the Clinicians.

Glucocorticoid (GC) therapy can ameliorate debilitating and life-threatening symptoms in several inflammatory/immunological disorders. However, it can also cause significant side effects, especially with higher doses and longer duration of use. Therefore, GCs should be used at the lowest effective dose for the shortest possible time to minimise adverse effects. GC therapy may cause suppression of the endogenous hypothalamic-pituitary-adrenal (HPA) axis and abrupt discontinuation predisposes patients to features of GC-induced adrenal insufficiency. The practice of tapering GC therapy allows for recovery of the HPA axis while minimising the risk of a disease flare-up or symptoms of AI. Moderate-to-high dose GC therapy may be tapered rapidly to near-physiological doses while watching for features of disease reactivation. Once close to the physiological dose, tapering is slower and at longer intervals to allow for recovery of the HPA axis. It is important to use short- or intermediate-acting GC preparations such as hydrocortisone or prednisolone in physiological doses, administered in the morning to mimic the endogenous cortisol rhythm. A general principle to follow is that HPA axis recovery takes longer if the period of suppression has been long. In such cases, tapering should be slower over a few months to even a year. In select cases at high risk of AI or if symptoms appear during tapering, the decision to further taper and discontinue steroids may be based on testing of HPA axis function using basal and/or stimulated serum cortisol. All patients on exogenous steroids should be advised about the need for an appropriate increase in GC doses during acute medical or surgical illness and should carry a steroid alert card to avoid adrenal crisis.

Thyroid hormone changes in critical surgical illness: a narrative review

The systemic response to stress caused by a critical surgical illness is characterized by a series of events that precede metabolic and neuroendocrine dysregulation. However, the relevance of theclassically described 'stress response' is now highly questionable in an era where profound physiological deconditioning is common in critically ill, surgical and non-surgical patients. Common assessment techniques do not accurately reflect the integrity of the hypothalamic-pituitary-thyroid axis in the course of a critical chronic disease state. The clinical presentation ismostly masked by symptoms of the underlying critical illness when plasma thyroid hormone concentrations are altered. The frequent development of multimorbidity in critically ill patients is the reason for the need for a more detailed analysis of the neuroendocrine model of activation. Basic scientific studies suggest that low levels of circulating thyroid hormones in the acute phase are an adaptive process, but the chronic condition could directly cause organ damage. Here, we review factors that have emerged to challenge the conventional model of euthyroid sick syndrome (ESS) in the surgically critically ill as an adaptive process, and suggest that the stage of the critical illness is an important consideration in the critically ill. Examining the stressresponse in the critically ill presents opportunities to improve outcomes through improved understanding of the neuroendocrine aspects.

Prevalence and risk factors of depression in patients with chronic obstructive airway disease: a tertiary care hospital, outpatient setting.

Chronic obstructive airway disease (COPD) has been found to be associated with depression. An overlap of COPD and depression may cause poor quality of life and an increase in mortality. A meta-analysis found that the prevalence and risk factors of depression in patients with COPD have high heterogeneity and are limited in tertiary care hospital outpatient settings. This study thus aimed to evaluate the prevalence and risk -factors of depression in patients with COPD using personal data in a tertiary care hospital outpatient setting. This cross-sectional study included adult patients who were diagnosed with COPD according to the GOLD guidelines, had stable functional status within the past 4 weeks with the same treatment regimen, and had no history of other serious medical or surgical illness. A diagnosis of depression was made according to a score of 11 or higher on the hospital anxiety and depression scale (HADS). The prevalence and predictors of depression were then computed. The study enrolled and evaluated 150 patients with COPD, out of which 6 (4%) had depression. While the predictive model for depression comprised two factors, only severity of COPD was independently associated with depression. The adjusted odds ratio of severity of COPD was 5.20 (95% confidence interval of 1.75, 15.42; p = 0.003). The prevalence of depression in patients with COPD in a tertiary care outpatient setting was low, at 4%. According to the study's comprehensive assessment, severity of COPD was the only factor associated with depression in patients with COPD.

Acute Appendicitis in Rural KwaZulu-Natal, South Africa

Abstract 
 The Lancet commission on Global Surgery identified a huge global burden of surgical illness which is not adequately treated, as the resources needed to effectively treat these many common surgical conditions are not readily available in many regions. This review aims to provide a comprehensive overview of the epidemiology, management, and outcomes of acute appendicitis in South Africa.
 Methods
 A scoping search was conducted across major electronic databases to identify relevant studies published between January 2000 and December 2023. Articles reporting on the incidence, presentation, diagnostic methods, surgical interventions, and outcomes of acute appendicitis in South Africa were included.
 Results
 The literature review revealed an increasing incidence of acute appendicitis among African patients in South Africa, potentially linked to dietary changes accompanying urbanization. Despite advancements in surgical techniques, open appendectomy remains the primary approach, particularly in public healthcare facilities, indicating disparities in access to laparoscopic surgery. Complications such as wound infections and hospital-acquired pneumonia contribute to prolonged hospital stays, high morbidity, and high mortality. However, outcomes in private healthcare settings demonstrate higher rates of laparoscopic procedures and lower complication rates compared to public institutions.
 Conclusion 
 Acute appendicitis in South Africa presents unique challenges, including disparities in surgical access and outcomes between public and private healthcare sectors. Addressing these challenges requires efforts to improve healthcare infrastructure, enhance surgical training, and promote equitable access to laparoscopic techniques. Collaborative research endeavors and evidence-based interventions are essential for optimizing the management and outcomes of acute appendicitis across diverse socio-economic contexts in South Africa.

Test-Only Learning via Virtual Patients to Improve Surgical Illness Scripts of Preclinical Medical Students as a Preparation for Clinical Clerkships: An Experimental Study.

The aim was to determine whether preclinical medical students can develop their illness scripts to a level comparable to that of clerkship students through test-only learning using repeated formative online testlets. In this experimental study, participants were 52 preclinical and 53 clinical medical students. The intervention group consisted of preclinical medical students, and the control group consisted of clinical medical students. The intervention group responded to online testlets containing feedback, an innovative formative assessment method called ContExtended Questions, on general surgery for 8days by spending no more than 30minutes each day. The control group completed the general surgery clerkship. The performances were assessed using 20 Key-Feature Question items. The intervention group was assessed twice: immediately after the intervention (the immediate test), and again 1month later (the delayed test). The control group was assessed once, immediately after the clerkship. All performance tests were identical. The preclinical students had a significantly higher mean score on the immediate test (83.1 ± 9.6) compared to the clinical students (75.4 ± 8.9), P < .001. The effect size (Cohen's d) was .83. However, the mean score in the delayed test (76.9 ± 13.6) was not significantly different from clinical students' mean score (75.4 ± 8.9), P > .05. Test-only learning as a spaced repetition of online formative testlets is effective in preparing preclinical medical students to the clinical clerkship. Through using this approach in preclinical period, they can prepare themselves for the clinical environment to optimize the benefits derived from clerkships.

Assessment of G10 Intraoperative Scoring System for Conversion in Patients Undergoing Laparoscopic Cholecystectomy: A Cross-Sectional Study From Nepal.

Various preoperative risk factors for conversion in laparoscopic cholecystectomy (LC) have been well studied. However, the assessment of intraoperative factors for conversion in patients with cholecystitis is unclear. The G10 scoring system, which incorporates 10 parameters, has tried to fill this void by developing a scoring system for the most commonly encountered surgical illnesses. So, we aimed to assess the utility of the G10 scoring system among patients presenting for LC for symptomatic cholelithiasis (both acute and chronic cholecystitis) in the clinical setting of a low- and middle-income country. All the patients undergoing LC were assigned a G10 value. Gallbladder surgery was considered easy if the G10 score was <2, moderate (2 ≦ 4), difficult (5 ≦ 7), and extreme (8 ≦ 10). All 10 risk factors were analyzed into a binary logistics model, and statistically significant risk factors were assessed. Among 177 patients, there were 36 males and 141 females. The median age of the patient was 42 years (range 11-79). There were 70 easy, 89 moderate, and 18 difficult cases. The overall mean G10 score was 2.32±1.5, which significantly increased as the severity progressed, with a mean value of 5.5±0.51 for difficult cases(P=0.0001). The mean G10 score for surgeries completed laparoscopically was 2.1±1.4, while it was 3.71±1.4 for open conversions[P=0.0001, AUC=0.79, CI=0.70-0.87]. There were 18 patients with G10 ≥5 with a conversion rate of 27.7%, while the overall conversion rate was 13.6%. Multivariate analysis showed free bile or pus outside the gallbladder [P=0.02, OR=5.1, CI=1.2-21.1] and fistula [P=0.01, OR=15.8, CI=1.9-129.8] as significant risk factors for conversion. Intraoperative risk factors for the prediction of conversion included the presence of free bile or pus outside the gallbladder and cholecystoenteric fistula. Based on the F1 score analysis, complemented with the Youden Index, the optimal cutoff value for conversion, based on the G10 score, lies around 4. Broader application and validation of the G10 scoring system are mandated to assess the utilization of this novel intraoperative scoring system.

The Impact of Educational Materials on Parental Anxiety and Productivity: A Clinical Trial in Pediatric Appendicitis

ObjectivesThere is limited literature on how acute appendicitis, the most common acute children's surgical illness, affects the family. We conducted a prospective study to assess the impact of educational materials on parents' anxiety and productivity during the child's illness. MethodsA quasi-experimental clinical trial was conducted among parents of children undergoing laparoscopic appendectomy. In Phase I, parents received the standard explanations at diagnosis and throughout the postoperative period. In Phase II, parents also received a comprehensive educational brochure on pediatric appendicitis at diagnosis. The primary outcome, parental preoperative anxiety, was assessed using the Amsterdam Preoperative Anxiety and Information Scale (APAIS). The secondary outcome, parental productivity, was evaluated through a post-recovery online questionnaire based on the Productivity and Disease Questionnaire (PRODISQ). Baseline characteristics and outcomes were compared between the two cohorts using t-tests, Mann–Whitney, chi-square, or Fischer's exact test as appropriate. ResultsPhases I and II included 67 and 66 families, respectively. Patient demographics and disease severity were similar between both groups. Of the 53 parents (80.3%) in Phase II who answered the postoperative questionnaire, most recommended the booklet (96.2%), as it decreased their stress (78.0%) and enhanced their understanding of appendicitis (94.1%). However, the two groups showed similar preoperative anxiety levels and postoperative productivity loss. ConclusionsEducational materials increased satisfaction with surgical care but did not mitigate the high parental preoperative anxiety levels and postoperative productivity loss. Additional research is required to elucidate interventions that may improve these important patient and family-centered outcomes. Type of studyNon-Randomized Clinical Trial. Level of evidenceII.

Utility of pediatric early warning score at emergency room in predicting the level of care required for next 48 h: A single-center, prospective, observational study

Abstract Background: Pediatric scores such as the Pediatric Early Warning Score (PEWS) are based on parameters available at the bedside. The aim of this study was to assess the utility of PEWS to determine the need for critical care support within the next 24–48 h. this study aimed to see if PEWS could predict a suitable level of care, namely ward, high-dependency unit (HDU), or pediatric intensive care unit (PICU). Subjects and Methods: It was a prospective observational study and a convenient sample method was used with children of age groups from 1 month to 18 years, coming to the pediatrics department being the subject. We correlated the level of care at admission and also after 48 h with PEWS at the time of admission of children already intubated, children on inotropes at the time of admission, children with surgical illness, and children admitted only for procedure/procedural sedation were excluded from this study. The Brighton PEWS was used to calculate PEWS. Results: A total of 953 patients were enrolled in this study. In this study, the likelihood of admission to PICU correlated well with PEWS above 6 with a positive predictive value of 56% and a negative predictive value of 99.43%. Conclusions: The admission PEWS can be used as an effective tool for deciding the level of care area. Score &lt;3 admission PEWS can be kept at the ward, while &gt;3 score at HDU/PICU where frequent periodic monitoring should be done.

Shock Severity Classification and Mortality in Adults With Cardiac, Medical, Surgical, and Neurological Critical Illness

ObjectiveTo evaluate whether the Society for Cardiovascular Angiography and Interventions (SCAI) Shock Classification could perform risk stratification in a mixed cohort of intensive care unit (ICU) patients, similar to its validation in patients with acute cardiac disease. MethodsWe included 21,461 adult Mayo Clinic ICU patient admissions from December 1, 2014, to February 28, 2018, including cardiac ICU (16.7%), medical ICU (37.4%), neurosciences ICU (27.7%), and surgical ICU (18.2%). The SCAI Shock Classification (a 5-stage classification from no shock [A] to refractory shock [E]) was assigned in each 4-hour period during the first 24 hours of ICU admission. ResultsThe median age was 65 years, and 43.2% were female. In-hospital mortality occurred in 1611 (7.5%) patients, with a stepwise increase in in-hospital mortality in each higher maximum SCAI Shock stage overall: A, 4.0%; B, 4.6%; C, 7.0%; D, 13.9%; and E, 40.2%. The SCAI Shock Classification provided incremental mortality risk stratification in each ICU, with the best performance in the cardiac ICU and the worse performance in the neurosciences ICU. The SCAI Shock Classification was associated with higher adjusted in-hospital mortality (adjusted odds ratio, 1.32 per each stage; 95% CI, 1.24 to 1.41; P<.001); this association was not observed in the neurosciences ICU when considered separately. ConclusionThe SCAI Shock Classification provided incremental mortality risk stratification beyond established prognostic markers across the spectrum of medical and surgical critical illness, proving utility outside its original intent.

Nurses’ pain management practices for admitted patients at the Comprehensive specialized hospitals and its associated factors, a multi-center study

BackgroundPain is the most common challenge that most hospitalized patients complain of and is influenced by several patients, nurses, and institutional-related factors. Most studies in Ethiopia on pain were focused on surgical illnesses only.ObjectiveTo assess nurses’ pain management practice and associated factors for admitted patients at Comprehensive Specialized Hospitals.Methods and materials: A multi-center institution-based cross-sectional study was conducted at the five randomly selected Comprehensive Specialized Hospitals of the Amhara region from May 01 to June 01, 2022. A multi-stage sampling method was employed to select a total of 430 nurses and patients for whom the nurses were responsible. Data were collected using standard self-administered, structured, and checklist questionnaires from nurses, patients, and patients’ charts respectively. The modified Bloom’s criteria categorized the overall practice as good, moderate, and poor. Data were checked, coded, and entered into Epi-Data version 4.6 and exported to SPSS version 25. An ordinal logistic regression model was applied, and variables with a p-value < 0.05 with a 95% CI in the multivariable analysis were considered significant.ResultsThe study evaluated the pain management practices of 430 nurses and only a quarter had good pain management practices. Those nurses with first degrees and above education level (AOR = 2.282) and who attended in-service training (AOR = 2.465) were found to have significantly higher pain management practice. Expected though patients with painful procedures (AOR = 5.648) and who had severe pain (AOR = 2.573) were receiving better pain management practices from their nurse care provider. Nurses working in the institutions with a pain-free initiative focal person (AOR = 6.339) had higher pain management practices.Conclusion and recommendation: Overall, the majority of nurses had poor pain management practices. Higher educational levels, in-service training, and assigning a pain-free focal person had an impact on pain management services. Patients with higher pain levels and painful procedures were getting better attention. Hospital administrations need to provide due attention to the pain management of hospitalized patients by providing in-service training and educational opportunities to improve the capacity of nurses. Patients would be benefited considerably if hospitals focus on assigning focal persons for advocating regular pain management for admitted patients regardless of their pain level.

Impact of COVID-19 Vaccination on General Surgical Emergencies in Al-Qassim Region, Saudi Arabia: A Single-Center Retrospective Chart Review.

Background This study sought to determine the COVID-19 pandemic and vaccination's effects on the number of patients presenting with emergent surgical illnesses or requiring emergency general surgical procedures. We compared the number of presenting cases and surgical emergencies before the pandemic, in 2019, and during the pandemic, before and after the COVID-19 vaccination's introduction. Method This observational retrospective chart review was conducted at a tertiary hospital in Al-Qassim, Saudi Arabia. The data were retrospectively collected for three periods (July 1 to September 30) in 2019, 2020, and 2021 using a data collection sheet for demographic data, visit date, comorbidities, emergency procedure type, COVID-19 test result, length of hospitalization, ICU admission status, and surgical case mortality. Results The study included 152 participants with a mean age of 36.1 (SD: 16) years, and 69.7% of them were male. Common surgical conditions were identified as acute appendicitis (49.3%), skin abscesses and pilonidal sinus (21.7%), and diabetic foot (9.2%) across all three years. The most frequent (48.7%) surgical procedure was appendectomy. A decrease in surgical emergencies rate was observed during the year 2020, as compared to 2019 and 2021. The general surgery emergency rate was highest in 2021 among patients admitted for procedures post-vaccination (38.8%). Conclusion Common surgical emergencies were most frequent in 2021, after the COVID-19 vaccine's introduction. Future research areas include the impact of the pandemic on delays or the severity and complication of surgical or medical cases.

Double-site Intussusception in an Infant

Background: Although intussusception is a well-known phenomenon in childhood, double-site intussusception is rarely encountered. We report an interesting case of idiopathic double-site, two ileoileal intussusceptions. Clinical Description: An 11-month-old baby girl presented with acute-onset vomiting and abdominal distension over 3 days. There was no associated history of fever, respiratory tract infection, or gastroenteritis. The infant was otherwise healthy, thriving well, without any significant medical or surgical illness in the past. On examination, the infant was alert, but irritable, hemodynamically stable, with abdominal distension without any lump or organomegaly. Management: The infant was stabilized with supportive care initially. The abdominal radiograph revealed multiple air–fluid levels with a paucity of distal gas shadows. Ultrasound showed a single-target sign in the right lumbar region. At laparotomy, an ileoileal intussusception was detected. During manual reduction, another intussusception was identified; the distal one was also ileoileal at the terminal ileum with its apex at the ileocecal junction. Both intussusceptions were successfully reduced. No pathological lead point was observed for each intussusception. Symptoms resolved, and there was no recurrence. Conclusion: This case creates awareness about the rare occurrence of double-site intussusceptions, which are not always detected by imaging methods. A careful inspection of the entire gut intraoperatively is essential to avoid missing such unsuspected second intussusceptions.

Rapunzel Syndrome in a Boy

Background: Trichobezoar is a rare phenomenon where a ball of swallowed hair collects in the stomach. When its tail extends beyond the pylorus in to the small intestine, it is termed Rapunzel syndrome. The condition is most commonly seen in females with psychological disturbances, many of whom have trichotillomania and or trichophagia. We report Rapunzel syndrome condition in a young boy having no overt mental disturbances. Clinical Description: A 5½-year-old male child presented with complaints of vomiting for 20 days, associated with dull aching epigastric pain over 1 year. A lump had been noticed in the abdomen which was increasing in size for the past 5 months and decreased appetite for past 1 month. Besides pica, the child had no other significant medical or surgical illness. On examination, the child was underweight with pallor, with dry, lusterless, easily pluckable hair. His abdomen revealed a palpable lump in epigastrium, with ultrasonography showing a large gastric mass with air foci. Contrast-enhanced computed tomography abdomen revealed a large, well-circumscribed, nonhomogeneous lesion in the lumen of the stomach suggestive of bezoar. The patient underwent exploratory laparotomy, which confirmed trichobezoar with a long tail of hair extending through the pylorus into the small bowel. After successful removal of the trichobezoar, the patient was discharged with no postoperative complication and advised follow up in surgery, pediatrics, and psychiatry department. Conclusion: This case creates awareness of the possibility of the rare, bizarre entity of trichobezoar in a toddler presenting with nothing more than the usual common symptoms as seen in this age group. After ruling out common causes, when there is persistence of symptoms, with some clinical clues like pica, anemia, and behavior abnormalities, pediatricians may suspect an underlying atypical diagnosis like trichobezoar, even in a male child.

Seven Years Analysis of Postpartum Death in Selangor, Malaysia: A Lesson Learnt

Information on determinants of postpartum death enhances understanding of the fundamental causes of mortality. Studies on postpartum death in Malaysia are limited despite increasing trends of postpartum mortality. This study aimed to ascertain the determinants of postpartum death in Selangor, Malaysia. A case control was conducted using data from the Maternal Death Registry, Selangor State Health Department, Malaysia. A total of 144 postpartum death cases were included for analysis after the removal of fortuitous and unknown death. Controls were mothers who survived six weeks after childbirth and were selected via simple random sampling. The odds of postpartum death among multiparous was almost two times higher (aOR; 1.76 95% CI 1.10,2.82). The presence of pre-existing medical or surgical problems were associated with a three-folds increase in the odds of postpartum death (aOR 3.23; 95% CI 1.91,5.47). The odds of postpartum death were ten times higher for those who gave birth in non-health facilities (aOR 10.62; 95% CI 2.64,42.74). Women who underwent caesarean section had almost three times more odds (aOR 2.50; 95% CI 1.60,3.91) for death. Women who received antenatal care in government health facilities had low odds (aOR 0.34; 95% CI 0.19,0.60) for postpartum death. The determinants showed significant association with postpartum death in Selangor, Malaysia which included the presence of pre-existing medical or surgical illness, place of birth, mode of birth, place of antenatal care and Malaysian ethnicity-citizenship. In the future, health programmes should not only aim to reduce postpartum deaths by emphasising maternal education and empowerment, but should also enhance pre-pregnancy care, provide continual obstetric emergency skill training to healthcare providers, collaborate with several agencies and underwrite migrants’ maternal healthcare fees.

Study on Autoimmune Thyroid Disorders in Chronic Spontaneous Urticaria at a Tertiary Care Central Rural Hospital in India.

Background Chronic spontaneous urticaria (CSU) is a medical condition characterized by the persistence of urticaria for more than six weeks, primarily caused by mast cell activation. Autoimmune thyroid diseases (AITDs) are the most common cause of dysfunction of the thyroid gland, and they are influenced by both genetic and environmental factors. Mast cell mediators have a significant role in the pathogenesis of CSU through two main pathways: the derangement of intracellular signaling pathways in mast cells and basophils and the production of autoantibodies against these cells. This study aimed to explore the association between AITDs and CSU by examining clinical features and measuring thyroid hormones and anti-thyroid peroxidase (anti-TPO) antibodies in patients. Aim and objectives The primary aims of this study are to investigate the prevalence and clinical characteristics of autoimmune thyroid disorders in patients with chronic spontaneous urticaria. The specific objectives are to evaluate the triiodothyronine (T3), tetraiodothyronine (T4), thyroid-stimulating hormone (TSH), and anti-thyroid peroxidase (anti-TPO) antibody levels in patients and controls and to explore the correlations between these parameters and the development and severity of chronic spontaneous urticaria. Material and method The present study was an observational investigation that enrolled 40 patients, consisting of 20 cases and 20 controls. The inclusion criteria involved patients of both sexes, aged above 18 years, who had chronic spontaneous urticaria and agreed to participate in the study with informed consent. Patients with other skin conditions lacking abnormal thyroid etiopathogenesis were also included. Exclusion criteria included patients with major systemic disease, uncontrolled medical or surgical illness, renal or hepatic disorders, and pregnant or lactating females. Patients with chronic spontaneous urticaria underwent a comprehensive clinical evaluation, and their urticaria severity was scored using an established scoring system. Blood samples were collected from both cases and controls for measuring T3, T4, TSH, and anti-TPO antibody levels. The anti-TPO antibody was processed using the enzyme-linked immunosorbent assay (ELISA) method. The autoimmune thyroid disease was screened by monitoring T3, T4, TSH, and anti-TPO antibody levels. Results There were significant variations observed in thyroid-stimulating hormone and anti-thyroperoxidase antibody levels. Among the cases analyzed, 40% demonstrated an urticaria severity score of one, while 25% reported a duration exceeding eight weeks. Additionally, 25% of patients experienced severe pruritus and intense wheals. Conclusions This research has discovered a robust association between serum anti-TPOantibodies and the occurrence of chronic spontaneous urticaria. To mitigate the potential for chronic spontaneous urticaria to lead to long-term morbidity, it is imperative to consider testing for serum anti-TPO antibodies in conjunction with primary thyroid markers, including T3, T4, and TSH.

A cost-effectiveness analysis of surgical care delivery in Eastern Uganda-a societal perspective

BackgroundThe mismatch between the global burden of surgical disease and global health funding for surgical illness exacerbates disparities in surgical care access worldwide. Amidst competing priorities, governments need to rationally allocate scarce resources to address local needs. To build an investment case for surgery, economic data on surgical care delivery is needed. This study focuses on femur fractures.MethodsThis prospective cohort study at Soroti Regional Referral Hospital (SRRH), captured demographic, clinical, and cost data from all surgical inpatients and their caregivers at SRRH from February 2018 through July 2019. We performed descriptive and inferential analyses. We estimated the cost effectiveness of intramedullary nailing relative to traction for femur fractures by using primary data and making extrapolations using regional data.ResultsAmong the 546 patients, 111 (20.3%) had femur fractures and their median [IQR] length of hospitalization was 27 days [14, 36 days]. The total societal cost and Quality Adjusted Life Year (QALY) gained was USD 61,748.10 and 78.81 for femur traction and USD 23,809 and 85.47 for intramedullary nailing. Intramedullary nailing was dominant over traction of femur fractures with an Incremental Cost Effectiveness Ratio of USD 5,681.75 per QALY gained.ConclusionFemur fractures are the most prevalent and most expensive surgical condition at SRRH. Relative to intramedullary nailing, the use of femur traction at SRRH is not cost effective. There is a need to explore and adopt more cost-effective approaches like internal fixation.

Historical Notes on the Founding of the Surgical Palliative Care Society.

The latter half of the twentieth century witnessed the emergence of the hospice movement as a response to the increasing medicalization of death and the associated suffering. Palliative care, a term coined by the Canadian urologic surgeon Balfour Mount, represents an expansion of hospice philosophy upstream within the health care system extending to the care of hospitalized patients with life-threatening illnesses. This article offers a brief history of the development of surgical palliative care, i.e., palliative care directed specifically toward relief of suffering associated with serious surgical illnesses and culminating in the formation of the Surgical Palliative Care Society.

Z-plasty in post-burn contracture of hand among pediatric patients.

Objective: To find out the frequency of hand burn and the effectiveness of Z-plasty in post-burn hand contractures. Study Design: Descriptive Cross-sectional study. Setting: Department of Pediatric Surgery, Khawaja Muhammad Safdar Medical College, Sialkot. Period: January to December 2021. Material &amp; Methods: A preformed proforma was used, consisting of 4 parts, the first part including demographic data like age and gender, second part consist of patient’s history, consisting of presenting complaint, its duration, past history of any medical or surgical illness or comorbidity. Third part consisted of physical clinical examination of the hand (fingers and palm) while fourth part was for post-operative complications of reconstructive procedure, Z-plasty. The data was analyzed by using Statistical Package for Social Sciences (SPSS) version-20. Results: The most commonly affected age group was less than 6 years of majority of them, 53.3%, were male. The most common cause was thermal burns as compared to electrical burns. Among 91.1% of the participants, the right hand was affected more. Majority of the cases (48.9%) reported single finger burn, followed by multiple fingers (31.1%) and very few (20%) were having palm burns. Segregating the single figure, results showed that little finger was affected in 20% of cases No post-operative complications, like skin necrosis, wound dehiscence, hematoma or infection, were noted. Conclusion: It can be concluded that post-burn hand contractures and hand deformity was common among children. Z-plasty with/without skin grafting is an ideal surgical management to subside the contracture of hand.

Pattern of Illness in Prisoners Admitted in a Tertiary Care Hospital of South Eastern Rajasthan

The delivery of health care among prisoners is one of the most important aspects of improving human rights compliance. Estimating common healthcare problems in prisoners will be helpful in assessing their health status and recommending the rectifying steps. Therefore, knowing the types of morbidities will help us in making health policies which will be helpful in reducing the health burden in prisoners and will also help in reintegration of prisoners into mainstream society. The present study is a retrospective analysis to find out the common medical conditions in prisoners. The study was carried out by collecting data of 500 admitted prisoner in a tertiary care institute in south-east Rajasthan. The majority (95.2%) of referred prisoners were male, from age group of 30-39 years, mean age of prisoners being 39.6 years and the majority (90%) were referred from Central Jail, Kota. The majority (53.2%) of prisoners were admitted to medicine department followed by psychiatry department (26.4%). A higher prevalence of anemia and pulmonary tuberculosis was reported among prisoners. Surgical illness related to infectious etiology and poor personal hygiene was common in prisoners. Psychosis not specified (17%), schizophrenia (8%), mixed anxiety depressive disorder (8%) and substance use disorders (16%) were common psychiatric conditions. Mean duration of hospitalization was 9 days.

INFLAMMATORY MARKERS IN THE DIAGNOSIS OF COMPLICATED APPENDICITIS IN CHILDHOOD

Acute abdominal pain is challenging because of the nonspecific nature of symptoms and difficulties in physical examination in children. In most of them, it is a manifestation of an urgent surgical or medical condition, where the biggest challenge is a timely diagnosis to start appropriate treatment without any diagnostic delays. There are many conditions that present with abdominal pain in all age groups, ranging from a common viral illness to a life-threatening surgical condition. History, physical examination, laboratory tests, and imaging are initially used to differentiate surgical illnesses categorized as urgent. Their characteristics, age, and physical examination of the patient direct appropriate tests in the context of these differences.