Surgical Illness Research Articles

Systematic review of oxygenation and clinical outcomes to inform oxygen targets in critically ill trauma patients.

Oxygen therapy is frequently administered to critically ill trauma patients to avoid hypoxia, but optimal oxygenation strategies are not clear. We conducted a systematic review of oxygen targets and clinical outcomes in trauma and critically ill patients. We searched Ovid MEDLINE, Cochrane Library, Embase, and Web of Science Core Collection from 1946 through 2017. Our initial search yielded 14,774 articles with 209 remaining after abstract review. We reviewed full text articles of human subjects with conditions of interest, an oxygen exposure or measurement, and clinical outcomes, narrowing the review to 43 articles. We assessed article quality using Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) criteria. Of the 43 final studies meeting inclusions criteria, 17 focused on trauma and 26 studies focused on medical and/or surgical critical illness without trauma specifically. Four trauma studies supported lower oxygenation/normoxia, two supported higher oxygenation, and 11 supported neither normoxia nor higher oxygenation (five neutral and six supported avoidance of hypoxia). Fifteen critical illness studies supported lower oxygenation/normoxia, one supported higher oxygenation, and 10 supported neither normoxia nor higher oxygenation (nine neutral and one supported avoidance of hypoxia). We identified seven randomized controlled trials (four high quality, three moderate quality). Of the high-quality randomized controlled trials (none trauma-related), one supported lower oxygenation/normoxia and three were neutral. Of the moderate-quality randomized controlled trials (one trauma-related), one supported higher oxygenation, one was neutral, and one supported avoidance of hypoxia. We identified few trauma-specific studies beyond traumatic brain injury; none were high quality. Extrapolating primarily from nontrauma critical illness, reduced oxygen administration targeting normoxia in critically ill trauma patients may result in better or equivalent clinical outcomes. Additional trauma-specific trials are needed to determine the optimal oxygen strategy in critically injured patients. Systematic review, level IV.

Multiple Organ Dysfunction Syndrome- Clinical Profile, Associations and Outcome in Critically ill Children Aged 1 Month to 14 Years Admitted to PICU in Nobel Medical College Teaching Hospital in Biratnagar

Introduction: Multiple organ dysfunction syndrome (MODS), characterized by a progressive physiologic dysfunction involving two or more organ systems after an acute threat to systemic homeostasis, is not a rare entity among patients admitted to the pediatric intensive care units. Despite recent advances made in the medical technology and newer treatment strategies, large numbers of deaths in the PICU are attributable to MODS.
 Objective: To describe the clinical profile of MODS among children admitted in PICU and to observe its associations and outcome.
 Methodology: A hospital based prospective observational study was conducted in PICU of Nobel medical college teaching hospital, Biratnagar, Nepal from June 2017- May 2018. Children aged 1 month to 14 years admitted in the PICU with various medical and surgical illnesses were included in the study. All variables defining MODS and the data showing the presence or absence of sepsis were collected within 1 hour of admission (day 0) and then every day until transfer or discharge from PICU or until patient's death.
 Results: Out of 150 admissions in the PICU, 103 fulfilled the inclusion criteria, and were enrolled in the study. A total of 53 patients (51%) developed MODS at some time during their stay at PICU and 88.7% of them had it at the time of admission. Of 103 cases under study, 26 died (mortality rate = 25.2%) and 92.3% of deaths were attributable to MODS. Children with neurological involvement had the highest risk of death [odds ratio (OR), 19.8; 95% confidence interval (95%CI), 4.37-90.30]. 75.5% of children with MODS had some sort of infection and 49% of them had sepsis. Conditions like SIRS, Sepsis, Severe sepsis, Septic shock and ARDS in the study patients were found significantly associated with MODS.
 Conclusion: A MODS is a common clinical entity among patients admitted to the PICU and are associated with significant mortality and morbidity. In children, MODS usually seem to develop early and in a simultaneous way. In developing countries like ours, morbidity and mortality associated with MODS in the PICUs is higher than that in the developed countries. Prevalence of sepsis in children with or without MODS is greater in the developing countries. Sepsis is further responsible for larger number of deaths in PICU.

Association of Surgical Intervention for Adhesive Small-Bowel Obstruction With the Risk of Recurrence

Adhesive small-bowel obstruction (aSBO) is a potentially chronic, recurring surgical illness. Although guidelines suggest trials of nonoperative management, the long-term association of this approach with recurrence is poorly understood. To compare the incidence of recurrence of aSBO in patients undergoing operative management at their first admission compared with nonoperative management. This longitudinal, propensity-matched, retrospective cohort study used health administrative data for the province of Ontario, Canada, for patients treated from April 1, 2005, through March 31, 2014. The study population included adults aged 18 to 80 years who were admitted for their first episode of aSBO. Patients with nonadhesive causes of SBO were excluded. A total of 27 904 patients were included and matched 1:1 by their propensity to undergo surgery. Factors used to calculate propensity included patient age, sex, comorbidity burden, socioeconomic status, and rurality of home residence. Data were analyzed from September 10, 2017, through October 4, 2018. Operative vs nonoperative management for aSBO. The primary outcome was the rate of recurrence of aSBO among those with operative vs nonoperative management. Time-to-event analyses were used to estimate hazard ratios of recurrence while accounting for the competing risk of death. Of 27 904 patients admitted with their first episode of aSBO, 6186 (22.2%) underwent operative management. Mean (SD) patient age was 61.2 (13.6) years, and 51.1% (14 228 of 27 904) were female. Patients undergoing operative management were younger (mean [SD] age, 60.2 [14.3] vs 61.5 [13.4] years) with fewer comorbidities (low burden, 382 [6.2%] vs 912 [4.2%]). After matching, those with operative management had a lower risk of recurrence (13.0% vs 21.3%; hazard ratio, 0.62; 95% CI, 0.56-0.68; P < .001). The 5-year probability of experiencing another recurrence increased with each episode until surgical intervention, at which point the risk of subsequent recurrence decreased by approximately 50%. According to this study, operative management of the first episode of aSBO is associated with significantly reduced risk of recurrence. Guidelines advocating trials of nonoperative management for aSBO may assume that surgery increases the risk of recurrence putatively through the formation of additional adhesions. The long-term risk of recurrence of aSBO should be considered in the management of this patient population.

Surgical and Perioperative Palliative Care: Updates from 2018 (TH307)

•Cite recently published literature on evidence and best practices for palliative care interventions in surgical patients.•Discuss areas of active surgical palliative care investigation in the context of common treatment dilemmas faced while caring for seriously ill patients with surgical disease.•Describe the application of surgical palliative care research and its impact on patient, family, and caregiver outcomes using concrete examples. Recent years have seen rapid expansion of the evidence base supporting the implementation of palliative care programs across health systems, ranging from the community to the intensive care unit. Surgical patients face uniquely complex decisions, significant symptom burden, and prognostic uncertainty, and their needs warrant surgery-specific palliative care delivery. Different models have been developed to address these needs, including communication training for surgical providers, embedded inpatient and outpatient surgical palliative care programs, improved prognostication models, and advanced care planning interventions. The core principles of surgery and anesthesiology closely mirror those of palliative care, and the intersection between them is characterized by an increasing annual volume of emerging research. This session will summarize landmark peer-reviewed papers on surgical palliative care published in 2018. The authors will search PubMed and hand-review key journals in surgery, anesthesiology, critical care, and palliative medicine to identify and select articles for inclusion based on journal impact factor and broad interest to the AAHPM/HPNA audience. Using a case-based format to provide clinical context, the panel will present literature drawn from the following topic domains: communication around surgical decision-making, frailty and surgical risk assessment, perioperative advanced care planning, specialty palliative care triggers and delivery models for surgical patients, innovative caregiver and clinician education strategies, and novel symptom management approaches applicable to surgical patient populations. The presenters consist of an HPM fellowship-trained practicing general surgeon and HPM-focused anesthesiologist, an HPM social worker with a specialized practice in surgical oncology and critical care, and an HPM physician whose clinical and academic interests are focused on surgical patient populations. The cross-specialty representation of the panelists ensures a diversity of perspectives that will enrich the audience’s appreciation for the role of surgical palliative care research in improving the outcomes of patients and families facing surgical illness across an array of care settings.

Редкие опухоли языка. Опухоль Абрикосова: клиническое наблюдение

Granular cell tumor (GCT; Abrikossoff’s tumor; Myoblastoma) is a rare tumor that can affect various regions of the body, such as skin, soft tissues, breast, nervous system, gastrointestinal tract, urinary bladder and lungs. GCT in the head and neck region, which represents 45% to 65% of all the involved sites, is encountered most commonly in the oral tongue, especially on its anterior one third. A 36-year-old male, with a chief complaint of a slow-growing mass on the back of the tongue for 2.5 years. It was not associated with pain or dysphagia. There was no history of any significant medical or surgical illness in the past. He was a smoker and social drinker with fair oral hygiene. No cervical lymphadenopathy on regional examination. On intraoral examination, a round mass of about 0.8x0.8 cm on the back of the tongue. The patient was advised for the MRI which showed the round heterogeneous structure with unclear and non-smooth contours. We then performed the wide excision of the mass under GA and the specimen was sent for histopathological examination. postoperative period was uneventful and the lesion healed well. Thus the final diagnosis of Granular Cell tumor of tongue was made. The Tumors cells were immunopositively for S-100 protein and CD68; immunopositively for CKAE1/AE3, Ki67, Desmin. In conclusion: they are 3 important steps in the management rare tumors of the tongue: correct using of diagnostic algorithm, histopathologic examination, using this results for tactics and strategy of managing the patient.

A Fatal Case of Non- typhoidal Salmonella Pyogenic Pericardial Effusion in an Immunocompetent Adolescent

BACKGROUND Salmonella infection is common in tropical countries including Malaysia. It is invasive in immunocompromised and those of extreme ages. It typically presents with gastrointestinal symptoms such as diarrhea, abdominal pain or vomiting. Extra-intestinal manifestations are seen in 30% of salmonellosis cases. These atypical manifestation leads to difficulty and delay diagnosis thus poorer outcome. Pericardium involvement is estimated to be less than 2% of all cases and has mortality rate as high as 50%1. As high as 70% of pericarditis cases were identified to be immunosuppressed2; these include chronic immunosuppressant usage, autoimmune disease, end stage renal failure, malignancy and etc. Herein, we report a fatal case of pyogenic pericardial effusion by Salmonella enteritidis in an immunocompetent adolescent. CASE PRESENTATION A 16-years-old Malay boy was referred from GP to our centre in April 2015 with CXR finding suggestive of pericardial effusion. He had prolonged cough for 8 months, associated with breathlessness and failure symptoms. He had on and off fever but denied gastrointestinal symptom. He had multiple visits to private practitioners and was investigated for Tuberculosis, which yielded negative result. His condition continued to deteriorate. Of note, he had no significant medical and surgical illness. There was no history of contact with tuberculosis patients, recent travelling history or high risk behaviour. Upon admission, he was tachypnea and in shock. His blood pressure was 90/56mmHg with a pulse rate of 102bpm. His JVP was raised and heart sound was muffled. Lung examination revealed reduced breath sound bilaterally with generalized rhonchi. Initial blood investigations revealed leukocytosis with predominant neutrophils (16 x 109/L). ABG showed type 1 respiratory failure. ESR was raised, 100mm/hour. Chest X-ray showed a congested lung field consistent with pulmonary oedema. Bedside echocardiogram revealed a large pericardial effusion with diastolic right atrium and ventricle collapsed, indicating temponade effect. Emergency pericardialcentesis drained 1.3L of frank pus. IV Augmentin (Amoxicillin and calvulanate potassium) was empirically started. Pericardial fluid culture grew Salmonella Enteritidis which was sensitive to ceftriaxone and ciprofloxacin, thus antibiotic was switch to Ceftriaxone. Despite given targeted therapy, his general condition did not improve; pericardial pus re- accumulates, causing temponade thus requiring second drainage. Antibiotic was switch to ciprofloxacin and later meropenem in worried of poor pericardium penetration. Average daily drainage was 25 to 35ml. Repeated Echocardiogram showed loculated collection of pus in pericardium. HIV screening and autoimmune screenings were negative. Full blood picture was normal. No screening of malignancy done. His condition continued to deteriorate, requiring ventilator and inotropic support. He succumbed to death on third week of admission.

Correlation between second and third trimester placental thickness with ultrasonographic gestational age

Objectives The objective of this study was to evaluate the correlation between placental thickness in the second and third trimesters with gestational age, weight, and fetal outcome. Background Ultrasonography enables the evaluation of the placenta and the detection of placental abnormalities using different parameters such as placental thickness and volume or special techniques like three-dimensional power Doppler. Materials and methods This cohort study was conducted at the Departments of Obstetrics and Gynecology of Menoufia University Hospitals and Shebien Elkom Teaching Hospital from June 2017 to May 2018. This cohort study comprised 100 pregnant women who were attending the antenatal clinic at 24 weeks and were followed-up at 32 and 36 weeks. Detailed history was taken to rule out medical and surgical illnesses that could affect the study. Thorough general, physical, and obstetrical examinations were carried out. US examinations were performed at three visits: first between 24 and 28 weeks, second between 28 and 32 weeks, and third between 32 and 36 weeks. Results There was a significant positive correlation between placental thickness and birth weight in the second and third trimesters. The mean age of cases was 28 ± 5 years. Mean birth weight was 3243 ± 402 g, and mean placental weight was 511 ± 64 g. US measures of placental thickness in the first, second and third visit were 24.91 ± 1.27, 29.50 ± 1.23, and 34.60 ± 1.6 mm, respectively. Conclusion Measurement of placental thickness by ultrasonography is a good predictor tool for estimating the fetal weight.

Determination of Visual Portfolio for Surgeons OverSeas Assessment of Surgical Needs Nigeria Study: Consensus Generation through an e-Delphi Process.

Background:Surgery as a public health priority has received little attention until recently. There is a significant unmeasured and unmet burden of surgical illness in low- and middle-income countries (LMICs). Our aim was to generate a consensus among expert pediatric surgeons practicing in LMICs regarding the spectrum of pediatric surgical conditions that we should look out for in a community-based survey for Surgeons OverSeas Assessment of Surgical Needs Nigeria study.Materials and Methods:The Delphi methodology was utilized to identify sets of variables from among a panel of experts. Each variable was scored on a 5-point Likert scale. The experts were provided with an anonymous summary of the results after the first round. A consensus was achieved after two rounds, defined by an improvement in the standard deviation (SD) of scores for a particular variable over that of the previous round. We invited 76 pediatric surgeons through e-mail across Africa but predominantly from Nigeria.Results:Twenty-one pediatric surgeons gave consent to participate through return of mail. Thirteen (62%) answered the first round statements and 8 (38%) the second round. In general, the strength of agreement to all statements of the questionnaire improved between the first and second rounds. Overall consensus, as expressed by the decrease in the mean SD from 0.84 in the first round to 0.68 in the second round, also improved over time. The strength of consensus improved for 23 (74%) of the statements. The strength of consensus decreased for the remaining 8 (26%) of statements. Out of the 31 consensus-generating statements, 16 (51%) scored high agreement, 13 (42%) scored low agreement, and 2 (15%) scored perfect disagreement.Conclusion:We have successfully identified the pediatric surgical conditions to be included in any community survey of pediatric surgical need in an LMIC setting.

Graduated compression stockings for prevention of deep vein thrombosis.

Background One of the settings where deep vein thrombosis (DVT) in the lower limb and pelvic veins occurs is in hospital with prolonged immobilisation of patients for various surgical and medical illnesses. Using graduated compression stockings (GCS) in these patients has been proposed to decrease the risk of DVT. This is an update of a Cochrane review first published in 2000 and updated in 2010. Objectives To evaluate the effectiveness and safety of graduated compression stockings in preventing DVT in various groups of hospitalised patients. Search methods For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched March 2014) and CENTRAL (2014, Issue 2). Selection criteria Randomised controlled trials (RCTs) involving GCS alone; or GCS used on a background of any other DVT prophylactic method. Results from both these groups of trials were combined in this update. Data collection and analysis For this update one review author (AS) extracted the data. These were cross-checked and authenticated by a second author (MJD). Two review authors (AS and MJD) assessed the quality of trials. Disagreements were resolved by discussion. Main results Nineteen RCTs were identified involving 1681 individual patients and 1064 individual legs (2745 analytic units). Of these 19 trials, nine included patients undergoing general surgery, six included patients undergoing orthopaedic surgery, and only one trial included medical patients. Graduated compression stockings were applied on the day before surgery or on the day of surgery and were worn up until discharge or until the patients were fully mobile. In the majority of the included studies DVT was identified by the radioactive I125 uptake test. Overall, included studies were of good quality. In the treatment group (GCS) of 1391 units 126 developed DVT (9%) in comparison to the control group (without GCS) of 1354 units where 282 (21%) developed DVT. The Peto odds ratio (OR) was 0.33 (95% confidence interval (CI) 0.26 to 0.41) with an overall effect favouring treatment with GCS (P < 0.00001). Based on results from eight included studies, the incidence of proximal DVT was 7 of 517 (1%) units in the treatment group and 28 of 518 (5%) units in the control group. The Peto OR was 0.26 (95% CI 0.13 to 0.53) with an overall effect favouring treatment with GCS (P = 0.0002). Based on results from five included studies, the incidence of PE was 5 of 283 (2%) participants in the treatment group and 14 of 286 (5%) in the control group. The Peto OR was 0.38 (95% CI 0.15 to 0.96) with an overall effect favouring treatment with GCS (P = 0.04). Limited data were available to accurately assess the incidence of adverse effects and complications with the use of GCS. Authors' conclusions GCS are effective in diminishing the risk of DVT in hospitalised patients, with strong evidence favouring their use in general and orthopaedic surgery. However, evidence for their effectiveness in medical patients is limited to one trial.

Epidemiology and Outcomes of Candidaemia among Adult Patients Admitted at Hospital Universiti Sains Malaysia (HUSM): A 5-Year Review

Introduction: Candida organisms are opportunistic fungal pathogens that have become a major cause of nosocomial infections worldwide. We investigated the clinical characteristics and outcomes of hospitalized patients with candidaemia caused by Candida albicans and non-albicans Candida spp at HUSM. Materials and Methods: We retrospectively evaluated all hospitalized patients with candidaemia from January 2010 till December 2014 based on inpatient hospital records and laboratory data. Results: A total of 134 patients with candidaemia were enrolled. Candida albicans and non-albicans Candida spp were responsible for 20% (27/134) and 80% (107/134) of candidaemia cases, respectively. Hospitalized patients with diabetes mellitus, surgical conditions, or concomitant septicaemia and those who received instrumentations such as CVC or CBD, and those admitted under medical settings were prone to develop candidaemia caused by either C. albicans or non-albicans Candida spp. All isolates were susceptible to Fluconazole except for C. krusei isolates. All-cause mortality within 30 days post diagnosis of candidaemia was 59%. Factors associated with mortality were solid tumor (p =0.014), surgical illness (p=0.128), central venous catheterization (p= 0.096) and leucocytosis (p=0.116). Only solid tumor was an independent contributory factor for mortality among patients with C. albicans candidaemia in the multivariate analyses (OR 5.09, 95% CI 1.38,18.74, p=0.014). Conclusions: The patients’ clinical characteristics were fairly comparable between Candida albicans and non-albicans candidaemia. The changing epidemiology of candidaemia at this centre was in fact alarming. The outcome associated with candidaemia was poor.

Barriers to Goal-concordant Care for Older Patients With Acute Surgical Illness: Communication Patterns Extrinsic to Decision Aids.

We sought to characterize patterns of communication extrinsic to a decision aid that may impede goal-concordant care. Decision aids are designed to facilitate difficult clinical decisions by providing better treatment information. However, these interventions may not be sufficient to effectively reveal patient values and promote preference-aligned decisions for seriously ill, older adults. We conducted a secondary analysis of 31 decision-making conversations between surgeons and frail, older inpatients with acute surgical problems at a single tertiary care hospital. Conversations occurred before and after surgeons were trained to use a decision aid. We used directed qualitative content analysis to characterize patterns within 3 communication elements: disclosure of prognosis, elicitation of patient preferences, and integration of preferences into a treatment recommendation. First, surgeons missed an opportunity to break bad news. By focusing on the acute surgical problem and need to make a treatment decision, surgeons failed to expose the life-limiting nature of the patient's illness. Second, surgeons asked patients to express preference for a specific treatment without gaining knowledge about the patient's priorities or exploring how patients might value specific health states or disabilities. Third, many surgeons struggled to integrate patients' goals and values to make a treatment recommendation. Instead, they presented options and noted, "It's your decision." A decision aid alone may be insufficient to facilitate a decision that is truly shared. Attention to elements beyond provision of treatment information has the potential to improve communication and promote goal-concordant care for seriously ill older patients.

Shared Decision-Making in Acute Surgical Illness: The Surgeon's Perspective

Surgical patients increasingly have more comorbidities and are of an older age, complicating surgical decision-making in emergent situations. Little is known about surgeons' perceptions of shared decision-making in these settings. Twenty semi-structured interviews were conducted with practicing surgeons at 2 large academic medical centers. Thirteen questions and 2 case vignettes were used to assess perceptions of decision-making, considerations when deciding whether to offer to operate, and communication patterns with patients and families. Thematic analysis revealed 6 major themes: responsibility for the decision to operate, perceived futility, surgeon judgment, surgeon introspection, pressure to operate, and costs of the operation. Perceived futility was universally considered a contraindication to surgical intervention. However, the challenge of defining futility led participants to emphasize the importance of patients' self-determined risk-to-benefit analysis when considering surgical intervention. More experienced surgeons reported greater comfort with communicating to patients that a condition was not amenable to an operation and reserved the right to refuse to operate. Due to external pressures and uncertainty, some providers err on the side of operative intervention, despite suspected futility. Greater experience allows surgeons to withstand external pressures, be confident in their assessments of perceived futility, and guide patients and their families away from additional interventions.

Abdominal Cocoon Syndrome following Primary Subfertility Management with IVF-ET

Abdominal cocoon syndrome is a rarely encountered surgical emergency first described by Foo et al. in 1978. This condition is characterised by a thick fibrous membrane which encases the small bowel partially or completely. Diagnosis of this condition is usually made per operatively and the treatment of choice is surgical release of entrapped bowel. This is a case report of abdominal cocoon syndrome diagnosed during laparotomy done with the provisional diagnosis of abdominal pregnancy following In vitro fertilization- embryo transfer. A 30 Years lady was admitted at Kathmandu Medical College for suspected ovarian hyper stimulation syndrome following In vitro fertilization- embryo transfer. Conservative treatment was done as the first line of management. Failing this, she was treated surgically with the provisional diagnosis of abdominal pregnancy. Abdominal cocoon syndrome was observed intraoperatively. Patient was managed medically with injection due to raised βhCG level and empty uterine cavity. Intrauterine gestational sac was seen after about seven weeks of In vitro fertilization- embryo transfer. Pregnancy was terminated medically and patient was discharged. Sub fertility is a common gynecological problem. Its management may sometimes produce challenging health hazards. Thorough screening for medical and surgical illness is very important before proceeding to any kind of assisted reproductive technologies. A multidisciplinary approach is very important to manage such cases. Keywords: abdominal cocoon syndrome; embryo transfer; In Vitro fertilization; ovarian Hyper stimulation syndrome; sub fertility.

Palliative Care in Surgery: Defining the Research Priorities.

To describe the existing science of palliative care in surgery within three priority areas and expose specific gaps within the field. Given the acute and often life-limiting nature of surgical illness, as well as the potential for treatment to induce further suffering, surgical patients have considerable palliative care needs. Yet these patients are less likely to receive palliative care than their medical counterparts and palliative care consultations often occur when death is imminent, reflecting poor quality end-of-life care. The National Institutes of Health and the National Palliative Care Research Center convened researchers from several medical subspecialties to develop a national agenda for palliative care research. The surgeon work group reviewed the existing surgical literature to identify critical knowledge gaps. To date, evidence to support the role of palliative care in surgical practice is sparse and palliative care research in surgery is encumbered by methodological challenges and entrenched cultural norms that impede appropriate provision of palliative care. Priorities for future research on palliative care in surgery include: 1) measuring outcomes that matter to patients, 2) communication and decision making, and 3) delivery of palliative care to surgical patients. Surgical patients would likely benefit from early palliative care delivered alongside surgical treatment to promote goal-concordant decision making and to improve patients' physical, emotional, social and spiritual well-being and quality of life. We propose a research agenda to address major gaps in the literature and provide a road map for future investigation.

Surgical resources in South Africa: a review of the number of functional operating theatres

Surgery has previously been neglected as a development initiative, despite the obvious effect of surgical illnesses on morbidity and mortality. Recently, greater attention has been given to surgical services, as there is growing evidence of cost-effectiveness of surgical interventions. Operating theatre numbers have been used as a measure of surgical capacity, despite there being limitations associated with this use of this metric. This study aims to analyse part of the surgical resources in South Africa. A descriptive analysis of surgical infrastructure in all nine provinces was performed. The total number of functional operating theatres was documented for all public and private hospitals in South Africa. Hospitals were contacted during the period from 1 October 2014 until 31 December 2014. The results showed 3.59 operating theatres per 100 000 population. This fell below the global average of 6.2 operating theatres per 100 000 as well as other developed countries. Theatres were concentrated in metropolitan areas, and there were a greater number of private operating theatres per insured population than in the uninsured public sector. Strengthening surgical systems will reduce the surgical burden of disease and improve health outcomes globally. Little is known about the available surgical resources such as operating theatre density, although using this metric to evaluate surgical capacity has its limitations.

Understanding the psychology of psychological help-seeking patterns in community and barriers to it: A brief discussion

Although help seeking is prominent at the time of distress due to medical or surgical illnesses, it is not the same when it comes for psychological causes. The psychology of such behavior or available service use is often complex and depends on variable factors. Proper pathway of care right from the community to tertiary care settings is necessary including understanding the various psychosocial barriers which may cause hindrance at any step of care.

EP25.07: Rare adenomatoid tumour of the uterus

A 33-year-old, white previously healthy woman (gravida 0, para 0) was referred to our hospital with a gross abdominal tumour, which was diagnosed during routine screening ultrasound. Patient had the sensation of fullness of abdomen, leading to decreased appetite. There was no history of abnormal uterine bleedings. There was no family history of malignancies. The patient had no history of the previous medical or surgical illnesses. Physically, the tumour was firm and bump up to a height of two fingers below the navel. A blood test revealed low hemoglobin level (9,9 g/dl), ca-125 level was 98,9U/ml, ca 19,9 6,8U/ml. A transvaginal ultrasonography demonstrated irregular multilocular-solid lesion measuring 12x10x9cm localised in close connection with posterior uterine wall and the left ovary. Solid component was irregular, did not present any acoustic shadowing and measured 6,3x6,2x6,7cm. Figure 1: Colour Doppler mapping showed intense vascular signals IOTA 4 (M4) within the solid component. In total according to IOTA simple rules, the lesion showed 2 malignant features and no benign features and was classified as suspected of malignancy. Using IOTA ADNEX validation the risk of malignancy was 77%. Without Ca-125 level the risk was 75.3%. Figure 2: Ovarian echostructure appeared normal, but it was not clear if the left ovary or the uterus constituted the origin of the lesion. The patient gave only the consent to remove the lesion. Excision of the tumour was performed during suprapubic laparotomy. The tumour was entirely removed according to the rules of oncologic sterility. The histopathology assessment revealed several multilocular cysts and adenomatoid tumour. They were lined with a single layer of cuboidal or flattened cells without atypia. Actually Patient is asymptomatic and stays in follow-up at our Department.

Urinary Mitochondrial DNA Levels Identify Acute Kidney Injury in Surgical Critical Illness Patients.

Recent studies showed that mitochondrial injury and mitochondrial DNA (mtDNA) damage are associated with the initiation and progression of acute kidney injury (AKI). However, practical limitations of existing assays of mitochondrial function have limited our ability to study the link between mitochondrial dysfunction and renal injury. Therefore, we evaluated urinary mtDNA (UmtDNA) as a biomarker of AKI in critical illness patients. DNA was isolated from urine samples in surgical intensive care unit (SICU) patients and quantified by quantitative polymerase chain reaction (PCR). Correlation analyses showed the relationships between the UmtDNA and several biomarkers of renal dysfunction. Moreover, we evaluated the predictive and diagnostic values of UmtDNA in newly developed AKI, renal replacement therapy (RRT), and hospital mortality using receiver operating characteristics curves. MtDNA were expressed as PCR threshold cycle (Tc) number. Lower Tc indicated increased urinary mtDNA concentration. The baseline UmtDNA levels were elevated in SICU patients especially in AKI patients, compared with that in healthy controls. UmtDNA Tc number inversely correlated with serum creatine and urinary neutrophil gelatinase-associated lipocalin and directly with estimated glomerular filtration rate. Furthermore, baseline UmtDNA levels had high effectiveness in predicting development of AKI, initiation of RRT, and hospital mortality. Elevated UmtDNA levels could identify newly developed AKI and predict RRT or hospital mortality in SICU patients. UmtDNA Tc number correlated with markers of renal injury and dysfunction, suggesting the involvement of mitochondrial injury in kidney damage among surgical critical illness patients.

Spontaneous pneumomediastinum, Hamman's syndrome, with diabetic ketoacidosis

A 34-year-old, fit Caucasian woman with no previous medical or surgical illness, presented to A&E with sudden onset of several episodes of projectile vomiting unrelieved by simple measures and associated with chest discomfort, breathlessness and headache. Initial evaluations showed high blood glucose 26 mmol/L, blood pressure 110/65 mmHg, pulse 112/min regular, respiratory rate 26/min, SPO2 100% on room air and temperature 37 °C; she was found to have blood ketones of 4.2 mmol/L, metabolic acidosis with pH 7.29, HCO3 11, CO2 4.3, O2 11.3, base excess −12, and lactate 1.2. She was diagnosed with diabetic ketoacidosis (DKA) and was managed as per local standard DKA protocol. Pneumomediastinum (Figure 1) was detected on a chest X-ray which was performed routinely as she complained of chest discomfort. ECG showed sinus tachycardia with no ST-T changes. After discussion with chest physicians and radiologists, CT imaging of the chest was done which confirmed pneumomedia­stinum. Further oesophageal swallow with water-soluble contrast CT was done with the advice of cardiothoracic surgeons and this ruled out oesophageal rupture (Boerhaave's syndrome). Gastro­enterologists were consulted to rule out oesophageal injury/Mallory-Weiss tear, due to her acute presentation of projectile vomiting. She had oesophagogastroduodenoscopy (OGD) and was completely normal. Her chest symptoms resolved with DKA treatment and did not require any further intervention. Pneumomediastinum (air in the mediastinum) was first described by Laennec in thoracic trauma patients in 1819.1 Hamman described spontaneous pneumomediastinum as a different entity in 1939.2 Subsequently, this entity was coined ‘Hamman's syndrome’. Pneumomediastinum may result from many factors such as direct chest trauma, oesophageal rupture or barotrauma. Spontaneous or primary pneumomediastinum occurs due to rupture of alveoli when there is an increase in the intrapleural volume with a dramatic increase in intrapleural pressure due to sneezing, coughing, vomiting and Valsalva manoeuvres.3 The incidence of this complication in diabetes is rarely reported. In DKA, hyperventilation due to acidosis and severe vomiting due to ketosis cause changes in the intra-alveolar pressure gradient in the lungs. The rise in the intra-alveolar pressure leads to rupture of alveoli and subsequently dissection of air escaping alongside the perivascular sheaths into the mediastinum.4 Air collection can develop at different anatomical sites depending on the site of alveolar rupture and present in different ways. Sub-pleural alveolar rupture causes pneumothorax and subcutaneous emphysema. Rupture seen adjacent to bronchovascular sheaths causes pneumomediastinum and/or pneumopericardium. Ruptured alveolar gas from posterior mediastinum can pass through the intervertebral foramina into the epidural space causing epidural pneumatosis.5 Chest pain/discomfort is the common presenting symptom in pneumomediastinum. Other symptoms include mild dyspnoea, odynophagia, palpitations, anxiety, subcutaneous emphysema etc depending on the site of air collection. Clinical signs depend on the site of air leak. In pneumomediastinum, a bubbling or crackling sound in the thorax heard on auscultation with cardiac systolic sounds is named ‘Hamman's sign’.6 Diagnostic investigation depends on the clinical presentation and differential diagnosis. Lateral view chest X-ray is the initial test but CT thorax is the gold standard as it can also rule out mediastinitis or oesophageal rupture.7 Oesophagogram can be used if Boerhaave's syndrome is suspected and the patient is alert. However, OGD or CT thorax can be considered if the patient is comatose. It is always necessary to avoid endoscopy until perforation is ruled out.8 Spontaneous pneumomediastinum in DKA is a benign condition and treatment directed towards pneumomediastinum per se is unnecessary unless the patient develops tension pneumothorax. However, correction of metabolic abnormality due to DKA is crucial and pneumomediastinum resolves on its own. Hamman's syndrome can also occur in pregnant diabetic patients presenting with DKA. Close observation is essential and appropriate surgical intervention may be needed depending on the presentation. If found during labour, it is crucial to avoid hypoxia and hence fetal monitoring is imperative. It is suggested that shortening the second stage of labour with instrumental delivery is essential to prevent increased mediastinal pressure. If caesarean section is essential, an epidural needs to be considered and general anaesthesia avoided.9 Awareness of this complication of DKA could have avoided unnecessary investigations in our patient who was very stable. She received treatment for DKA as per the DKA protocol and her chest symptoms resolved within 24–48 hours. She was discharged home with diabetes management. References are available at www.practicaldiabetes.com.

Validation of SICK score - A severity of illness scoring system at a tertiary care centre in Puducherry

Objectives: Validation of SICK score for its ability to predict out come. Validation based on predominant system involved. Methods: Prospective study done at tertiary care centre in puducherry. Inclusion criteria: All children admitted in PICU between 1 month & 12 year in 6 month period. Exclusion criteria: Patients with surgical illness, congenital anomalies, non availability of consent. Physical variables of Temperature, Heart Rate, Respiratory Rate, Blood pressure, Capiallary Refill time, Oxygen saturation & sensoriurn (using AVPU scale) were recorded at the time of admission. SICK score was calculated and outcome was recorded as survived or expired. Association of patients outcome with total score was done using logistic regression analysis. The receiver operating characteristic (ROC) curve analysis was performed to decide the optimum cut off point in terms of total score that provides maximum sensitivity & specificity. Area under ROC curve (AUC) was used to compare the predictive power of total score. All analysis was carried out using SPPS software version 13.0. Results: Total of 354 Children were analyzed. For SICK score of <1 mortality was 0%, which gradually increased to 100% with a score of 7 or more. The area under the ROC curve was 93% (95%: CI: 89.8% - 97.3%) indicating good predictive ability of the score. Conclusion: SICK score has good predictive ability and uses only physical criteria. Further SICK score is not influenced by predominant system involved.