Search results for: emergency general surgery

Authors: Nouini Adrâa

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Background: The management of dizziness and vertigo can be challenging in the emergency department (ED). It is important to rapidly diagnose vertebrobasilar stroke (VBS), as therapeutic options such as thrombolysis and anticoagulation require prompt decisions. Objective: This study aims to assess the rate of misdiagnosis in patients with dizziness caused by VBS in the ED. Methods and Results: The cohort was comprised of 82 patients with a mean age of 55 years; 51% were women and 49% were men. Among dizzy patients, 15% had VBS. We used Cohen’s kappa test to quantify the agreement between two raters – namely, emergency physicians and neurologists – regarding the causes of dizziness in the ED. The agreement between emergency physicians and neurologists is low for the final diagnosis of central vertigo disorders and moderate for the final diagnosis of VBS. The sensitivity of ED clinal examination for benign conditions such as BPPV was low at 56%. The positive predictive value of the ED clinical examination for VBS was also low at 50%. Conclusion: There is a substantial rate of misdiagnosis in patients with dizziness caused by VBS in the ED. To reduce the number of missing diagnoses of VBS in the future, there is a need to train emergency physicians in neuro vestibular examinations, including the HINTS examination for acute vestibular syndrome (AVS) and the Dix-Hallpike (DH) maneuver for episodic vestibular syndrome. Using video head impulse tests could help reduce the rate of misdiagnosis of VBS in the ED.

Keywords: dizziness, vertigo, vestibular disease, emergency

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Authors: Samar Mousa, Rebecca Shirley

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Injuries to the hand account for 20% of all emergency department attendances, with an estimated annual treatment cost of over £100 million in the UK. Functional impairments as a result of hand injuries often necessitate absence from employment, resulting in reduced productivity estimated to incur an additional £600m loss to the UK economy. Appropriate and early management is vital to preserve anatomy, prevent stiffness and allow function. The initial assessment and management of hand injuries are usually undertaken by junior staff, many of whom have little or no training or experience in splinting hand fractures. In our plastic surgery department at Stoke Mandeville hospital Buckinghamshire trust, we carried out an audit project to detect errors in hand splinting in the period between April 2022 and July 2022 and find out measures to support junior doctors, nurses and hand therapists in providing the best possible care for hand trauma patients. Our standards were The British Society for Surgery of the Hand (BSSH) standard of care in hand trauma, AO surgery reference and Stoke Mandeville hospital hand therapy mini protocol Feb 2022 During the period of 4 months, 5 cases were identified. Two cases of wrong splint choice, two cases of early removal of the splint and one tight splint that required change. In order to avoid those mistakes, a training program was given to junior doctors and nurses in collaboration with the hand therapy team regarding ways of splinting the hand in different injuries like fractures, tendons injuries, muscle injuries and ligamentous injuries. In addition to, a poster hung in the examination rooms and theatres to help junior doctors reach the correct decision.

Keywords: splinting, hand trauma, plastic surgery, tendon injury, hand fracrture

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Authors: Shang Yee Chong

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Perioperative pain is a complex mechanism activated by various nociceptive, neuropathic, and inflammatory pathways. Opioids have long been a mainstay for analgesia in this period, even as we are continuously moving towards a multimodal model to improve pain control while minimising side effects. Dexmedetomidine, a potent alpha-2 agonist, is a useful sedative and hypnotic agent. Its use in the intensive care unit has been well described, and it is increasingly an adjunct intraoperatively for its opioid sparing effects and to decrease pain scores. We describe a case of a general surgical patient in whom minimal opioids was required with dexmedetomidine use. The patient was a 61-year-old Indian gentleman with a history of hyperlipidaemia and type 2 diabetes mellitus, presenting with rectal adenocarcinoma detected on colonoscopy. He was scheduled for a robotic ultra-low anterior resection. The patient was induced with intravenous fentanyl 75mcg, propofol 160mg and atracurium 40mg. He was intubated conventionally and mechanically ventilated. Anaesthesia was maintained with inhalational desflurane and anaesthetic depth was measured with the Masimo EEG Sedline brain function monitor. An initial intravenous dexmedetomidine dose (bolus) of 1ug/kg for 10 minutes was given prior to anaesthetic induction and thereafter, an infusion of 0.2-0.4ug/kg/hr to the end of surgery. In addition, a bolus dose of intravenous lignocaine 1.5mg/kg followed by an infusion at 1mg/kg/hr throughout the surgery was administered. A total of 10mmol of magnesium sulphate and intravenous paracetamol 1000mg were also given for analgesia. There were no significant episodes of bradycardia or hypotension. A total of intravenous phenylephrine 650mcg was given throughout to maintain the patient’s mean arterial pressure within 10-15mmHg of baseline. The surgical time lasted for 5 hours and 40minutes. Postoperatively the patient was reversed and extubated successfully. He was alert and comfortable and pain scores were minimal in the immediate post op period in the postoperative recovery unit. Time to first analgesia was 4 hours postoperatively – with paracetamol 1g administered. This was given at 6 hourly intervals strictly for 5 days post surgery, along with celecoxib 200mg BD as prescribed by the surgeon regardless of pain scores. Oral oxycodone was prescribed as a rescue analgesic for pain scores > 3/10, but the patient did not require any dose. Neither was there nausea or vomiting. The patient was discharged on postoperative day 5. This case has reinforced the use of dexmedetomidine as an adjunct in general surgery cases, highlighting its excellent opioid-sparing effects. In the entire patient’s hospital stay, the only dose of opioid he received was 75mcg of fentanyl at the time of anaesthetic induction. The patient suffered no opioid adverse effects such as nausea, vomiting or postoperative ileus, and pain scores varied from 0-2/10. However, intravenous lignocaine infusion was also used in this instance, which would have helped improve pain scores. Paracetamol, lignocaine, and dexmedetomidine is thus an effective, opioid-sparing combination of multi-modal analgesia for major abdominal surgery cases.

Keywords: analgesia, dexmedetomidine, general surgery, opioid sparing

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Authors: Luay Alsalmi

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Background: Facial filler is the most common type of cosmetic surgery next to botox. Permanent filler is preferred nowadays due to the low cost brought about by non-recurring injection appointments. However, such fillers pose a higher risk for complications, with even greater adverse effects when the procedure is done using unknown dermal filler injections. AIM: This study aimed to establish an algorithm to categorize and manage patients that receive permanent fillers. Materials and Methods: Twelve participants were presented to the service through emergency or as outpatient from November 2015 to May 2021. Demographics such as age, sex, date of injection, time of onset, and types of complications were collected. After examination, all cases were managed based on an algorithm established. FACE-Q was used to measure overall satisfaction and psychological well-being. Results: The algorithm to diagnose and manage these patients effectively with a high satisfaction rate was established in this study. All participants were non-smoker females with no known medical comorbidities. The algorithm presented determined the treatment plan when faced with complications. Results revealed high appearance-related psychosocial distress was observed prior to surgery, while it significantly dropped after surgery. FACE-Q was able to establish evidence of satisfactory ratings among patients prior to and after surgery. Conclusion: This treatment algorithm can guide the surgeon in formulating a suitable plan with fewer complications and a high satisfaction rate.

Keywords: facial filler, FACE-Q, psycho-social stress, botox, treatment algorithm

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Authors: Bashayer AlRobayaan, Munira Saad, Alaa AlBawab, Fatma AlHamad, Sara AlAwadhi, Sherif Fahmy

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This paper addresses the problem of long waiting times in government hospitals emergency departments (ED). It aims at finding feasible and simple ways of reducing waiting times that do not require a lot of resources and/or expenses. AlAdan Hospital in Kuwait was chosen to be understudy to further understand and capture the problem.

Keywords: healthcare, hospital, Kuwait, waiting times, emergency department

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Authors: Estelle Démoulin, Dionysios Adamopoulos, Tornike Sologashvili, Mathieu Van Steenberghe, Jalal Jolou, Haran Burri, Christoph Huber, Mustafa Cikirikcioglu

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Background & objective: Mitral valve surgeries are mainly performed by median sternotomy with conventional direct atriotomy. Good exposure to the mitral valve is challenging, especially for acute pathologies, where left atrium dilation does not occur. Other atriotomies, such as transseptal or superior septal, are used as they allow better access and visualization. Peri- and postoperative outcomes of these three different left atriotomies were compared. Methods: Patients undergoing mitral valve surgery between January 2010 and December 2020 were included and divided into three groups: group 1 (conventional direct, n=115), group 2 (transseptal, n=33) and group 3 (superior septal, n=59). To improve the sampling size, all patients underwent mitral valve surgery with or without associated procedures (CABG, aortic-tricuspid surgery, Maze procedure). The study protocol was approved by SwissEthics. Results: No difference was shown for the etiology of mitral valve disease, except endocarditis, which was more frequent in group 3 (p = 0.014). Elective surgeries and isolated mitral valve surgery were more frequent in group 1 (p = 0.008, p = 0.011) and aortic clamping and cardiopulmonary bypass were shorter (p = 0.002, p<0.001). Group 3 had more emergency procedures (p = 0.011) and longer lengths of intensive care unit and hospital stay (p = 0.000, p = 0.003). There was no difference in permanent pacemaker implantation, postoperative complications and mortality between the groups. Conclusion: Mitral valve surgeries can be safely performed using those three left atriotomies. Conventional direct may lead to shorter aortic clamping and cardiopulmonary bypass times. Superior septal is mostly used for acute pathologies, and it does not increase postoperative arrhythmias and permanent pacemaker implantation. However, intensive care unit and hospital lengths of stay were found to be longer in this group. In our opinion, this outcome is more related to the pathology and type of surgery than the incision itself.

Keywords: Mitral valve surgery, cardiac surgery, atriotomy, Operative outcomes

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Authors: Jenee Gooden, Kevin Vasquez-monterroso, Lady Paula Dejesus, Sandra Wainwright, Daniel Kim, Mackenzie Walker

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Introduction: Pyoderma gangrenosum (PG) is a rare, rapidly progressive, neutrophilic ulcerative colitis condition with an incidence of 3 to 10 cases per year ¹ ². Due to the similar appearance, PG is often misdiagnosed as a diabetic ulcer in diabetic patients. Though they may clinically appear similar in appearance, the treatment protocol and diagnostic criteria differ. Also, end-stage renal disease (ESRD) is often a condition seen in diabetic patients, which can have a significant impact on wound healing due to the wide range of uremic toxins³. This case study demonstrates a multidisciplinary team and multimodal treatment approach by podiatric surgery, general surgery, rheumatology, infectious disease, interventional cardiology, wound care and hyperbaric medicine for an uncontrolled diabetic with pyoderma gangrenosum of a significant circumferential wound, covering almost the entire right lower extremity. Methods:56 y.o male presents with multiple PG ulcerations, including the chest, right posterior lower extremity and sacrum. All ulcerations were previously managed by the same wound care specialist. His chief complaint was worsening PG ulcerations accompanied by a fever of 103 °F . This case study focuses on the wound to his RLE. Past medical history significant for diabetes mellitus type 2 with hemoglobin A1c of 10% and end stage renal disease (ESRD) on hemodialysis. A multidisciplinary team approach by podiatric surgery, general surgery, rheumatology, infectious disease, interventional cardiology, wound care and hyperbaric medicine was successfully used to perform right lower extremity limb salvage. The patient was managed by rheumatology for the continuation of prior medication, as well as the mutual agreement with wound care for the addition of dapsone. A coronary CT angiogram was performed by interventional cardiology, but no significant disease was noted, and no further vascular workup was necessary. Multiple surgical sharp wide excisional debridements with application of allografts and split thickness skin grafts for the circumferential ulceration that encompassed almost the entire right lower extremity were performed by both podiatric surgery and general surgery. Wound cultures and soft tissue biopsies were performed, and infectious disease managed antibiotic therapy. Hyperbaric oxygen therapy and wound vac therapy by wound care were also completed as adjunct management. Results: Prevention of leg amputation by limb salvage of the RLE was accomplished by a multidisciplinary team approach, with the wound size decreasing over a total of 29 weeks from 600 cm² to 12.0 x 3.5 x 0.2 cm. Our multidisciplinary team included podiatric surgery, general surgery, rheumatology, infectious disease, interventional cardiology, wound care and hyperbaric medicine. Discussion: Wound healing, in general, can have its challenges, and those challenges are only magnified when accompanied by multiple systemic illnesses. Though the negative impact of diabetes on wound healing is well known, the compound impact of being a diabetic with ESRD and having pyoderma gangrenosum is not. This case demonstrates the necessity for a multidisciplinary team approach with a wide array of treatment modalities to optimize wound healing and perform limb salvage with prevention of lower extremity amputation.

Keywords: diabetes, podiatry, pyoderma gangrenosum, end stage renal disease

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Authors: Majda Al Salti

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Tourism industry is considered globally as one of the leading industries due to its noticeable contribution to countries' gross domestic product (GDP) and job creation. However, tourism is vulnerable to crisis and disaster that requires its preparedness. With its limited capabilities, there is a need to improve links and the understanding between the tourism industry and the emergency services, thus facilitating future emergency response to any potential incident. This study aims to develop the concept of an integrated emergency management system for the tourism industry. The study used face-to-face semi-structured interviews to evaluate the level of crisis and disaster preparedness of the tourism industry in Oman. The findings suggested that there is a lack of understanding of crisis and disaster management, and hence preparedness level among Oman Tourism Authorities appears to be under-expectation. Therefore, a clear need for tourism sector inter- and intra-integration and collaboration is important in the pre-disaster stage. The need for such integrations can help the tourism industry in Oman to prepare for future incidents as well as identifying its requirements in time of crisis for effective response.

Keywords: tourism, emergency services, crisis, disaster

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Authors: Karim Hajjar, Luis Lillo, Diego Martinez, Manuel Hermosilla, Nicholas Risko

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Objectives: This study examines the relationship between universal health coverage (UCH) and the burden of emergency diseases at a global level. Methods: Data on Disability-Adjusted Life Years (DALYs) from emergency conditions were extracted from the Institute for Health Metrics and Evaluation (IHME) database for the years 2015 and 2019. Data on UHC, measured using two variables, 1) coverage of essential health services and 2) proportion of population spending more than 10% of household income on out-of-pocket health care expenditure, was extracted from the World Bank Database for years preceding our outcome of interest. Linear regression was performed, analyzing the effect of the UHC variables on the DALYs of emergency diseases, controlling for other variables. Results: A total of 133 countries were included. 44.4% of the analyzed countries had coverage of essential health services index of at least 70/100, and 35.3% had at least 10% of their population spend greater than 10% of their household income on healthcare. For every point increase in the coverage of essential health services index, there was a 13-point reduction in DALYs of emergency medical diseases (95% CI -16, -11). Conversely, for every percent decrease in the population with large household expenditure on healthcare, there was a 0.48 increase in DALYs of emergency medical diseases (95% CI -5.6, 4.7). Conclusions: After adjusting for multiple variables, an increase in coverage of essential health services was significantly associated with improvement in DALYs for emergency conditions. There was, however, no association between catastrophic health expenditure and DALYs.

Keywords: emergency medicine, universal healthcare, global health, health economics

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Authors: Minna Salim, James Brady

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Postoperative nausea and pain (PONV) are adverse effects following surgical procedures. It is especially pronounced in patients undergoing orthognathic surgery, as their mouth is closed postoperatively using wires or rubber bands. Postoperative mouth closure increases the discomfort and risk of complications associated with nausea and vomiting. Many surgeons and institutions apply gastric decompression in hopes of aspirating stomach contents and, therefore, decreasing PONV incidence. This review observed that PONV incidence was not affected by gastric decompression overall. However, the effect of gastric decompression on PONV in orthognathic surgery was variable. This paper aims to summarize the findings of gastric decompression on PONV and to determine the need for it in orthognathic surgery.

Keywords: gastric decompression, nasogastric tube, orthognathic surgery, postoperative nausea, vomiting

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Authors: Recep Sait Arpat, Hakan Güreşci

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Emergency, disaster and crisis management terms are generally perceived as the same processes. This conflict effects the approach and delegating policy of the political order. Crisis management starts in the aftermath of the mismanagement of disaster and emergency. In the light of the information stated above in this article Turkey and United Kingdom(UK)’s crisis management systems are analyzed. This article’s main aim is to clarify the main points of the emergency management system of United Kingdom and Turkey’s disaster management system by comparing them. To do this: A prototype model of the political decision making processes of the countries is drawn, decision making mechanisms and the planning functions are compared. As a result it’s found that emergency management policy in Turkey is reactive whereas it’s proactive in UK; as the delegating policy Turkey’s system is similar to UK; levels of emergency situations are similar but not the same; the differences are stemming from the civil order and nongovernmental organizations effectiveness; UK has a detailed government engagement model to emergencies, which shapes the doctrine of the approach to emergencies, and it’s successful in gathering and controlling the whole state’s efforts; crisis management is a sub-phase of UK emergency management whereas it’s accepted as a outmoded management perception and the focal point of crisis management perception in UK is security crisis and natural disasters while in Turkey it is natural disasters. In every anlysis proposals are given to Turkey.

Keywords: crisis management, disaster management, emergency management, turkey, united kingdom

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Authors: Langhit Kurar, Loren Charles

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Introduction: In light of recent BOAST 12 (August 2016) published guidance on management of ankle fractures, the project aimed to highlight key discrepancies throughout the care trajectory from admission to point of discharge at a district general hospital. Wide breadth of data covering three key domains: accident and emergency, radiology, and orthopaedic surgery were subsequently stratified and recommendations on note documentation, and outpatient follow up were made. Methods: A retrospective twelve month audit was conducted reviewing results of ankle fracture management in 37 patients. Inclusion criterion involved all patients seen at Darent Valley Hospital (DVH) emergency department with radiographic evidence of an ankle fracture. Exclusion criterion involved all patients managed solely by nursing staff or having sustained purely ligamentous injury. Medical notes, including discharge summaries and the PACS online radiographic tool were used for data extraction. Results: Cross-examination of the A & E domain revealed limited awareness of the BOAST 12 recent publication including requirements to document skin integrity and neurovascular assessment. This had direct implications as this would have changed the surgical plan for acutely compromised patients. The majority of results obtained from the radiographic domain were satisfactory with appropriate X-rays taken in over 95% of cases. However, due to time pressures within A & E, patients were often left without a post manipulation XRAY in a backslab. Poorly reduced fractures were subsequently left for a long period resulting in swollen ankles and a time-dependent lag to surgical intervention. This had knocked on implications for prolonged inpatient stay resulting in hospital-acquired co-morbidity including pressure sores. Discussion: The audit has highlighted several areas of improvement throughout the disease trajectory from review in the emergency department to follow up as an outpatient. This has prompted the creation of an algorithm to ensure patients with significant fractures presenting to the emergency department are seen promptly and treatment expedited as per recent guidance. This includes timing for X-rays taken in A & E. Re-audit has shown significant improvement in both documentation at time of presentation and appropriate follow-up strategies. Within the orthopedic domain, we are in the process of creating an ankle fracture pathway to ensure imaging and weight bearing status are made clear to the consulting clinicians in an outpatient setting. Significance/Clinical Relevance: As a result of the ankle fracture algorithm we have adapted the BOAST 12 guidance to shape an intrinsic pathway to not only improve patient management within the emergency department but also create a standardised format for follow up.

Keywords: ankle, fracture, BOAST, radiology

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Authors: Wheyming Tina Song, Chi-Hao Hong

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In this study, we investigate the effect of a new boarding policy - short stay, on the overcrowding efficiency in emergency department (ED). The decision variables are no. of short stay beds for least acuity ED patients. The performance measurements used are national emergency department overcrowding score (NEDOCS) and ED retention rate (the percentage that patients stay in ED over than 48 hours in one month). Discrete event simulation (DES) is used as an analysis tool to evaluate the strategy. Also, common random number (CRN) technique is applied to enhance the simulation precision. The DES model was based on a census of 6 months' patients who were treated in the ED of the National Taiwan University Hospital Yunlin Branch. Our results show that the new short-stay boarding significantly impacts both the NEDOCS and ED retention rate when the no. of short stay beds is more than three.

Keywords: emergency department (ED), common random number (CRN), national emergency department overcrowding score (NEDOCS), discrete event simulation (DES)

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Authors: Ryan Goh, Nicholas Beech

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Introduction: Le Fort I Osteotomies, although are common procedures in Oral and Maxillofacial Surgery, carry a degree of risk of unfavourable propagation of the down-fracture of the maxilla. This may be the first reported case in the literature for meningoencephalitis to occur following a Le Fort I Osteotomy. Case: A 32-year-old female was brought into the Emergency Department four days after a Le Fort I Osteotomy, with a Glasgow Coma Scale (GCS) of 8 (E3V1M4). A Computed Tomography (CT) Head showed a skull base fracture at the right sphenoid sinus. Lumbar puncture was completed, and Klebsiella oxytoca was found in the Cerebrospinal Fluid (CSF). She was treated with Meropenem, and rapidly improved thereafter. CSF rhinorrhoea was identified when she was extubated, which was successfully managed via a continuous lumbar drain. She was discharged on day 14 without any neurological deficits. Conclusion: The most likely aspect of the Le Fort I Osteotomy to obtain a skull base fracture is during the pterygomaxillary disjunction. Care should always be taken to avoid significant risks of skull base fractures, CSF rhinorrhoea, meningitis and encephalitis.

Keywords: meningitis, orthognathic surgery, post-operative complication, skull base, rhinorrhea

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Authors: Ayu Nabila Kusuma Pradana, Aprinaldi Jasa Mantau, Tomohiko Akahoshi

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The incidence of Disseminated intravascular coagulation (DIC) following gastrointestinal surgery has a poor prognosis. Therefore, it is important to determine the factors that can predict the prognosis of DIC. This study will investigate the factors that may influence the outcome of DIC in patients after gastrointestinal surgery. Eighty-one patients were admitted to the intensive care unit after gastrointestinal surgery in Kyushu University Hospital from 2003 to 2021. Acute DIC scores were estimated using the new Japanese Association for Acute Medicine (JAAM) score from before and after surgery from day 1, day 3, and day 7. Acute DIC scores will be compared with The Sequential Organ Failure Assessment (SOFA) score, platelet count, lactate level, and a variety of biochemical parameters. This study applied machine learning algorithms to predict the prognosis of DIC after gastrointestinal surgery. The results of this study are expected to be used as an indicator for evaluating patient prognosis so that it can increase life expectancy and reduce mortality from cases of DIC patients after gastrointestinal surgery.

Keywords: the survival rate, gastrointestinal surgery, JAAM score, neural network, machine learning, disseminated intravascular coagulation (DIC)

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Authors: R. Litt, A. Kana, K. House

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The primary aim of this patient-related experience questionnaire was to gain a better understanding of our patients' experience as inpatients when they undergo orthognathic surgery. The secondary aim of this study was to identify ways in which we can improve the orthognathic inpatient experience and to share this with other units. All patients who received orthognathic surgery at an NHS hospital - Bristol Royal Infirmary, England, over the course of 6 months were asked to complete a questionnaire regarding their care. This data was then analysed and compared to the same questionnaire given to patients treated in a private hospital where orthognathic surgery was completed. All treatment was completed by the same surgeon. The design of the questions took into account NICE (National Institute for Health and Care Excellence) guidance on improving the experience of patient care. Particularly taking into account patients' essential requirements of care, for example, assessing and managing pain, ensuring adequate and appropriate nutrition, and ensuring the patients' personal needs are regularly reviewed and addressed. Overall the patient-related experience after orthognathic surgery was comparable in both the NHS and private hospitals. However, the questionnaire highlighted aspects of inpatient care after orthognathic surgery that can easily be improved in order to provide our patients with the best possible care.

Keywords: orthognathic surgery, patient feedback, jaw surgery, inpatient experience

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Authors: Titap Yazicioglu

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Purpose: To determine the etiological factors responsible for the eye removal surgery and to evaluate our surgical results. Material and Methods: Medical records of 226 patients, who underwent eye removal surgery, were analyzed retrospectively. Demographic information, clinical history, surgical procedure, and histopathological data were all collected. Evisceration surgery was performed under general anesthesia in all patients except tumor cases and one patient with rhino-orbital mucormycosis. The patients were followed for an average of 16.46±10.78 months and checked for the possible complications, cosmesis, and functional results.Results: 144 men, and 82 women,with a mean age of 41.78±22.6 years, were underwent enucleation (n=15) or evisceration (n=211) due to traumatic (n=169) and non-traumatic (n=57) causes. In the traumatic group, 79.8% of 169 patients were injured by penetrating and 14.2% by blunt trauma.3.6% of the patients were injured in a traffic accident, and 2.4% of them were injured by explosives. In the non-traumatic group, 40% of 25 patients had post-traumatic endophthalmitis, 32% had endophthalmitis due to corneal ulceration and melting, and 24% had endophthalmitis after cataract surgery. One patient had panophthalmitis due to rhino-orbital mucormycosis. Another cause in the non-traumatic group was glaucoma, of which 92.3% had neovascular glaucoma, and 8.7% had congenital glaucoma. Of the 14 patients who were enucleated for tumor, 35.7% had retinoblastoma, 14.3% had medulloepithelioma, 42.9% had uveal melanoma, and 7.1% had metastatic tumor from paranasal sinuses.The most common complaint in the follow-up period was discharging, seen in all prosthesis-wearing patients. 13.3% of the patients had itching due to ocular prosthesis. 4.4% of the patients were complaining about deep superior sulcus. 4.4% had pyogenic granuloma, and 17.8% had implant exposure. Conclusion: Etiological factors should be carefully evaluated, and precautions should be taken in order to reduce the devastating effect of the physical loss of the eye.

Keywords: enucleation, evisceration, ocular injury, etiology, frequency

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Authors: Jaleh Shoshtarian Malak, Niloofar Mohamadzadeh

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Managing pre-hospital emergency patients requires real-time practices and efficient resource utilization. Since we are facing a distributed Network of healthcare providers, services and applications choosing the right resources and treatment protocol considering patient situation is a critical task. Delivering care to emergency patients at right time and with the suitable treatment settings can save ones live and prevent further complication. In recent years Multi Agent Systems (MAS) introduced great solutions to deal with real-time, distributed and complicated problems. In this paper we propose a multi agent based pre-hospital emergency management architecture in order to manage coordination, collaboration, treatment protocol and healthcare provider selection between different parties in pre-hospital emergency in a self-organizing manner. We used AnyLogic Agent Based Modeling (ABM) tool in order to simulate our proposed architecture. We have analyzed and described the functionality of EMS center, Ambulance, Consultation Center, EHR Repository and Quality of Care Monitoring as main collaborating agents. Future work includes implementation of the proposed architecture and evaluation of its impact on patient quality of care improvement.

Keywords: multi agent systems, pre-hospital emergency, simulation, software architecture

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Authors: Sangram A. Sathe, Neha A. Madgulkar, Shruti S. Raut, S. P. Wadkar

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Transforaminal lumbar interbody fusion (TLIF) surgeries have nowadays became popular for treatment of degenerated spinal disorders. The interbody fusion technique like TLIF maintains load bearing capacity of the spine and a suitable disc height. Currently many techniques have been introduced to cure Spondylolisthesis. This surgery provides greater rehabilitation of degenerative spines. While performing this TLIF surgery existing methods use guideway, which is a troublesome surgery technique as the use of two separate instruments is required to perform this surgery. This paper presents a concept which eliminates the use of guideway. This concept also eliminates problems that occur like reverting the cage. The concept discussed in this paper also gives high accuracy while performing surgery.

Keywords: TLIF, spondylolisthesis, spine, instruments

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Authors: Rosemarie Basile, Maria Loizos, John Pallarino, Karen Gibbs

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Given that complications can be significant following bariatric surgery and with rates of long-term success measured in excess weight loss varying as low as 33% after five years, an understanding of the psychological factors that may mitigate findings and increase success and result in better screening and supports prior to surgery are critical. An internally oriented locus of control (LOC) has been identified as a predictor for success in obesity therapy, but has not been investigated within the context of bariatric surgery. It is hypothesized that making behavioral changes prior to surgery which mirror those that are required post-surgery may ultimately predict long-term success. 122 subjects participated in a clinical interview and completed self-report measures including the Multidimensional Health Locus of Control Scale, Overeating Questionnaire (OQ), and Lifestyle Questionnaire (LQ). Pearson correlations were computed between locus of control orientation and likelihood to make behavior changes prior to surgery. Pearson correlations revealed a positive correlation between locus of control and likelihood to make behavior changes r = 0.23, p < .05. As hypothesized, there was a significant correlation between internal locus of control and likelihood to make behavior changes. Participants with a higher LOC believe that they are able to make decisions about their own health. Future research will focus on whether this positive correlation is a predictor for future bariatric surgery success.

Keywords: bariatric surgery, behavior modification, health locus of control, overeating questionnaire

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Authors: Misbah Nizamani, Saira Malik

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Introduction: Bariatric surgery is the most effective treatment for patients suffering from morbid obesity. Laparoscopic sleeve gastrectomy (LSG) accounts for over 50% of total bariatric procedures. The aim of our meta-analysis is to investigate the effectiveness and safety of Enhanced Recovery After Surgery (ERAS) protocols for patients undergoing laparoscopic sleeve gastrectomy. Method: To gather data, we searched PubMed, Google Scholar, ScienceDirect, and Cochrane Central. Eligible studies were randomized controlled trials and cohort studies involving adult patients (≥18 years) undergoing bariatric surgeries, i.e., Laparoscopic sleeve gastrectomy. Outcome measures included LOS, postoperative narcotic usage, postoperative pain score, postoperative nausea and vomiting, postoperative complications and mortality, emergency department visits and readmission rates. RevMan version 5.4 was used to analyze outcomes. Results: Three RCTs and three cohorts with 1522 patients were included in this study. ERAS group and control group were compared for eight outcomes. LOS was reduced significantly in the intervention group (p=0.00001), readmission rates had borderline differences (p=0.35) and higher postoperative complications in the control group, but the result was non-significant (p=0.68), whereas postoperative pain score was significantly reduced (p=0.005). Total MME requirements became significant after performing sensitivity analysis (p= 0.0004). Postoperative mortality could not be analyzed on account of invalid data showing 0% mortality in two cohort studies. Conclusion: This systemic review indicated the effectiveness of the application of ERAS protocols in LSG in reducing the length of stay, post-operative pain and total MME requirements postoperatively, indicating the feasibility and assurance of its application.

Keywords: eras protocol, sleeve gastrectomy, bariatric surgery, enhanced recovery after surgery

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Authors: Euan Donley

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Emergency Departments (EDs) are heavily burdened as presentation rates continue to rise. To improve patient flow National Emergency Access Targets (NEAT) were introduced. NEAT implements timelines for ED presentations, such as discharging patients within four hours of arrival. Mental health patients use EDs more than the general population and are generally more complex in their presentations. The aim of this study is to examine the impact of NEAT on psychiatric risk assessment of mental health patients in the ED. Seventy-eight mental health clinicians from 7 Victoria, Australia, hospital EDs participated in a mixed method analysis via anonymous online survey. NEAT was considered helpful as mental health patients were seen quicker, were less likely to abscond, could improve teamwork amongst ED staff, and in some cases administrative processes were better streamlined. However, clinicians felt that NEAT was also responsible for less time with patients and relatives’, resulted in rushed assessments, placed undue pressure on mental health clinicians, was not conducive to training, and the emphasis on time was the wrong focus for patient treatment. The profile of a patient typically likely to be treated within NEAT timelines showed a perfect storm of luck and compliance. If a patient was sober, medically stable, referred early, did not require much collateral information and did not have distressed relatives, NEAT was more likely to be met. Organisationally participants reported no organisational change or training to meet NEAT. Poor mental health staffing, multiple ED presentations and a shortage of mental health beds also hamper meeting NEAT. Findings suggest participants were supportive of NEAT in principle, but a demanding workload and organisational barriers meant NEAT had an overall negative effect on psychiatric risk assessment of mental health patients in ED.

Keywords: assessment, emergency, risk, psychiatric

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Authors: Boshra Mozaffar, Iskandar Idris

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Taste change is a common complication after Bariatric surgery (BS). However, the cause of this is still not clear. Since zinc is important fortaste perception, zinc deficiency, which is common after BS, may play an important role for taste change after BS. In this review, we aimto collate evidence relating to taste change and zinc deficiencyin relation to BS; effects of zinc replacement on taste perception in general and thereafter discuss the possible role of zinc deficiency to induce taste change after BS. A literature search was conducted, using four electronic bibliographical databases—EMBASE, PubMed, AMED and MEDLINE. We identified all available and relevant articles published before 30th February 2021.In total, 33 studies were included. The total number of participants analysed was N= 3264. We showed that taste change is a frequent complication after BS, especially after Roux-en-Y gastric bypass RYGBP comparing to other types of procedures. Patients' taste sensitivity differs among studies, but the most important decline in taste preference was observed for sweet food. Twelve studies investigating zinc deficiency following BS showed a significant decrease in zinc levels at six months after surgery. Supplementation with 45–50 mg of zinc sulphate was effective in improving taste, except in cancer patients, who showed no improvement in taste following zinc supplementation. Zinc deficiency appears to be associated with taste change after BS. Supplementation with much higher levels of zinc, at 45–50 mg, was effective in taste change treatment for many cases of taste disorder. The currently recommended levels of zinc replacements currently prescribed to patients following BS were not effective for avoiding zinc deficiency after BS—and thus not effective for averting taste change. It is therefore suggested that taste change following BS is closely related to zinc deficiency induced by the surgery.

Keywords: taste change, taste disorder, bariatric surgery, zinc, zinc sulphate or Zn, deficiency, supplementation, and micro-nutrient deficiencies

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Authors: Fedili Benamar, Beloulou Mohamed Lamine, Ouahes Hassane, Ghattas Samir

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Background and aims: While in Western countries, unilateral spinal anesthesia has been widely practiced for a long time, it remains little known in the local anesthesia community, and has not been the object of many studies. However, it is a simple, practical and effective technique. Our objective was to evaluate this practice in emergency anesthesia management in frail patients and to compare it with conventional spinal anesthesia. Methods: This is a prospective, observational, comparative study between hypobaric unilateral and conventional spinal anaesthesia for hip fracture surgery carried out in the operating room of the university military hospital of Staoueli. The work was spread over of 12-month period from 2019 to 2020. The parameters analyzed were hemodynamic variations, vasopressor use, block efficiency, postoperative adverse events, and postoperative morphine consumption. Results: -75 cases (mean age 72±14 years) -Group1= 41 patients (54.6%) divided into (ASA1=14.6% ASA2=60.98% ASA3=24.39%) single shoot spinal anaesthesia -Group2= 34 patients (45.3%) divided into (ASA1=2.9%, ASA2=26.4% ASA3=61.7%, ASA4=8.8%) unilateral hypobaric spinal anesthesia. -Hemodynamic variations were more severe in group 1 (51% hypotension) compared to 30% in group 2 RR=1.69 and odds ratio=2.4 -these variations were more marked in the ASA3 subgroup (group 1=70% hypotension versus group 2=30%) with an RR=2.33 and an odds ratio=5.44 -39% of group 1 required vasoactive drugs (15mg +/- 11) versus 32% of group 2 (8mg+/- 6.49) - no difference in the use of morphine in post-op. Conclusions: Within the limits of the population studied, this work demonstrates the clinical value of unilateral spinal anesthesia in ortho-trauma surgery in the frail patient.

Keywords: spinal anaesthesia, vasopressor, morphine, hypobaric unilateral spinal anesthesia, ropivacaine, hip surgery, eldery, hemodynamic

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Authors: Neda Valizadeh, Soudabeh Shafiee Ardestani, Arvin Najafi

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Objectives: The aim of this study is to evaluate the association of mid-regional pro-atrial natriuretic peptide (MRproANP), procalcitonin (PCT), proendothelin-1 (proET-1) levels with sepsis severity in Emergency ward patients. Materials and Methods: We assessed the predictive value of MRproANP, PCT, copeptin, and proET-1 in early sepsis among patients referring to the emergency ward with a suspected sepsis. Results-132 patients were enrolled in this study. 45 (34%) patients had a final diagnosis of sepsis. A higher percentage of patients with definite sepsis had systemic inflammatory response syndrome (SIRS) criteria at initial visit in comparison with no-sepsis patients (P<0.05) and were admitted to the hospital (P<0.05). PCT levels were higher in sepsis patients [P<0.05]. There was no significant differences for MRproANP or proET-1 in sepsis patients (P=0.47). Conclusion: A combination of SIRS criteria and PCT levels is beneficial for the early sepsis diagnosis in emergency ward patients with a suspicious infection disease.

Keywords: emergency, prolactin, sepsis, biomarkers

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Authors: Anuruddha Jagoda, Samiddhi Samarakoon, Anil Jasinghe

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In its simplest form, data quality can be defined as 'fitness for use' and it is a concept with multi-dimensions. Emergency Departments(ED) require information to treat patients and on the other hand it is the primary source of information regarding accidents, injuries, emergencies etc. Also, it is the starting point of various patient registries, databases and surveillance systems. This interventional study was carried out to improve data quality at the ED of the National Hospital of Sri Lanka (NHSL) by introducing an e health solution to improve data quality. The NHSL is the premier trauma care centre in Sri Lanka. The study consisted of three components. A research study was conducted to assess the quality of data in relation to selected five dimensions of data quality namely accuracy, completeness, timeliness, legibility and reliability. The intervention was to develop and deploy an electronic emergency department information system (eEDIS). Post assessment of the intervention confirmed that all five dimensions of data quality had improved. The most significant improvements are noticed in accuracy and timeliness dimensions.

Keywords: electronic health records, electronic emergency department information system, emergency department, data quality

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Authors: Le Jiang, Chua Jinxing

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Introduction: The recent outbreak of Ebola virus disease in the west Africa has drawn global concern. With a high fatality rate and direct human-to-human transmission, it has spread between countries and caused great damages for patients and family who are affected. Being the designated hospital to manage epidemic outbreak in Singapore, Tan Tock Seng Hospital (TTSH) is facing great challenges in preparation and managing of potential outbreak of emerging infectious disease such as Ebola virus disease. Aim: We conducted an infection control drill in TTSH emergency department to assess the readiness of healthcare and allied health workers in managing suspected Ebola patients. It also helps to review current Ebola clinical protocol and work instruction to ensure more smooth and safe practice in managing Ebola patients in TTSH emergency department. Result: General preparedness level of staffs involved in managing Ebola virus disease in TTSH emergency department is not adequate. Knowledge deficits of staffs on Ebola personal protective equipment gowning and degowning process increase the risk of potential cross contamination in patient care. Loopholes are also found in current clinical protocol, such as unclear instructions and inaccurate information, which need to be revised to promote better staff performance in patient management. Logistic issues such as equipment dysfunction and inadequate supplies can lead to ineffective communication among teams and causing harm to patients in emergency situation. Conclusion: The infection control drill identified the need for more well-structured and clear clinical protocols to be in place to promote participants performance. In addition to quality protocols and guidelines, systemic training and annual refresher for all staffs in the emergency department are essential to prepare staffs for the outbreak of Ebola virus disease. Collaboration and communication with allied health staffs are also crucial for smooth delivery of patient care and minimising the potential human suffering, properties loss or injuries caused by disease. Therefore, more clinical drills with collaboration among various departments involved are recommended to be conducted in the future to monitor and assess readiness of TTSH emergency department in managing Ebola virus disease.

Keywords: ebola, emergency department, infection control drill, Tan Tock Seng Hospital

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Authors: Mahmoud Abdel Hameed Shahin

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Job demands that are incompatible with an employee's skills, resources, or needs cause unpleasant emotional and physical reactions known as job stress. Nurses offer care in hospital emergency rooms all around the world, and since they operate in such a dynamic and unpredictable setting, they are constantly under pressure. It has been discovered that job stress has harmful impacts on nurses' health as well as their capacity to handle the demands of their jobs. The purpose of this study was to evaluate the level of job stress experienced by the emergency department nurses at King Fahad Specialist Hospital in Buraidah City, Saudi Arabia. In October 2021, a cross-sectional descriptive study was conducted. 80 nurses were conveniently selected for the study, the bulk of them worked at King Fahad Specialist Hospital's emergency department. An electronic questionnaire with a sociodemographic data sheet and a job stress scale was given to the participating nurses after ethical approval was received from the Ministry of Health's representative bodies. Using SPSS Version 26, both descriptive and inferential statistics were employed to analyze and tabulate the acquired data. According to the findings, the factors that contributed to the most job stress in the clinical setting were having an excessive amount of work to do and working under arbitrary deadlines, whereas the factors that contributed to the least stress were receiving the proper recognition or rewards for good work. In the emergency room of King Fahad Specialist Hospital, nurses had a moderate level of stress (M=3.32 ± 0.567/5). Based on their experience, emergency nurses' levels of job stress varied greatly, with nurses with less than a year of experience notably experiencing the lowest levels of job stress. The amount of job stress did not differ significantly based on the emergency nurses' age, nationality, gender, marital status, position, or level of education. The causes and impact of stress on emergency nurses should be identified and alleviated by hospitals through the implementation of interventional programs.

Keywords: emergency nurses, job pressure, Qassim, Saudi Arabia, job stress

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Authors: Etta Conteh, Tracy Macintosh

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Introduction: Restraints are often used in the Emergency Department when it is necessary for a patient to be restrained in order to decrease their agitation and better treat them. Chemical and physical restraints may be used on these patients at the discretion of the medical provider. Racism and injustice are rampant within our country, and medicine and healthcare are not spared. While racism and racial bias in medicine and healthcare have been studied, information on the differences in the use of restraints by race are scarce. Objective: The objective of this study is to determine if African Americans and Hispanic-American patients are restrained at higher rates compared to their White counterparts. Methods: This study will be carried out through a retrospective analysis utilizing the Hospital Corporation of America (HCA) national Emergency Department (ED) and inpatient database with patient visits from 2016-2019. All patient visits, with patients aged 18 years or older, will be reviewed, looking specifically for the race and the use and type of restraints. Other factors, such a pre-existing psychiatric condition, will be used for sub-analysis. Rationale: The outcome of this project will demonstrate the absence or presence of a racial disparity in the use of restraints in the Emergency Department. These results can be used as a foundation for improving racial equity in healthcare treatment.

Keywords: emergency medicine, public health, racism, restraint use

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Authors: Ahuja Ashish, Nain Prabhdeep Singh

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Introduction: Polycystic ovarian syndrome(PCOS) is the most common endocrine disorder among women of reproductive age.Pcos encompasses a broad spectrum of signs&symptoms of ovary dysfunction,obesity,blood pressure,insulin resistance & infertility. Bariatric Surgery can be an effective means of weight loss in Pcos & curing infertility. Materials and Methods: 15 female patients were enrolled in the study from 2012-2014.66%(n=10) were in age group of 20-25 years,33%(n=5) were in age group of 25-33 years who underwent. Bariatric surgery in form of Laproscopic sleeve Gastrectomy(LSG)& Roux-en-Y gastric bypass. LSG 73%(n=11), RYGB26% (n=4). Results: There was a significant improvement in obesity (60% excess weight loss)over 1 year after bariatric surgery, in 12 patients there was gross improvement in restoration of menstrual cycle who had irregular menstrual cycle. In 80% patients the serum insulin level showed normal value. Over two years 8 patients become pregnant. Conclusions: 1)Obese women with Pcos maybe able to conceive after Bariatric Surgery. 2) Women with Pcos should only consider bariatric surgery if they were already considering it for other reasons to treat obesity, blood pressure & other co-morbid conditions.

Keywords: obesity, bariatric surgery, polycystic ovarian syndrome, infertility

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