Search results for: general surgery department

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: 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: Sibel Kurt

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In this study, with the use of Goffee and Jones’s corporate culture classification and the scale of this classification, there aimed to analyze a company’s corporate culture which does not have a public relations or communication department. First of all, the type of corporate culture in the company had been determined. Then it questioned if there are subcultures which formed according to demographics or the department of work. In the survey questionnaire, there are 53 questions total. 6 of these questions are about demographics, and 47 of them are about corporate culture. 152 personnel of the company had answered the survey, and the data have been evaluated according to frequency, descriptive, and compare means tests. The type of corporate culture of the company was determined as the 'communal' from the typology of Goffee and Jones in the positive form. There are no subcultures in the company which bases on the demographics, but only one subculture has determined according to the department of work. As a result, the absence of public relations department, personnel’s low level of awareness about corporate culture, and the lack of information between management and employees has been revealed.

Keywords: corporate culture, subculture, public relations, organizational communication

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Authors: Saut Samuel Simamora

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PURPOSE: Nucleus drop is one of the most feared and severe complications of modern cataract surgery. The lens material may drop through iatrogenic breaks of the posterior capsule. The incidence of the nucleus as the complication of phacoemulsification increases concomitant to the increased frequency of phacoemulsification. Pars plana vitrectomy (PPV) followed by endofragmentation and secondary intraocular lens (IOL) implantation is the choice of management procedure. This case report aims to present the outcome of PPV for the treatment dropped nucleus after cataract surgery METHODS: A 65 year old female patient came to Vitreoretina department with chief complaints blurry vision in her left eye after phacoemulsification one month before. Ophthalmological examination revealed visual acuity of the right eye (VA RE) was 6/15, and the left eye (VA LE) was hand movement. The intraocular pressure (IOP) on the right eye was 18 mmHg, and on the left eye was 59 mmHg. On her left eye, there were aphakic, dropped lens nucleus and secondary glaucoma.RESULTS: The patient got antiglaucoma agent until her IOP was decreased. She underwent pars plana vitrectomy to remove dropped nucleus and iris fixated IOL. One week post operative evaluation revealed VA LE was 6/7.5 and iris fixated IOL in proper position. CONCLUSIONS: Nucleus drop generally occurs in phacoemulsification cataract surgery techniques. Retained lens nucleus or fragments in the vitreous may cause severe intraocular inflammation leading to secondary glaucoma. The proper and good management for retained lens fragments in nucleus drop give excellent outcome to patient.

Keywords: secondary glaucoma, complication of phacoemulsification, nucleus drop, pars plana vitrectomy

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Authors: Victor Au, Khin Maung Than, Zaw Win Aung, Linawati Jumat

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Background & Objectives: Cardiac arrests can occur anywhere or anytime, and most of the cases will be brought to the emergency department except the cases that happened in at in-patient setting. Raja IsteriPangiran Anak Saleha (RIPAS) Hospital is the only tertiary government hospital which located in Brunei Muara district and received all referral from other Brunei districts. Data of cardiac arrests in Brunei Darussalam scattered between Emergency Medical Ambulance Services (EMAS), Emergency Department (ED), general inpatient wards, and Intensive Care Unit (ICU). In this audit, we only focused on cardiac arrest cases which had happened or presented to the emergency department RIPAS Hospital. Theobjectives of this audit were to look at demographic of cardiac arrest cases and the survival to discharge rate of In-Hospital Cardiac Arrest (IHCA) and Out-Hospital Cardiac Arrest (OHCA). Methodology: This audit retrospective study was conducted on all cardiac arrest cases that underwent Cardiopulmonary Resuscitation (CPR) in ED RIPAS Hospital, Brunei Muara, in the year 2019-2020. All cardiac arrest cases that happened or were brought in to emergency department were included. All the relevant data were retrieved from ED visit registry book and electronic medical record “Bru-HIMS” with keyword diagnosis of “cardiac arrest”. Data were analyzed and tabulated using Excel software. Result: 313 cardiac arrests were recorded in the emergency department in year 2019-2020. 92% cases were categorized as OHCA, and the remaining 8% as IHCA. Majority of the cases were male with age between 50-60 years old. In OHCA subgroup, only 12.4% received bystander CPR, and 0.4% received Automatic External Defibrillator (AED) before emergency medical personnel arrived. Initial shockable rhythm in IHCA group accounted for 12% compare to 4.9% in OHCA group. Outcome of ED resuscitation, 32% of IHCA group achieved return of spontaneous circulation (ROSC) with a survival to discharge rate was 16%. For OHCA group, 12.35% achieved ROSC, but unfortunately, none of them survive till discharge. Conclusion: Standardized registry for cardiac arrest in the emergency department is required to provide valid baseline data to measure the quality and outcome of cardiac arrest. Zero survival rate for out hospital cardiac arrest is very concerning, and it might represent the significant breach in cardiac arrest chains of survival. Systematic prospective data collection is needed to identify contributing factors and to improve resuscitation outcome.

Keywords: cardiac arrest, OHCA, IHCA, resuscitation, emergency department

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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: 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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Authors: Kristian Bugeja, Upeshala A. Jayawardena, Clarissa Fenech, Mark Zammit Vincenti

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Introduction: Biliary colic, acute cholecystitis, and gallstone pancreatitis are some of the most common surgical presentations at Gozo General Hospital (GGH). National Institute for Health and Care Excellence (NICE) guidelines advise that suitable patients with acute biliary problems should be offered a laparoscopic cholecystectomy within one week of diagnosis. There has traditionally been difficulty in achieving this mainly due to the reluctance of some surgeons to operate in the acute setting, limited, timely access to MRCP and ERCP, and organizational issues. Methodology: A retrospective study was performed involving all biliary pathology-related admissions to GGH during the two-year period of 2019 and 2020. Patients’ files and electronic case summary (ECS) were used for data collection, which included demographic data, primary diagnosis, co-morbidities, management, waiting time to surgery, length of stay, readmissions, and reason for readmissions. NICE clinical guidance 188 – Gallstone disease were used as the standard. Results: 51 patients were included in the study. The mean age was 58 years, and 35 (68.6%) were female. The main diagnoses on admission were biliary colic in 31 (60.8%), acute cholecystitis in 10 (19.6%). Others included gallstone pancreatitis in 3 (5.89%), chronic cholecystitis in 2 (3.92%), gall bladder malignancy in 4 (7.84%), and ascending cholangitis in 1 (1.97%). Management included laparoscopic cholecystectomy in 34 (66.7%); conservative in 8 (15.7%) and ERCP in 6 (11.7%). The mean waiting time for laparoscopic cholecystectomy for patients with acute cholecystitis was 74 days – range being between 3 and 146 days since the date of diagnosis. Only one patient who was diagnosed with acute cholecystitis and managed with laparoscopic cholecystectomy was done so within the 7-day time frame. Hospital re-admissions were reported in 5 patients (9.8%) due to vomiting (1), ascending cholangitis (1), and gallstone pancreatitis (3). Discussion: Guidelines were not met for patients presenting to Gozo General Hospital with acute biliary pathology. This resulted in 5 patients being re-admitted to hospital while waiting for definitive surgery. The local issues resulting in the delay to surgery need to be identified and steps are taken to facilitate the provision of urgent cholecystectomy for suitable patients.

Keywords: biliary colic, acute cholecystits, laparoscopic cholecystectomy, conservative management

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Authors: Azadeh Mottaghi, Reyhaneh Yousefi, Saeed Safari

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Background: Bariatric surgery is widely proposed as the most effective approach to mitigate the growing pace of morbid obesity. As bariatric surgery candidates suffer from pre-existing nutritional deficiencies, it is of great importance to assess nutritional status of candidates before surgery in order to establish appropriate nutritional interventions. Objectives: The present study assessed and represented baseline data according to the nutritional status among candidates for bariatric surgery. Methods: A cross-sectional analysis of pre-surgery data was collected on 170 morbidly obese patients undergoing bariatric surgery between October 2017 and February 2018. Dietary intake data (evaluated through 147-item food frequency questionnaire), anthropometric measures and biochemical parameters were assessed. Results: Participants included 145 females (25 males) with average age of 37.3 ± 10.2 years, BMI of 45.7 ± 6.4 kg/m² and reported to have a total of 72.3 ± 22.2 kg excess body weight. The most common nutritional deficiencies referred to iron, ferritin, transferrin, albumin, vitamin B12, and vitamin D, the prevalence of which in the study population were as followed; 6.5, 6.5, 3, 2, 17.6 and 66%, respectively. Mean energy, protein, fat, and carbohydrate intake were 3887.3 ± 1748.32 kcal/day, 121.6 ± 57.1, 144.1 ± 83.05, and 552.4 ± 240.5 gr/day, respectively. The study population consumed lower levels of iron, calcium, folic acid, and vitamin B12 compared to the Dietary Reference Intake (DRI) recommendations (2, 26, 2.5, and 13%, respectively). Conclusion: According to the poor dietary quality of bariatric surgery candidates, leading to nutritional deficiencies pre-operatively, close monitoring and tailored supplementation pre- and post-bariatric surgery are required.

Keywords: bariatric surgery, food frequency questionnaire, obesity, nutritional status

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Authors: Max Butler

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Melanoma accounts for 80% of skin cancer-related deaths globally. The poor prognosis and increasing incidence of melanoma impose a significant burden on global healthcare systems. Early detection, precise diagnosis, and preventative strategies are critical to improving patient outcomes. Dermoscopy is the gold standard for specialist assessments of pigmented skin lesions, as it can differentiate between benign and malignant growths with greater accuracy than visual inspection. In the United Kingdom, guidelines from the National Institute of Clinical Excellence (NICE) state dermoscopy should be used in all specialist assessments of pigmented skin lesions. Compliance with this guideline is low, resulting in missed and delayed melanoma diagnoses. To address this problem, a quality improvement project was initiated at Buckinghamshire Healthcare Trust (BHT) within the plastic surgery department. The target group was a trainee and consultant plastic surgeons conducting outpatient skin cancer clinics. Analysis of clinic documentation over a one-month period found that only 62% (38/61) of patients referred with pigmented skin lesions were examined using dermoscopy. To increase dermoscopy rates, teaching was delivered to the department highlighting national guidelines and the evidence base for dermoscopic examination. In addition, clinic paperwork was redesigned to include a text box for dermoscopic examination. Reauditing after the intervention found a significant increase in dermoscopy rates (52/61, p = 0.014). In conclusion, implementing a quality improvement project with targeted teaching and documentation template templates successfully increased dermoscopy rates. This is a promising step toward improving early melanoma detection and patient outcomes.

Keywords: melanoma, dermoscopy, plastic surgery, quality improvement

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Authors: Sharon Baoas, Toni Beninato, Michael Zenilman, Gokhan Ozuner

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Background An enhanced recovery after surgery (ERAS) protocol was implemented to improve quality and cost effectiveness of surgical care in elective colorectal procedures. Results A total of 109 patients, 55 (pre-ERAS) and 54 (post-ERAS) are included in the final analysis. There were no differences in complications were recorded (p = 0.37) and 30-day readmissions (p = 0.785). The mean hospital stay was 5.89 ± 2.62 days in pre-ERAS and 4.94 ± 2.27 days in post-ERAS group which was statistically significant (p = 0.047). Conclusions An ERAS protocol for colorectal surgery harmonised perioperative care and decreased length of stay.

Keywords: 30-day readmission, lenght of stay, Enhanced Recovery after surgery, Surgical site infection

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Authors: Mohammad J. Mortazavi, Arvin Najafi, Pejman Mansouri

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Hemophilia A is simply described as deficiency of factor VIII(FVIII) and patients with this disorder have bleeding complications in different organs. By using the recombinant factor VIII in these patients, elective orthopedic surgeries have been done approximately in 40 last years. About 10-30 % of these patients have bleeding complications in their surgeries even by using recombinant factor VIII because of their inhibitor against FVIII molecule. Preoperative haemostatic management in these patients is challenging. We treated a 28-year-old male patient with hemophilia A with FVIII inhibitor which had been detected when he was14 years old (with the titer 54 Bethesda unit(BU)) scheduled for total knee arthroplasty (TKA). We use 90 µg/kg rFVIIa just before the surgery and every 2 hours during surgery. The patient did not have any significant hemorrhage during the surgery and after that. For the 2 days after surgery, the rFVIIa repeated every 2 hours as the same as preoperative dosage(90 µg/kg) and for another 2 days of postoperative admission it continued every 4 hours. After 4th day, the rFVIIa continued every 6 hours with the same dosage until the sixth day from the surgery, and finally the patient were discharged about two weeks after surgery. Seven days after the discharge, he came back for the follow up visit. On the follow up examination, the site of the surgery had neither infection hemarthroses signs.

Keywords: hemophilia, factor VIII inhibitor, total knee replacement, rFVIIa

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Authors: Nareerut Rodwring

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The purposes of this research were to study the current problems of the management of welfare fund at the department of labor protection and welfare, to study important factors affecting the management of welfare fund at the department of labor protection and welfare, to study major influences of the management of welfare fund at the department of labor protection and welfare, and finally to propose the proper guidelines for the management of welfare fund at the department of labor protection and welfare. This research study utilized the information from document, laws, rules, and regulations of the government, handbook for welfare, and government policy in the past. Moreover, the qualitative research was conducted by retrieving insight information from key informants, 15 persons for the committee of welfare employees, and 10 persons from a high level of management in the welfare area, academics, and experts. In terms of quantitative method, the study covers all 76 provinces and 10 areas of Bangkok. Independent variables included strategy, structure, shared value, system, whereas the dependent variables included the management factors such as speed, punctuation, and quality of work.

Keywords: strategy, welfare, labor protection, management

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Authors: Abshari Nabilah Fiqi, Amira Eka Pratiwi, Sekar Ayu Dian Kusumaningtyas

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Indonesia is one of the developing countries in the world. However, people in Indonesia, especially in big and modern cities like Jakarta (the capital city of Indonesia), have shown some consumptive behavior. As an indicator, there are about 173 malls and department stores in Jakarta, and of course these malls and department store is always crowded by visitors. This study is trying to describe the dynamics of consumptive behavior that shown by people in Jakarta. We are trying to find out why Indonesian love to go to the malls and department stores despite the low income.

Keywords: consumptive behavior, hedonism, mall, shopping

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Authors: Eunjoo Lee

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Background: As the number of surgeries increases, the incidence of adverse events is likely to become more prevalent. Patients who are somewhat knowledgeable about surgery-related adverse events are more likely to engage in safety initiatives to prevent them. Objectives: To evaluate the impact of a smartphone application developed during the study to enhance patients’ knowledge of surgery-related adverse events during hospitalization. Design: Non-randomized, one group, measured pre- and post-intervention. Participants: Thirty-six hospitalized patients admitted to the orthopedics unit of a general hospital in South Korea. Methods. First, a smartphone application to enhance patients’ knowledge of surgery-related adverse events was developed through an iterative process, which included a literature review, expert consultation, and pilot testing. The application was installed on participants’ smartphones, and research assistants taught the participants to use it. Twenty-five true/false questions were used to assess patients’ knowledge of preoperative precautions (eight items), surgical site infection (five items), Foley catheter management (four items), drainage management (four items), and anesthesia-related complications (four items). Results: Overall, the percentage of correct answers increased significantly, from 57.02% to 73.82%, although answers related to a few specific topics did not increase that much. Although the patients’ understanding of drainage management and the Foley catheter did increase substantially after they used the smartphone application, it was still relatively low. Conclusions: The smartphone application developed during this study enhanced the patients’ knowledge of surgery-related adverse events during hospitalization. However, nurses must make an additional effort to help patients to understand certain topics, including drainage and Foley catheter management. Relevance to clinical practice: Insufficient patient knowledge increases the risk of adverse events during hospitalization. Nurses should take active steps to enhance patients’ knowledge of a range of safety issues during hospitalization, in order to decrease the number of surgery-related adverse events.

Keywords: patient education, patient participation, patient safety, smartphone application, surgical errors

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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: Maryam Nazari, Atefeh Ghanbari, Saghar Noorinia

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Obesity, as an abnormal or excessive accumulation of fat, is caused by genetic, behavioral and environmental factors. Recently, obesity surgeries, such as bariatric surgery, as the last measure to control obesity, have attracted experts and society, especially women, attention, so knowing the possible complications of this major surgery and their control in reproductive age is of particular importance due to its effects on pregnancy outcomes. Bariatric surgery reduces the risk of diabetes and high blood pressure associated with pregnancy, premature birth, macrosomia, stillbirth and dumping syndrome. Although in the first months after surgery, nausea and vomiting caused by changes in intra-abdominal pressure are associated with an increased risk of malabsorption of micronutrients such as folic acid, iron, vitamin B1, D, calcium, selenium and phosphorus and finally, fetal growth disorder. Moreover, serum levels of micronutrients such as vitamin D, calcium, and iron in mothers who used to have bariatric surgery and their babies have been shown to be lower than in mothers without a history of bariatric surgery. Moreover, vitamin A deficiency is shown to be more widespread in pregnancies after bariatric surgery, which leads to visual problems in newborns and premature delivery. However, complications such as the duration of hospitalization of newborns in the NICU, disease rate in the first 28 days of life and congenital anomalies are not significantly different in babies born to mothers undergoing bariatric surgery compared to the control group. In spite of the vast advantages following obesity surgeries, due to the catabolic conditions and severe weight loss followed by such major intervention and the probability of nutrients malnutrition in a pregnant woman and her baby, after having surgery, at least 12 to 18 months should be considered to get pregnant as a recovery period. In addition, taking essential supplements before and at least 6 months after this approach is recommended.

Keywords: bariatric surgery, pregnancy, malnutrition, vitamin and mineral deficiency

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Authors: Alessandro Marano

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Aim: The author describes the aesthetic modification using orthognathic surgery and closed rhinoplasty. Methods: Series of case study. After orthognathic surgery we can observe a dramatical change of aesthetic especially in the mid-face and nose projection. The advancement of maxillary bone through Le Fort I osteotomy will change the nasal tip projection and lips roundness; combining orthognathic surgery with closed approach rhinoplasty will manage both function and aesthetic of all mid face district. Results: Combining Le Fort I osteotomy with closed approach rhinoplasty resulted in good objective results with high patient satisfaction. Le Fort I osteotomy will increase projection of mid face and the closed approach rhinoplasty will modify the nasal shape to be more harmonic with the new maxillary district. The scars are not visible because hidden inside the mouth and nose. Conclusions: The orthognathic surgery combined with closed approach rhinoplasty are very effective for changing the aesthetic of the mid face. The results illustrate the difference between the use of orthognathic surgery only and to use it in association of closed approach rhinoplasty. Using both will allow to obtain a long lasting and pleasing results.

Keywords: orthognathic, rhinoplasty, aesthetic, face

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Authors: Mwafak Shakoor

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The purpose of this study was to reduce patient waiting times, improve system throughput and improve resources utilization in radiology department. A discrete event simulation model was developed using Arena simulation software to investigate different alternatives to improve the overall system delivery based on adding resource scenarios due to the linkage between patient waiting times and resource availability. The study revealed that there is no addition investment need to procure additional scanner but hospital management deploy managerial tactics to enhance machine utilization and reduce the long waiting time in the department.

Keywords: discrete event simulation, radiology department, arena, waiting time, healthcare modeling, computed tomography

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Authors: Teagan Fink, Lynn Chong, Michael Hii, Brett Knowles

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Background: Telemedicine is a rapidly advancing field providing healthcare to patients at a distance from their treating clinician. There is a paucity of high-quality evidence detailing the safety and acceptability of telemedicine for postoperative outpatient follow-up. This randomized controlled trial – conducted prior to the COVID 19 pandemic – aimed to assess patient satisfaction and safety (as determined by readmission, reoperation and complication rates) of telephone compared to face-to-face clinic follow-up after uncomplicated general surgical procedures. Methods: Patients following uncomplicated laparoscopic appendicectomy or cholecystectomy and laparoscopic or open umbilical or inguinal hernia repairs were randomized to a telephone or face-to-face outpatient clinic follow-up. Data points including patient demographics, perioperative details and postoperative outcomes (eg. wound healing complications, pain scores, unplanned readmission to hospital and return to daily activities) were compared between groups. Patients also completed a Likert patient satisfaction survey following their consultation. Results: 103 patients were recruited over a 12-month period (21 laparoscopic appendicectomies, 65 laparoscopic cholecystectomies, nine open umbilical hernia repairs, six laparoscopic inguinal hernia repairs and two laparoscopic umbilical hernia repairs). Baseline patient demographics and operative interventions were the same in both groups. Patient or clinician-reported concerns on postoperative pain, use of analgesia, wound healing complications and return to daily activities at clinic follow-up were not significantly different between the two groups. Of the 58 patients randomized to the telemedicine arm, 40% reported high and 60% reported very high patient satisfaction. Telemedicine clinic mean consultation times were significantly shorter than face-to-face consultation times (telemedicine 10.3 +/- 7.2 minutes, face-to-face 19.2 +/- 23.8 minutes, p-value = 0.014). Rates of failing to attend clinic were not significantly different (telemedicine 3%, control 6%). There was no increased rate of postoperative complications in patients followed up by telemedicine compared to in-person. There were no unplanned readmissions, return to theatre, or mortalities in this study. Conclusion: Telemedicine follow-up of patients undergoing uncomplicated general surgery is safe and does not result in any missed diagnosis or higher rates of complications. Telemedicine provides high patient satisfaction and steps to implement this modality in inpatient care should be undertaken.

Keywords: general surgery, telemedicine, patient satisfaction, patient safety

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Authors: Vishal Bhatnagar

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The objective of this study is to compare the efficacy of epidural analgesia of two amide local anesthetics, ropivacaine and levobupivacaine, with fentanyl for postoperative analgesia in major abdominal surgery CRS+HIPEC. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS+HIPEC) are done for primary peritoneal malignancies or peritoneal spread of malignant neoplasm. CRS and HIPEC are considered one of the most painful surgery among all major abdominal surgeries. Poorly managed postoperative pain elevates stress, increases anxiety, causes prolonged Hospital stay, increases opioid requirement and side effects, increases the cost of treatment and psychological effects on patient and family. It affects the quality of life of patients. The epidural technique provides better postoperative analgesia, earlier recovery of bowel function, fewer side effects, higher patient satisfaction, and an improvement in life quality in the postoperative days after abdominal surgery than other analgesic techniques.

Keywords: HIPEC, postoperative analgesia, cytoreductive surgery, VAS score, rescue analgesia

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Authors: Faranak Omidian

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This study has been carried out to examine the status of architecture department at bachelor's level of engineering architecture in Islamic Azad University of Dezful in 2012-13 academic year. The present research is a descriptive cross sectional study and in terms of measurement, it is descriptive and analytical, which was done based on 7 steps and in 7 areas with 32 criteria and 169 indicators. The sample includes 201 students, 14 faculty members, 72 graduates and 39 employers. Simple random sampling method, complete enumeration method, network sampling (snowball sampling) were used for students, faculty members and graduates respectively. All sample responded to the questions. After data collection, the findings were ranked on Likert scale from desirable to undesirable with the scores ranging from 1 to 3.The results showed that the department with a score of 1.88 in regard to objectives, organizational status, management and organizations, with a score of 2 in relation to students, with a score of 1.8 in regard to faculty members was in a relatively desirable status. Regarding training courses and curriculum, it gained a score of 2.33 which indicates the desirable status of the department in this regard. It gained scores of 1.75, 2, and 1.8 with respect to educational and research facilities and equipment, teaching and learning strategies, and graduates respectively, all of which shows the relatively desirable status of the department. The results showed that the department of architecture, with an average score of 2.14 in all evaluated areas, was in a desirable situation. Therefore, although the department generally has a desirable status, it needs to put in more effort to tackle its weaknesses and shortages and corrects its defects in order to promote educational quality, taking to the desirable level.

Keywords: internal evaluation, architecture department in Islamic, Azad University, Dezful

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Authors: Sukhee Park, Gaab Soo Kim

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Purpose: We aimed to evaluate the adequacy of second-generation laryngeal mask airway use during prolonged abdominal surgery in respect of ventilation, oxygenation, postoperative pulmonary complications (PPC), and postoperative non-pulmonary complications on living donor kidney transplant (LDKT) surgery. Methods: In total, 257 recipients who underwent LDKT using either laryngeal mask airway-ProSeal (LMA-P) or endotracheal tube (ETT) were retrospectively analyzed. Arterial partial pressure of carbon dioxide (PaCO2 and ratio of arterial partial pressure of oxygen to fractional inspired oxygen (PFR) during surgery were compared between two groups. In addition, PPC including pulmonary aspiration and postoperative non-pulmonary complications including nausea, vomiting, hoarseness, vocal cord palsy, delirium, and atrial fibrillation were also compared. Results: PaCO2 and PFR during surgery were not significantly different between the two groups. PPC was also not significantly different between the two groups. Interestingly, the incidence of delirium was significantly lower in the LMA-P group than the ETT group (3.0% vs. 10.3%, P = 0.029). Conclusions: During prolonged abdominal surgery such as LDKT, second-generation laryngeal mask airway offers adequate ventilation and oxygenation and can be considered a suitable alternative to ETT.

Keywords: laryngeal mask airway, prolonged abdominal surgery, kidney transplantation, postoperative pulmonary complication

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Authors: Prachi Abhishek Dave, Manisha Singh

Abstract:

Purpose: The purpose is to study the microbiological profile, prognostic factors, and outcomes of surgery for microbial keratitis (MK) associated endophthalmitis. Methods: It is a retrospective analysis of 39 MK associated endophthalmitis cases which underwent combined PKP with VR surgery. Results: The majority (84.6%) of patients had a history of previous ocular surgery, cataract surgery being the most common (51.2%). Six patients had a history of trauma and 8 patients had corneal graft infection. The culture positivity rate was 92.3%. Organisms isolated were Streptococcal sp (20.5%), Pseudomonas (15.3%), Staphylococcal sp (12.8%) and Fungus (35.8%). Final visual acuities ranged from NPL to 20/120. Poor anatomic success was seen in 15(38.46%) eyes (9-phthisis, 6-eviscerated). Fungal cases had a poor success rate (P-0.02). Conclusion: MK associated endophthalmitis is a sight threatening ocular condition. Fungal etiology carries a poorer prognosis. Timely surgical intervention can achieve favourable anatomical and functional results.

Keywords: endophthalmitis, microbial keratitis, penetrating keratoplasty, vitreo retinal surgery

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Authors: Gabrielle O'Donoghue

Abstract:

Background: Pre-operative radiographs facilitate assessment and treatment planning in minor oral surgery. Quality assurance for dental radiography advocates the As Low As Reasonably Achievable (ALARA) principle in collecting accurate diagnostic information. Aims: To audit the quality of digital intraoral periapicals (IOPAs) taken prior to dental extractions in a metropolitan general dental practice setting. Standards: The National Radiological Protection Board (NRPB) guidance outlines three grades of radiograph quality: excellent (Grade 1 > 70% of total exposures), diagnostically acceptable (Grade 2 <20%), and unacceptable (Grade 3 <10%). Methodology: A study of pre-operative radiographs taken prior to dental extractions across 12 private general dental practices in a large metropolitan area by 44 practitioners. A total of 725 extractions were assessed, allowing 258 IOPAs to be reviewed in one audit cycle. Results: First cycle: Of 258 IOPAs: 223(86.4%) scored Grade 1, 27(10.5%) Grade 2, and 8(3.1%) Grade 3. The standard was met. 35 dental extractions were performed without an available pre-operative radiograph. Action Plan & Recommendations: Results were distributed to all staff and a continuous professional development evening organized to outline recommendations to improve image quality. A second audit cycle is proposed at a six-month interval to review the recommendations and appraise results. Conclusion: The overall standard of radiographs met the published guidelines. A significant improvement in the number of procedures undertaken without pre-operative imaging is expected at a six-month interval period. An investigation into undiagnostic imaging and associated adverse patient outcomes is being considered. Maintenance of the standards achieved is predicted in the second audit cycle to ensure consistent high quality imaging.

Keywords: audit, oral radiology, oral surgery, periapical radiographs, quality assurance

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Authors: Langhit Kurar, Loren Charles

Abstract:

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: A. Gazdzinska, P. Jagielski, E. Kaniewska, S. P. Gazdzinski, M. Wylezol

Abstract:

Background: In the multi-factor etiology of obesity, an increasing degree of importance is attributed to behavioral factors. Lifestyle and health-oriented behaviors heavily influence the treatment of multiple diseases, including obesity. However, only a few studies evaluated health-related behaviors exhibited by patients qualified for bariatric surgery. None of them was performed in Polish population. Aim: Assessment of health behaviors of obese patients according to the degree of mood disorders. Method: The study involved 93 patients (66 females) who were qualified for bariatric surgery in the Department of Surgery of the Military Institute of Aviation Medicine in Warsaw. Diagnostic instrument was the Juczynski’s Inventory of Health Behavior (HBI), which evaluates health behavior in four categories, i.e. proper nutrition habits (PNH), preventive behavior (PH), health practices (HP) and positive mental attitude (PMA). The average HBI falls in the range between 24 and 120 points, for each category of health behaviors fall between 1 and 5 (higher score means higher severity declared healthy behaviors). The depressive symptoms in patients were assessed with Beck Depression Inventory (BDI). All analyses were conducted using STATISTICA 12. Results: The average age was 44.2 ± 11.5 years, mean BMI was 44.3 ± 10.5 kg/m2 and 46.8 ± 7.6 kg/m2, in females and males respectively. According to BDI, 32% patients had mild level of depression, 10% moderate and 14% severe depression. BDI scores were not different between females and males. Low results with regard to the health behaviors declared were obtained by 35.5 % of patients, medium by 44.0%, while high ones by only 20.5%. On average, patients gained 3.28 points in PNH, 3.37 points in PH, 3.29 points in HP, while 3.42 in the PMA category, showing average intensity of these behaviors. These health behaviors were practiced significantly more often by women (p = 0.04). The average HBI was 80.2; with average score of 81.5 for females and 76.6 for males, respectively (p = 0.03). Women were better in the PNH category (p = 0.02). A positive correlation was found between age and all categories of health behaviors, in particular PNH (R = 0.38; p = 0.001), PH (R = 0.26; p = 0.01), HP (R = 0.27; p = 0.01) and PMA (R = 0.24; p = 0.02), independent of gender. The severity of depression had a significant impact only on the behaviors associated with proper eating habits, which saw a negative correlation between BDI scores and the PNH (R = -0.21; p = 0.04). Conclusions: Majority of morbidly obese patients qualified for bariatric surgery obtained low to average scores in health behavior questionnaire. However, these results are similar in comparison with the Polish adult population. In accordance to these results, it seems that healthy behaviors, among them eating behaviors, do not appear to be a cause of obesity epidemic or they might be acquired when the disease is already underway. Female gender and age had a positive effect, and depression had a negative effect on the level of health behaviors among patients qualified for bariatric surgery.

Keywords: depression, habits, health behaviours, obesity

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Authors: Abhishek Dave, Manisha Singh

Abstract:

Purpose: The study aims to evaluate the outcomes of combined Penetrating keratoplasty (PKP) and Vitreo-Retinal (VR) surgery in patients having endophthalmitis with poor corneal clarity. Methods: PKP with VR Surgery was performed in 43 eyes. This is a retrospective analysis of their preoperative, intraoperative and microbiological characteristics and anatomical and functional outcomes. Results: Corneal opacification was due to corneal ulcer in 30 (69.7%), graft infection in 8 (18.6%), bullous keratopathy in 4 and corneal scar in 1 eye. Postoperative visual acuity improved in 20 (46.5%), not changed in 14 (32.5%) and deteriorated in 9 eyes (20.9%). Poor anatomic success was seen in 15 (34.88%) eyes (9-phthisis bulbi, 6-eviscerated). Graft remained clear in 24 eyes (1 year). Microbiology revealed bacteria in 26, fungus in 14 and no growth in 3 eyes. Six out of 11 patients having poor vision in the fellow eye, too, achieved functional success. Conclusion: PKP with VR surgery is a complex but globe-salvaging procedure for poor prognosis eyes, which otherwise would need evisceration.

Keywords: penetrating keratoplasty, VR surgery, endophthalmitis, corneal ulcer

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Authors: D. Bheenick, M. Young, M.Elmussareh, A.Ali

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Objective: Coronavirus disease 2019 (COVID-19) has had unprecedented effects on the healthcare system in the UK. The pandemic has impacted every service within secondary care, including urology. Our objective is to determine how COVID-19 has influenced acute urology admissions in a busy district general hospital in the UK. Patient and methods: Retrospective data of patients presenting acutely to the urology department was collected between 13th January to 22nd March 2020 (pre-lockdown period) and 23rd March to 31st May 2020 (lockdown period). The nature of referrals, types of admission encountered, and management required in accordance with the new set of protocols established during the lockdown period were analysed and compared to the same data prior to UK lockdown. Results: 1092 patients were included in the study. An overall reduction of 32.5% was seen in the total number of admissions. A marked decrease was seen in non-urological pathology as compared to other categories. Urolithiasis showed the highest proportional increase. Treatment varied proportionately to the diagnosis, with conservative management accounting for the most likely treatment during lockdown. However, the proportion of patients requiring interventions during the lockdown period increased overall. No comparative differences were observed during the two periods in terms of source of referral, length of stay and patient age. Conclusion: The admission rate showed a decrease, with no significant difference in the nature and timing of presentation. Our department was able to continue providing effective management to patients presenting acutely during the COVID-19 outbreak.

Keywords: COVID-19, lockdown, admissions, urology

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Authors: Ramon Sancibrian, Carlos Redondo-Figuero, Maria C. Gutierrez-Diez, Esther G. Sarabia, Maria A. Benito-Gonzalez, Jose C. Manuel-Palazuelos

Abstract:

In this paper, the design and evaluation of a handle for laparoscopic surgery is presented. The design of the handle is based on ergonomic principles and tries to avoid awkward postures for surgeons. The handle combines the so-called power-grip and accurate-grip in order to provide strength and accuracy in the performance of surgery. The handle is tested using both objective and subjective approaches. The objective approach uses motion capture techniques to obtain the angles of forearm, arm, wrist and hand. The muscular effort is obtained with electromyography electrodes. On the other hand, a subjective survey has been carried out using questionnaires. Results confirm that the handle is preferred by the majority of the surgeons.

Keywords: laparoscopic surgery, ergonomics, mechanical design, biomechanics

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