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   Table of Contents - Current issue
April-June 2020
Volume 8 | Issue 2
Page Nos. 67-104

Online since Wednesday, February 24, 2021

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Timing and dose of pharmacological thromboprophylaxis in adult trauma patients: Perceptions, barriers, and experience of Saudi Arabia practicing physicians p. 67
Marwa Amer, Mohammed Bawazeer, Khalid Maghrabi, Rashid Amin, Edward De Vol, Mohammed Hijazi
Background: Pharmacological venous thromboembolism prophylaxis (PVTE-Px) in trauma care is challenging and frequently delayed until the postinjury bleeding risk is perceived to be sufficiently low; yet, data for optimal initiation time are lacking. This study assessed the practice pattern of PVTE-Px initiation time and dose in traumatic brain injury (TBI), spinal cord injury (SCI), and nonoperative (NOR) solid organ injuries. Methods: This was a multicenter, cross-sectional, observational, survey-based study involving intensivists, trauma surgeons, general surgeons, spine orthopedics, and neurosurgeons practicing in trauma centers. The data of demographics, PVTE-Px timing and dose, and five clinical case scenarios were obtained. Analyses were stratified by early initiators versus late initiators and logistic regression models were used to identify factors associated with earlya initiation of PVTE-Px. Results: Of 102 physicians (29% response rate), most respondents were intensivists (63.7%) and surgeons (who are general and trauma surgeons) (22.5%); majority were consultants (58%), practicing at level 1 trauma centers (40.6%) or academic teaching hospitals (45.1%). A third of respondents (34.2%) indicated that decision to initiate PVTE-Px in TBI and SCI was made by a consensus between surgical, critical care, and neurosurgical services. For patients with NOR solid organ injuries, 34.2% of respondents indicated trauma surgeons initiated the decision on PVTE-Px timing. About 53.7% of the respondents considered their PVTE-Px practice as appropriate, half used combined mechanical and PVTE-Px (57.1%), 52% preferred enoxaparin (40 mg once daily), and only 6.5% used anti-Xa level to guide enoxaparin prophylactic dose. Responses to clinical cases varied. For TBI and TBI with intracranial pressure monitor, 40.3% and 45.6% of the respondents were early initiators with stable repeated head computed tomography (CT), respectively. For SCI, most respondents were early initiators without repeated CT spine (36.8%). With regard to NOR solid organ injuries (gunshot wound to the liver and Grade IV splenic injuries), 49.1% and 36.4% of respondents were early initiators without a repeat CT abdomen. Conclusions: Variations were observed in PVTE-Px initiation time influenced by trauma type. Our findings suggested that enoxaparin is preferred in a standard prophylactic dose. More robust data from randomized trials are needed and the use of clinicians' judgment is recommended.
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Stapled hemorrhoidopexy: A single-center 8 years' experience p. 82
Rishi Kumar Agrawal, Priti Agrawal, Jyotirmay Chandrakar
Purpose: Stapled hemorrhoidopexy (SH) is associated with shorter operative time, reduced inpatient stay, less pain, and earlier return to normal activities. The present study was conducted to assess the clinical consequences of SH and to establish the suitability of SH for all patients of grade III or IV hemorrhoids. Patients and Methods: This study included 250 patients who underwent SH at Aarogya Hospital, Raipur, India, from January 1, 2012 to December 31, 2017 and follow-up completed on December 31, 2019. SH procedure was performed according to the LONGO technique. The pain was assessed using a visual analog scale (VAS). Patients were followed up after 1 week, then monthly for 2 months, and 6 monthly for 2 years. Results: There were 163 males (65.2%) and 87 (34.8) females. Preoperatively, 87.2% of cases had anal bleeding, constipation in 73.2% cases, and associated pain in 52.4% cases. Operative time duration ranged between 25 and 50 min. Two-hundred and twenty-one (88.4%) patients were discharged within 24 h postoperatively and remaining within 48 h. Discussion: The most important advantage of SH as cited by various studies is a profound reduction in postoperative pain analgesia requirement and better quality of life. The postoperative pain rapidly decreased in severity to the VAS score of 2, in 73.6 cases within 24 h, facilitating early discharge of the patients our recurrence rates were nil in SH. Conclusion: Our study demonstrates that SH is a safe, effective, and well-tolerated procedure with minimum postoperative pain and complication rates.
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Clinical, laboratory, and imaging predictors of surgical exploration in nontraumatic acute abdomen p. 86
Abhiram Ramesh Mundle, Satish Deshmukh, Murtaza Akhtar
Introduction: Acute abdominal pain (AAP) accounts for a substantial proportion of patients arriving at a surgical emergency department. As AAP may be caused by both life-threatening diseases and conditions that are spontaneously resolved, a correct diagnosis is of importance for the prognosis of the patient. Materials and Methods: Clinical, laboratory, and imaging studies were done in patients presenting with a history of acute, nontraumatic pain in the abdomen in the Department of Surgery of NKP SIMS and Lata Mangeshkar Hospital, Nagpur, over a period of 2 years. Results: A total of 400 patients with a mean age of 38.05 ± 11.45 with a male: female ratio of 2.07:1 were enrolled. Of them, 233 patients underwent exploration and 167 were managed conservatively. During univariate analysis, age group, pulse rate, temperature, hemoglobin, total leukocyte count (TLC), tenderness, guarding, distension, bowel sounds, chest radiograph, and abdominal radiograph were found to be significant. On multivariate analysis, hemoglobin, TLC, tenderness, distension, and abdomen radiograph were significantly associated with exploration. Conclusion: In a patient of nontraumatic acute abdomen, clinical predictors such as tenderness and distension, laboratory predictors such as hemoglobin and TLC, and abdominal standing radiograph as an imaging predictor were the most statistically significant for exploration.
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Surgeons in training in the face of COVID-19 pandemic in the eastern province of Saudi Arabia: A cross sectional study tackling capabilities, opportunities, and motivation p. 90
Maryam Mozafarinia, Nikki Ow, Kedar K. V. Mate, Magdalena Cordoba, Haider Alyaseen, Layla Ajasim, Carlos Cordoba
Background: Urgent safety measures and management protocols of COVID-19 are continuously being updated. Surgical residents, amongst other health-care professionals, need to modify their clinical practice both in and out of the operating room. Understanding and applying the communicated guidelines are crucial to limit the spread of the virus. Objective: To estimate the extent of association between clinical behaviors and the recommended practice guidelines, issued by national and international health agencies, during the COVID-19 pandemic among surgical residents in the Eastern Province of Saudi Arabia. Methods: A descriptive, cross-sectional study was conducted with 52 surgical residents training in affiliated teaching public and private hospitals. Correlations were conducted to estimate the associations between knowledge, perception, motivation, and surgical residents' clinical behavior. Further cluster analysis was conducted to identify groups of people with similar patterns of clinical behavior. Results: The response rate was 52%. Surgical residents' behavior and their adherence to practice guidelines were varied and individualized. Nearly 50% lacked some fundamental bio-medical and disease specific knowledge. Despite demonstrating a fair knowledge on the transmission aspect of the disease, less than 60% agreed on ways of infection control and usefulness of personal protective equipment and nearly 50% did not endorse the use of facemasks and gloves. High levels of stress with respect to COVID-19 was reported by 63%; 58% were confident with their personal safety techniques, and 80% needed more information about the COVID-19. Conclusion: The results suggest a collective action is needed at both the personal and institutional level to increase compliance with the recommended guidelines.
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Primary heterotopic mesenteric ossification p. 98
Raafat Alturfi, Mohammed Atallah
Heterotopic ossification (HO) is the presence of bone in nonossifying tissue. Mesenteric HO usually results from previous abdominal trauma or surgery. This is a case report of 87-year-old lady who presented with subacute intestinal obstruction, she had neither previous history of abdominal trauma nor surgery. On exploration, there was spiral ossified tissue trapping small bowel that was removed and the condition resolved completely. As long as to our knowledge, this is the first reported case of intra-abdominal Heterotopic ossification without previous cause in English articles. HO should keep in mind in any ossified peritoneal lesion even without previous surgery or trauma.
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Acute chylous peritonitis: Report of a case and literature review p. 101
MS Alamri, Raed A Alenezi, Khulaif K Alanazi, Mishal M Alrsheedi, Bassam Z Alshammary, Hani A Almutair
Acute chylous peritonitis is an extensively rare condition; chylous ascites may result from many pathological conditions, including congenital defects of the lymphatic system, trauma, peritoneal infections, and malignant neoplasms. In most cases, the presence of tenderness and rebound leads the patients to be misdiagnosed with acute appendicitis. In our case, the preoperative diagnosis was perforated acute appendicitis.
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