The Role of Neutrophil to Lymphocyte Ratio and its Common Clinical Outcomes Among Patients with Non-ST Elevation Acute Coronary Syndrome.

Objectives: To evaluate the admission neutrophil-to-lymphocyte ratio (NLR) for risk stratification for in-hospital outcomes and complications in non-ST-elevation acute coronary syndrome (non-ST-ACS) patients. Methods: We recruited consecutive patients with non-ST-ACS. The NLR was obtained and stratified as low, intermediate, and high-risk based on <3.0, 3.0-6.0, and >6.0, respectively. The new ST-T changes, arrhythmias, contrast-induced nephropathy (CIN), and mortality were recorded. Results: Median NLR was 3 [2.1-5.3] for 346 patients with 19.9% and 30.6% in high- and intermediate-risk group. New ST-T changes were observed in 3.5% (12) out of which 8, 3, and 1 patient in low, intermediate, and high-risk group (p = 0.424), respectively. Arrhythmias were observed in 5.8% (20) with 7, 5, and 8 patients in low, intermediate, and high-risk group (p = 0.067), respectively. CIN was observed in 4.9% (17) with 5, 5, and 7 in low, intermediate, and high-risk group (p = 0.064), respectively. In-hospital mortality was recorded in 1.4% (5) with 2 and 3 patients in high and low-risk group (p = 0.260), respectively. Conclusion: A significant number of non-ST-ACS patients fall in the high-risk category of NLR. Although, the association between NLR and in-hospital mortality and adverse events was not statistically significant but relatively higher rates of events were observed in high risk group.

Prognostic Significance of Electrocardiography, Echocardiography, and Troponin in Patients Admitted With Non-ST Elevation Myocardial Infarction.

BACKGROUND: Non-ST segment elevation myocardial infarction (NSTEMI) is a clinical condition characterized by typical symptoms of myocardial ischemia along with electrocardiographic changes and a positive value of troponin. After presentation in the emergency department, these patients have their troponin I value and electrocardiography done. Echocardiography (echo) should also be performed on these patients. This study was conducted to determine the prognostic significance of ECG, echo, and troponin. METHODS: This observational study was conducted at a tertiary care cardiac hospital on 221 diagnosed patients of NSTEMI. Electrocardiography was performed to see any particular resting ECG findings and the peak values of cardiospecific troponin were analyzed for associations with major adverse events after a six-month period of follow-up. On echo, the left ventricular ejection fraction was divided into two categories: left ventricular ejection fraction (LVEF) <40% and LVEF >40%. RESULTS:  The most frequent finding on presenting ECG was ST depression in anterior leads (V1-V6) in 27.6%. Median troponin I at presentation was 3.2 ng/dl and the median ejection fraction was 45%. The overall all-cause mortality rate at six months was observed to be 8.6%; re-infarction in 5%, re-hospitalization in 16.3%, and heart failure in 25.3% were observed. However, mortality was higher for patients with baseline ECG findings of A-fib, generalized ST-depression, poor R-wave progression, Wellens sign, and T-wave inversion in inferior; the mortality rate was also relatively higher among patients with poor LVEF (<30%). CONCLUSION: ECG and echo were prognostically significant and with the combined incidence of adverse events. However, troponin lacks prognostic significance at six months.

Impact of COVID-19 on cardiovascular clinics: Are we ready for telemedicine?

Objective: The need for telemedicine was felt more than ever during the COVID-19 pandemic, which impacted health care worldwide. Therefore, this study aimed to determine the difficulties faced by patients in visiting the cardiac outpatient department during COVID-19, along with assessing the awareness and acceptability of telemedicine. Methods: In this cross-sectional study, selected patients presenting to outpatient department of a tertiary care cardiac hospital were interviewed regarding the difficulties faced by patients in visiting the outpatient department during COVID-19 and their awareness and acceptability of telemedicine using a self-designed structured questionnaire. Results: Of the 403 patients, 58.3% were male, the mean age was 53.04 ± 11.73 years, and most (77.7%) were urban residents. Ischemic heart disease was present in 69.5%, followed by hypertension (38.7%) and heart failure (29.3%). A total of 26.6% required emergency room visits. Limited appointments (55.6%) was the most common problem faced by patients during COVID-19, followed by financial issues (17.1%), fear of acquiring infection (13.4%), and limited mobility due to lockdown (22.6%). Only 12.2% were aware of telemedicine, 4.5% had previously used it, and 41.2% were willing to opt for telemedicine in the future. No internet access (39.2%) was the key barrier to the usage of telemedicine, followed by a lack of free medicine (39%) and a lack of a smart device (31.5%). Conclusion: Limited appointments due to COVID-19 restrictions has made it difficult for patients to visit the clinics, which has led to increased emergency room visits. Telemedicine awareness was found to be limited; however, many patients were willing to adopt it provided their limitations could be overcome.

Non-Obstructive Coronaries In Patients Presenting With The Non St-Elevation Acute Coronary Syndrome.

BACKGROUND: Worldwide, cardiovascular diseases are the major cause of mortality and morbidity with acute coronary syndrome as the most common clinical manifestation. In a typical clinical setup, around 30% of the patients presented with "ST-segment elevation myocardial infarction (STEMI)" caused by the complete occlusion of the coronary artery and the remaining 70% with intermittent or partial occlusion of the coronary termed as non-ST elevation The aim of this study was to assess the prevalence and characteristics of non-obstructive coronary arteries among patients presenting with non ST-elevation acute coronary syndrome (NSTE-ACS) at a tertiary care cardiac center of Karachi, Pakistan. METHODS: This was a descriptive cross-sectional study, conducted at a tertiary care hospital in Karachi. Study inclusion criteria were patients of either gender admitted with NSTE-ACS and aged between 30-70 years. A routine coronary angiogram was performed in all the patients and the absence of ≥50% stenosis in any major epicardial vessel was taken in non-obstructive coronaries. RESULTS: A total of 174 patients (30-70 years) were included, of which 99 (56.9%) were male and the mean age was 59.43±11.24 years. In the distribution of socioeconomic status, 54 (31.0%) were lower class, middle class 81 (46.6%) while upper-class status were 39 (22.4%). Hypertension was observed in 76 (43.7%), chronic kidney disease in 20 (11.5%), and hyperlipidemia in 55 (31.6%). Non-obstructive coronary arteries were noted in 25 (14.4%) patients. CONCLUSIONS: It is to be concluded that non-obstructive coronary arteries are fairly prevalent in patients arriving in hospitals with NSTE-ACS in our population. Further research is needed to better understand the underlying pathophysiology and optimal management strategies for patients with NOCA in the setting of NSTEMI.

Does Diagnostic Laparoscopy Still Have a Role in the Evaluation of Right Iliac Fossa Pain Versus Imaging Techniques or Experience?

Background Right iliac fossa (RIF) pain is the most common cause of emergency surgical presentation, and a significant number of patients are eventually diagnosed with acute appendicitis. Typically, appendicitis is a clinical diagnosis, and it is prudent to take the patient to theatre for an early diagnostic laparoscopy (DL) to prevent complications as a result of acute appendicitis with the caveat it may lead to an increased number of negative appendectomies. The primary objective of this study was to ascertain the efficacy of DL in tackling RIF pain. The secondary objective was to compare the results among the diagnostic versus imaging groups (negative appendectomy rate, postoperative complications, and length of stay). Methodology The data were collected retrospectively for patients presenting with RIF pain in the surgical unit of the Royal Oldham Hospital between April 2017 and March 2019. The electronic database was utilized to identify all patients who underwent appendicectomy during this period. Patients were divided into two groups, group one had DL as their primary operation, and group two had imaging prior to surgery. Group two was further subdivided into computed tomography (CT) and ultrasonography (USG). Data included blood results, imaging reports, intraoperative findings, length of stay (LOS), postoperative complications, and histopathology results. The data were analysed using an Excel sheet and SPSS version 27 (IBM Corp., Armonk, NY, USA). Results A total of 340 patients were identified. Group one had 165 (48.53%) and group two had 175 (51.47%) patients. Most surgeries were carried out by middle-grade doctors (80.95%). Comparison with the histopathology report revealed that the negative appendectomy rate was 20% in group one, 3.8% in the CT group, and 27.5% in the USG group. The average length of stay was 2 ± 1.38 days in the diagnostic group and 3 ± 2.7 and 3 ± 0.8 days in subsequent groups. Conclusions This study shows that DL is a valuable first option when trained surgeons are available for tackling RIF pain, particularly in the young age group where it can reduce the risk of radiation exposure, decrease LOS, and avoid complications because of perforation.

Solve study: a study to capture global variations in practices concerning laparoscopic cholecystectomy.

BACKGROUND: There is a lack of published data on variations in practices concerning laparoscopic cholecystectomy. The purpose of this study was to capture variations in practices on a range of preoperative, perioperative, and postoperative aspects of this procedure. METHODS: A 45-item electronic survey was designed to capture global variations in practices concerning laparoscopic cholecystectomy, and disseminated through professional surgical and training organisations and social media. RESULTS: 638 surgeons from 70 countries completed the survey. Pre-operatively only 5.6% routinely perform an endoscopy to rule out peptic ulcer disease. In the presence of preoperatively diagnosed common bile duct (CBD) stones, 85.4% (n = 545) of the surgeons would recommend an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) before surgery, while only 10.8% (n = 69) of the surgeons would perform a CBD exploration with cholecystectomy. In patients presenting with gallstone pancreatitis, 61.2% (n = 389) of the surgeons perform cholecystectomy during the same admission once pancreatitis has settled down. Approximately, 57% (n = 363) would always administer prophylactic antibiotics and 70% (n = 444) do not routinely use pharmacological DVT prophylaxis preoperatively. Open juxta umbilical is the preferred method of pneumoperitoneum for most patients used by 64.6% of surgeons (n = 410) but in patients with advanced obesity (BMI > 35 kg/m2, only 42% (n = 268) would use this technique and only 32% (n = 203) would use this technique if the patient has had a previous laparotomy. Most surgeons (57.7%; n = 369) prefer blunt ports. Liga clips and Hem-o-loks® were used by 66% (n = 419) and 30% (n = 186) surgeons respectively for controlling cystic duct and (n = 477) 75% and (n = 125) 20% respectively for controlling cystic artery. Almost all (97.4%) surgeons felt it was important or very important to remove stones from Hartmann's pouch if the surgeon is unable to perform a total cholecystectomy. CONCLUSIONS: This study highlights significant variations in practices concerning various aspects of laparoscopic cholecystectomy.

Management of Complicated Acute Pancreatitis: The Role of Hub-and-Spoke Model.

OBJECTIVE: To determine the primary and secondary outcomes of patients with complicated acute pancreatitis (CAP) of moderate to severe intensity managed by using the hub-and-spoke model. STUDY DESIGN: An observational study. PLACE AND DURATION OF STUDY: Department of Surgery, North Cumbria Integrated Care, Carlisle, UK, from January 2014 to December 2018. METHODOLOGY: Retrospective analysis of 496 episodes of acute pancreatitis managed in 405 patients was done. Data for demographic features and clinical outcomes were analysed. In patients with recurrent admissions, only index admission was considered for analysis. Complicated acute pancreatitis was defined by using the revised Atlanta classification and included all the acute pancreatitis patients with local and or systemic complications.    Results: The frequency of CAP was 21.7% (88/405). The mean patients' age was 62.11 ± 17.90 years. The intensive therapy unit (ITU) admission rate was 33% (n = 29), whereas the overall intervention rate was 43.2% (n = 38). The in-hospital mortality rate was 10.2% (n = 9), and the overall mortality rate was 14.8% (n = 13). A comparative analysis of clinical outcomes according to the revised Atlanta classification showed that the rate of complications, need for ITU admission, duration of hospital stay, in-hospital mortality and overall mortality were significantly higher in patients with moderately severe AP (MSAP) and severe AP (SAP). CONCLUSION: The rate of progression from mild AP to MSAP and SAP remains high. Patients with CAP are at higher risk of ITU admission, prolonged hospital stay, in-hospital mortality and overall mortality. To improve clinical outcomes, the progression of AP to severer forms should be prevented by developing newer strategies, and in cases where complications have already developed, the mortality rate needs to be improved by developing innovative treatment modalities. KEY WORDS: Acute pancreatitis, Complicated acute pancreatitis, Revised Atlanta classification, Morbidity, Mortality, Survival analysis, Hub and spoke model.

C-Reactive Protein as a Predictor of Complicated Acute Pancreatitis: Reality or a Myth?

Introduction C-reactive protein (CRP) has been reported as a predictor of the severity of acute pancreatitis (AP). However, there is conflicting evidence in the literature. The proposed cut-off values and intervals for best prediction include an absolute value of 150 at 48 hours; an absolute value of 190 at 48 hours; and the interval change in CRP of 90 at 48 hours. The current study assesses the value of CRP at different intervals and cut-offs in predicting complicated acute pancreatitis (CAP) and compares its performance against other available predictors like neutrophil to lymphocyte ratio (NLR); Glasgow scoring system and modified CT severity index (MCTSI).  Methods Analysis of prospectively maintained data for index episodes of acute pancreatitis managed in 225 patients over a period of five years (2014-2018) was done. CAP was defined by using revised Atlanta classification and included all the AP patients with local and or systemic complications. It was used as a gold standard. Diagnostic and predictive performance of different biochemical markers and multifactorial scoring systems were determined by analyzing receiving operating curves (ROCs), the area under the curve (AUC), sensitivity, specificity, and predictive values (positive and negative).  Results Out of 225 patients, 122 were female while 103 patients were male. CAP developed in 47 patients (20.9%) while 178 (79.1%) patients had mild AP. Overall, in-hospital mortality rate was 1.8% (n=4). ROC analysis demonstrated that CRP at admission had low discriminatory value (AUC= 0.54, p-value=0.74). CRP at 48 hours had AUC of 0.70 (p-value=0.007). At a cut-off of 150, the positive predictive value (PPV) of 150 was 30 %. The PPV of CRP at 48 hours at a cut-off of 190 was 28%. Interval change in CRP at 48 hours greater than 90 had a PPV of 26 %. Further comparison of CRP with other scoring systems like Glasgow scoring system (AUC= 0.65), NL ratio (AUC=0.54), and MCTSI was performed. Among the single predictors, although, NL ratio showed good sensitivity at a cut-off value of 4.7 (87.23%), however, its discriminatory power was negligible (AUC=0.542, p-value=0.513). The overall best performance was achieved by the MCTSI scoring system at a cut-off of 3 (AUC=0.90, sensitivity=83.33 %, specificity=100%, diagnostic accuracy=94.49%).  Conclusion CRP measured at admission or at 48 hours has a very limited role in the prediction of CAP. Along with other scoring systems, its negative predictive value should be used to predict cases with mild AP which can help in clinical decision making for early discharge or management of such patients on ambulatory care basis. MCTSI scoring system can be used in cases with high suspicion of CAP.

Review-Insights into Off-Label therapeutic strategies against mild and severe COVID-19 infection.

Currently, prevention and control of the coronavirus disease pneumonia epidemic situation are grim globally. To cope with total sheer carriers and patients of COVID-19 requires intensive medical support and adjunctive therapies to overcome the disease. The epidemic can be controlled with the help of both, disease suppression via community health measures and adjunctive therapies for patients suffering from infection. Till date, we do not have any proper anti-COVID-19 therapy. In order to achieve the overall realization of this pandemic, there is a need to identify treatments depending upon their direct or indirect targets; like inhibition of polyprotein synthesis, transmembrane serine protease, inhibition of viral entry and endocytosis. This could be possible by turning the focus in the direction towards the development of numerous tentative drugs, particularly in the severe to badly ill. Though, majority of these off-label adjunctive medicines are being inspected in a lot of clinical trials at different stages, scientific organizations have endeavored to elucidate the situation where these adjunctive drugs might be practiced as off-label, open- label or compassionate. Our review compiles the adjunctive therapies adopted in COVID-19 infected patients according to clinical severity in conjugation with practicing recommendations from existing guidance rules issued by global professional bodies in healthcare.

Diagnostic Performance of Artificial Intelligence-Based Models for the Detection of Early Esophageal Cancers in Barret's Esophagus: A Meta-Analysis of Patient-Based Studies.

Introduction Barret's esophagus (BE) is a precursor of adenocarcinoma of the esophagus. The detection of high-grade dysplasia and adenocarcinoma at an early stage can improve survival but is very challenging. Artificial intelligence (AI)-based models have been claimed to improve diagnostic accuracy. The aim of the current study was to carry out a meta-analysis of papers reporting the results of artificial intelligence-based models used in real-time white light endoscopy of patients with BE to detect early esophageal adenocarcinoma (EEAC). Methods This meta-analysis was registered with the International Prospective Register of Systematic Reviews (PROSPERO; Reg No. CRD42021246148) and its conduction and reporting followed the Preferred Reporting Items for Systematic Review and Meta-Analysis of Diagnostic Test Accuracy (PRISMA-DTA) statement guidelines. All peer-reviewed and preprint original articles that reported the sensitivity and specificity of AI-based models on white light endoscopic imaging as an index test against the standard criterion of histologically proven early oesophageal cancer on the background of Barret's esophagus reported as per-patient analysis were considered for inclusion. There was no restriction on type and year of publication, however, articles published in the English language were searched. The search engines used included Medline, PubMed, EMBASE, EMCARE, AMED, BNI, and HMIC. The search strategy included the following keywords for all search engines: ("Esophageal Cancer" OR "Esophageal Neoplasms" OR " Oesophageal Cancer" OR "Oesophageal Neoplasms" OR "Barrett's Esophagus" OR "Barrett's Oesophagus") And ("Artificial Intelligence" OR "Deep Learning" OR "Machine Learning" OR "Convolutional Network"). This search was conducted on November 30, 2020. Duplicate studies were excluded. Studies that reported more than one dataset per patient for the diagnostic accuracy of the AI-based model were included twice. Quantitative and qualitative data, including first author, year of publication, true positives (TP), false negatives (FN), false positives (FP), true negatives (TN), the threshold of the index test, and country where the study was conducted, were extracted using a data extraction sheet. The Quality Appraisal for Diverse Studies 2 (QUADS-2) tool was used to assess the quality of each study. Data were analyzed using MetaDTA, interactive online software for meta-analysis of diagnostic studies. The diagnostic performance of the meta-analysis was assessed by a summary receiver operating characteristics (sROC) plot. A meta-analysis tree was constructed using MetaDTA software to determine the effect of cumulative sensitivity and specificity on surveillance of patients with BE in terms of miss rate and overdiagnosis. Results The literature search revealed 171 relevant records. After removing duplicates, 117 records were screened. Full-text articles of 28 studies were assessed for eligibility. Only three studies reporting four datasets met the inclusion criteria. The summary sensitivity and specificity of AI-based models were 0.90 (95% CI, 0.83- 0.944) and 0.86 (95% CI, 0.781-0.91), respectively. The area under the curve for all the available evidence was 0.88. Conclusion Collective evidence for the routine usage of AI-based models in the detection of EEAC is encouraging but is limited by the low number of studies. Further prospective studies reporting the patient-based diagnostic accuracy of such models are required.

Novel Use Of Age-Adjusted Charlson Comorbidity Index (ACCI) As A Risk Stratification Tool For Development Of Postoperative SARS-COV-2 Infection In Surgical Patients.

BACKGROUND: Current study documents the role of Age adjusted Charlson Comorbidity Index (ACCI) as a stratification tool for the development of postoperative SARS-CoV-2 infection in surgical patients. METHODS: This prospective cohort study was conducted over the period of 8 weeks starting on 1st of March 2020. Sampling was convenience and purposive and included all consecutive patients who underwent any surgical procedure. Follow up period was 30 days. Outcomes included postoperative SARS-CoV-2 infection, morbidity and 30-day mortality. Risk factors for development of infection were detected by univariate and multivariate analysis. RESULTS: Postoperative SARS-CoV-2 infection developed in 37 cases while 131cases remained confirmed negative. Of 37 patients, 18 were male while 19 were female. Postoperative complications developed in 17 patients (45.9%). In-hospital 30-day mortality was 16.2% (n=6). The factors that increased the chances of postoperative SARS-CoV-2 infection (p<0·00) included increasing age, higher ACCI Score, emergency surgery, trauma, orthopaedic and vascular procedures, spinal anaesthesia, and surgeries of complex nature. In adjusted analyses, predictors of postoperative infection included ACCI score of 4 or more (5.54 [1·51-20.34], p<0·01), and orthopaedics or vascular procedures versus others (12.32 [1.98-76.46], p<0·007). Based on infection rates across the different scores of ACCI, cohort was divided into 3 groups. ACCI score of zero had postoperative SARS-CoV-2 infection rate of 1.9 % (negative predictive value, 98.1%) compared with 36.26% in patients with score of 4 or more (sensitivity, 89.19%). CONCLUSIONS: Low risk surgical patients (ACCI=0) should have universal precautions, while intermediate risk group (ACCI=1- 3) should have extra precautions. The options for high-risk patients (ACCI ≥4) include cancellation of nonurgent surgery; delaying the surgery till optimization of modifiable factors; or reverse isolation/ shielding in perioperative period if surgery cannot be cancelled.

Burden of Tobacco in Pakistan: Findings From Global Adult Tobacco Survey 2014.

Introduction: The Global Adult Tobacco Survey (GATS) is the global standard for systematically monitoring adult tobacco use and tracking key tobacco control indicators. Methods: Using a multistage stratified cluster design, 9856 households were sampled, and one individual was randomly selected from each household. Standard GATS questionnaire was used to collect information on tobacco use, cessation, second-hand smoke, knowledge, attitudes, and perceptions. Data were analyzed per standard GATS protocol. Results: Of 9856 individuals, 7831 individuals completed the interview. The response rate was 81%. Overall, 19.1% adults were currently using tobacco products and among them, 12.4% smoked tobacco, and 7.7% smokeless tobacco. Exposure to second-hand smoke was seen in 86% in a restaurant while it was 76% on public transportation. A total of 24.7% smokers made a quit attempt in the past 12 months. Anticigarette smoking information was observed by 37.7% adults, while 29.7% current smokers thought about quitting after reading health warning labels on cigarette packages. Most (85%) adults favored no smoking in public places, and 74.8% favored increasing taxes on tobacco products. Current cigarette smokers spent Pakistani Rupees 767.3 per month (7.78 USD) on manufactured cigarettes and consumed 4500 cigarette sticks (225 packs) annually. Conclusions: Besides 19.1% tobacco users, the majority (86%) were exposed to second-hand smoke at public places indicating that ban on tobacco use in public places is not being followed. A quarter of current smokers wants to quit smoking who may be provided assistance to reduce tobacco burden. Implications: This study provides national-level data about tobacco use and its burden and also indicates weak implantation of tobacco control laws. There is need to devise a strategy for proper implementation of these laws to reduce the tobacco burden in the country.

Laparoscopic Splenectomy Alone for Sickle Cell Disease: Account of 50 paediatric cases.

OBJECTIVES: In Oman, the most frequent indication for a splenectomy in children is sickle cell disease (SCD), which is one of the most common haematological disorders in the Gulf region. This study aimed to describe paediatric laparoscopic splenectomies alone for SCD at a tertiary hospital in Oman. METHODS: This study was conducted between February 2010 and October 2015 at the Sultan Qaboos University Hospital, Muscat, Oman. The medical records of all children aged ≤15 years old undergoing splenectomies during the study period were reviewed. RESULTS: A total of 71 children underwent laparoscopic splenectomies during the study period; of these, 50 children (28 male and 22 female) underwent laparoscopic splenectomies alone for SCD. The children's weight ranged between 11-43 kg. The most common indication for a splenectomy was a recurrent splenic sequestration crisis (92%). Surgically removed spleens weighed between 155-1,200 g and measured between 9-22 cm. Operative times ranged between 66-204 minutes and intraoperative blood loss ranged between 10-800 mL. One patient required conversion to an open splenectomy. Postoperative complications were noted in only four patients. The median hospital stay duration was three days. CONCLUSION: Among this cohort, the mean operating time was comparable to that reported in the international literature. In addition, rates of conversion and postoperative complications were very low. These findings indicate that a laparoscopic splenectomy alone in paediatric patients with SCD is a feasible option.

Paediatric Blunt Torso Trauma: Injury mechanisms, patterns and outcomes among children requiring hospitalisation at the Sultan Qaboos University Hospital, Oman.

OBJECTIVES: Trauma is the greatest cause of morbidity and mortality in paediatric/adolescent populations worldwide. This study aimed to describe trauma mechanisms, patterns and outcomes among children with blunt torso trauma admitted to the Sultan Qaboos University Hospital (SQUH) in Muscat, Oman. METHODS: This retrospective single-centre study involved all children ≤12 years old with blunt torso trauma admitted for paediatric surgical care at SQUH between January 2009 and December 2013. Medical records were analysed to collect demographic and clinical data. RESULTS: A total of 70 children were admitted with blunt torso trauma during the study period, including 39 (55.7%) male patients. The mean age was 5.19 ± 2.66 years. Of the cohort, 35 children (50.0%) received their injuries after having been hit by cars as pedestrians, while 19 (27.1%) were injured by falls, 12 (17.1%) during car accidents as passengers and four (5.7%) by falling heavy objects. According to computed tomography scans, thoracic injuries were most common (65.7%), followed by abdominal injuries (42.9%). The most commonly involved solid organs were the liver (15.7%) and spleen (11.4%). The majority of the patients were managed conservatively (92.9%) with a good outcome (74.3%). The mortality rate was 7.1%. Most deaths were due to multisystem involvement. CONCLUSION: Among children with blunt torso trauma admitted to SQUH, the main mechanism of injury was motor vehicle accidents. As a result, parental education and enforcement of infant car seat/child seat belt laws are recommended. Conservative management was the most successful approach.

Factors responsible for the prolonged stay of surgical neonates in intensive care units.

OBJECTIVES: The length of hospital stay (HS) for patients is a major concern due to its social, economic and administrative implications; this is particularly important for neonates admitted to intensive care units (ICUs). This study aimed to determine the factors responsible for prolonged HS in surgical neonates. METHODS: This retrospective study was conducted at Sultan Qaboos University Hospital, in Muscat, Oman. The medical records of 95 neonates admitted to the neonatal ICU who underwent general surgical procedures between July 2009 and June 2013 were reviewed. Mann-Whitney U and Pearson's Chi-squared tests were used for non-parametric numerical and categorical variables, respectively. A multiple regression analysis was performed to find a relationship between the variables and to detect the most important factor responsible for prolonged HS. A P value of <0.05 was considered statistically significant. RESULTS: Gestational age, birth weight, number of days on a ventilator and postoperative morbidity were associated with prolonged HS. Furthermore, the age of neonates at first full enteral feed was associated with increased HS using both independent and multiple regression analyses. CONCLUSION: Prolonged HS can occur as a result of many factors. In this study, a number of factors were identified, including low gestational age, low birth weight, increased number of days on a ventilator and postoperative morbidity. Additionally, neonate age at first full enteral feeds also correlated with increased HS. Further research on this topic is suggested to explore this correlation in more detail and to inform future practices.

Infected hydrocele of the canal of nuck.

Hydrocele of the canal of Nuck in children is rare. It may present as incarcerated inguinal hernia and necessitates emergency exploration. Risk of infection in hydrocele of the canal of nuck is very rare. We present a case report of a 5-year-old girl who presented with a left tender inguinolabial region swelling with fever, tachycardia, and mild dehydration. The clinical features were suggestive of strangulated left inguinal hernia and further imaging and surgical exploration revealed it to be an infected hydrocele of the canal of Nuck. High ligation and hydrocelectomy were performed. Hydrocele of the canal of Nuck in a female child presenting with an inguinal swelling should be considered in differential diagnosis.

Cost Comparison between Laparoscopic and Open Appendectomies in Children.

OBJECTIVES: Laparoscopic appendectomy (LA) for children has become very popular and is routinely performed in most health care centres around the world. The cost of surgical procedures is always a concern for patients and health care providers. This study compares, the total cost of open appendectomy (OA) with LA in children who required an appendectomy for acute appendicitis. Suitable and safe cost-effective techniques were also explored to reduce the cost of these procedures. METHODS: The medical records of all the children (ranging between 0 and 12 years) at Sultan Qaboos University Hospital in Oman, who required OA or LA from June 2009 to July 2011, were reviewed. RESULTS: LA were performed in 75 patients while OA were done in 34. Patients from the OA and LA groups were age- and gender-matched. The average operative time was 76 minutes for LA and 49 minutes for OA (P <0.001) while the average hospital stay was 3.14 days for LA and 2.15 days for OA (P = 0.08). The average cost of the two procedures was Omani riyals (OMR) 534 for LA and OMR 343 for OA (P = 0.00). The complication rate following procedures was lower in the case of LA, however this was not statistically significant (LA = 8% versus OA = 11.7 %, P = 0.32). CONCLUSION: LA are costlier procedures than OA, however they are as safe as OA, and do not increase morbidity or the duration of hospital stay.

Asymptomatic Ileal Schwannoma presenting as a Mesenteric Tumour: Case report and review of literature.

A schwannoma is a benign tumour which arises from the schwann cells of the central or peripheral nervous system. Common sites include the head and limbs; it is rare that this tumour arises from the gastrointestinal tract's neural plexus. It is even rarer to find the ileum as the site of origin. We report a patient who presented with a central abdominal mass which was preoperatively diagnosed as a mesenteric tumour. However, immunohistochemistry of the surgically-removed specimen proved it to be a benign ileal schwannoma.

Extra-luminal Air Fluid Level on Abdominal X-ray of a Patient with Isolated Jejunal Blow Out: Case report.

Patients with trivial blunt abdominal trauma may present with isolated jejunal blow out (IJBO). A high index of suspicion is required as delayed presentation or delayed diagnosis may increase morbidity. Presentation with frank perforation peritonitis can be diagnosed by abdominal X-rays. We report the case of a patient who presented with features of peritonitis 10 days after being injured by a knee kick trauma. An erect abdominal X-ray showed extraluminal air-fluid levels, suggesting a hollow viscous injury which on exploration was found to be IJBO.