Interns' perspectives about communicating bad news to patients: a qualitative study.

INTRODUCTION: Communicating bad news to patients and families is an essential skill for physicians but can be difficult for interns. Very little is known about skills in this area for interns in developing countries. METHOD: Two focus groups, consisting of a total of 12 interns, were conducted in the Seth G.S. Medical College and KEM Hospital in Mumbai, India. The grounded theory approach was used to identify common themes and concepts, which related to: (1) barriers in communicating bad news, (2) interns' confidence in communicating bad news, (3) interns' perceptions about their need for such training and (4) interns' suggested methods for training. RESULTS: Interns described barriers in time constraints, language, their personal fears, patients' illiteracy, crowded wards with no privacy and lack of training. All interns lacked confidence in breaking news of death, but seven were confident in breaking bad news about chronic diseases or cancers. Subjects reported they had received very little classroom teaching or formal instruction in this area, though they had had opportunities to observe a few instances of breaking bad news. They expressed need for increased focus on communication skills curriculum in the form of case discussions, workshops and small group teaching, in addition to clinical observation. CONCLUSIONS: Interns in our school in Mumbai reported inadequate training and low comfort and skill in communicating bad news and expressed need for focused training.

Influence of timing on performance of laparoscopic cholecystectomy for acute biliary pancreatitis.

AIM: Gallstone disease is the most common cause of acute pancreatitis. Cholecystectomy is mandatory to avoid recurrence of pancreatitis. Our objective was to evaluate the results of laparoscopic cholecystectomy (LC) in patients with gall-stone induced pancreatitis. METHODS: All patients presenting to us within the time frame from February 2004 to June 2008 with acute biliary pancreatitis were included in the study. The severity of pancreatitis was assessed by Ranson's criteria. ERCP and endoscopic sphincterotomy was performed when the common bile duct (CBD) was dilated (>6 mm) with either calculi or sludge as seen on imaging. Patients with successful ERCP with predicted demanding laparoscopic cholecystectomy were discharged instead for an elective LC, 4-6 weeks later. Patients with mild pancreatitis (with Ranson's score of 3 or less) and predicted uncomplicated LC underwent surgery at the same admission. The difficulty of the procedure was determined by the presence of adhesions in the gallbladder area, dissection in Calot's triangle, tackling the dilated cystic duct, intra-operative bleeding, and the need for a drain. RESULTS: A total of 26 patients (12 male and 14 female; age range 23-75 years) with acute biliary pancreatitis comprised the study group. Eleven patients with suspected choledocholithiasis underwent ERCP and clearance of the CBD was done in all of them. Nine patients (2 ERCP and 7 non-ERCP) underwent early LC in the same admission. Seventeen patients (9 ERCP and 8 non-ERCP) were predicted as difficult cases for LC and underwent delayed LC. No patient had recurrent pancreatitis in the interval period. CONCLUSION: There was no significant difference in the operative difficulty between early and delayed LC when patients were selected for timing of LC based on pre-defined criteria.

Varied presentations of gastrointestinal stromal tumour.

Gastrointestinal stromal tumours (GIST) are soft tissue tumours arising from the mesenchyma in the gastrointestinal tract. These are rare tumours. However, over the past few years with the better understanding of the pathogenesis of GIST and better imaging facilities, the diagnosis is made more frequently. The characteristic diagnostic feature of GIST is the expression of CD34 and receptor tyrosine kinase KIT, CD117 by these tumours. The use of tyrosine kinase inhibitor imatinib mesylate has led to improved outcome. The presentation of GIST however remains non-specific, and varies depending upon the size and the organ of origin. We present a series of four cases of GIST with varied presentation.

Laparoscopic splenectomy using conventional instruments.

INTRODUCTION: Laparoscopic splenectomy (LS) is an accepted procedure for elective splenectomy. Advancement in technology has extended the possibility of LS in massive splenomegaly [Choy et al., J Laparoendosc Adv Surg Tech A 14(4), 197-200 (2004)], trauma [Ren et al., Surg Endosc 15(3), 324 (2001); Mostafa et al., Surg Laparosc Endosc Percutan Tech 12(4), 283-286 (2002)], and cirrhosis with portal hypertension [Hashizume et al., Hepatogastroenterology 49(45), 847-852 (2002)]. In a developing country, these advanced gadgets may not be always available. We performed LS using conventional and reusable instruments in a public teaching the hospital without the use of the advanced technology. The technique of LS and the outcome in these patients is reported. MATERIALS AND METHODS: Patients undergoing LS for various hematological disorders from 1998 to 2004 were included. Electrocoagulation, clips, and intracorporeal knotting were the techniques used for tackling short-gastric vessels and splenic pedicle. Specimen was delivered through a Pfannensteil incision. RESULTS: A total of 26 patients underwent LS. Twenty-two (85%) of patients had spleen size more than 500 g (average weight being 942.55 g). Mean operative time was 214 min (45-390 min). The conversion rate was 11.5% (n = 3). Average duration of stay was 5.65 days (3-30 days). Accessory spleen was detected and successfully removed in two patients. One patient developed subphrenic abscess. There was no mortality. There was no recurrence of hematological disease. CONCLUSION: Laparoscopic splenectomy using conventional equipment and instruments is safe and effective. Advanced technology has a definite advantage but is not a deterrent to the practice of LS.

Laparoscopic orchidectomy for undescended testis in adults.

BACKGROUND: Impalpable testis is a significant diagnostic and therapeutic challenge in adults, for both radiologist and surgeons, with few reports in literature addressing this problem in adults. Laparoscopy is a reliable and definitive procedure obviating the necessity of advance investigation and subsequent inguinal exploration in adults. AIMS: To study the utility of laparoscopy as combined diagnostic and therapeutic modality for undescended testis in adults. SETTINGS AND DESIGN: Prospective study from a single surgical unit of a large tertiary referral centre during August 2000 to January 2002. METHODS AND MATERIAL: Nine patients of unilateral undescended testis with average age 22.7 years (range 13-31 years) underwent diagnostic laparoscopy and orchidectomy subsequent to detailed clinical, ultrasound and examination under anaesthesia (EUA) procedure. All patients were operated with one 10 mm umbilical camera port, one suprapubic port and 1 lateral port. RESULTS: None of the patients had palpable testis or an inguinal cough impulse on clinical examination and during EUA. In only 3(33.3%) patients, the ultrasound could locate the testis situated at the deep ring. On laparoscopy all testes were identified, 4 were present at the deep ring, 3 were intra-abdominal and 2 had blind ending vas entering the deep ring. Mesh plug was inserted in the internal ring in these 2 patients, after dissecting the peritoneum. None of the patients had intra or post-operative complications and all were discharged on the next day. CONCLUSION: Laparoscopy is one of the most satisfactory methods for the diagnosis and management of non-palpable testis in adult cryptorchid patients.

Role of computed tomography in the diagnosis of rib and lung involvement in tuberculous retromammary abscesses.

OBJECTIVE: To assess the role of computed tomography (CT) in the diagnosis of rib and lung involvement in tuberculous abscess in the retromammary region. DESIGN AND PATIENTS: Eight patients with tuberculous retromammary abscess were examined by CT and the findings were evaluated. A cold abscess (purulent collection with absence of acute inflammation) was aspirated in all cases. Diagnosis was confirmed by acid-fast bacillus culture, or histologic examination. RESULTS: CT showed a relatively well marginated, inhomogeneous, hypodense lesions in all eight cases. Following administration of intravenous contrast medium, these lesions showed enhancing walls, suggestive of an infective collection. Lung involvement was seen in one patient. A direct communication from the retromammary lesion through the thoracic wall into the pleura was seen in five cases. In four cases destroyed rib fragments within the abscess were noted. CONCLUSION: A tuberculous abscess in the retromammary region is usually shown on CT as a focal, well-marginated, inhomogeneous, hypodense lesion with a surrounding enhancing rim. A direct communication with the pleura, a destroyed rib fragment in the abscess, and associated lung involvement may be revealed by CT.

Necrotising perineal infection: a fatal outcome of ischiorectal fossa abscesses.

INTRODUCTION: Necrotizing perineal infection or Fournier's gangrene is an uncommon but lethal complication of ischiorectal fossa abscesses. It is associated with a high mortality, especially in diabetics and immunocompromised individuals. Attempts have been made to study factors which could serve as prognostic indicators. The role of faecal diversion has not been clearly determined. MATERIALS AND METHODS: The medical records of 8 patients who presented with necrotizing perineal infection as a complication of ischiorectal fossa abscesses were reviewed. Various parameters were studied to see if any of them could serve as predictors of outcome. Mean surface area of involvement was calculated using modified burns assessment criteria. To study the effect of colostomy on the general condition of the patient the physiological and biochemical parameters before and after the procedure were compared. Statistical analysis was done using the unpaired and paired 't' tests. RESULTS: The mean age of the patients was 50.6 +/- 10.3 years. Five patients were diabetic, of whom four died; all the non-diabetics survived. The mean surface area of involvement was 5.1 +/- 0.75%, among the survivors, and 9.6 +/- 3.4% among the non-survivors. Colostomy was performed in four patients one of whom died. While in one patient the colostomy was created along with the initial radical debridement, in three other patients it was formed on days three, five and five, respectively. There was a significant improvement in their general status and biological parameters. All patients with testicular involvement died. CONCLUSION: Evidence of systemic sepsis at presentation, extent of tissue and testicular involvement, a low haematocrit, a high blood urea and creatinine and a low serum albumin, were associated with a higher mortality. Prompt recognition of the condition, urgent radical surgical debridement and the use of appropriate antibiotics are the mainstays of management. Formation of a diverting colostomy appears to favour survival.

Giant prosthesis for reinforcement of visceral sac for complex bilateral and recurrent inguinal hernias: a prospective evaluation.

AIMS: To evaluate giant prosthesis for reinforcement of visceral sac (GPRVS) as a treatment for complex bilateral and recurrent inguinal hernias. SUBJECTS AND METHODS: The prospective study carried out in a single surgical unit at a tertiary health care center involved consecutive series of 31 patients with complex bilateral and recurrent inguinal hernias who underwent GPRVS. All were men and the mean age was 58 years (range 49-95 years). Factors predicting high risk for recurrence included a large hernia ( greater, similar5cms, 32%, 10/31 patients), failure of one or more previous repairs (45%, 14/31 patients), chronic obstructive pulmonary disease (25%, 8/31 patients) and poor muscle tone (70%, 22/31 patients). Operative time, length of postoperative stay, complications and death were the main outcome measures. RESULTS: Mean -/+ SEM operative time was 65 -/+ 11 minutes (range 45-115 minutes). Mean -/+ SEM length of stay was 3.5 -/+ 0.7 days (range 2-5 days). There were 4 minor complications, but no mesh infections and death. Follow up was obtained for a mean period of 14.6 months (range 12-23 months); there were no recurrences. CONCLUSION: GPRVS provides a definitive and safe cure for repair of complex bilateral and recurrent inguinal hernias because of its simplicity, ease of the procedure, good results and low recurrence rate.

Paraesophageal mediastinal drainage with diversion for delayed presentation of esophageal perforation.

Esophageal perforation is a serious condition; a delay of more than 48 hours in initiation of treatment leads to increased morbidity and mortality. Management of such patients is a surgical dilemma. We successfully managed 4 patients (2-iatrogenic, 1-tuberculous, 1-Boerhaave's syndrome) with delayed presentation of esophageal perforation by esophageal exclusion and paraesophageal mediastinal drainage, achieving good control of mediastinal sepsis, healing of perforation and at the same time avoiding thoracotomy and subsequent second surgery.

Shouldice's herniorrhaphy versus Moloney's darn herniorrhaphy in young patients (a prospective randomised study).

AIMS: Shouldice's repair (SR) and Moloney's darn repair (DR) are commonly practised repairs for hernias in the young age group with acceptably low recurrence rates. The SR is considered technically challenging and difficult, while the DR is gaining popularity in recent years. Therefore, there is a need to compare these repairs. MATERIAL AND METHODS: To compare these techniques a total of 50 cases (age group 18-40 years) were randomised to two groups (SR 25, DR 25). These were well matched for age, the side and the type of hernia. Both groups were studied with respect to operative time; postoperative pain at 6,12 and 24 hours (evaluated by pain scale 1-10) need for analgesia, ambulation (evaluated by a four-point scale), complications and return to work. RESULTS: The SR required a longer time (average 81 minutes) compared to DR (average 43 minutes). Patients undergoing SR complained of pain of a higher scale at 6, 12 and 24 hours post surgery and had a significant higher need for analgesia on day 1 and 2 (p < 0.05). Ambulation grades were significantly better in the DR group on the first postoperative day (p < 0.05). There was no significant difference in the two groups with respect to postoperative complications, return to work, and recurrences rate (2-year follow-up). CONCLUSION: The SR and DR are comparable for young patients having a primary hernia. However, DR is superior in terms of the time taken, post-operative pain, need for analgesia and early ambulation.

Spontaneous oesophageal perforation due to mediastinal tuberculous lymphadenitis - atypical presentation of tuberculosis.

Spontaneous non-traumatic oesophageal perforation secondary to bursting of a mediastinal tuberculous abscess into the oesophagus is rare. The diagnosis is delayed, as perforation remains localised due to mediastinal lymph nodes. Patient can be effectively managed by paraoesophageal drainage of the mediastinal abscess and oesophageal diversion.

Synchronous primary adenocarcinoma of small and large bowel.

Synchronous cancer of the small and large bowel is rare. We report a 45-year-old woman with synchronous primary cancer of the jejunum and descending colon who presented with intestinal obstruction.

A study of stress in medical students at Seth G.S. Medical College.

BACKGROUND: It is usually observed that medical students undergo tremendous stress during various stages of the MBBS course. There is a high rate of suicide among them. METHODS: To determine incidence of stress and factors controlling stress in medical students at various stages of MBBS course at Seth G S Medical college, 238 students (First year 98, Second 76, Third 64) were asked to complete a questionnaire on personal data (gender, stay at hostel, mode of travel, time spent in travel every day, medium of study in school, place of school education.), Stress inducing factors, Zung's depression scale, ways of coping, stress relievers, perceived social support and personality type. Statistical tests used were ANOVA, critical ratio and Student's 't' test. RESULTS: Majority of medical students (175/238--73%) perceived stress. Stress was found to be significantly more in Second and Third MBBS students rather than First MBBS levels (p < 0.05). Stress was not found to differ significantly on the basis of sex, stay at hostel, model of travel, time spent in travel every day, medium of study in school, place of school education. Stress was found to be significantly more in students having more than 95% of marks at 12th Standard as compared to others. Academic factors were greater perceived cause of stress in medical students. There was no significant difference in the students at different levels of MBBS regarding academic factors and social factors as a stress inducing factors. Physical factors were found to be significantly more in Second and Third MBBS students as compared to First MBBS students. Emotional factors were found to be significantly more in First MBBS students as compared to Second & Third MBBS students. Stress was more common in medical students who have dominant strategy of coping as positive reappraisal, accepting responsibility and planful problem solving. Stress was less common in medical students at Seth G S Medical College who have dominant strategy of coping as escaping and distancing from difficult situation. Family and Friend as perceived social supports were more in Second MBBS than First MBBS medical students. Stress was not found to be significantly more in students having their personality factor contributing to stress (Type A--52/67) as compared to others (Type B--123/171). This indicates that the stress was not trait oriented but was process oriented (p = NS). CONCLUSION: Stress in medical students is common and is process oriented. It is more in second and third year. Academic factors are greater perceived cause of stress in medical students at Seth G S medical college. Emotional factors are found to be significantly more in First MBBS. It is dependent on person's ways of coping and social support.

Factors predicting morbidity and mortality in intestinal fistulae.

INTRODUCTION: Intestinal fistulae are a daunting clinical problem. AIM: To evaluate the influence of various severity factors on morbidity and mortality in patients with intestinal fistulae. METHOD: In 29 patients with intestinal fistulae, eight severity factors, viz., age, associated bowel disease, anemia, hypoalbuminemia, high-output fistula, category IV fistula, excoriation of skin surrounding the stoma, and sepsis, were analyzed prospectively to assess their effect on healing of fistulae and mortality. Chi-squared test with Yates' correction was used. RESULTS: Age, presence of associated bowel disease, and hemoglobin levels had no significant effect on healing or mortality. Hypoalbuminemia, category IV fistulae, presence of local skin excoriation, and sepsis significantly delayed healing (p < 0.05). High-output fistula, category IV fistula, local skin excoriation, and sepsis were significantly associated with high mortality (p < 0.05). CONCLUSION: Identification of these prognostic factors in intestinal fistulae may guide the need for more intensive care or intervention.