Global treatment of haemorrhoids-A worldwide snapshot audit conducted by the International Society of University Colon and Rectal Surgeons.

AIM: There is no universally accepted treatment consensus for haemorrhoids, and thus, management has been individualized all over the world. This study was conducted to assess a global view of how surgeons manage haemorrhoids. METHODS: The research panel of the International Society of University Colon and Rectal Surgeons (ISUCRS) developed a voluntary, anonymous questionnaire evaluating surgeons' experience, volume and treatment approaches to haemorrhoids. The 44 multiple-choice questionnaire was available for one month via the ISUCRS email database and the social media platforms Viber and WhatsApp. RESULTS: The survey was completed by 1005 surgeons from 103 countries; 931 (92.6%) were in active practice, 819 (81.5%) were between 30 and 60 years of age, and 822 (81.8%) were male. Detailed patient history (92.9%), perineal inspection (91.2%), and digital rectal examination (91.1%) were the most common assessment methods. For internal haemorrhoids, 924 (91.9%) of participants graded them I-IV, with the degree of haemorrhoids being the most important factor considered to determine the treatment approach (76.3%). The most common nonprocedural/conservative treatment consisted of increased daily fibre intake (86.9%), increased water intake (82.7%), and normalization of bowel habits/toilet training (74.4%). Conservative treatment was the first-line treatment for symptomatic first (92.5%), second (72.4%) and third (47.3%) degree haemorrhoids; however, surgery was the first-line treatment for symptomatic fourth degree haemorrhoids (77.6%). Rubber band ligation was the second-line treatment in first (50.7%) and second (47.2%) degree haemorrhoids, whereas surgery was the second-line treatment in third (82.9%) and fourth (16.7%) degree symptomatic haemorrhoids. Rubber band ligation was performed in the office by 645(64.2%) of the participants. The most common surgical procedure performed for haemorrhoids was an excisional haemorrhoidectomy for both internal (87.1%) and external (89.7%) haemorrhoids - with 716 (71.2%) of participants removing 1, 2 or 3 sectors as necessary. CONCLUSION: Although there is no global haemorrhoidal treatment consensus, there are many practice similarities among the different cultures, resources, volume and experience of surgeons around the world. With additional studies, a consensus statement could potentially be developed.

Protocol for conducting advanced cyclic tests in lithium-ion batteries to estimate capacity fade.

Using advanced cyclic testing techniques improves accuracy in estimating capacity fade and incorporates real-world scenarios in battery cycle aging assessment. Here, we present a protocol for conducting cyclic tests in lithium-ion batteries to estimate capacity fade. We describe steps for implementing strategies for accounting for variations in rest periods, charge-discharge rates, and temperatures. We also detail procedures for validating tests experimentally within a climate-controlled chamber and for developing an empirical model to estimate capacity fading under various testing objectives. For complete details on the use and execution of this protocol, please refer to Mulpuri et al.1.

A comparative study on effects of defect closure versus non-closure in laparoscopic totally extraperitoneal repair of direct inguinal hernia.

Introduction: Totally extraperitoneal (TEP) and transabdominal preperitoneal (TAPP) repair are the principal techniques in laparoscopic hernia repair. Seroma formation and pain are frequent complications of moderate-large size laparoscopic direct inguinal hernia mesh repair. This study was conducted to evaluate the feasibility of defect closure in moderate-large direct inguinal hernias and its effect on various outcomes. Method: This is a prospective cohort study from September 2020 to August 2021, where a total of 88 patients with uncomplicated direct inguinal hernia (M3 or more) were enrolled in the study and divided into two equal groups of TEP defect closure and non-closure, and various outcome measures were noted. Results: The majority of patients were male (94.31%), with a mean age range of 18-85 years, and had right-sided inguinal hernia (46.5%). Seroma formation at 10th POD in the defect closure and non-closure were 24% and 33% (p value: 0.225), which reduced to 11% and 18%, respectively, at 1 month (p value: 1.000). All seromas resolved within 6 months. Pain in VAS at 10th POD in the defect closure and non-closure were 1.55±0.571 and 1.38±0.527, respectively (p value: 0.121), which gradually decreased to 1.20±0.524 and 1.16±0.420 at a 6-month interval (p value: 0.689). The mean operative time in the bilateral and unilateral defect closure groups was 72.3±4.1 and 56.5±4.3 min, respectively, whereas that in the bilateral and unilateral defect non-closure groups was 62.3±3.7 and 45.7±3.6 min, respectively. Conclusion: The defect closure was found to have higher pain and less seroma formation at various intervals of time following TEP for moderate-large direct inguinal hernia. Although these findings were statistically insignificant, they may be clinically significant, and further studies with a larger sample size are suggested.

Loco-regional recurrence of adrenocortical carcinoma: A case report.

INTRODUCTION: Adrenocortical carcinoma (ACC) is a rare and aggressive endocrine malignancy with a high recurrence rate. Approximately half of the patients are asymptomatic, while others experience symptoms due to the tumor's size or hormone secretion. Ro resection if possible is the best option for treatment of primary as well as locoregional recurrent ACC. CASE PRESENTATION: A 20-year-old female who previously underwent open left adrenalectomy for Stage III ACC presented with complaints of heaviness and vague discomfort in the left upper abdomen. Current hormonal assays were normal. Imaging revealed a lesion in the spleen suggestive of recurrence. She underwent elective surgery involving en bloc resection of the spleen, diaphragm, and associated structures. Postoperative recovery was uneventful, histopathology confirmed recurrence and subsequent PET-CT showed no recurrence. She is currently on mitotane and remains symptom-free with no signs of recurrence after initial surgery. CLINICAL DISCUSSION: Complete resection (Ro) if possible, for recurrent and metastatic disease has been linked to long-term survival and offers significant palliative benefits, particularly in cases involving symptomatic steroid production. CONCLUSION: ACC has a high frequency of local recurrence therefore management of recurrence should be considered from the initial diagnosis. Ro resection of recurrence is the best potential treatment. Follow-up protocols and improving integration between surgical, oncological, and supportive care departments are crucial for overcoming healthcare challenges in Nepal.

Unraveling capacity fading in lithium-ion batteries using advanced cyclic tests: A real-world approach.

Battery lifespan estimation is essential for effective battery management systems, aiding users and manufacturers in strategic planning. However, accurately estimating battery capacity is complex, owing to diverse capacity fading phenomena tied to factors such as temperature, charge-discharge rate, and rest period duration. In this work, we present an innovative approach that integrates real-world driving behaviors into cyclic testing. Unlike conventional methods that lack rest periods and involve fixed charge-discharge rates, our approach involves 1000 unique test cycles tailored to specific objectives and applications, capturing the nuanced effects of temperature, charge-discharge rate, and rest duration on capacity fading. This yields comprehensive insights into cell-level battery degradation, unveiling growth patterns of the solid electrolyte interface (SEI) layer and lithium plating, influenced by cyclic test parameters. The results yield critical empirical relations for evaluating capacity fading under specific testing conditions.

Uropathogens and their antimicrobial-resistant pattern among suspected urinary tract infections patients in eastern Nepal: A hospital inpatients-based study.

Background: Urinary tract infections are the primary factors that cause mortality and morbidity in patients with underlying comorbid conditions and are responsible for most hospital admissions worldwide. Objectives: The study aims to identify the common bacterial uropathogens and determine their antimicrobial susceptibility pattern, including multidrug-resistant/extensively drug-resistant bacteria. Methods: The descriptive cross-sectional study was conducted among inpatients provisionally suspected of urinary tract infections in the medical ward of Koshi Hospital, Biratnagar, Nepal. Samples were inoculated in a cystine lysine electrolyte-deficient medium, and pure growth of significant bacteria was further subjected Gram staining, biochemical identification, and antimicrobial susceptibility testing as per laboratory standard procedure and Clinical Laboratory Standards Institute guidelines, respectively. Descriptive and inferential statistical analysis was performed to analyze the outcomes and a p-value < 0.05 was considered statistically significant. Results: A total of 305 patients urine specimens were examined, of which 251 (82.29%) samples resulted in significant bacterial growth in the culture. Escherichia coli (62.94%) was the most predominantly isolated organism, followed by Klebsiella pneumoniae (12.35%), Staphylococcus aureus (9.16%), and Pseudomonas aeruginosa (8.76%). Among antimicrobials, colistin had shown absolute susceptibility (100%) toward gram-negative uropathogens followed by carbapenem and aminoglycosides in a majority of uropathogens. Escherichia coli was found to be the leading drug-resistant bacteria (70%) among uropathogens. The presence of multidrug-resistant/extensively drug-resistant bacteria uropathogens was found to be significantly associated with diabetes mellitus and those with combined antimicrobial therapies. Diabetic patients were twice (OR~2) more likely to colonize and develop uropathogens as compared to non-diabetics. Conclusion: Escherichia coli was the most common uropathogens followed by Klebsiella pneumoniae in urinary tract infection patients. The polymyxin group (colistin) of antimicrobials was found to be effective in all multidrug-resistant and extensively drug-resistant uropathogens. The study recommends the need of optimized antimicrobial stewardship program to develop effective strategies in the management of urinary tract infections in diverse healthcare settings.

Reporting of Medical Errors in Autopsied Cases.

This report describes the cases autopsied at B. P. Koirala Institute of Health Sciences- Nepal, during the period of two years in which the treatment provided falls below the accepted standard practice causing the death of the patient. Postmortem examination provides an opportunity to find out the actual cause of death in which the cause of death is suspicious. Sometimes the cause of death found through postmortem examination is different from the clinical cause of death. The autopsy finding on the cause of death will help doctors even to think about unusual conditions that lead to death and hence apply preventive measures for those unusual conditions. The cause of medical error is not always due to the doctor's mistake, but sometimes also due to the obsolete hospital protocol. The autopsy reporting of medical errors can be used to identify lacunae in hospital protocols, problem-prone clinical processes and suggest interventions that may reduce negligence.