Objective—To examine the influence of socioeconomic deprivation on case fatality following acute ... more Objective—To examine the influence of socioeconomic deprivation on case fatality following acute myocardial infarction. Design—Prospective cohort observational study. Setting—General hospital. Patients—1417 white and south Asian patients admitted with acute myocardial infarction between January 1988 and December 1996, and classified by the Carstairs socioeconomic deprivation score of the enumeration district of residence. Main outcome measures—30 day and one year survival. Results—There was little variation across deprivation groups in age, sex, or smoking status, though a higher proportion of patients from more deprived enumeration districts were diabetic and of south Asian origin, and a higher proportion of them developed Q wave infarction and left ventricular failure. There was no appreciable variation in clinical treatment with deprivation. Patients from more deprived enumeration districts had a higher risk of recurrent ischaemic events (death, recurrent myocardial infarction, o...
ABSTRACT Background & Objective: Most plastic surgeries are performed on an ambulatory ba... more ABSTRACT Background & Objective: Most plastic surgeries are performed on an ambulatory basis. While patient safety is a priority for plastic surgeons, many are unaware of the current ASA preoperative fasting guidelines.1-3 Decades of research attest to the safety and health benefits of consuming carbohydrate-rich clear liquids 2 hours before elective surgery. This best evidence is rarely put into practice. The objective of this study was to assess the effects of such a beverage (Clearfast® ) on patients’ discomforts from preoperative fasting and their safety and compliance. Methods: A two-part multicenter, prospective clinical trial involved ASA Risk I-II adult patients having elective plastic, orthopedic or general surgical procedures at 5 hospitals. Part I was a descriptive observational pilot (n=263: Controls =108; Intervention =155). Part II was an IRB approved randomized trial (n=34: Controls =21; Intervention =13). All sites had previously adopted the ASA guidelines that determined patient eligibility. Exclusion criteria were pregnancy, obesity and GERD. Control groups observed the traditional midnight fast; Intervention groups consumed a carbohydrate-rich drink (Clearfast® ) about 2 hours pre-op. Patient demographics, length of fasting, occurrence of regurgitation and/or aspiration and patient preoperative questionnaires assessing thirst, hunger, headache, nausea, anxiety about fasting and surgery plus discomfort were analyzed by a biostatistician. Results: Regurgitation, aspiration, or other perioperative complications did not occur in Part I or II. Binary logistic regression model of Part I showed that if patients (1) did not have Clearfast®, (2) had surgical anxiety or (3) had fasting anxiety, or (4) had all three, they were (1) 5.7, (2) 4.1, (3) 2.7 or (4) 63 times more likely to be uncomfortable with their preoperative experience. Mann-Whitney mean rank scores from the pooled data (n=297) indicated that, if patients did not consume Clearfast®, they were more likely to be thirsty (P=0.00), hungry (P<0.05), nauseous (P<0.05), anxious about both fasting and surgery (P<0.05) and uncomfortable (P=0.00). Control vs. Intervention fasting times were markedly different: 5-20 vs. 2-5 hours (P=0.00). Conclusions: In appropriately selected patients, following the ASA guidelines and using a preoperative carbohydrate-rich beverage 2 hours prior to elective ambulatory surgery resulted in significantly shorter fasting times, reduced thirst, hunger, anxiety and nausea and improved comfort. Plastic surgeons should be aware of and comply with these guidelines to improve patient safety and satisfaction.
Johor River is a major raw water supplier for a highly populated region, Johor state as well as S... more Johor River is a major raw water supplier for a highly populated region, Johor state as well as Singapore. Because of the development over the entire catchment, water quality has become a sensitive matter. For this reason, several studies have been carried out in order to investigate its affects on the environment. Computer simulation and Numerical model are considered as essential and powerful tools in water resources monitoring plan in decision-making process. HEC-RAS is integrated system software designed to perform one dimensional hydraulic calculation. It was used to estimate the hydraulic changes due to the hydrological alteration of Johor River in response to the change of river discharges and to calculate the sediment transport capacity. Also in this study, QUAL2E was used as the water quality modeling analysis tool. It is suitable for one-dimensional analysis with constant flow and it is applied to predict the water quality model for the Johor River. The model was used to s...
This research paper is an attempt to explore the image of Islam manifested in the post 9/11 Ameri... more This research paper is an attempt to explore the image of Islam manifested in the post 9/11 American literary contexts, an image that revives in the Orientalist studies that intellectually emerged as NeoOrientalism. In their discourses, many neo-Orientalists overemphasize a distorted image of Islam as an anti-modern, anti-democratic, and antiWestern ideology that is based on antagonism and terrorism against the non-Muslim Western ‘Other’. Consequently, Muslims are distortedly depicted as terrorists who hold a Jihadist agenda against Westerners generally and Americans particularly. These neo-Orientalist misrepresentations of Islam and Muslim have highly affected the post 9/11 American literary canon. Published in 2006, John Updike’s Terrorist is considered one of the remarkable novels that centers on examining the nature of Islam and the features of Muslims, within the framework of neo-Orientalism. Pivoting around Edward Said’s antiOrientalist approach, this study aims at offering a ...
Background Rheumatic heart disease (RHD) was found in the THESUS-HF registry to be the third most... more Background Rheumatic heart disease (RHD) was found in the THESUS-HF registry to be the third most common cause of acute heart failure (AHF) in Sub-Saharan Africa. Methods One thousand six patients with AHF from 9 Sub-Saharan African countries were recruited in THESUS-HF, of which 143 (14.3%) had RHD-AHF. Clinical characteristics and outcomes in patients with RHD-AHF and non-RHD-AHF were compared. Kaplan-Meier plots for time to all-cause death and/or HF readmission according to the presence of RHD-AHF and non-RHD-AHF were performed and survival distributions compared using the log-rank test. Cox regression was used to determine the hazard ratio of death to day 180 and death or readmission to day 60 after adjusting for confounders. Results Patients with RHD-AHF were younger, more often females, had higher rates of atrial fibrillation, had less hypertension, hyperlipidemia and diabetes, had lower BP, and higher pulse rate and better kidney function and echocardiographic higher ejection...
We describe a case of acute coronary syndrome and de Winter electrocardiographic pattern treated ... more We describe a case of acute coronary syndrome and de Winter electrocardiographic pattern treated with a pharmaco-invasive approach. We discuss the treatment plan and controversies in management of similar cases in limited resource setting especially the role of fibrinolysis.
Purpose For many types of surgical cases, there is an increase in length with the participation o... more Purpose For many types of surgical cases, there is an increase in length with the participation of a resident physician. The lost operative time productivity is not necessarily mitigated in any fashion other than to benefit the experience of the trainee. Moreover, increasing pressures to maximize productivity, coupled with diminishing reimbursements serve to disincentive resident involvement. The aim of this study was to examine the opportunity cost in the academic setting for intraoperative resident participation during specific hand surgery cases. Methods Retrospective analysis was performed on the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database from 2006 to 2015. Cases were identified by Current Procedural Terminology code to isolate distal radius fracture repairs, carpal tunnel releases, scaphoid fractures repairs, and metacarpal fracture repairs. Variables collected included operation time, presence or absence of resident physician, and postgraduate year level. Statistical analysis was performed using the statistical computing software R 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria). Cost analysis was performed to quantify the effect of operative times in terms of relative value units (RVUs) lost. Results A total of 3727 cases were identified. Of those, 1264 cases were performed with a resident present. Residents participated in cases with higher total RVU (14.91 vs 13.16, P < 0.001). There was a statistically significant increase of 24.3 minutes (P < 0.001) in the mean operation time with a resident present as compared with those without. Moreover, RVU per hour in resident cases was significantly lower by 2.97 RVU per hour or 21% (P < 0.001). Using the late 2018 Medicare physician conversion factor of US $33.9996, the opportunity cost to attending physicians is US $159.20 per case. Conclusions Resident participation in surgical cases is paramount to the education of future trainees, particularly in the era of trainee duty hour reform. Because residents are participating in higher total RVU cases, this selection bias may be playing a role in explaining our result. Nonetheless, resident involvement for certain procedures comes at an opportunity cost to faculty surgeons. How to balance the cost to train residents in the emerging value-based health systems will prove to be challenging but requires consideration.
A Bochdalek hernia is a congenital diaphragmatic hernia that results from a failure of closure of... more A Bochdalek hernia is a congenital diaphragmatic hernia that results from a failure of closure of the pleuroperitoneal folds during embryologic development. While it is most often diagnosed in neonates and infants, Bochdalek hernias can rarely present in adulthood for the first time. We describe the case of a 42-year-old lady who presented with sudden onset of severe abdominal pain following a Zumba dance session. Her chest radiograph showed an elevated left hemi-diaphragm with visualization of a gastric bubble in the thorax. A computed tomography (CT) scan of the abdomen showed a defect in the left hemi-diaphragm with herniation of the stomach and abdominal viscera through the defect. The patient was taken for diagnostic laparoscopy, and the diaphragmatic defect was repaired with a synthetic mesh. Perioperatively, perforation of the anterior wall of the stomach was noted, and a diagnosis of Bochdalek hernia with gastric strangulation was made. This case demonstrates a rare presenta...
the-art research facilities of Fuwai Hospital and the NCCD, and with full support from their visi... more the-art research facilities of Fuwai Hospital and the NCCD, and with full support from their visionary director Professor Hu, this young group's scientific efforts are likely to shed more light into various unresolved issues related to this challenging heart disease. Moreover, the group members have research ambitions to cover all cardiomyopathies and ultimately provide better health care solutions for these patients and their relatives at risk. To this end, they intend to launch a nationwide screening program for cardiomyopathies and establish a comprehensive Chinese database, incorporating detailed clinical and pathological records, imaging data, genetic information, and a largescale biobank in the near future. 'Learning is a treasure that will follow its owner everywhere', says a Chinese proverb. The young clinicians and researchers at Fuwai Hospital are putting tremendous effort to get more in-depth knowledge and experience in their fields of research. Without any doubt, their scientific work will follow them as a treasure and help them and others to understand mechanisms of cardiovascular diseases and improve management strategies.
The growing elderly population necessitates a greater number of aging patients requiring complex ... more The growing elderly population necessitates a greater number of aging patients requiring complex reconstructive surgery involving free tissue transfer. The purpose of this study was to assess the safety, efficacy, and outcomes of microsurgical free tissue transfer in elderly patients using a national multi-institutional database. We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients undergoing free tissue transfer. We stratified cohorts based on ages 18-49, 50-59, 60-69, 70-79, and 80+ years and analyzed primary outcomes of surgical complications, medical complications, mortality, and flap failure. A total of 5,951 patients were identified for inclusion in the analysis. Univariate analysis demonstrated progressively increasing surgical (P = .001) and medical (P &lt; .001) complication rates with increasing age. After controlling for confounding variables, age was not significantly associated with rates of surgical (OR 1.00, 95% CI 0.99-1.01, P = .737) or medical (OR 1.01, 95% CI 0.99-1.03, P = .209) complications, flap failure (OR 1.00, 95% CI 1.00-1.02, P = .689), or reoperation (OR 1.01, 95% CI 1.00-1.03, P = 0.165). Factors associated with surgical complications included BMI (OR 1.03, 95% CI 1.00-1.05, P = .031), prolonged operative time (OR 1.001, 95% CI 1.000-1.002, P = .002), American Society of Anesthesiologists (ASA) classification of 3 or greater (OR 1.62, 95% CI 1.17-2.23, P = .003), and prolonged hospitalization (OR 1.03, 95% CI 1.02-1.04, P &lt; .001). ASA classification of 3 or greater (OR 2.57, 95% CI 1.48-4.45, P = .001), renal history (OR 10.13, 95% CI 1.57-65.55, P = .015), and prolonged hospitalization (OR 1.06, 95% CI 1.04-1.08, P &lt; .001) were associated with medical complications. Age was associated with increased mortality (OR 1.06, 95% CI 1.00-1.13, P = .048). Age alone should not be used as an absolute or even relative contraindication in patient assessment. Rather, preoperative assessment should focus on comorbidities and assessment of physiologic age instead of chronologic age. Optimization of these comorbidities is key to sustaining favorable outcomes in microsurgical free flap reconstruction in the elderly population.
International journal of surgery case reports, Jan 4, 2017
Amyand hernia (AH) is a rare type of hernia characterized by the presence of appendix vermiformis... more Amyand hernia (AH) is a rare type of hernia characterized by the presence of appendix vermiformis in the inguinal hernial sac. It is rarely reported in women. We presented a case of a 60- year old woman who was admitted initially with an abdominal wall abscess and found to have perforated appendix in the right inguinal hernia. The patient underwent standard open appendectomy and the post-operative course was uneventful. The initial presentation of our case as an abdominal wall abscess is rare in the contemporary literature. A high index of suspicious, early diagnosis and timely surgical intervention are the keys to have favorable outcome in amyand hernia. The management should follow general guidelines of appendectomy, hernia repair and dealing with the associated pathology if present.
Background: The role of echocardiography in the risk stratification of acute heart failure (HF) i... more Background: The role of echocardiography in the risk stratification of acute heart failure (HF) is unknown. Some small studies and retrospective analyses have found little change in echocardiographic variables during admission for acute HF and some echocardiographic parameters were not found to be associated with outcomes. It is unknown which echocardiographic variables will predict outcomes in sub-Saharan African patients admitted with acute HF. Using echocardiograms, this study aimed to determine the predictors of death and re-admissions within 60 days and deaths up to 180 days in patients with acute heart failure. Methods: Out of the 1 006 patients in the THESUS-HF registry, 954 had had an echocardiogram performed within a few weeks of admission. Echocardiographic measurements were performed according to the American Society of Echocardiography guidelines. We examined the associations between each echocardiographic predictor and outcome using regression models. Results: Heart rate and left atrial size predicted death within 60 days or re-admission. Heart rate, left ventricular posterior wall thickness in diastole (PWTd), and presence of aortic stenosis were associated with the risk of death within 180 days. PTWd added to clinical variables in predicting 180-day mortality rates. Conclusions: Echocardiographic variables, especially those of left ventricular size and function, were not found to have additional predictive value in patients admitted for acute HF. Left atrial size, aortic stenosis, heart rate and measures of hypertrophy (LV PWTd) had some predictive value, suggesting the importance of early treatment of hypertension and severe valvular heart disease.
Methylmethacrylate is a prosthetic material commonly used for the reconstruction of large chest w... more Methylmethacrylate is a prosthetic material commonly used for the reconstruction of large chest wall defects. We present the first reported case of delayed methylmethacrylate plate migration, which resulted in an aortic pseudoaneurysm with aortopulmonary fistula. Treatment management, including staged repair combining endovascular and open approaches, is also discussed.
Background: Encapsulating Peritoneal Sclerosis (EPS) describes a variety of diseases that are fre... more Background: Encapsulating Peritoneal Sclerosis (EPS) describes a variety of diseases that are frequently confused with different names and different etiopathogeneses. The aim of this article is to report personal experience of focusing on correct classification and the status of current diagnosis and treatment. Methods: A retrospective analysis was performed. Age, sex, ethnic origin, past medical history, symptoms and their duration, radiological tools and signs, laboratory tests, preoperative diagnosis, surgical approach, intraoperative findings, pathological findings, hospital stay, morbidity and mortality were studied. Results: A total of seven patients, including six males and one female, aged from 24 to 72 years were observed. Four patients had recurrent abdominal colic pain for 3 months, 1, 2 and 9 years; two patients also reported recurrent attacks but without any specification of the duration. All seven patients presented at the emergency department with abdominal pain that was mainly diffused over the entire abdomen. Six patients were submitted to a CT scan. Only in two patients was the diagnosis of EPS made preoperatively. All seven patients were submitted to open surgery. The hospital stay was between 4 and 60 days. One patient had morbidity, and one patient died of MOF. Conclusions: Currently, the correct identification of EPS is more easily possible than in the past, but the diagnosis is still a challenge. Surgery must be performed as soon as possible to avoid a poorer quality of life.
Symptoms and signs of heart failure (HF) are the most common reasons for admission to hospital fo... more Symptoms and signs of heart failure (HF) are the most common reasons for admission to hospital for acute HF (AHF) and are used routinely throughout admission, to assess the severity of disease and response to therapy. The data were collected in the sub Saharan Africa survey on heart failure (THESUS-HF) study, a prospective, multicenter, observational survey of AHF, from 9 countries in sub-Saharan Africa. 1006 patients, 12 years or older, hospitalized for acute heart failure were recruited.. Symptoms and signs of HF and changes in dyspnea and well-being, relative to admission, were assessed at entry and on days 1, 2, and 7 (or on discharge if earlier) and included oxygen saturation, degree of edema and rales, body weight and level of orthopnea. The patient determined dyspnea and general well-being, whereas the physician determined symptoms and signs of HF, as well as improvements in vital sign measurement, throughout the admission. After multivariable adjustment, baseline rales and changes to day 7 or discharge in general well-being, predicted death or HF hospitalization through day 60, while baseline orthopnea, edema, rales, oxygen saturation and changes to day 7 or on discharge in respiratory rate, and general well-being were predictive of death through day 180. In AHF patients in Sub-Saharan Africa, symptoms and signs of HF improve throughout admission and simple assessments including edema, rales, oxygen saturation, respiratory rate and asking the patient about general well-being are valuable tools in patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; clinical assessment.
Objective—To examine the influence of socioeconomic deprivation on case fatality following acute ... more Objective—To examine the influence of socioeconomic deprivation on case fatality following acute myocardial infarction. Design—Prospective cohort observational study. Setting—General hospital. Patients—1417 white and south Asian patients admitted with acute myocardial infarction between January 1988 and December 1996, and classified by the Carstairs socioeconomic deprivation score of the enumeration district of residence. Main outcome measures—30 day and one year survival. Results—There was little variation across deprivation groups in age, sex, or smoking status, though a higher proportion of patients from more deprived enumeration districts were diabetic and of south Asian origin, and a higher proportion of them developed Q wave infarction and left ventricular failure. There was no appreciable variation in clinical treatment with deprivation. Patients from more deprived enumeration districts had a higher risk of recurrent ischaemic events (death, recurrent myocardial infarction, o...
ABSTRACT Background &amp; Objective: Most plastic surgeries are performed on an ambulatory ba... more ABSTRACT Background &amp; Objective: Most plastic surgeries are performed on an ambulatory basis. While patient safety is a priority for plastic surgeons, many are unaware of the current ASA preoperative fasting guidelines.1-3 Decades of research attest to the safety and health benefits of consuming carbohydrate-rich clear liquids 2 hours before elective surgery. This best evidence is rarely put into practice. The objective of this study was to assess the effects of such a beverage (Clearfast® ) on patients’ discomforts from preoperative fasting and their safety and compliance. Methods: A two-part multicenter, prospective clinical trial involved ASA Risk I-II adult patients having elective plastic, orthopedic or general surgical procedures at 5 hospitals. Part I was a descriptive observational pilot (n=263: Controls =108; Intervention =155). Part II was an IRB approved randomized trial (n=34: Controls =21; Intervention =13). All sites had previously adopted the ASA guidelines that determined patient eligibility. Exclusion criteria were pregnancy, obesity and GERD. Control groups observed the traditional midnight fast; Intervention groups consumed a carbohydrate-rich drink (Clearfast® ) about 2 hours pre-op. Patient demographics, length of fasting, occurrence of regurgitation and/or aspiration and patient preoperative questionnaires assessing thirst, hunger, headache, nausea, anxiety about fasting and surgery plus discomfort were analyzed by a biostatistician. Results: Regurgitation, aspiration, or other perioperative complications did not occur in Part I or II. Binary logistic regression model of Part I showed that if patients (1) did not have Clearfast®, (2) had surgical anxiety or (3) had fasting anxiety, or (4) had all three, they were (1) 5.7, (2) 4.1, (3) 2.7 or (4) 63 times more likely to be uncomfortable with their preoperative experience. Mann-Whitney mean rank scores from the pooled data (n=297) indicated that, if patients did not consume Clearfast®, they were more likely to be thirsty (P=0.00), hungry (P&lt;0.05), nauseous (P&lt;0.05), anxious about both fasting and surgery (P&lt;0.05) and uncomfortable (P=0.00). Control vs. Intervention fasting times were markedly different: 5-20 vs. 2-5 hours (P=0.00). Conclusions: In appropriately selected patients, following the ASA guidelines and using a preoperative carbohydrate-rich beverage 2 hours prior to elective ambulatory surgery resulted in significantly shorter fasting times, reduced thirst, hunger, anxiety and nausea and improved comfort. Plastic surgeons should be aware of and comply with these guidelines to improve patient safety and satisfaction.
Johor River is a major raw water supplier for a highly populated region, Johor state as well as S... more Johor River is a major raw water supplier for a highly populated region, Johor state as well as Singapore. Because of the development over the entire catchment, water quality has become a sensitive matter. For this reason, several studies have been carried out in order to investigate its affects on the environment. Computer simulation and Numerical model are considered as essential and powerful tools in water resources monitoring plan in decision-making process. HEC-RAS is integrated system software designed to perform one dimensional hydraulic calculation. It was used to estimate the hydraulic changes due to the hydrological alteration of Johor River in response to the change of river discharges and to calculate the sediment transport capacity. Also in this study, QUAL2E was used as the water quality modeling analysis tool. It is suitable for one-dimensional analysis with constant flow and it is applied to predict the water quality model for the Johor River. The model was used to s...
This research paper is an attempt to explore the image of Islam manifested in the post 9/11 Ameri... more This research paper is an attempt to explore the image of Islam manifested in the post 9/11 American literary contexts, an image that revives in the Orientalist studies that intellectually emerged as NeoOrientalism. In their discourses, many neo-Orientalists overemphasize a distorted image of Islam as an anti-modern, anti-democratic, and antiWestern ideology that is based on antagonism and terrorism against the non-Muslim Western ‘Other’. Consequently, Muslims are distortedly depicted as terrorists who hold a Jihadist agenda against Westerners generally and Americans particularly. These neo-Orientalist misrepresentations of Islam and Muslim have highly affected the post 9/11 American literary canon. Published in 2006, John Updike’s Terrorist is considered one of the remarkable novels that centers on examining the nature of Islam and the features of Muslims, within the framework of neo-Orientalism. Pivoting around Edward Said’s antiOrientalist approach, this study aims at offering a ...
Background Rheumatic heart disease (RHD) was found in the THESUS-HF registry to be the third most... more Background Rheumatic heart disease (RHD) was found in the THESUS-HF registry to be the third most common cause of acute heart failure (AHF) in Sub-Saharan Africa. Methods One thousand six patients with AHF from 9 Sub-Saharan African countries were recruited in THESUS-HF, of which 143 (14.3%) had RHD-AHF. Clinical characteristics and outcomes in patients with RHD-AHF and non-RHD-AHF were compared. Kaplan-Meier plots for time to all-cause death and/or HF readmission according to the presence of RHD-AHF and non-RHD-AHF were performed and survival distributions compared using the log-rank test. Cox regression was used to determine the hazard ratio of death to day 180 and death or readmission to day 60 after adjusting for confounders. Results Patients with RHD-AHF were younger, more often females, had higher rates of atrial fibrillation, had less hypertension, hyperlipidemia and diabetes, had lower BP, and higher pulse rate and better kidney function and echocardiographic higher ejection...
We describe a case of acute coronary syndrome and de Winter electrocardiographic pattern treated ... more We describe a case of acute coronary syndrome and de Winter electrocardiographic pattern treated with a pharmaco-invasive approach. We discuss the treatment plan and controversies in management of similar cases in limited resource setting especially the role of fibrinolysis.
Purpose For many types of surgical cases, there is an increase in length with the participation o... more Purpose For many types of surgical cases, there is an increase in length with the participation of a resident physician. The lost operative time productivity is not necessarily mitigated in any fashion other than to benefit the experience of the trainee. Moreover, increasing pressures to maximize productivity, coupled with diminishing reimbursements serve to disincentive resident involvement. The aim of this study was to examine the opportunity cost in the academic setting for intraoperative resident participation during specific hand surgery cases. Methods Retrospective analysis was performed on the American College of Surgeons National Surgical Quality Improvement Project (NSQIP) database from 2006 to 2015. Cases were identified by Current Procedural Terminology code to isolate distal radius fracture repairs, carpal tunnel releases, scaphoid fractures repairs, and metacarpal fracture repairs. Variables collected included operation time, presence or absence of resident physician, and postgraduate year level. Statistical analysis was performed using the statistical computing software R 3.4.2 (R Foundation for Statistical Computing, Vienna, Austria). Cost analysis was performed to quantify the effect of operative times in terms of relative value units (RVUs) lost. Results A total of 3727 cases were identified. Of those, 1264 cases were performed with a resident present. Residents participated in cases with higher total RVU (14.91 vs 13.16, P < 0.001). There was a statistically significant increase of 24.3 minutes (P < 0.001) in the mean operation time with a resident present as compared with those without. Moreover, RVU per hour in resident cases was significantly lower by 2.97 RVU per hour or 21% (P < 0.001). Using the late 2018 Medicare physician conversion factor of US $33.9996, the opportunity cost to attending physicians is US $159.20 per case. Conclusions Resident participation in surgical cases is paramount to the education of future trainees, particularly in the era of trainee duty hour reform. Because residents are participating in higher total RVU cases, this selection bias may be playing a role in explaining our result. Nonetheless, resident involvement for certain procedures comes at an opportunity cost to faculty surgeons. How to balance the cost to train residents in the emerging value-based health systems will prove to be challenging but requires consideration.
A Bochdalek hernia is a congenital diaphragmatic hernia that results from a failure of closure of... more A Bochdalek hernia is a congenital diaphragmatic hernia that results from a failure of closure of the pleuroperitoneal folds during embryologic development. While it is most often diagnosed in neonates and infants, Bochdalek hernias can rarely present in adulthood for the first time. We describe the case of a 42-year-old lady who presented with sudden onset of severe abdominal pain following a Zumba dance session. Her chest radiograph showed an elevated left hemi-diaphragm with visualization of a gastric bubble in the thorax. A computed tomography (CT) scan of the abdomen showed a defect in the left hemi-diaphragm with herniation of the stomach and abdominal viscera through the defect. The patient was taken for diagnostic laparoscopy, and the diaphragmatic defect was repaired with a synthetic mesh. Perioperatively, perforation of the anterior wall of the stomach was noted, and a diagnosis of Bochdalek hernia with gastric strangulation was made. This case demonstrates a rare presenta...
the-art research facilities of Fuwai Hospital and the NCCD, and with full support from their visi... more the-art research facilities of Fuwai Hospital and the NCCD, and with full support from their visionary director Professor Hu, this young group's scientific efforts are likely to shed more light into various unresolved issues related to this challenging heart disease. Moreover, the group members have research ambitions to cover all cardiomyopathies and ultimately provide better health care solutions for these patients and their relatives at risk. To this end, they intend to launch a nationwide screening program for cardiomyopathies and establish a comprehensive Chinese database, incorporating detailed clinical and pathological records, imaging data, genetic information, and a largescale biobank in the near future. 'Learning is a treasure that will follow its owner everywhere', says a Chinese proverb. The young clinicians and researchers at Fuwai Hospital are putting tremendous effort to get more in-depth knowledge and experience in their fields of research. Without any doubt, their scientific work will follow them as a treasure and help them and others to understand mechanisms of cardiovascular diseases and improve management strategies.
The growing elderly population necessitates a greater number of aging patients requiring complex ... more The growing elderly population necessitates a greater number of aging patients requiring complex reconstructive surgery involving free tissue transfer. The purpose of this study was to assess the safety, efficacy, and outcomes of microsurgical free tissue transfer in elderly patients using a national multi-institutional database. We performed a retrospective analysis of the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database to identify patients undergoing free tissue transfer. We stratified cohorts based on ages 18-49, 50-59, 60-69, 70-79, and 80+ years and analyzed primary outcomes of surgical complications, medical complications, mortality, and flap failure. A total of 5,951 patients were identified for inclusion in the analysis. Univariate analysis demonstrated progressively increasing surgical (P = .001) and medical (P &lt; .001) complication rates with increasing age. After controlling for confounding variables, age was not significantly associated with rates of surgical (OR 1.00, 95% CI 0.99-1.01, P = .737) or medical (OR 1.01, 95% CI 0.99-1.03, P = .209) complications, flap failure (OR 1.00, 95% CI 1.00-1.02, P = .689), or reoperation (OR 1.01, 95% CI 1.00-1.03, P = 0.165). Factors associated with surgical complications included BMI (OR 1.03, 95% CI 1.00-1.05, P = .031), prolonged operative time (OR 1.001, 95% CI 1.000-1.002, P = .002), American Society of Anesthesiologists (ASA) classification of 3 or greater (OR 1.62, 95% CI 1.17-2.23, P = .003), and prolonged hospitalization (OR 1.03, 95% CI 1.02-1.04, P &lt; .001). ASA classification of 3 or greater (OR 2.57, 95% CI 1.48-4.45, P = .001), renal history (OR 10.13, 95% CI 1.57-65.55, P = .015), and prolonged hospitalization (OR 1.06, 95% CI 1.04-1.08, P &lt; .001) were associated with medical complications. Age was associated with increased mortality (OR 1.06, 95% CI 1.00-1.13, P = .048). Age alone should not be used as an absolute or even relative contraindication in patient assessment. Rather, preoperative assessment should focus on comorbidities and assessment of physiologic age instead of chronologic age. Optimization of these comorbidities is key to sustaining favorable outcomes in microsurgical free flap reconstruction in the elderly population.
International journal of surgery case reports, Jan 4, 2017
Amyand hernia (AH) is a rare type of hernia characterized by the presence of appendix vermiformis... more Amyand hernia (AH) is a rare type of hernia characterized by the presence of appendix vermiformis in the inguinal hernial sac. It is rarely reported in women. We presented a case of a 60- year old woman who was admitted initially with an abdominal wall abscess and found to have perforated appendix in the right inguinal hernia. The patient underwent standard open appendectomy and the post-operative course was uneventful. The initial presentation of our case as an abdominal wall abscess is rare in the contemporary literature. A high index of suspicious, early diagnosis and timely surgical intervention are the keys to have favorable outcome in amyand hernia. The management should follow general guidelines of appendectomy, hernia repair and dealing with the associated pathology if present.
Background: The role of echocardiography in the risk stratification of acute heart failure (HF) i... more Background: The role of echocardiography in the risk stratification of acute heart failure (HF) is unknown. Some small studies and retrospective analyses have found little change in echocardiographic variables during admission for acute HF and some echocardiographic parameters were not found to be associated with outcomes. It is unknown which echocardiographic variables will predict outcomes in sub-Saharan African patients admitted with acute HF. Using echocardiograms, this study aimed to determine the predictors of death and re-admissions within 60 days and deaths up to 180 days in patients with acute heart failure. Methods: Out of the 1 006 patients in the THESUS-HF registry, 954 had had an echocardiogram performed within a few weeks of admission. Echocardiographic measurements were performed according to the American Society of Echocardiography guidelines. We examined the associations between each echocardiographic predictor and outcome using regression models. Results: Heart rate and left atrial size predicted death within 60 days or re-admission. Heart rate, left ventricular posterior wall thickness in diastole (PWTd), and presence of aortic stenosis were associated with the risk of death within 180 days. PTWd added to clinical variables in predicting 180-day mortality rates. Conclusions: Echocardiographic variables, especially those of left ventricular size and function, were not found to have additional predictive value in patients admitted for acute HF. Left atrial size, aortic stenosis, heart rate and measures of hypertrophy (LV PWTd) had some predictive value, suggesting the importance of early treatment of hypertension and severe valvular heart disease.
Methylmethacrylate is a prosthetic material commonly used for the reconstruction of large chest w... more Methylmethacrylate is a prosthetic material commonly used for the reconstruction of large chest wall defects. We present the first reported case of delayed methylmethacrylate plate migration, which resulted in an aortic pseudoaneurysm with aortopulmonary fistula. Treatment management, including staged repair combining endovascular and open approaches, is also discussed.
Background: Encapsulating Peritoneal Sclerosis (EPS) describes a variety of diseases that are fre... more Background: Encapsulating Peritoneal Sclerosis (EPS) describes a variety of diseases that are frequently confused with different names and different etiopathogeneses. The aim of this article is to report personal experience of focusing on correct classification and the status of current diagnosis and treatment. Methods: A retrospective analysis was performed. Age, sex, ethnic origin, past medical history, symptoms and their duration, radiological tools and signs, laboratory tests, preoperative diagnosis, surgical approach, intraoperative findings, pathological findings, hospital stay, morbidity and mortality were studied. Results: A total of seven patients, including six males and one female, aged from 24 to 72 years were observed. Four patients had recurrent abdominal colic pain for 3 months, 1, 2 and 9 years; two patients also reported recurrent attacks but without any specification of the duration. All seven patients presented at the emergency department with abdominal pain that was mainly diffused over the entire abdomen. Six patients were submitted to a CT scan. Only in two patients was the diagnosis of EPS made preoperatively. All seven patients were submitted to open surgery. The hospital stay was between 4 and 60 days. One patient had morbidity, and one patient died of MOF. Conclusions: Currently, the correct identification of EPS is more easily possible than in the past, but the diagnosis is still a challenge. Surgery must be performed as soon as possible to avoid a poorer quality of life.
Symptoms and signs of heart failure (HF) are the most common reasons for admission to hospital fo... more Symptoms and signs of heart failure (HF) are the most common reasons for admission to hospital for acute HF (AHF) and are used routinely throughout admission, to assess the severity of disease and response to therapy. The data were collected in the sub Saharan Africa survey on heart failure (THESUS-HF) study, a prospective, multicenter, observational survey of AHF, from 9 countries in sub-Saharan Africa. 1006 patients, 12 years or older, hospitalized for acute heart failure were recruited.. Symptoms and signs of HF and changes in dyspnea and well-being, relative to admission, were assessed at entry and on days 1, 2, and 7 (or on discharge if earlier) and included oxygen saturation, degree of edema and rales, body weight and level of orthopnea. The patient determined dyspnea and general well-being, whereas the physician determined symptoms and signs of HF, as well as improvements in vital sign measurement, throughout the admission. After multivariable adjustment, baseline rales and changes to day 7 or discharge in general well-being, predicted death or HF hospitalization through day 60, while baseline orthopnea, edema, rales, oxygen saturation and changes to day 7 or on discharge in respiratory rate, and general well-being were predictive of death through day 180. In AHF patients in Sub-Saharan Africa, symptoms and signs of HF improve throughout admission and simple assessments including edema, rales, oxygen saturation, respiratory rate and asking the patient about general well-being are valuable tools in patients&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39; clinical assessment.
Uploads
Papers by Ahmed Suliman