Delayed Psychological Morbidity Associated with Snakebite Envenoming

Introduction The psychological impact of snakebite on its victims, especially possible late effects, has not been systematically studied. Objectives To assess delayed somatic symptoms, depressive disorder, post-traumatic stress disorder (PTSD), and impairment in functioning, among snakebite victims. Methods The study had qualitative and quantitative arms. In the quantitative arm, 88 persons who had systemic envenoming following snakebite from the North Central Province of Sri Lanka were randomly identified from an established research database and interviewed 12 to 48 months (mean 30) after the incident. Persons with no history of snakebite, matched for age, sex, geograpical location and occupation, acted as controls. A modified version of the Beck Depression Inventory, Post-Traumatic Stress Symptom Scale, Hopkins Somatic Symptoms Checklist, Sheehan Disability Inventory and a structured questionnaire were administered. In the qualitative arm, focus group discussions among snakebite victims explored common somatic symptoms attributed to envenoming. Results Previous snakebite victims (cases) had more symptoms than controls as measured by the modified Beck Depression Scale (mean 19.1 Vs 14.4; p<0.001) and Hopkins Symptoms Checklist (38.9 vs. 28.2; p<0.001). 48 (54%) cases met criteria for depressive disorder compared to 13 (15%) controls. 19 (21.6%) cases also met criteria for PTSD. 24 (27%) claimed that the snakebite caused a negative change in their employment; nine (10.2%) had stopped working and 15 (17%) claimed residual physical disability. The themes identified in the qualitative arm included blindness, tooth decay, body aches, headaches, tiredness and weakness. Conclusions Snakebite causes significant ongoing psychological morbidity, a complication not previously documented. The economic and social impacts of this problem need further investigation

A randomized, double-blind, placebo-controlled trial on the role of preemptive analgesia with acetaminophen [paracetamol] in reducing headache following electroconvulsive therapy [ECT]

Abstract Background Electroconvulsive therapy (ECT) is a safe and efficient treatment for several severe psychiatric disorders, but its use is limited by side effects. Post-ECT headache is one of the commonest side effects. Preemptive analgesia is effective in post-surgical pain management. The most commonly used analgesic is acetaminophen (paracetamol). However, acetaminophen as a preemptive analgesic for post-ECT headache has not been studied adequately. This study was conducted to compare the incidence and severity of post-ECT headache in patients who were administered acetaminophen pre-ECT with a placebo group. Methods This study was a randomised, double-blind, placebo-controlled trial. Sixty-three patients received 1 g acetaminophen and 63 patients received a placebo identical to acetaminophen. The incidence and severity of headache 2 h before and after ECT were compared between placebo and acetaminophen groups. The severity was measured using a visual analog scale. Generalised linear models were used to evaluate variables associated with post ECT headache. Results Demographic and clinical variables of placebo and acetaminophen groups were comparable except for the energy level used to induce a seizure. Higher proportion of the placebo group (71.4%) experienced post-ECT headache when compared to the acetaminophen group (p < 0.001). The median pain score for headache was 0 (Inter quartile range: 0–2) in acetaminophen group whereas the score was 2 (IQR: 0–4) in placebo group (P < 0.001). Model fitting showed that the administration of acetaminophen is associated with less post-ECT headache (odds ratio = 0.23, 95% CI: 0.11–0.48, P < 0.001). Conclusion A significant reduction was seen in both the incidence and severity of post-ECT headache with preemptive analgesia with acetaminophen. Trial registration Ethical approval was granted by an Ethic review committee, University of Kelaniya, Sri Lanka (P/166/10/2015) and the trial was registered in the Sri Lanka Clinical Trials Registry ( SLCTR/2015/27 )

Oncoplastic breast conserving surgery versus standard breast conserving surgery for early and locally advanced breast cancer: a retrospective analysis from Sri Lanka

Abstract Background Breast aesthetics is becoming increasingly important in breast cancer surgery due to changes in patient expectations and greater emphasis been placed on the psychosocial outcomes. Studies have shown no difference in local recurrence risk between mastectomy and breast conserving surgery (BCS) and also a higher overall survival rate after BCS. Breast preservation improves the quality of life substantially compared to mastectomy. Oncoplastic breast-conserving surgery (O-BCS) involves tumour excision whilst overcoming the limitations of standard breast conserving surgery (S-BCS) by allowing larger resection volumes, avoiding deformities with better aesthetic results. Our study aims to compare the oncosurgical and aesthetic outcomes of O-BCS versus S-BCS among women in Sri Lanka. Methods We conducted a retrospective study over a 4-year period including patients who underwent breast conservation surgery for primary non-metastatic breast cancer in two tertiary care units. We assessed outcomes in terms of re-excision rates, resection margin, complications and aesthetic outcomes using a Likert scale questionnaire to grade specific outcomes such as symmetry, volume, nipple position, scar visibility. Non-parametric tests were used for statistical analyses. Results Fifty-four and seventy-three patients underwent S-BCS and O-BCS respectively. The median specimen volume and the maximum tumour diameter were significantly higher in O-BCS [160(range:65–220); 4.2(range: 1.2–5.2)] compared to S-BCS [65(range:45–86); 2.4(range: 1.0-2.6)]. The median closest tumour margin was 16 mm (range:4-25 mm) in O-BCS while 6 mm (range:<1 – 12 mm) in S-BCS (p = 0.01). Close (< 1 mm) and positive margins needing re-excision were seen mostly in S-BCS. Superior aesthetic outcomes with statistical significant difference were reported in the O-BCS compared to S-BCS group with better symmetry, volume, nipple position and scar visibility. The re-excision rates were significantly lower in O-BCS group. There was no significant difference in the operative time and complications while the aesthetic outcomes were significantly superior in OBCS. Conclusions Overall, Level 2 perforator flap based reconstruction had superior aesthetic outcomes. O-BCS is safe and more aesthetically acceptable with no difference in oncological outcome and operative time. More consideration should be given to aesthetic parameters such as scar visibility, nipple position, breast volume and shape when considering the best surgical option for the patients

Evaluation of the efficacy of shadowing house officer experience in surgical training

Abstract Background The shadowing house officer is an experiential learning activity that usually takes place within the final year clinical rotations of medical undergraduates. An exposure to a surgical intern is especially useful as the work extends to more practical aspects of ward work. Objective We assessed the impact of the shadowing house officer exprience during medical student clinical rotation on the surgical internship and to evaluate the challenges of the shadowing period. Methods A descriptive cross-sectional survey was carried out among 108 surgical intern doctors in Sri Lanka via electronic media in 2023. Results Our study population consisted of 108 interns, with a response rate of 43.2%. This study demonstrates that on average a final year medical student undergoes a 4- day shadowing period in surgery which was considered by a majority to help in smooth transition to internship. 56% had a clear understanding about learning outcomes and less than half has had an induction session prior to commencement of shadowing. Official documentation, routine ward work, team work and communication skills were meaningfully experienced during shadowing. The main criticisms were inadequate breaks leading to exhaustion and missing out on important teaching activities. Another major concern was shadowing close to the final examination. Conclusions Surgical shadowing house officer is an authentic work experience that intern doctors consider as important component in orientating the role of an intern. Introduction of shadowing at an earlier stage would be more beneficial and provide a broader view about the clinical set up to undergraduates

A randomized controlled trial of a brief intervention for delayed psychological effects in snakebite victims

BACKGROUND: Snakebite results in delayed psychological morbidity and negative psycho-social impact. However, psychological support is rarely provided to victims. AIM: To assess the effectiveness of a brief intervention which can be provided by non-specialist doctors aimed at reducing psychological morbidity following snakebite envenoming. METHOD: In a single blind, randomized controlled trial, snakebite victims with systemic envenoming [n = 225, 168 males, mean age 42.1 (SD 12.4) years] were randomized into three arms. One arm received no intervention (n = 68, Group A), the second received psychological first aid and psychoeducation (dispelling prevalent cultural beliefs related to snakebite which promote development of a sick role) at discharge from hospital (n = 65, Group B), while the third received psychological first aid and psychoeducation at discharge and a second intervention one month later based on cognitive behavioural principles (n = 69, Group C). All patients were assessed six months after hospital discharge for the presence of psychological symptoms and level of functioning using standardized tools. RESULTS: At six months, there was a decreasing trend in the proportion of patients who were positive for psychiatric symptoms of depression and anxiety from Group A through Group B to Group C (Chi square test for trend = 7.901, p = 0.005). This was mainly due to a decreasing trend for symptoms of anxiety (chi-square for trend = 11.256, p = 0.001). There was also decreasing trend in the overall prevalence of disability from Group A through Group B to Group C (chi square for trend = 7.551, p = 0.006), predominantly in relation to disability in family life (p = 0.006) and social life (p = 0.005). However, there was no difference in the proportion of patients diagnosed with depression between the three groups (chi square for trend = 0.391, p = 0.532), and the intervention also had no effect on post-traumatic stress disorder. CONCLUSIONS: A brief psychological intervention, which included psychological first aid and psychoeducation plus cognitive behavioural therapy that can be provided by non-specialist doctors appeared to reduce psychiatric symptoms and disability after snakebite envenoming, but not depression or post-traumatic stress disorder

Correlation with post-traumatic stress disorder symptom (PTSD) score.

<p>**Correlation is significant at the 0.01 level.</p

Characteristics of the snakebite victims who responded to the invitation and non-responders.

<p>NS – not significant.</p

Severity of depression among the study groups (BDI).

<p>*Significant difference identified through item-wise analysis</p><p>Severity of depression among the study groups (BDI).</p

Study flow chart.

<p>Study flow chart.</p