Abdominal Pain Patient Referrals to Emergency Surgical Service: Appropriateness of Diagnosis and Attitudes of General Practitioners

This study evaluate the need for general practitioners referrals and self referrals of acute abdominal pain patients to emergency surgical service, the appropriateness of GP referral diagnosis and their attitudes dealing with abdominal pain. In three months period all acute abdominal pain patient referrals to our hospital emergency surgical service were audited. Data on final diagnosis, surgical treatment, admission to hospital and surgery performance were recorded. Self referral or GP referral, referring GP diagnosis, referral letters indicating presenting complaint or history, axillar and rectal temperature measurement, laboratory checking and abdominal radiography checking by GP were recorded as well. Also, GPs examination details as palpation, auscultation and digit-rectal checking were recorded. We calculated sensitivity, specificity, positive and negative predictive value (PV) for referring diagnosis. Self referrals and GP referrals differences were evaluated. During the study 318 patients were admitted. A total of 163 (51.25%) referrals were deemed inappropriate; 102 (52.6% of GP referrals) and 61 (49.2% of self referred) (p<0.05). There were no differences in general treatment, hospital admission and operative treatment in self referred and GP referred groups (p<0.05 for all three categories). Sensitivity, specificity, positive and negative predictive values for most frequent GP referral diagnoses were: abdominal colic/abdomen in observation 0.78; 0.66; 0.74; 0.70; acute appendicitis 0.37; 0.92; 0.44; 0.90; acute abdomen/peritonitis 0.30; 0.97; 0.54; 0.92; constipation 0.95; 0.98; 0.85; 0.99; and ileus 0.83; 0.97; 0.50; 0.99. Data on GP including clinical examination, patient history and running basic diagnostics were poor. Our results suggest that a general agreement within the profession about what constitutes a »necessary« hospital referral is necessary. GP consultation quality must be improved by booking more time per patient and by giving more medical/technical attention to patients

A Randomised Two-way Comparison of Mastectomy Performed Using Harmonic Scalpel or Monopolar Diathermy

The purpose of this study was to perform an overall evaluation and comparison of the success rate of modified radical mastectomy by harmonic scalpel and monopolar electrocauter. The prospective study included all of the patients that were planned for and mastectiomized because of breast carcinoma during July 1st 2008 until December 21 st 2008 at the Department of Surgery and Urology, University Hospital Mostar. Duration of the surgical procedure, intraoperative blood loss and operational drain secretion was measured and registered. Leukocyte number (Le), interleukin 6 (IL-6), C-reactive protein (CRP) and erythrocyte sedimentation rate was tested and registered out of peripheral venous blood before the operation, 4 hrs after it, as well as on the first, second and third day after the operation. Every patient was tested for postoperative pain intensity, amount of administered analgesics during hospital stay, number and types of postoperative complications; also the time needed for return to everyday activities was registered. 61 patients were included in the study. 31 patients were operated with the harmonic scalpel, and 30 of them with the monopolar electrocauter. There is no statistically significant difference between the operation time in the two groups: 78.50±17.50 minutes by harmonic scalpel and 82.50±18.50 minutes by electrocauter (p=0.796). The smaller amount of intraoperative blood loss is statistically significant in the group of patients mastectomized by harmonic scalpel 78±31 ml compared to 256±112 ml in the group mastectomized by electrocauter (p<0.001); as is the total operational drain secretion: patients mastectomized by harmonic scalpel 540±390 mL compared to 960±710 mL in patients mastectomized by electrocauter (p<0.001). There is no statistical difference in the number of leukocytes in blood after modified radical mastectomy using the harmonic scalpel or electrocauter (p=0.957), or in erythrocyte sedimentation rate (p=0.114), CRP (p=0.071) and IL-6 (p=0.082). The duration of postoperative hospital stay does not differ statistically between the two groups, nor does the postoperative pain intensity, amount of administered analgesics, number or types of postoperative complications, as well as the time needed for return to everyday activities. Therefore using the ultrasound harmonic scalpel in comparison to monopolar electrocauter brings certain advantages, which however do not contribute significantly to the total success rate of the operation

ACCURACY OF MODIFIED ALVARADO SCORE, ESKELINEN SCORE AND OHMANN SCORE IN DIAGNOSING ACUTE APPENDICITIS

Introduction: By processing the data of a large number of patients with abdominal pain, diagnostic scores whose implementation attempts to facilitate acute appendicitis diagnostics were developed. Modified Alvarado score, Ohmann score and Eskelinen score are used as assistance when setting the diagnosis and making a decision to undertake surgery. Aim: To assess accuracy of Alvarado score, Ohmann score and Eskelinen score in diagnosing acute appendicitis and to establish connection of total score of these scoring systems with histopathological degree of appendicitis. Subjects and methods: A cross-sectional study was conducted at the Department of Surgery of University Clinical Hospital Mostar. The study included 70 patients who underwent appendectomy and were scored before surgery. All tested persons were examined by experienced surgeon who took anamnesis, physical status and ordered laboratory diagnostic tests. Appendicitis was excluded or confirmed by means of histopathological diagnostics, and the degree of appendicitis was determined. Results: According to accuracy parameters (sensitivity, specificity, negative and positive predictive value), the score which was of highest value was Ohmann score, followed by Eskelinen score, while the lowest value was the one of modified Alvarado score. Total score in all three scoring systems follows the degree of appendicitis, but statistical significance was proven only for Ohmann and Eskelinen scores. Conclusion: Ohmann and Eskelinen scores can be useful in diagnosing acute appendicitis, predicting the degree of appendicitis, as well as assistance when making decision to undertake an operative procedure. Modified Alvarado score in our subjects did not prove sufficient value. Diagnostics of acute appendicitis still must be led by contemporary algorithms in which diagnostic scoring is implemented

The Advantages of End-to-Side Arteriovenous Anastomosis over the Other Two Types of Arteriovenous Anastomosis in Dialysis Patients

The functional duration of vascular access in dialysis patients depends on the emergence of threatening complications. Discussions are constantly being held in an attempt to discover their causality and decrease their emergence. In 260 patients undergoing haemodialysis, we have studied the potential existence of a cause-and-effect relation between the emergence of complications in the vascular access and the applied type of arteriovenous (av.) anastomosis in the arteriovenous (AV) fistula. We have observed the incidence of all complications, both that of the thrombosis incidence as well as the primary and secondary fistula patency (survival). The complications – The examinees with the end-to-end anastomosis showed the incidence of 8.08%, 6.15% of the patients with the end-to-side anastomosis and 7.31% of the patients with the side-to-side anastomosis. The differences regarding incidences are statistically significant ( 2-test = 29.25; P=0.0001). Thrombosis – it has been found that thrombosis was the most frequent complication developing in 30.00 % patients with the end-to-end av. anastomosis, in 2.31% patients with end-to-side av. anastomosis and in 5.56% patients with side-to-side av. anastomosis. The difference between the highest and the lowest assessment is 27.69%, and it is statistically relevant ( 2-test = 33.920; P=0.0001). The »primary patency« (primary survival): within a 6-month interval following the establishment of vascular access, the first complications arose in 62.50% of patients with end-to-end av. anastomosis, 10.76% in those with end-to-side av. anastomosis and 18.88% in those with side-to-side av. anastomosis. The difference between the highest and the lowest assessment is 51.74%, which is statistically significant ( 2-test = 49.009; P=0.0001). The secondary patency: 24 months subsequent to the establishment of vascular access, the AV-fistula was still functional in 52.50% of the patients with end-to-end av. anastomosis, 89.23% in those with end-to-side av. anastomosis and 81.11% in those with side-to-side av. anastomosis. The difference between the highest and the lowest assessment is 36.73%, which is also statistically significant ( 2-test = 26.579; P=0.0001). According to our research, the end- -to-side type of av. anastomosis in vascular access provides better results both in relation to the duration as well as the maintenance of the functionality of the Av-fistula and in the lower incidence of the complications than the other types, and hence it shows a definite advantage

PAIN INTENSITY SCALES COMPARISON IN PATIENT WITH ABDOMINAL PAIN

Background: The aim of study was to explore efficiency of the pain rating scales on patients experiencing abdominal pain, determine correlation between the scales and their applicability to general population and determine the minimal clinical important difference in mm on the VAS as discriminatory for difference in pain intensity. Subjects and methods: The study was performed at the Emergency Department of the University Clinical Hospital of Mostar on patients with abdominal pain which started less than 24 hours before, excluding patients under 16 years old, uncooperative patients and those with altered state of consciousness. The sample data were collected from February to May 2010. Hundred patients completed the questionnaire. Two patients, admitted to the Abdominal Surgery Department, were excluded. The patients were asked to sign the informed consent form and assess the level of pain on three scales (VAS, NRS, VRS). Results: The NRS showed a significant difference in assessing the pain intensity in the observed time. By lapse of time, the patients were reporting lower pain intensity (P=0.017). VAS and NRS had high correlation coefficient values, indicating strong correlation and credibility. The NRS showed strong results correlation (r=0.784; P<0.001). Inter-scale correlation was growing over time. Correlation between VAS and NRS was very strong, the strongest in the last measurement (r=0.950; P<0.001). The NRS correlation with VRS (r=0.430; P<0.001) was slightly better than with VAS (r=0.402; P<0.001). The NRS proved to be the most sensitive to changes in pain intensity (SRM=0.305), whereas the VRS showed extremely low responsiveness (SRM=0.185). Conclusion: Having proved as the most useful, reliable and efficient pain assessment instrument, the NRS is hereby recommended as method of pain objectification and determining changes in pain intensity

ATTITUDES OF STUDENTS OF MEDICINE, UNIVERSITY OF MOSTAR ACCORDING TO INDUCED ABORTION

Background: Aim of this study was to establish attitudes of medical students on induced abortion and connection of those attitudes with religiousness, length of their studies, sex and various circumstances of pregnancy. Subjects and methods: In total, 148 students of the first, second, fifth and sixth year of medical faculty participated in the research. The study was conducted at the Medical Faculty of the University in Mostar. While collecting the data, we used a survey taken over from literature. The data were tested with adequate statistical methods afterwards. Results: 81.1% of students would perform an abortion under certain circumstances (χ2=57.189; P<0.001). Most students answered that they would perform an abortion in case that a fetus had malformations (χ2=3.892; P=0.49) or if the mother’s life were endangered (χ2=47.676; P<0.001). By comparison of students’ readiness to perform an abortion under various circumstances of pregnancy depending on length of medical education, statistically significant difference was proved in the following circumstances: rape (χ2=6.097; P=0.014) and if the pregnancy would endanger mother’s mental health (χ2=4.488; P=0.034). Students with shorter medical education expressed more liberal attitudes in the above stated circumstances. By comparison of students’ readiness to perform an abortion under various circumstances of pregnancy depending on religiousness statistically significant difference was proved in the following circumstances: in case of ‘abortion on demand’, no matter the reason (χ2=11.908; P=0.012), teenage pregnancy (χ2=33.308; P<0.001) and if the pregnancy would interfere with mother’s career (χ2=35.897; P<0.001). Unreligious students expressed more liberal attitudes. Conclusion: Influence of length of medical education and sex on attitudes on abortion was not proved statistically. Impact of religiousness on that attitude cannot be commented due to very small share of unreligious students in the sample

The Relation between the Serum Calcium Level and the Complication Incidence in Haemodialysis Uremic Patients

The mineral metabolism disorder is the most influential factor of the morbidity and mortality incidence of haemodialysis uremic patients. The second most influential factor is the infection, which is the most frequent complication with an undesirable outcome. In recent times, the relation of the increased serum calcium and phosphorus level on the one hand, and the morbidity and mortality of that population in case on the other, has been observed. However, insufficient professional and scientific thought has been given to the relation of the lower serum levels of the aforementioned minerals and the morbidity and mortality incidence. We have researched the relation between lower serum calcium level (hypocalcaemia) and the complication incidence, especially infection. Throughout the time period of 18 months, 120 haemodialysis uremic patients were observed and 76 (63.3%) of them had serum calcium level below the lower threshold of referent values (9.0–9.5 mg/dL). In the patients with a lower serum calcium level (hypocalcaemia) a significant infection incidence (c2=3.99; p=0.0468), a significant sepses incidence (c2=8.016; p=0.04), a significant total complication incidence (p<0.05) were determined, as well as a higher vascular access local infection incidence, but without statistically significant research results of this relation (c2=0.098; p=0.7598). We are of the belief that the incidence of the vascular access local infection should be examined on a greater number of patients; therefore, the significance of the examined relation in such an instance would be expected. The total infection incidence in all 120 observed patients is 3.8 for 100 months. It is to be concluded that the research findings indicate the association regarding the appearance of low serum calcium concentration (hypocalcaemia) and an increased complication incidence, especially the inflammation that leads to the requirement of further research in order to decrease morbidity, and consequently also the mortality of the observed population of patients by means of programmed therapy approach