Intussusception in a 20 weeks pregnant woman: a case report

Intussusception in pregnancy is rare and poses unique diagnostic and therapeutic challenges. We present the case of a 22 year old, 20 weeks pregnant woman who presented with acute abdominal pain. Following abdominal ultrasound scanning she was diagnosed with intussusception. The patient underwent laparotomy and a small bowel resection was performed without any post operative complications. We review the literature to give a concise and up to date summary on the diagnosis and treatment of the condition with particular emphasis on the recently recognised usefulness of ultrasound scanning

Understanding the influences on successful quality improvement in emergency general surgery: learning from the RCS Chole-QuIC project

Abstract: Background: Acute gallstone disease is the highest volume Emergency General Surgical presentation in the UK. Recent data indicate wide variations in the quality of care provided across the country, with national guidance for care delivery not implemented in most UK hospitals. Against this backdrop, the Royal College of Surgeons of England set up a 13-hospital quality improvement collaborative (Chole-QuIC) to support clinical teams to reduce time to surgery for patients with acute gallstone disease requiring emergency cholecystectomy. Methods: Prospective, mixed-methods process evaluation to answer the following: (1) how was the collaborative delivered by the faculty and received, understood and enacted by the participants; (2) what influenced teams’ ability to improve care for patients requiring emergency cholecystectomy? We collected and analysed a range of data including field notes, ethnographic observations of meetings, and project documentation. Analysis was based on the framework approach, informed by Normalisation Process Theory, and involved the creation of comparative case studies based on hospital performance during the project. Results: Chole-QuIC was delivered as planned and was well received and understood by participants. Four hospitals were identified as highly successful, based upon a substantial increase in the number of patients having surgery in line with national guidance. Conversely, four hospitals were identified as challenged, achieving no significant improvement. The comparative analysis indicate that six inter-related influences appeared most associated with improvement: (1) achieving clarity of purpose amongst site leads and key stakeholders; (2) capacity to lead and effective project support; (3) ideas to action; (4) learning from own and others’ experience; (5) creating additional capacity to do emergency cholecystectomies; and (6) coordinating/managing the patient pathway. Conclusion: Collaborative-based quality improvement is a viable strategy for emergency surgery but success requires the deployment of effective clinical strategies in conjunction with improvement strategies. In particular, achieving clarity of purpose about proposed changes amongst key stakeholders was a vital precursor to improvement, enabling the creation of additional surgical capacity and new pathways to be implemented effectively. Protected time, testing ideas, and the ability to learn quickly from data and experience were associated with greater impact within this cohort

Burnout among surgeons before and during the SARS-CoV-2 pandemic: an international survey

Background: SARS-CoV-2 pandemic has had many significant impacts within the surgical realm, and surgeons have been obligated to reconsider almost every aspect of daily clinical practice. Methods: This is a cross-sectional study reported in compliance with the CHERRIES guidelines and conducted through an online platform from June 14th to July 15th, 2020. The primary outcome was the burden of burnout during the pandemic indicated by the validated Shirom-Melamed Burnout Measure. Results: Nine hundred fifty-four surgeons completed the survey. The median length of practice was 10 years; 78.2% included were male with a median age of 37 years old, 39.5% were consultants, 68.9% were general surgeons, and 55.7% were affiliated with an academic institution. Overall, there was a significant increase in the mean burnout score during the pandemic; longer years of practice and older age were significantly associated with less burnout. There were significant reductions in the median number of outpatient visits, operated cases, on-call hours, emergency visits, and research work, so, 48.2% of respondents felt that the training resources were insufficient. The majority (81.3%) of respondents reported that their hospitals were included in the management of COVID-19, 66.5% felt their roles had been minimized; 41% were asked to assist in non-surgical medical practices, and 37.6% of respondents were included in COVID-19 management. Conclusions: There was a significant burnout among trainees. Almost all aspects of clinical and research activities were affected with a significant reduction in the volume of research, outpatient clinic visits, surgical procedures, on-call hours, and emergency cases hindering the training. Trial registration: The study was registered on clicaltrials.gov "NCT04433286" on 16/06/2020

Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy.

BACKGROUND: Acute gallstone disease is a high-volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance. METHODS: Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole-QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods. RESULTS: Of 13 sites invited to join Chole-QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole-QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8-day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals. CONCLUSION: A surgeon-led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy

جريمة البث الإذاعي غير المصرح به وفق إتفاقية الأمم المتحدة لقانون البحار1982

إن السفينة في أعالي البحارلاتخضع كقاعدة عامة أثناء وجودها فيها إلا للدولة التي تنتمي إليها بجنسيتها وهذا مايعرف بمبدأ"إختصاص دولة العلم ". ولكن هناك قيود ترد على اختصاص دولة العلم وهي قيود تفرضها ضرورات حماية المصالح الجوهرية للجماعة الدولية وتتمثل هذه القيود في محاربة وإلغاء بعض النشاطات المحرمة دولياً التي تحتاج إلى التضامن لمحاربتها.وتتمثل هذه النشاطات في كل من جريمة القرصنة البحرية ،تجارة الرقيق، الإتجار غير المشروع بالمخدرات ،جريمة البث الإذاعي غيرالمشروع. ومن هذا المنطلق بادر القانون الدولي بوضع قواعد تكفل ممارسة هذه الحريات في إطارقانوني بأن أوكلت إلى الدول جميعاً السلطة القانونية والإختصاص العالمي في مكافحة هذه الجريمة الخطيرة والتي يكون لها الحق في متابعتها في أعالي البحا

Improved clustering using robust and classical principal component

k-means algorithm is a popular data clustering algorithm. k-means clustering aims to partition n observations into k clusters in which each observation belongs to the cluster with the nearest mean, serving as a prototype of the cluster. Finding the appropriate number of clusters for a given data set is generally a trial-and-error process which made more difficult by the subjective nature of deciding what constitutes ‘correct’ clustering. When dimension of data is large it is often difficult to apply k-means clustering algorithm since it needs lots of computational times. To remedy this problem, we propose to integrate Principal Component analysis (PCA) which is useful for dimensionality reduction of a dataset with the k-means clustering algorithm. We call our propose method as k-means by principal components (pc1). In this study, the kernels that are created by using the k-means method are replaced with kernels which are created by using PCA method where the PCA method reduces the dimensionality of a data. The results of the study show that the k-means by PCA is faster and more efficient than the classical k-means algorithm. The classical k-means algorithm and the k-means by PCA algorithm are very sensitive to the presence of outlier. Hence the k-means by robust PCA is developed to rectify the problem of outliers in the dataset. The findings indicate that in the absence of outliers, the performances of both methods; the k-means by PCA and the k-means by robust PCA are equally good. Nonetheless, the k-means by robust PCA is not much affected by outliers compared to the k-means by classical PCA