Medical conditions mimicking the acute surgical abdomen in children

Background: We present our experience with children landing up in our pediatric surgery emergency with potentially confounding medical conditions that evade diagnosis. It is imperative to apply sound clinical judgement in the evaluation of these patients so that an unnecessary laparotomy can be avoided but, at the same time, a lifesaving intervention is not denied.Patients and methods: This is a retrospective descriptive analysis pertaining to all patients who were admitted in our department from 1 January 2014 to 31 July 2017. A total of 27 867 patients presented to our out-patient department of these, 3034 were admitted to our ward. A total of 1531 surgeries were performed, of which 288 were for various abdominal surgical conditions. A total of 16 patients, representing 0.5 % of the admissions, were eventually found to have an acute abdomen secondary to a medical cause.Results: Out of the above 16 patients, 10 had to undergo exploratory laparotomy (62.5%). Eight patients of the 10 operated had a negative laparotomy. Two of the 10 operated were found to have a surgically correctable cause, one with ovarian torsion and one with severe colonic edema secondary to Kawasaki’s disease causing intestinal obstruction.Conclusion: Although eight patients with negative laparotomy result constitute only 0.5% of all the surgeries and 2.7% of all the laparotomies, it still forms the bulk (i.e. 8/16=50%) of the patients with underlying medical cause of the surgical abdomen. There were two deaths, representing a mortality of 12.5% (2/16=12.5%), with one in the operated group and one in the nonoperated group. This is why we want to stress the importance of caution and sound clinical judgement in evaluating this subset of patients.Keywords: acute abdomen, medical conditions mimicking, surgical abdomen in childre

Розробка удосконаленого алгоритму розкиданого пошуку з використанням дискретно-хаотичної карти кота Арнольда

Solving optimization problems is an ever-growing subject with an enormous number of algorithms. Examples of such algorithms are Scatter Search (SS) and genetic algorithms. Modifying and improving of algorithms can be done by adding diversity and guidance to them. Chaotic maps are quite sensitive to the initial point, which means even a very slight change in the value of the initial point would result in a dramatic change of the sequence produced by the chaotic map Arnold's Cat Map. Arnold's Cat Map is a chaotic map technique that provides long non-repetitive random-like sequences.  Chaotic maps play an important role in improving evolutionary optimization algorithms and meta-heuristics by avoiding local optima and speeding up the convergence. This paper proposes an implementation of the scatter search algorithm with travelling salesman as a case study, then implements and compares the developed hyper Scatter Arnold's Cat Map Search (SACMS) method against the traditional Scatter Search Algorithm. SACMS is a hyper Scatter Search Algorithm with Arnold's Cat Map Chaotic Algorithm. Scatter Arnold's Cat Map Search shows promising results by decreasing the number of iterations required by the Scatter Search Algorithm to get an optimal solution(s). Travelling Salesman Problem, which is a popular and well-known optimization example, is implemented in this paper to demonstrate the results of the modified algorithm Scatter Arnold's Cat Map Search (SACMS). Implementation of both algorithms is done with the same parameters: population size, number of cities, maximum number of iterations, reference set size, etc. The results show improvement by the modified algorithm in terms of the number of iterations required by SS with an iteration reduction of 10–46 % and improvements in time to obtain solutions with 65 % time reductionРешение задач оптимизации является предметом постоянно растущего интереса с огромным количеством алгоритмов. Примерами таких алгоритмов являются разбросанный поиск (РП) и генетические алгоритмы. Изменение и совершенствование алгоритмов может осуществляться путем добавления разнообразия и ориентированности. Хаотические карты довольно чувствительны к начальной точке, что означает, что даже небольшое изменение значения начальной точки приведет к резкому изменению последовательности, создаваемой хаотической картой кота Арнольда. Карта кота Арнольда – это техника хаотической карты, которая предоставляет длинные неповторяющиеся случайные последовательности.  Хаотические карты играют важную роль в улучшении алгоритмов эволюционной оптимизации и метаэвристик, избегая локальных оптимумов и ускоряя сходимость. В данной работе предлагается реализация алгоритма разбросанного поиска с коммивояжером в качестве примера, реализуется и сравнивается разработанный гипер-метод разбросанного поиска по карте кота Арнольда (РПККА) с традиционным алгоритмом разбросанного поиска. РПККА – это гипер-алгоритм разбросанного поиска с хаотическим алгоритмом карты кота Арнольда. Разбросанный поиск по карте кота Арнольда показывает многообещающие результаты за счет уменьшения количества итераций, необходимых для алгоритма разбросанного поиска для получения оптимального решения (решений). В данной работе для демонстрации результатов модифицированного алгоритма разбросанного поиска по карте кота Арнольда (РПККА) реализована задача коммивояжера, которая является популярным и хорошо известным примером оптимизации. Реализация обоих алгоритмов осуществляется с одинаковыми параметрами: размер популяции, количество городов, максимальное количество итераций, размер эталонного набора и т.д. Результаты показывают улучшение модифицированного алгоритма по количеству итераций, необходимых для РП, с сокращением итераций на 10–46 % и улучшением времени получения решений с сокращением времени на 65 %. Вирішення задач оптимізації є предметом постійно зростаючого інтересу з величезною кількістю алгоритмів. Прикладами таких алгоритмів є розкиданий пошук (РП) і генетичні алгоритми. Зміна та вдосконалення алгоритмів може здійснюватися шляхом додавання різноманітності та орієнтованості. Хаотичні карти досить чутливі до початкової точки, що означає, що навіть невелика зміна значення початкової точки призведе до різкої зміни послідовності, створюваної хаотичною картою кота Арнольда. Карта кота Арнольда – це техніка хаотичної карти, яка надає довгі неповторювані випадкові послідовності.  Хаотичні карти відіграють важливу роль у вдосконаленні алгоритмів еволюційної оптимізації та метаевристики, уникаючи локальних оптимумів та прискорюючи збіжність. У даній роботі пропонується реалізація алгоритму розкиданого пошуку з комівояжером в якості прикладу, реалізується і порівнюється розроблений гіпер-метод розкиданого пошуку по карті кота Арнольда (РПККА) з традиційним алгоритмом розкиданого пошуку. РПККА – це гіпер-алгоритм розкиданого пошуку з хаотичним алгоритмом карти кота Арнольда. Розкиданий пошук по карті кота Арнольда показує багатообіцяючі результати за рахунок зменшення кількості ітерацій, необхідних для алгоритму розкиданого пошуку для отримання оптимального рішення (рішень). У даній роботі для демонстрації результатів модифікованого алгоритму розкиданого пошуку по карті кота Арнольда (РПККА) реалізована задача комівояжера, яка є популярним і добре відомим прикладом оптимізації. Реалізація обох алгоритмів здійснюється з однаковими параметрами: розмір популяції, кількість міст, максимальна кількість ітерацій, розмір еталонного набору і т.д. Результати показують поліпшення модифікованого алгоритму за кількістю ітерацій, необхідних для РП, зі скороченням ітерацій на 10–46 % і поліпшенням часу отримання рішень зі скороченням часу на 65 %

Treatment Outcome of Cervical Cancer Patients in the Elderly Population Aged 80 Years and Above: A Single Institution Study

Introduction: Age-related deficits such as malnutrition, functional reliance, and cognitive decline also occur in older women, as they are typically weaker and have many co-morbid conditions like diabetes or cardiac illness. These prognostic factors might predict overall survival and progression-free survival. Aim: To analyse the management outcomes of elderly patients with cervical carcinoma treated with radiotherapy and brachytherapy. Materials and Methods: A retrospective observational study was conducted in the Department of Radiation Oncology at Himalayan Institute of Medical Sciences, Dehradun, Uttarakhand, India. Medical records were collected from 876 patients with cervical cancer who had been treated with radiotherapy or combined radiotherapy and chemotherapy from January 2009 to December 2021. A total of 876 patients presented with cervical cancer in the Outpatient Department (OPD), and 20 patients meeting the inclusion criteria were selected. Patients diagnosed with cervical cancer, Federation International Federation of Gynaecology and Obstetrics (FIGO) stage IB to IVA, aged equal to or greater than 80 years old, and Eastern Cooperative Oncology Group (ECOG) performance status I to III were considered for inclusion. Categorical variables were expressed as counts and percentages. The following clinicopathological characteristics of the study population were examined: FIGO staging, including stage IB to stage IVA, histopathological features of adenocarcinoma, squamous carcinoma, or adenosquamous carcinoma, doses of radiotherapy and brachytherapy, overall survival, disease-free survival, and the patient’s current status (alive or dead) was determined. If death occurred, the cause of death was determined. The Kaplan-Meier approach was used to analyse overall survival and disease-free survival in the study population using XLSTAT statistical software. Results: The study population was age standardised, with 18 patients (90%) falling between the ages of 80 and 85, and 2 patients (10%) falling between the ages of 86 and 90. A total of 12 patients (60%) belonged to ECOG PS II. A total of 19 (95%) patients had histologically confirmed squamous cell carcinoma. 75% of the population was in a locally advanced stage (stage III-IVA). The overall survival (in months) was 65.58 months, which was statistically significant (p<0.0083). Similarly, the average disease-free interval was 38.73 months, which was also significant (p<0.0062). Conclusion: According to the findings of the study, age may not be an independent risk factor for determining the outcome of cervical cancer patients in the Indian scenario. Even though elderly females may present with multiple co-morbidities, the standard treatment protocol must be radical

Global variation in postoperative mortality and complications after cancer surgery: a multicentre, prospective cohort study in 82 countries

© 2021 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY-NC-ND 4.0 licenseBackground: 80% of individuals with cancer will require a surgical procedure, yet little comparative data exist on early outcomes in low-income and middle-income countries (LMICs). We compared postoperative outcomes in breast, colorectal, and gastric cancer surgery in hospitals worldwide, focusing on the effect of disease stage and complications on postoperative mortality. Methods: This was a multicentre, international prospective cohort study of consecutive adult patients undergoing surgery for primary breast, colorectal, or gastric cancer requiring a skin incision done under general or neuraxial anaesthesia. The primary outcome was death or major complication within 30 days of surgery. Multilevel logistic regression determined relationships within three-level nested models of patients within hospitals and countries. Hospital-level infrastructure effects were explored with three-way mediation analyses. This study was registered with ClinicalTrials.gov, NCT03471494. Findings: Between April 1, 2018, and Jan 31, 2019, we enrolled 15 958 patients from 428 hospitals in 82 countries (high income 9106 patients, 31 countries; upper-middle income 2721 patients, 23 countries; or lower-middle income 4131 patients, 28 countries). Patients in LMICs presented with more advanced disease compared with patients in high-income countries. 30-day mortality was higher for gastric cancer in low-income or lower-middle-income countries (adjusted odds ratio 3·72, 95% CI 1·70–8·16) and for colorectal cancer in low-income or lower-middle-income countries (4·59, 2·39–8·80) and upper-middle-income countries (2·06, 1·11–3·83). No difference in 30-day mortality was seen in breast cancer. The proportion of patients who died after a major complication was greatest in low-income or lower-middle-income countries (6·15, 3·26–11·59) and upper-middle-income countries (3·89, 2·08–7·29). Postoperative death after complications was partly explained by patient factors (60%) and partly by hospital or country (40%). The absence of consistently available postoperative care facilities was associated with seven to 10 more deaths per 100 major complications in LMICs. Cancer stage alone explained little of the early variation in mortality or postoperative complications. Interpretation: Higher levels of mortality after cancer surgery in LMICs was not fully explained by later presentation of disease. The capacity to rescue patients from surgical complications is a tangible opportunity for meaningful intervention. Early death after cancer surgery might be reduced by policies focusing on strengthening perioperative care systems to detect and intervene in common complications. Funding: National Institute for Health Research Global Health Research Unit

Effects of hospital facilities on patient outcomes after cancer surgery: an international, prospective, observational study

© 2022 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 licenseBackground: Early death after cancer surgery is higher in low-income and middle-income countries (LMICs) compared with in high-income countries, yet the impact of facility characteristics on early postoperative outcomes is unknown. The aim of this study was to examine the association between hospital infrastructure, resource availability, and processes on early outcomes after cancer surgery worldwide. Methods: A multimethods analysis was performed as part of the GlobalSurg 3 study—a multicentre, international, prospective cohort study of patients who had surgery for breast, colorectal, or gastric cancer. The primary outcomes were 30-day mortality and 30-day major complication rates. Potentially beneficial hospital facilities were identified by variable selection to select those associated with 30-day mortality. Adjusted outcomes were determined using generalised estimating equations to account for patient characteristics and country-income group, with population stratification by hospital. Findings: Between April 1, 2018, and April 23, 2019, facility-level data were collected for 9685 patients across 238 hospitals in 66 countries (91 hospitals in 20 high-income countries; 57 hospitals in 19 upper-middle-income countries; and 90 hospitals in 27 low-income to lower-middle-income countries). The availability of five hospital facilities was inversely associated with mortality: ultrasound, CT scanner, critical care unit, opioid analgesia, and oncologist. After adjustment for case-mix and country income group, hospitals with three or fewer of these facilities (62 hospitals, 1294 patients) had higher mortality compared with those with four or five (adjusted odds ratio [OR] 3·85 [95% CI 2·58–5·75]; p<0·0001), with excess mortality predominantly explained by a limited capacity to rescue following the development of major complications (63·0% vs 82·7%; OR 0·35 [0·23–0·53]; p<0·0001). Across LMICs, improvements in hospital facilities would prevent one to three deaths for every 100 patients undergoing surgery for cancer. Interpretation: Hospitals with higher levels of infrastructure and resources have better outcomes after cancer surgery, independent of country income. Without urgent strengthening of hospital infrastructure and resources, the reductions in cancer-associated mortality associated with improved access will not be realised. Funding: National Institute for Health and Care Research