Frank Branicki

Perforated Peptic Ulcer: Different Ethnic, Climatic and Fasting Risk Factors for Morbidity in Al-Ain Medical District, United Arab Emirates

AIM To evaluate risk factors, morbidity and mortality rates of perforated peptic ulcer (PPU) and to investigate factors affecting postoperative complications of PPU. BACKGROUND The incidence of PPU has remained constant, simple closure with omental patch repair being the mainstay of treatment. PATIENTS AND METHODS One hundred and nineteen patients admitted to Al-Ain Hospital with PPU between January 2000 and March 2004 was studied retrospectively; two with deficient data were excluded from the analysis. Logistic regression was used to define factors affecting postoperative complications. RESULTS The mean age of patients was 35.3 years (range, 20-65). 45.7% of patients were Bangladeshi, and 85.3% originated from the Indian subcontinent. One patient, subsequently found to have a perforated gastric cancer, died. In 116 patients, 26 complications were recorded in 20 patients (17.2%). Common risk factors for perforation were smoking, history of peptic ulcer disease (PUD) and use of non-steroidal anti-inflammatory drugs (NSAIDs). A significantly increased risk of perforation was evident during the daytime fasting month of Ramadan. An increase in the acute physiology and chronic health evaluation (APACHE) II score (p = 0.047) and a reduced white blood cell count (0.04) were highly significant for the prediction of postoperative complications. CONCLUSION Patients with dyspeptic symptoms and a history of previous PUD should be considered for prophylactic treatment to prevent ulcer recurrence during prolonged daytime fasting in Ramadan, especially during the winter time.

The long term effects of early analysis of a trauma registry

BackgroundWe established a trauma registry in 2003 to collect data on trauma patients, which is a major cause of death in the United Arab Emirates (UAE). The aim of this paper is to report on the long term effects of our early analysis of this registry.MethodsData in the early stages of this trauma registry were collected for 503 patients during a period of 6 months in 2003. Data was collected on a paper form and then entered into the trauma registry using a self-developed Access database. Descriptive analysis was performed.ResultsMost were males (87%), the mean age (SD) was 30.5 (14.9). UAE citizens formed 18.5%. Road traffic collisions caused an overwhelming 34.2% of injuries with 29.7% of those involving UAE citizens while work-related injuries were 26.2%. The early analysis of this registry had two major impacts. Firstly, the alarmingly high rate of UAE nationals in road traffic collisions standardized to the population led to major concerns and to the development of a specialized road traffic collision registry three years later. Second, the equally alarming high rate of work-related injuries led to collaboration with a Preventive Medicine team who helped with refining data elements of the trauma registry to include data important for research in trauma prevention.ConclusionAnalysis of a trauma registry as early as six months can lead to useful information which has long term effects on the progress of trauma research and prevention.

Camel bite injuries in United Arab Emirates: A 6 year prospective study

PURPOSE To prospectively study the incidence, mechanism, distribution of injury, and outcome of patients admitted to Al-Ain Hospital with camel bite injuries in Al-Ain, United Arab Emirates. METHODOLOGY All patients admitted to Al-Ain Hospital with a camel bite were prospectively studied during the period of October 2001-October 2007. Patients demography, mechanism of injury including behaviour of the camel, distribution and severity of injury, and outcome were studied. RESULTS 33 patients were studied having a median (range) age of 27 (10-58), all were males. 97% were from the Indian subcontinent. A majority of injuries (73%) occurred during the camel rutting season (November-March). Twenty-five patients were camel caregivers whilst five were camel jockeys. All camel jockeys were children. Seven patients were raised up by the camels mouth and thrown to the ground whilst 26 patients were only bitten. Most injuries were in the upper limb (64%) and head and face (15%). 48% of upper limb injuries had associated fractures. Two patients who were bitten at the neck were admitted to the ICU. One of these died due to massive left-brain infarction and the other had complete quadriplegia due to spinal cord injury. The median hospital stay was 6 days. There was only one death (3%). CONCLUSION The behaviour of the camel is occasionally unpredictable, especially during the rutting season. The mechanism of camel bite injuries, which are usually severe, are complex including penetrating and crushing injuries by the camel jaw and blunt injuries when patients are picked up and thrown away. Care should be taken when handling camels, particularly in the rut.

Pancreatic Injuries in the United Arab Emirates

Purpose: To study the mechanism, management and outcome of patients who had sustained pancreatic trauma. Methodology: Patients who were treated for pancreatic trauma in Al-Ain hospital between October 2002 and August 2007 were retrospectively studied. Results: All eleven patients were males having a median age of 30 years (range 24–52 years). Nine had blunt trauma while two had suffered penetrating injury. Three presented with shock. Associated injuries were present in nine patients (head, chest, and extremities) while seven had other intra-abdominal injuries. Only one patient had isolated pancreatic injury. Early serum amylase was elevated in six patients. CT abdomen was diagnostic for pancreatic injury in seven patients. Two cases were missed by early CT scan (sensitivity of 78%) while the remaining two patients were taken immediately to the operating theater. All patients underwent laparotomy. Five patients were treated by drainage alone, four had distal pancreatectomy, abdominal packing was performed in one patient and in another gastrocystostomy was carried out. Pancreatic fistula occurred in three patients. Median hospital stay was 25 days (range 12–152 days). Two patients (18%) died. Conclusions: Blunt trauma is the main cause of pancreatic injury in our country. Early CT scan may miss pancreatic injury in almost a quarter of the patients. Thin sliced CT scan, with special views in a dedicated abdominal pancreatic study, is recommended. A high index of clinical suspicion, depending on the mechanism of injury, is important for diagnosis of pancreatic injury. Mortality is mainly attributable to other associated injuries so simple procedures should initially be adopted for pancreatic injury, especially in haemodynamically unstable patients.

Stromal Sarcoma of the Breast: A Case Report

We report a case of a 36-year-old lady who presented with a huge fungating tumour that involved the entire right breast. The tumour was diagnosed histologically as undifferentiated primary stromal tumour of the breast with axillary lymph node metastasis. We review the literature of this rare malignant tumour. Stromal sarcomas of the breast lack epithelial participation, and diagnosis of these tumours can be difficult. Genome-wide expression profiling is currently used to determine the cell of origin of most sarcomas. Surgery offers the best therapeutic option. Adjuvant radiotherapy is not very beneficial, while chemotherapy has, to date, no established role in the management of this disease. The prognosis is dismal for patients with lymph node involvement. The size of the tumour has a lesser bearing on outcome.

Prevention of Child Camel Jockey Injuries: A Success Story From the United Arab Emirates

Objective:To study the effects of a law banning children from taking part in camel racing on child camel jockey injuries in Al-Ain City, United Arab Emirates. Design:Prospective study. Setting:University Teaching Hospital. Patients:All patients who were admitted to Al-Ain Hospital and were injured while riding camels were prospectively studied between January 1, 2002, and December 31, 2009. Assessment of Risk Factors:Two periods, before the law and after its introduction, were compared. Main Outcome Measures:Pediatric injuries, their anatomical distribution, and severity of injury. Results:Fifty-four patients were studied, and all were males. There were 13 children and 41 adults. All children were camel jockeys except 1 child who was riding a camel for fun. None of the adult camel riders was a camel jockey. The median (range) age of patients admitted before the law was 12.5 (5-45) years, which was significantly less compared with 27.2 (20-40) years after its introduction (P = 0.001, Mann–Whitney test). All 13 children sustained their injuries before the law was implemented, whereas 12 of 41 adults sustained their injuries before the legislation was in place (P < 0.0001, Fisher exact test). The total length of hospital stay of patients was significantly reduced after the law enforcement (P < 0.01, Mann–Whitney test). Conclusions:Our findings emphasize the important role of law enforcement in injury prevention, illustrated by the replacement of children by robot substitutes. This is possibly one of the few examples where child injury has been completely prevented by legislation.

Laparoscopy in gastrointestinal malignancies.

This paper presents an update of the role of minimally invasive surgery (MIS) in gastrointestinal malignancy. A review of indications, surgical technique, and radicality of laparoscopy in the field of gastrointestinal cancer surgery is discussed. The feasibility and safety of laparoscopic procedures are compared with established and implemented standards in the diagnosis and treatment of oncological disorders. It is important to appreciate that only the “access” is different with all its attendant advantages. The use of laparoscopy in tumor staging and palliative and curative resection is evaluated on review of the literature, and special indications for a laparoscopic approach in gastrointestinal malignancy in different organs are discussed. In conclusion, MIS is safe and feasible, with many short‐term advantages; long‐term results should be further assessed in randomized controlled studies. Until the outcomes of such studies are available MIS for malignant disease should be performed by experienced surgeons in specialized centers.

Pediatric trauma research in the Gulf Cooperation Council countries

BACKGROUND/OBJECTIVE To review published pediatric trauma research from the Gulf Cooperation Council (GCC) countries so as to identify research fields that need to be enhanced. METHODS A MEDLINE search for articles on pediatric trauma from GCC countries during the period 1960 to 2010 was performed. The content of articles was analyzed, classified and summarized. RESULTS Fifty-three articles were found and retrieved of which 18 (34%) were published in the last 5 years, 42 (79.2%) were original articles. The first author was affiliated to a university in 29 reports (54.7%), to a community hospital in 13 (24.5%) and to a military hospital in 10 (18.9%). All articles were observational studies that included 18 (34%) case-control studies, 18 (34%) case reports/case series studies, 8 (15.1%) prospective studies, and 7 (13.2%) cross sectional studies. The median (range) impact factor of the journals was 1.3 (0.5-3.72). No meta-analysis studies were found. CONCLUSION A strategic plan is required to support pediatric trauma research in GCC countries so as to address unmet needs. Areas of deficiency include pre-hospital care, post-traumatic psychological effects and post-traumatic rehabilitation, interventional studies focused on a safe child environment and attitude changes, and the socioeconomic impact of pediatric trauma.

Ethics teaching in a medical education environment: preferences for diversity of learning and assessment methods

ABSTRACT Background: Ethics and professionalism are an integral part of medical school curricula; however, medical students’ views on these topics have not been assessed in many countries. Objective: The study aimed to examine medical students’ perceptions toward ethics and professionalism teaching, and its learning and assessment methods. Design: A self-administered questionnaire eliciting views on professionalism and ethics education was distributed to a total of 128 final-year medical students. Results: A total of 108 students completed the survey, with an 84% response rate. Medical students reported frequently encountering ethical conflicts during training but stated only a moderate level of ethics training at medical school (mean = 5.14 ± 1.8). They noted that their education had helped somewhat to deal with ethical conflicts (mean = 5.39 ± 2.0). Students strongly affirmed the importance of ethics education (mean = 7.63 ± 1.03) and endorsed the value of positive role models (mean = 7.45 ± 1.5) as the preferred learning method. The cohort voiced interest in direct faculty supervision as an approach to assessment of knowledge and skills (mean = 7.62 ± 1.26). Female students perceived greater need for more ethics education compared to males (p = < 0.05). Students who claimed that they had experienced some unprofessional treatment had a more limited view of the importance of ethics as a subject (P = 0.001). Conclusion: Medical students viewed ethics education positively and preferred clinically attuned methods for learning.

Informed consent learning: Needs and preferences in medical clerkship environments

Purpose Limited information exists regarding students’ routine educational needs in support of ethics and professionalism practices faced in real clinical practice. As such the authors aimed to explore medical students learning needs and preferences for informed consent and relevant ethical issues in the clerkship environments. Materials and methods A cross-sectional study using a self-administered, printed survey distributed to final year clinical clerks. Results 84% completed the survey. Students indicated the need for more attention to all topics related to informed consent (mean = 7.1 on a scale of 0 to 9; ±1.2). Most additional instructional attention was requested for topics raised in discussions with patients concerning the risks, benefits and alternatives to recommended treatments (7.3 ±1.4). The cohort expressed the need for education in the care of vulnerable patients (7.2 ±1.2) with a maximum score for the care of abused children. Women perceived greater need for education concerning informed consent than male respondents (p>0.05). There were significant differences between students who scored high or low on the item “being treated in professional manner” and “endorsement of educational needs for care of adolescents” (p = 0.05). Conclusion There was heightened perception among final year medical students of the need for greater attention to be paid to informed consent education.