Colombo South Teaching Hospital

Introduction Severe tearing-type chest pain radiating to the back is the typical presentation of Aortic Dissection, commonly manifest with tachycardia and hypertension, especially Stanford type B Aortic Dissections. We present a case of sinus bradycardia in a type B aortic dissection patient with a severe, painful aortic dissection, not involving the coronary arteries initially. This is a case of paradoxical bradycardia with severe pain. Case Report A 17-year-old, previously unscreened Sri Lankan male presented with acute onset abdominal pain radiating to the back with no hematuria, limb paralysis, fever or other urinary bowel symptoms. The clinical examination revealed no radio-radial or radio-femoral delay or blood pressure discrepancy. He had Marfanoid features and kyphoscoliosis, but the vital parameters were stable, other than severe bradycardia and sinus arrhythmia. The pain was not settling with intravenous Morphine, requiring additional analgesia. Despite being in severe pain (worst-ever 10/10), the patient was in persistent bradycardia around 40bpm. He has been taking alcohol & cannabis occasionally, but has not taken them recently. He was neither an athlete nor involved in physical exercises. Troponin I, Serum Amylase, and other biochemicals were negative. An extensive point-of-care ultrasound revealed aortic dissection with an intraluminal flap-like object in the lower thoracic region, with no evidence of pericardial effusion/ cardiac tamponade, regional wall motion abnormalities or pneumothorax. However, the patient succumbed to death, like 50% of the cases, but the postmortem confirmed the diagnosis of aortic dissection. Discussion Bradycardia in a type B aortic dissection is an atypical presentation. Life-threatening aortic dissection should be suspected in the presence of risk factors for aortic dissection( eg- Marfan’s Syndrome), even if the clinical signs do not provide evidence of aortic dissection, especially if there is severe abdominal/ back pain. The paradoxical phenomenon of bradycardia in severe pain could mislead the diagnosis and result in devastating consequences.

Background: Efficient operating theatre utilisation stands as a cornerstone of surgical service delivery, particularly within resource-limited healthcare environments. Across South Asia, public hospitals continue to grapple with suboptimal theatre usage despite considerable investment in surgical infrastructure. This audit examines how effectively routine elective operating theatres are being used at Colombo South Teaching Hospital (CSTH), one of Sri Lanka's leading tertiary teaching institutions, with the aim of identifying practical opportunities for improvement. Methods: We conducted a prospective audit spanning 30 consecutive working days, tracking activity across six routine elective operating theatres at CSTH. Theatre logbooks provided detailed records of case timings, first-case delays, and procedure classifications. We calculated utilisation using two different approaches: an 8-hour scheduled session framework representing standard utilisation, and a 12-hour extended capacity framework reflecting maximum potential theatre availability. Statistical correlation analysis explored how first-case start-time delays influenced overall daily utilisation patterns. Results: Our findings revealed a mean scheduled-session utilisation of 58.1% (SD = 14.2%), while extended capacity utilisation reached 38.7%. A notable moderate to strong negative correlation emerged between first-case start-time delays and daily utilisation rates (r = −0.60, p < 0.01), suggesting that punctuality significantly impacts theatre productivity. Day-to-day variability proved substantial, with utilisation fluctuating between 32% and 84%. When compared against previous institutional data from 2019, scheduled utilisation showed encouraging improvement, though extended capacity remained considerably underutilised. Conclusions: While CSTH has made meaningful progress in scheduled session utilisation, significant untapped capacity persists during extended theatre hours. Start-time discipline emerged as the single most influential modifiable factor affecting daily surgical throughput. Targeted administrative interventions—including stricter punctuality protocols, predictive scheduling systems, and streamlined turnover processes—offer realistic pathways to expand surgical capacity without requiring additional infrastructure investment. These findings have direct implications for surgical service planning in similar resource-constrained settings.

Introduction and importance: Internal hernias are a rare cause of small bowel blockages in less than 1% of patients. Paraduodenal hernias are the most common internal hernia but can be challenging to identify because presentation is nonspecific. Timely detection with early surgical intervention is essential as delayed diagnosis can lead to strangulation, ischemia, and ultimately mortality. Case presentation: We present a challenging case of a small bowel obstruction due to a paraduodenal hernia in a 74-year-old man with multiple comorbidities that was complicated intraoperatively by ventricular fibrillation (VF) requiring cardiopulmonary resuscitation and defibrillation. Following clinical assessment, imaging workup raised the possibility of internal hernia. After initial resuscitation, exploratory laparotomy was performed and found to have viable jejunal loop incarcerated in the left paraduodenal recess with impending risk of strangulation. Adhesiolysis, release of bowel contents, and repair of the hernia sac were performed. Intraoperative cardiac arrhythmia (VF) was successfully managed by the anesthesia team. Following surgery, patient was managed with intensive care and other supportive measures and ultimately discharged after full recovery. Clinical discussion: Paraduodenal hernias are embryological defects resulting from midgut malrotation. The clinical spectrum of presentation is variable. Patients may complain of intermittent abdominal pain or present with an acute intestinal obstruction. A contrast enhanced computed tomography scan is the preferred diagnostic imaging modality to assess the small bowel, and it may show loops of small bowel that are encapsulated in the paraduodenal recess. If recognized early, surgery is the only definitive management and can be performed through an open technique or laparoscopic approach. Prompt surgical intervention is important as the morbidity related to paraduodenal hernias can be minimized, and since recurrence can occur. Conclusion: This case illustrates the significance of weighing paraduodenal hernia as a differential diagnosis in small bowel obstruction. It is significant, as it again illustrates that a rare, yet critical diagnosis can be overlooked, specifically in the resource-limited circumstances. The report reaffirms that early recognition through clinical suspicion supported by imaging, followed by timely surgical intervention with careful consideration of comorbidities, is essential to achieving better patient outcomes. The take-home lessons for clinical practice and learning points include always have a high suspicion for internal hernia, recognition of the importance of imaging to allow early diagnosis and provide timely surgical intervention to avoid bowel ischemia and its complications.

Background and aim Gestational diabetes mellitus (GDM) affects 6-15% of pregnancies globally and is traditionally diagnosed at 24-28 weeks of gestation. Early identification of high-risk women during the first trimester could enable timely interventions and improved pregnancy outcomes. This study aimed to develop and evaluate machine learning models for early GDM prediction using first-trimester clinical and laboratory parameters. To achieve this aim, the study has the following five key objectives: first, to generate a clinically representative synthetic dataset incorporating demographic characteristics, clinical risk factors, and first-trimester laboratory parameters; second, to implement comprehensive feature selection methodologies to identify optimal predictors from candidate variables; third, to systematically evaluate multiple machine learning algorithms with hyperparameter optimization; fourth, to assess model interpretability using SHapley Additive exPlanations (SHAP) analysis; and fifth, to establish clinically actionable threshold values for first-trimester biomarkers. Methods A synthetic dataset of 10,000 patient records was generated using evidence-based probabilistic modeling, incorporating demographic characteristics (maternal age, pre-pregnancy BMI, ethnicity), clinical risk factors (family history of diabetes, previous GDM, polycystic ovary syndrome (PCOS), previous macrosomia), and first-trimester laboratory parameters (random blood sugar, post-prandial blood sugar, HbA1c, and oral glucose tolerance test {OGTT} values). Seven feature selection methodologies were employed to identify optimal predictors from 18 candidate variables. Eleven machine learning algorithms were systematically evaluated, with hyperparameter optimization performed via GridSearchCV (France, Le Chesnay-Rocquencourt: INRIA) using 10-fold stratified cross-validation. Model interpretability was assessed using SHapley Additive exPlanations (SHAP) analysis. Results The Multi-layer Perceptron neural network achieved optimal performance, with an F1-score of 0.7213, an accuracy of 71.7%, and an AUC-ROC of 0.7692 on the independent test set. Feature importance analysis identified early HbA1c as the primary predictor (importance score: 0.405), followed by pre-pregnancy BMI (0.291) and family history of diabetes (0.271). SHAP analysis confirmed these findings, with family history demonstrating the highest mean absolute SHAP value. Clinically actionable thresholds were identified as follows: early RBS ≥125 mg/dL (borderline) and ≥140 mg/dL (concerning); early PPBS ≥160 mg/dL (borderline) and ≥180 mg/dL (concerning); and HbA1c ≥5.7% (intermediate risk), ≥6.0% (high risk), and ≥6.5% (diagnostic). Conclusions First-trimester laboratory parameters, particularly HbA1c combined with clinical risk factors, enable effective early GDM risk stratification with clinically acceptable accuracy. The machine learning framework demonstrates potential for enhancing prenatal screening through personalized risk assessment, though prospective validation in real-world clinical populations is essential before implementation.

Tracheal injury following thyroidectomy is rare, with delayed presentation being even less common. Tracheal mucosal herniation through a small tracheal wall defect represents an exceptionally unusual postoperative complication. This report describes a 49-year-old woman who developed a delayed anterolateral tracheal defect with mucosal herniation two weeks after a total thyroidectomy. Conservative management led to complete recovery. This case highlights the importance of maintaining a high index of clinical suspicion for airway complications in the late postoperative period and demonstrates that small, contained tracheal defects can be safely managed nonoperatively.