|ABSTRACTS FOR NSRS CONFERENCE
|Year : 2016 | Volume
| Issue : 1 | Page : 53-57
Book of Abstracts for the 67th Biannual Scientific Conference of the Nigerian Surgical Research Society, Yenagoa, July 2015
|Date of Web Publication||15-Feb-2016|
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
. Book of Abstracts for the 67th Biannual Scientific Conference of the Nigerian Surgical Research Society, Yenagoa, July 2015. Niger J Surg 2016;22:53-7
| Pattern Of Gastrointestinal Perforation In A South-South Nigerian Tertiary Hospital|| |
Campbell FC, Akhator A, Odigie VI, Akporaiye L, Oside P, Akpo E, Odigie L1
Departments of Surgery and 1Pathology, Delta State University Teaching Hospital, Oghara Delta State, Nigeria
Introduction: Gastrointestinal perforation (GIP) is a common surgical emergency worldwide, most common causes are related to geographical and racial disposition of the patients, no age is exempt. Presentation is often late and resources scarce in developing countries resulting in higher morbidity and mortality. Aim: To highlight the causes, presentation and management of Gastrointestinal perforation. Patients and Methods: All patients who had GIP between January 1, 2014–30th April 2015 in Delta State University Teaching Hospital Oghara Delta State South-South Nigeria were prospectively studied via a profoma after due consent from them. Data were analyzed using Statistical Package for Social Sciences version 11. Results: 104 patients had GIP, 92 of the patients gave consent (88.4%). Peak age group was the 3rd decade, mean age 35.4 ± 8.08, age range 2–87 years and male female ratio 5:1. Fever 91.3%, abdominal pain 97.8%, abdominal distension 94.5%, and guarding 91.3% were the most common presenting features. Generalized peritonitis was seen in 95.6%. The most common causes of GIP were perforated appendix 31.5%, perforated peptic ulcer disease 22.8%, traumatic perforation 17.4%, and typhoid ileal perforation 13%. About 1 in 4 perforations were at the ileum. Almost 4 out of every 9 patients (45.8%) presented late more than 5 days from symptom onset. Overall complication rate was 36.9%; surgical site infection was the most common 21.7%; and Overall mortality was 17.4%. Conclusion: Perforated appendix is the most common cause of GIP in our center. Mortality in GIP is high and is related to late presentation to our tertiary center. There is need for early presentation and referral of patients with GIP in the, region.
| Pattern And Outcome Of Patients With Burns Admitted Into The Intensive Care Unit In University Of Port Harcourt Teaching Hospital|| |
Johnson UU, Kejeh BM1
Department of Anaesthesia and Intensive Care, 1Burns and Plastics Unit, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
Background: Oil exploration activities in the Niger Delta region may increase the risk of burns, and admission into the Intensive Unit may be indicated. Aims: To study the pattern of burns and outcome in the Intensive Care Unit (ICU). Materials and Methods: A retrospective study of admissions in the ICU was carried out between January, 2007 and December, 2014. Data on age, sex, type of burns, length of stay in the ICU and outcome were collated. The data were analyzed using Statistical Package for Social Sciences version 20. Result: Total admission was 127; sex ratio is 1:1. The youngest was 3 months and the oldest was 71 years with an average of 25.3. The burns were as a result of Kerosene explosion (40%), petrol explosion (20%), gas explosion (12.3%), and electrocution (6.15%). Hot liquid, carbon monoxide poisoning, chemical, drug reaction, and gun powder explosion had (1.53%) each. 75% of the patients had over 50% burns, and there was associated inhalational injury in 47. The length of stay was between 1 and 45 days. Eighty-nine patients (70%) died. Conclusion: Explosion of petroleum products is the most common cause of burns in the region, often with a very high mortality rate. Admission of most of these patients, the outcome already known to be poor only increases pressure on the personnel and material resource.
| Thyroid Function Test After Sub-Total Thyroidectomy For Graves' Disease In Zaria North-Western Nigeria|| |
Abur PP, Odigie VI, Yusufu LMD
Department of Surgery, ABU Teaching Hospital, Zaria, Nigeria
Introduction: Subtotal thyroidectomy is the gold standard for treating Graves' disease. It has stood the test of time and is commonly used in low resource countries were radioiodine is not readily available/affordable. Aim: To prospectively evaluate thyroid function after subtotal thyroidectomy for patients with Graves' disease managed in our hospital. Patients andMethods: We prospectively analyzed the thyroid function test at discharge, 3 months, 6 months, 12 months, and 24 months of patients who had subtotal thyroidectomy for Graves' disease between January 2003 and December 2012 (10 years) in our hospital. Thyroid function test was defined according to plasma level of triiodothyronine, thyroxine, and thyroid stimulating hormone. Results: A total of 41 patients had subtotal thyroidectomy for Graves' disease 37 females and 4 males. Age range (17–59) years. Majority of the patients, 87.8% were euthyroid, only 7.3% were hypothyroid, while 4.9% had recurrent hyperthyroidism. There was no mortality. Conclusion: Majority of the patients who had subtotal thyroidectomy for Graves' disease in this study were euthyroid after 2 years of follow-up. Those patients with hypothyroidism were seen within the first 6 months postoperatively while recurrent hyperthyroidism occurred after 1 year of surgery.
| Topic-Neoadjuvant Chemotherapy Default in Premenopausal Female Breast Cancer Patients in Zaria North-Western Nigeria|| |
Abur PP, Odigie VI, Yusufu LMD
Department of Surgery, ABU Teaching Hospital, Zaria, Nigeria
Background: The most common icon of presentation of breast cancer in Zaria is locally advanced disease necessitating the frequent use of neoadjuvant chemotherapy (NAC) to downstage the disease. Aims
: To determine the factors responsible for compliance and noncompliance to NAC by patients. Patients and Methods: A
2 years prospective study of premenopausal women with locally advanced breast cancer were counseled for NAC from January 2013 to December 2014 in our hospital. Full compliance was completion of three cycles before surgery. Results: One hundred and twenty-one patients consented for the study. Their ages ranged from 18 to 50 years with mean of 38.2 years ± 5.2 years. Fifty-three patients (43.8%) defaulted from NAC. Twenty-six patients (49.0%) defaulted after first cycle, seventeen (32.1%) patients after second cycle and ten (18.9%) patients after third cycle. Fourteen patients (26.4%) defaulted because of lack of funds, 11 (20.8%) because of fear of subsequent mastectomy, and ten (18.9%) to seek spiritual healing from the clergy. Conclusion: Lack of funds, fear of mastectomy and strong belief for spiritual healing were main factors for default of NAC. There is need for government to declare free treatment for breast cancer patients. Our clergy men should encourage their subjects to accept orthodox treatment of breast cancer.
| Gunshot Injuries In Delta State University Teaching Hospital|| |
Umuago UR, Odigie VI, Oside CP, Akhator A, Akporiaye L, Akpo EE
Department of Surgery, Delta State University Teaching Hospital, Oghara, Nigeria
Introduction: Gunshot injuries are either of low or high velocity projectiles. It is not uncommon in the Niger Delta region; probably because of the increasing prevalence of Militancy, socioeconomic vices, civil violence, and availability of guns in the region. Visceral injuries occur in 80-90% of penetrating abdominal injuries resulting in high morbidity and mortality in delayed hospital presentation. Aim: To highlight causes of gunshot injuries, clinical presentation and management over a 16 months prospective period. Patients and Methods: All patients who presented within the study period of January 1, 2014, to April 30, 2015 where prospectively studied and analyzed. Resuscitation and optimization of patients were of utmost priority before surgery. Serum amylase was not routinely done for abdominal penetrating injury. Results: The total number of cases in the study period was 27. M: F = 5.6:1. The age range was 19–49 years. Peak age group was 21–30 years (55.56%) mean age was 29.89 years ± 7.74. Presentation was within 24 h. Armed robbery 44.44% was the most common etiological factor and shot gun 55.56% the most implicated weapon. One in three patients had gunshot wound to the lower limbs, abdomen 1 in 5, head injuries the least with 1 in 30. 70.4% had single region injured. Mean hospital stay was 15.1 days mortality was 11.1% and the most common complication was surgical site infection 33.33%. Conclusion: Gunshot wounds commonly affect the young in Delta State. Armed robbery is the most common cause. There is the need to reduce the frequency of armed robbery in Delta state by improving the socioeconomic disparities and motivating factors, increased vigilance and reduction in proliferation of small arms among the youth.
| Prospective Audit Of Compliance With Utilization Of World Health Organization Surgical Safety Checklist As Part Of Quality Improvement Program In A Tertiary Hospital In Bayelsa State, Nigeria|| |
Ogoina D, Alagoa PJ1, Azebi EA2, Nyingifa IR3, Kunle-Olowu OE4
Departments of Internal Medicine, 1Surgery, 2Anaesthesia, 3Nursing Sciences and 4Paediatrics, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria
Introduction: Utilization of surgical safety checklist (SSC) promotes safe surgery, but compliance remains a challenge around the world. We prospectively audited the compliance with usage of a modified World Health Organization (WHO) SSC in Niger Delta University Teaching Hospital (NDUTH), Bayelsa State. Methods: In January 2013, members of the operating team (OT) of NDUTH were sensitized and educated on usage and completion of a modified WHO SSC consisting of sections to be filled and signed by members of OT in the surgical ward and operating theatre. We analyzed SSC usage compliance rates by retrieving folders of patients who had surgeries 6 months and 1 year after the introduction of the policy. We interviewed 10 members of the OT to identify barriers to usage of the SSC. Results: One hundred and sixty hospital folders were audited, including 60 folders at 6 months and 100 at 12 months. Availability of SSC in folders improved from 78% at 6 months to 84% at 12 months. At 6 months and 12 months, respectively, the SSC usage compliance rates were 76.1% versus 85.5% for ward-based nurses, 24.4% versus 28% for peri-operative nurses, 10.6% versus 9.5% for surgeons, and 27.7% versus 39% for anesthetists. These differences were not significant (P > 0.05). Excess workload, time constraints, and unavailability of SSC were the major reasons adduced for noncompletion of SSC. Conclusion: Our study reveals low rates of compliance with usage of SSC especially among surgeons and peri-operative nurses. Continuous education and training are necessary to guarantee sustainable compliance with usage of SSC.
| Peri-Operative Antibiotic Use And Compliance With Surgical Antibiotic Prophylaxis Guidelines In A Tertiary Hospital In Nigeria|| |
Ogoina D, Alagoa PJ1
Departments of Internal Medicine and 1Surgery, Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria
Background and Objective: We aimed to evaluate the prevalence and pattern of peri-operative surgical antibiotic use and compliance with established standards of antibiotic prophylaxis among adult surgical patients seen at Niger Delta University Teaching Hospital, Bayelsa State. Methods: We retrospectively reviewed the hospital records of adult surgical patients who had surgical operations between April 2012 and April 2013. Demographic information, type of surgery, wound class, type, and duration of antibiotic used pre- and post-operatively, among other relevant clinical were obtained from patient records using a standardized data form. Type, timing, and duration of prophylactic antibiotic use were compared with established standards. Results: Of 122 study participants with median age of 44 years, 79 (64.8%) were males, 90 (73.8%) were nonorthopedic surgical cases, and 40 (32.8%) were cases of emergency surgeries. The prevalence of pre- and post-operative antibiotic use was 50.8% and 100%, respectively. Postoperative antibiotics were given for treatment of apparent surgical wound infections in 36 (24.5%) cases and empirically in 86 (70.6%) cases. The choices of antibiotic were variable but ceftriaxone and metronidazole were most commonly used. Of 90 patients who had clean or clean contaminated wounds, 35 (37.6%) received antibiotics prophylaxis before surgery and majority (93.5%) of these patients received antibiotics for more than 24 h after surgery. Conclusion: Antibiotic use among surgical patients in study site is variable and inconsistent with established standards. Institution and implementation of local and national surgical antibiotic guidelines in Nigeria will mitigate inappropriate surgical antibiotic use and its consequences.
| Benign Breast Lumps In A Tertiary Center In South - South Nigeria|| |
Promise N Wichendu, Amabra Dodiyi-Manuel
Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Nigeria
Background: The presence of a lump in the breast is a cause of anxiety and fear to most patients. This may be due to the increased awareness of breast cancer which is the most common malignancy affecting females worldwide. Objective: To determine the clinic dermographic and histologic pattern of benign breast diseases as seen in University of Port Harcourt Teaching Hospital (UPTH). Materials and Methods: This is a 9-year (2006–2014) prospective study of all patients presenting with benign breast lumps in UPTH. Data were collected and analyzed using Statistical Package for Social Sciences version 17. Results: There were 308 patients with benign breast lumps within the study period and they were all females. The overall mean age was 24.8 ± 7.8 years with an age range of 12–43 years and a peak age incidence occurring in the third decade. The most common lump was fibroadenoma accounting for 72.4% of cases followed by fibrocystic disease (20.8%) with mean ages of 23.7 ± 7.7 years and 26.9 ± 7.5 years, respectively. Both lesions had a peak occurrence in the third decade. Conclusion: Benign breast lumps occurred predominantly in the third decade with fibroadenoma being the most common lesion encountered.
| Otorhinolaryngological Emergencies In A Tertiary Hospital In Port Harcourt; Presentations And Management|| |
Department of Ear Nose and Throat Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
Background: Emergencies are not uncommon in a typical ORL clinic. The knowledge of the profile and prevalence of these emergencies will go a long way in helping to equip as well as aid proper and prompt management of these conditions so as to reduce their morbidity and mortality. Patients and Methods: A descriptive retrospective 9-year review of all patients that presented to the Ear Nose and Throat surgery department from January 2004 to December 2012. This includes referrals from the accident and emergency as well as the children emergency ward. The patients case files, the ward and theatre records were the source of data. Data collected included; age, sex, presentations, diagnosis, and management. Results: There were a total number of 3660 patients that presented as emergencies; however, only 2160 cases were real emergencies. Males were 1328 and females 832 with a ratio of 1.6:1. The age ranged from 6 months to 70 years. The age range 0–10 years were the most affected 670 (31.02%) followed by age range 21–30 years 534 (24.72%). The least was 61–70 years 26 (1.20%). Foreign body aspiration/ingestion was the most common emergency 900 cases (41.7%) followed by trauma 850 (39.4%). There were five cases of mortality (0.23%). Direct laryngoscopy and oesophagoscopy were the most common form of management. Conclusion: ORL emergencies are common. The pediatric age group is most affected; foreign body and trauma comprise the most common emergency in our environment.
| Laryngoscopy In Otolaryngology Clinics: Analysis Of 202 cases In Port Harcourt, Nigeria|| |
Onotai LO, Nwosu Chibuike
Department of Ear Nose and Throat Surgery, University of Port Harcourt Teaching Hospital Port Harcourt, Rivers State, Nigeria
Background: Laryngoscopy is a visual examination of the larynx and its related structures. It is an effective procedure for ascertaining the causes of laryngeal disorders, pain in the throat, and difficulty in swallowing. The procedure is relatively painless, but the idea of having a scope inserted into the throat of a patient can be worrisome. This study establishes the use of laryngoscopy in adult patients who presented to the Ear Nose and Throat (ENT) clinics of the Department of ENT Surgery of University of Port Harcourt Teaching Hospital (UPTH) and Kinx Medical Consultants Clinic in Port Harcourt. It analyses the indications, findings and the role it played in the management of the patients. Patients and Methods: This is a 2 years (January 2013 to December 2014) prospective study of 202 laryngoscopies done in the ENT surgery clinics of UPTH and Kinx Medical Consultants Clinic in Port Harcourt. All laryngoscopies done were documented by the researchers in a profoma prepared for the study. The data collected were bio-data (age and sex), presenting symptoms/indications for the procedure, type of laryngoscopy, findings at laryngoscopy/biopsy results, and the role the procedure played in the management of the patients. The data were entered into a Statistical Package for Social Sciences version 14 computer software and analyzed descriptively. Results: There were 60 males and 142 females with a M: F ratio of 1:2.4. The age range was 18–83 years with a mean of 54.5 ± 5.64. Age group 40–50 years had the highest number of cases n = 65, (32.18%). The most common type of laryngoscopy done was indirect laryngoscopy using the laryngeal mirror n = 115 (56.93%). The most common indication was preoperative evaluation for thyroidectomy n = 58 (28.71%). The most common positive finding was hyperemia and indurations in 25 cases (12.38%). The entire patient that presented with globus pharyngeus and those for preoperative assessment for thyroidectomy had negative findings. Conclusion: Laryngoscopy remains a very useful cost effective diagnostic procedure. It can exclude laryngeal pathologies in most patients that have psychosomatic disorders and select the patients that will benefit from examination under anesthesia, direct laryngoscopy, and biopsy.
| Traumatic Perforations Of Tympanic Membrane: Clinical Profile And Management Outcomes In Port Harcourt Nigeria|| |
Onotai LO, Oghenekaro Edirin
Department of Ear Nose and Throat Surgery, University of Port Harcourt Teaching Hospital Port Harcourt, Rivers State, Nigeria
Background: Traumatic perforation of tympanic membrane appears to be in the increase in our environment. This study determines the prevalence of traumatic perforations of tympanic membranes and highlights the clinical profile and management outcome as seen recently in Port Harcourt, Nigeria. Patients and Methods: A prospective (January 2014–December 2014) study of 35 patients clinically diagnosed at the Ear Nose and Throat (ENT) surgery clinics of University of Port Harcourt Teaching Hospital and Kinx Medical Consultants Clinic in Port Harcourt. They all did pure tone audiometry to ascertain their hearing status. Data obtained from the patients were documented by the researchers in a profoma prepared for the study. The data collected were bio-data (age and sex), clinical presentations, otoscopic findings, source of injury, complications, and management outcome. The data were entered into a Statistical Package for Social Sciences version 14 computer software and analyzed descriptively. Results: Thirty-five patients were found to have traumatic tympanic membrane perforations out of 1257 patients with aural diseases that were seen during the study period giving a prevalence of 2.78%. In these patients, only one ear was affected. Age range was 2 years to 70 years with a mean age of 35.2 ± 6.3 years. The most common age group affected was 35–45 years n = 10, (28.57%), the male to female ratio was 1:1.3. The most common etiological factor was from slaps n = 15 (42.86%), followed by cotton bud injury n = 10, (28.57%). The slap injuries were from security agents n = 8, (22.86%) and domestic assault n = 7 (20.00%). Bleeding from the ear was the most common n = 15 (42.86%) symptom; some of the patients n = 12, (34.29%) had first aid treatment in the chemist prior to presentation. The left ear n = 19 (52.29%) was more affected than the right. The most common otoscopic finding was blood clots in the external auditory canal with central tympanic membrane perforation n = 15, (42.86%). The most common n = 6, (17.14%) complication encountered was Chronic Suppurative Otitis Media. Only 14 (40%) patients responded to treatment after 1 month of conservative management, with antibiotic oral medications, vitamin c, and analgesics. Six (17.14%) patients were lost to follow-up. Conclusion: Traumatic perforation of the tympanic membrane is still common in our environment. Slaps and injudicious use of cotton buds ranked highest as etiological factors. Prompt diagnosis and expert management will help reduce the morbidity associated with this condition. Public enlightenment campaigns to educate the public on how to prevent traumatic membrane perforations will go a long way to reduce the complications associated with this condition.
| Percutaneous Drainage Of Pericardial Effusion With Central Venous Catheters|| |
Edaigbini SA, Orogade AA
Department of Surgery, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
Background: Life-threatening pericardial effusions require emergency drainage. Where the kits available, percutaneous drainage by means of Seldinger's technique provides the fastest means of relief especially in centers where infrastructural challenges delay even the most emergent cases for hours. Aim: To evaluate our emergency drainage of massive pericardial effusions with central venous catheters. Materials and Methods: The indications for drainage are based on two-dimensional echocardiographic diagnosis of pericardial tamponade and the request by physicians for the relief of the tamponade. The procedures were done by the bedside under local anesthesia at the xiphisternum with patient in 20–30° head-up position. We used a size 7F or 7.5F polyurethrane central venous catheters were inserted using the Seldinger's technique into the pericardial space. Results: Over a period of 5 years (May 2010–April 2015) we manage 14 patients with this approach. There were six males and eight females (M: F = 1:1.3). The age range was 9 months to 60 years with a mean of 24.6 years. The procedure was successful in 13 (92.9%) cases with improvement in patients' hemodynamic status and general condition and was abandoned in one case (7.1%). The average duration of catheter in situ position was 7.1 days with a range of 4–10 days. Conclusion: Central venous catheter is an invaluable alternative to pericardial catheter for emergency drainage of massive pericardial effusions with tamponade where the expertise is available especially in our locality were infrastructural challenges can delay emergency surgical interventions for hours.
| The Practice Of Inguinal Hernia Repair In Nigeria|| |
Udo IA, Umeh KU
Department of Surgery, University of Uyo Teaching Hospital, Uyo, Nigeria
Background: Techniques for inguinal hernia repair have evolved enormously in the past decade in Europe and North America. The Lichtenstein repair is the most commonly practiced open repair. Low income economies, especially in Sub-Saharan Africa, are lagging for multiple reasons; making comparison of technique and outcome more challenging. Objective
: To examine the trend in inguinal hernia repair among hernia surgeons in Nigeria and the factors influencing same. Willingness to adopt a newer technique was also assessed. Methods: A questionnaire was administered to general surgeons at the 8th Congress of Association of Surgeons of Nigeria. Analysis of completed questionnaires was by Statistical Package for Social Sciences 17. Results: There were 40 respondents. Darning (42.5%), Bassini's (25.0%), and Shouldice (10.0%) were the common techniques employed. Training (22.5%), facilities (20.0%), and habit (10%) were primarily responsible for the technique adopted. Sixty-two percent of surgeons were willing to change technique and the reasons advanced for change to a new technique were low recurrence, tension free, and low cost. Conclusion: The trend in inguinal hernia repair in Nigeria is still based on traditional suture methods. There is a strong desire among hernia surgeons to evolve to newer techniques.
| Errors In Surgery: Surgeons' Definition And Perspectives On Reporting And Disclosure|| |
Wichendu P1,2, Ajoku U2, Egwhurudjakpor P1,2
1Department of Surgery, College of Health Sciences, University of Port Harcourt, 2Department of Surgery, University of Port Harcourt Teaching Hospital, Port Harcourt, Rivers State, Nigeria
Background: The surgeon faces a unique challenge; fulfilling his professional duty in a transparent manner while remaining safe in a litigious world. Error reporting and disclosure are essential ingredients of a transparent practice. Aim: To ascertain what surgeons consider as error, the causes, frequency, and their opinion about error reporting/disclosure. Methods: A 28-item questionnaire developed after a pilot study in University of Port Harcourt Teaching Hospital was distributed at ICS conference held in Port Harcourt. Results: Seventy-six fully completed responses were received across all the surgical sub specialties. Opinion on what constituted an error (yes/no): wrong judgment; 72/4 (94% vs. 6%), technical failure; 66/10 (86.84% vs. 13.16%), inappropriate delegation of duty; 67/9 (88.16% vs. 11.84%), system error; 39/37 (51.32% vs. 48.68%), mechanical failure of equipment; 43/35 (56.58% vs. 43.425), nursing error; 46/30 (60.53% vs. 39.47%), communication failure; 59/17 (77.63% vs. 22.37%). Systemic error was the most common error; 33 (43.42%). Eight respondents (10.53%) considered error as an “act of God.” Forty-eight surgeons (63.16%) said there was no institutional protocol on error reporting where they practice, 15 (19.74%) admitted they had, while 13 (17.11%) were unsure. All the respondents agreed there was need for an institutional protocol. Sixty-six (86.84%) admitted to have made at least a nonfatal error. Of this, 53 (69.74%) disclosed this error to the patient or relative. Forty-two respondents (55.26%) made fatal errors; 16 (38.10%) disclosed such error to the patients' relatives. Of those that did not disclose their error, 13 (56.52%) did not think it was necessary, while six (26.09%) worried about potential litigation. Error disclosure to patients was supported by 52 (68.42%). Of those who opposed disclosure, 13 (54.17%) were concerned about litigation. Forty-three (56.58%) agreed error disclosure to patients was beneficial, 18 (23.68) disagreed, while 15 (19.74) were unsure. All but six respondents agreed reporting error can improve patients' safety. Conclusion: Differences exist among surgeons as to what constitutes an error. Most fatal errors are not disclosed, although error disclosure to patients was deemed beneficial.