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Purpose: Limb amputation is one of the oldest medical operations, dating back over 2500 years to Hippocrates' time. In developing countries like India, most of the patients are young, and trauma is the primary cause of limb amputation. The objectives of this study were to investigate the factors that can predict the outcome of patients who underwent upper or lower limb amputations. Materials and methods: This was a retrospective analysis of the prospectively collected data of patients who underwent limb amputations from January 2015 to December 2019. Results: From January 2015 to December 2019, 547 patients underwent limb amputations. Males predominated (86%). Road traffic injuries (RTI) were the most common (323, 59%) mechanism of injury. Hemorrhagic shock was present in 125 (22.9%) patients. Above-knee amputation was the most common (33%) amputation procedure performed. The correlation of hemodynamic status at presentation with the outcome was statistically significant (p-0.001). Outcome measures like delayed presentation, hemorrhagic shock, Injury severity scores (ISS), and the new injury severity scores (NISS) were statistically significant (p-0.001) when compared to the outcome. There were 47 (8.6%) mortalities during the study period. Conclusion: Factors that affected the outcome were delayed presentation, hemorrhagic shock, higher ISS, NISS, MESS scores, surgical-site infection, and associated injuries. Overall mortality during the study was 8.6%. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the efficacy of corneal neurotisation using sural nerve graft coaptation of the contralateral supratrochlear nerve in unilateral neurotrophic keratopathy and corneal anesthesia. Corneal neuralization has emerged as a potential option in the treatment of neurotropic keratopathy, however not free from the predicament. We evaluated the long-term outcome of corneal neurotisation in the treatment of unresponsive unilateral neurotropic keratopathy using surgical variations to mimic and expedient the surgical procedure. Methods: A Prospective interventional study involving patients with unilateral neurotrophic keratopathy (NK) who did not respond to medical measures was conducted. The study parameters evaluated were best-corrected visual acuity improvement, ocular surface evaluation parameters [tear break-up time (TBUT), Schirmer's 1, and ocular surface staining scores (corneal and conjunctival staining)], central corneal sensation (Cochet Bonnet esthesiometer), sub-basal nerve fiber length (SBNFL), and sub-basal nerve fiber density (SBNFD) determined by central confocal microscopy at recruitment and during follow-up at 1-month, 3-month, 6-month, 9-month and 12-month respectively, following corneal neurotization. Results: Eleven eyes of 11 patients with unilateral neurotrophic keratopathy (NK) who underwent corneal neurotisation were studied. The mean follow-up was 10.09±2.31months (range, 6–12). Mean best corrected visual acuity in log MAR at baseline, 1.35±0.52 improved significantly to 1.06±0.76 (P = 0.012) at 3 months and continued to 0.55±0.60 (P = 0.027) at 12 months. There was a significant reduction in NK grade severity and improvement in the ocular surface as early as 1 month, and central corneal sensations (P = 0.024) as soon as 3 months. Mean corneal SBNF improved from 3.12±1.84 mm/mm2 to 4.49±1.88 at 1 month (P = 0.008), 13.31±3.61 mm/mm2 (P = 0.028) at 12 months. Mean central corneal SBNFD evident at 6 months was 1.83±2.54no/mm2 (P = 0.018) and 4.90±3.12no/mm2 (P = 0.028) at 12 months. Conclusion: This study substantiates the routine practice of corneal neurotisation by simplifying the intricacies observed during the procedure. [ABSTRACT FROM AUTHOR]

Isolated urogenital sinus is a rare anomaly. These cases may have high confluence which adds complexity to surgical correction. There are controversies regarding timing and techniques of management. We present a case report on managing such a case in an infant with bladder outlet obstruction and pyocolpos. [ABSTRACT FROM AUTHOR]

Actionable incidental findings (AIFs) are common imaging findings unrelated to the clinical indication for the imaging test for which follow-up is recommended. Increasing utilization of imaging in the emergency department (ED) in recent years has resulted in more patients with AIFs. When these findings are not properly communicated and followed up upon, there is harm to the patient's health outcome as well as possible increased financial costs for the patient, the health system, and potential litigation. Tracking these findings can be difficult, especially so in a large health system. In this report, we detail our experience implementing a closed-loop AIF program within the ED of 11 satellite hospitals of a large academic health system. Our new workflow streamlined radiologist reporting of AIFs through system macros and by using a standardized form integrated into the dictation software. Upon completion of the form, an automatic email is sent to a dedicated nurse navigator who documented the findings and closed the loop by coordinating follow-up imaging or clinic visits with patients, primary care providers, and specialists. Through the new workflow, a total of 1207 incidental finding reports have been submitted from July 2021 to May 2022. The vast majority of AIFs were identified on CT, and the most common categories included lung nodules, pancreas lesions, liver lesions, and other potentially cancerous lesions. At least 10 new cancers have been detected. We hope this report can help guide other health systems in the design of a closed-loop incidental findings program. [ABSTRACT FROM AUTHOR]

The new coronavirus (COVID-19) infection, first detected in Wuhan, China in 2019 has become a pandemic that has spread to nearly every country in the world. Through October 11, 2021, more than 23 billion confirmed cases and 4.8 million fatalities were reported globally. The bulk of individuals afflicted in India during the first wave were elderly persons. The second wave, however, resulted in more severe diseases and mortality in even younger age groups due to mutations in the wild virus. Symptoms may range from being asymptomatic to fatal acute respiratory distress syndrome (ARDS). In addition to respiratory symptoms, patients may present with gastrointestinal symptoms such as stomach pain, vomiting, loose stools, or mesenteric vein thrombosis. The frequency of patients presenting with thromboembolic symptoms has recently increased. According to certain studies, the prevalence of venous thromboembolism among hospitalized patients ranges from 9 to 25%. It was also shown that the incidence is significantly greater among critically sick patients, with a prevalence of 21–31%. Although the exact origin of thromboembolism is unknown, it is considered to be produced by several altered pathways that manifest as pulmonary embolism, myocardial infarction, stroke, limb gangrene, and acute mesenteric ischemia. Acute mesenteric ischemia (AMI) is becoming an increasingly prevalent cause of acute surgical abdomen in both intensive care unit (ICU) and emergency room (ER) patients. Mesenteric ischemia should be evaluated in situations with unexplained stomach discomfort. In suspected situations, appropriate imaging techniques and early intervention, either non-surgical or surgical, are necessary to avert mortality. The purpose of this article is to look at the data on acute mesenteric ischemia in people infected with COVID-19. [ABSTRACT FROM AUTHOR]

Purpose: Penetrating abdominal trauma was traditionally managed by mandatory exploration, which led to high rates of non-therapeutic surgery and prolonged hospital stay. Diagnostic laparoscopy (DL) is a less-invasive alternative; however, it requires general anaesthesia and carries a potential risk of iatrogenic injuries. Contrast-enhanced computed tomography (CECT)-guided selective non-operative management (SNOM) may avoid surgery altogether, but there is apprehension of missed injury. Randomised trials comparing these two modalities are lacking. This study is aimed at comparing outcomes of these two management approaches. Methods: Hemodynamically stable patients with penetrating trauma to anterior abdominal wall were randomised in 1:1 ratio to DL or CECT-based management. Primary outcome was length of hospital stay (LOS). Secondary outcomes were rate of non-therapeutic surgery, complications, and length of intensive care unit (ICU) stay. Results: There were 52 patients in DL group and 54 patients in CECT group. Mean LOS was comparable (3 vs 3.5 days; p = 0.423). Rate of non-therapeutic surgery was significantly lower in CECT group (65.4 vs 17.4%, p = 0.0001). Rate of complications and length of ICU stay were similar. Selective non-operative management based on CECT findings was successful in 93.8% of patients; 2 patients had delayed surgery. Conclusion: In patients with penetrating trauma to anterior abdominal wall, DL and CECT-based management led to comparable hospital stay. Significant reduction in non-therapeutic surgery could be achieved using a CECT-based approach. Trial registration: Clinical trials registry-India (CTRI/2019/04/018721, REF/2019/01/023400). [ABSTRACT FROM AUTHOR]

Aim: Posterior cloacal malformations (PCMs) are distinguished from classical cloacal malformations by the posterior location of the common opening in the perineum. We aim to describe our experience of management of these rare and complex malformations. Methods: This study was a retrospective chart review of all patients with PCM who underwent treatment at Kalawati Saran Children's Hospital (KSCH), New Delhi, and Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, between 2013 and 2021. Individual anatomical variations and their impact on the clinical presentation, management, and final outcome (cosmesis and function) were recorded and analyzed. Results: During the study period, four girls with a median age of 2 (range: 0–5) years presented to us with PCM. Three patients were referred to KSCH as ambiguous genitalia whereas one patient was born at SGPGIMS with an antenatal diagnosis of "urorectal septal defect." On examination, three patients had the urogenital sinus (UGS) opening immediately anterior to the normally located anal opening (2 orifices), whereas one had a single orifice at the normal location of the anus with the UGS opening in the anterior rectal wall. Associated anomalies included: (a) hydrocolpos (n = 3), which was managed by a tube vaginostomy; (b) urethral duplication with dorsal atretic urethra (n = 3); (c) uterine didelphys (n = 1); (d) bilateral grade 5 vesicoureteric reflux (n = 1); and (e) vaginal calculus (n = 1). Total urogenital mobilization (anterior sagittal approach) with feminizing genitoplasty was performed for patients with UGS and normal anus (n = 3). In the patient with a single opening at the normal location of the anus, posterior sagittal ano-recto-urethro-vaginoplasty was performed. At a median follow-up of 24 months, three patients are continent for urine and stool, whereas one patient is yet to be toilet trained. Conclusions: PCMs are unusual complex malformations that necessitate meticulous clinical examination, detailed diagnostic workup, and multistaged surgical management. Management should be tailored as per each individual patient's anatomy and clinical presentation for an optimal outcome. [ABSTRACT FROM AUTHOR]

Since the description of bilateral ligation of internal iliac arteries (BLIIA) and preperitoneal pelvic packing (PPP) for hemorrhage control in pelvic injury patients, multiple reports have been published advocating its use with acceptable outcomes. We analyzed our experience with this technique in a setting where the facility of hybrid operating room for simultaneous angioembolization is not available. We analyzed data of sixty-six patients who presented in a state of unresponsive shock with pelvic fracture between January 2014 and September 2019. After initial resuscitation, they all underwent BLIIA with PPP as part of damage control surgery. Out of 66 patients, 55 were male. The mean age was 36.12 years. All patients sustained blunt trauma, with road traffic injuries being the most common mechanism involving 65% of the patients followed by fall from height. The mean systolic blood pressure at the time of surgery was 77 ± 34.46 mm Hg. Median packed red blood cell transfusion in the first 24 h was 8.5 units with IQR of 6–12. The hemorrhage-related mortality was 48%. BLIIA with PPP may be considered as a viable treatment option in hemodynamically unstable patients with pelvic injuries in resource constraint facilities. [ABSTRACT FROM AUTHOR]

Aim: To analyze the outcome of upfront pyeloplasty in kidneys of children with unilateral ureteropelvic junction obstruction (UPJO). Materials and Methods: Thirty-three consecutive cases with split renal function (SRF) of ≤20% on dynamic renal scintigraphy (DRS) underwent upfront pyeloplasty with a nephrostomy tube and trans-anastomotic stent. Outcome was analyzed based on symptomatic relief, nephrostomy output, surgical complications and changes noted in pre-and post-operative findings on renal ultrasound (US), and DRS. Results: The most common symptom was abdominal lump in <5-year age group (79%) and abdominal pain in >5-year age group (93%). Postoperatively, symptoms were relieved in all (100%), parenchymal thickness (PT) on US improved in 82% and SRF improved significantly (>5%) in 75.8% of patients. The improvement was more significant in patients with abdominal lump and large kidneys. The mean nephrostomy output showed an inverse relationship with age at pyeloplasty and a direct correlation with the change in PT and SRF. The degree of improvement in SRF also was inversely related to the age at pyeloplasty with a significantly better outcome in <2-year-age. Although age at pyeloplasty, nephrostomy output and change in PT individually showed significant correlation with change in SRF, multiple regression analysis showed PT as the only significant factor. Conclusion: Upfront pyeloplasty should be the first option in children with poorly functioning kidneys as it has a favorable outcome in almost all the cases with a very low incidence of complications. The degree of improvement in SRF can be predicted by the nephrostomy output and improvement in PT on US. [ABSTRACT FROM AUTHOR]

Background: Traumatic arterio-enteric fistula is predominantly seen after penetrating trauma with only 21 reported cases documented in the past 25 years. They may present in an acute or delayed manner with upper or lower gastrointestinal bleed. A detailed clinical examination with requisite imaging can help in detecting such injuries. Case Description: Case 1: A 20-year-old gentleman, presented with penetrating stab injury to the gluteal region with bleeding per rectum. Imaging revealed evidence of injury to the inferior rectal artery which was found to be communicating with the extraperitoneal portion of the rectum. He was managed with a combination of endovascular and open surgery with a successful outcome. Case 2: A 29-year-old gentleman, presented in a delayed manner 2 weeks after a gunshot wound to the gluteal region, which was managed operatively in another hospital. He developed a massive lower gastrointestinal bleed 2 weeks after presentation. Imaging revealed evidence of a pseudoaneurysm of the inferior gluteal artery which had a fistulous communication with the gastrointestinal tract leading to bleeding. It was managed by endovascular techniques successfully. Conclusion: Arterio-enteric fistulas following trauma are rare phenomena and they need a high index of suspicion for diagnosis. Once diagnosed, they can be managed based on their location and patient physiology by interventional techniques, surgery, or a combination of the two. [ABSTRACT FROM AUTHOR]

Aim: The aim of the study was to evaluate the results of injection sclerotherapy with bleomycin in pediatric patients with lymphatic malformations. Materials and Methods: In this prospective cohort study, all consenting pediatric patients with macrocystic lymphatic malformations were managed with injection bleomycin sclerotherapy (0.5 mg/kg, not exceeding 5 mg at a time) under ultrasound (US) guidance. After aspirating the cyst fluid bleomycin was instilled intralesionally in a ratio of 5:1 (aspirated cyst fluid volume: diluted bleomycin solution volume). Patients were reassessed at three weekly intervals. The response to therapy was assessed clinically as well as by size and volume on ultrasound Doppler study. The response was classified as excellent response, i.e., complete regression, good response >50% regression, and poor response <50% regression. Results: Sixty patients with lymphatic malformations were enrolled in the study, the mean age was 3.22 years, and the male-to-female was 2.5:1. The most common site of lesion was in the neck (43.3%), followed by the axilla (15%) and flank (8.3%). The responses were excellent, good, and poor in 43 (71.6%), 12 (20%), and five (8.3%) patients, respectively. Two patients underwent surgical excision of the residual lesion. Complications noted were fever in six, local pain in five, and residual lesion in three patients. Conclusion: Sclerotherapy with bleomycin is simple, safe, and effective in the first line of management for macrocystic lymphatic malformations in children. [ABSTRACT FROM AUTHOR]

Background: Advances in surgery and anesthesia have paved the way for the establishment of day-care surgery (DCS). Observations that children achieve better convalescence in the home environment along with significant economic advantages have led to this paradigm shift in clinical practice. Aims and Objectives: This study is aimed to evaluate the feasibility of performing various surgical procedures on day-care basis and assess parental satisfaction with DCS in children. Materials and Methods: In this prospective observational study, all children >3 months of age undergoing various elective surgical procedures as day-care cases in our institution were enrolled. Types of operations, complications, including any unplanned admissions and parental satisfaction, were recorded. Results: Between December 2015 and December 2018, a total of 654 day-care surgeries were performed in our institution by pediatric surgeons. The mean age was 5.5 years with M: F 5.5:1. Thirty different surgical procedures were successfully performed as DCS, the common procedures being inguinal herniotomy (31.5%), and orchidopexy (14.3%). Unplanned admissions were recorded in 2.29% (15/654) patients (scrotal edema-5, postoperative pain-8, and a long recovery from anesthesia-2). No major complications occurred; two minor complications during follow-up were superficial wound infection and drug reaction. Overall parental satisfaction was very high (100%)-preoperative prolonged fasting period and long waiting time in the preoperative room of afternoon shift patients (7.95% and 8.3%) were the reasons for their discontent. Conclusions: DCS in children is safe and effective with high parental satisfaction. It can substantially reduce the waiting list for several surgical procedures in children. [ABSTRACT FROM AUTHOR]

Thoracic trauma severity score (TTSS) has been used to assess severity and risk of pulmonary complications in patients with chest trauma. The role of cytokines and biomarkers in patients with chest trauma and its association with TTSS is not well elucidated. The aim of the study was to assess the cytokines (IL-1β, IL-6, IL-8, IL-10, and TNF-α) and biomarkers (vWF, CC-16) in patients of thoracic trauma and correlate it with TTSS and patient's outcome. This was a prospective observational study. Serum and bronchoalveolar lavage fluid samples were collected from chest trauma patients. TTSS was calculated in all patients. Suitable controls for serum and bronchoalveolar lavage (BAL) sample were selected. The outcome parameters included patient discharge or death, duration of hospital, and intensive care unit (ICU) stay. Forty-three patients were included. There was no significant correlation between the measured cytokines and biomarkers and TTSS. The mean TTSS of patients who had a fatal outcome was significantly higher than the patients who recovered. Patients with a high TTSS score had a significant prolonged ICU stay. Patients with a prolonged hospital stay had lower values of CC-16. TTSS is a useful tool to predict severity of chest trauma and prolonged ICU stay. Lower levels of CC-16 in BAL fluid of chest trauma patients were associated with prolonged hospital stay suggestive of its protective role in the airway. Longer prospective studies are required to determine the role of cytokines and biomarkers in patients with thoracic trauma in predicting the patient's outcome. [ABSTRACT FROM AUTHOR]

Lower limb crush injury is a major source of mortality and morbidity in trauma patients. Complications, especially surgical site infections (SSIs) are a major source of financial burden to the institute and to the patient as it delays rehabilitation. As such, every possible attempt should be made to reduce any complications. We, thus, aimed to compare the outcomes in early vs delayed closure of lower extremity stumps in cases of lower limb crush injury requiring amputation, so as to achieve best possible outcome. A randomised controlled study was conducted in the Division of Trauma Surgery & Critical Care at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi from 1 September 2018 to 30 June 2019 and included patients undergoing lower limb amputation below hip joint. Patients were randomised in two groups, in one group amputation stump was closed primarily, while in the second group delayed primary closure of stump was performed. We compared rate of SSI, length of hospital stay, and number of surgeries in both the groups. Fifty‐six patients with 63 amputation stumps were recruited in the study. Mean age of patients in the study was 34 years, of which about 95% patients were males. The most common mechanism of injury was road traffic injury in 66% of patients. Mean injury severity score was 12.28 and four patients had diabetes preoperatively. Total 63 extremities were randomised with 30 cases in group I and 33 cases in group II as per computer‐generated random number. Above knee amputations was commonest (57.14%) followed by below knee amputations (33.3%). Two patients died in the current study. In group I, In‐hospital infection was detected in 7 cases (23.3%) and in group II 9 cases (27.3%) had SSI during hospital admission (P >.05). Mean hospital stay in group I was 10.32 ± 7.68 days and in group II was 11 ± 8.17 days (P >.05). Road traffic injuries and train‐associated injuries are a major cause of lower limb crush injuries, leading to limb loss. Delayed primary closure of such wounds requires extra number of surgical interventions than primary closure. There is no difference in extra number of surgical interventions required in both the groups. Thus, primary closure can be safely performed in patients undergoing lower limb amputations following trauma, provided that a good lavage and wound debridement is performed. [ABSTRACT FROM AUTHOR]

Background: Peritoneal dialysis (PD) is the preferred modality of dialysis among children with end-stage renal disease. Methods: To study the incidence of technique failure and survival among children with end-stage renal disease on continuous ambulatory peritoneal dialysis (CAPD), we included children younger than 18 years of age who commenced and continued PD for more than 3 months as their primary form of dialysis between 1st January 2005 and 31st December 2016. Kaplan–Meier survival analysis was applied to analyze the CAPD outcomes. Results: A total of 68 Tenckhoff (58 double cuffs, and ten single cuffs) catheters were inserted in 66 patients (mean age 12.3 ± 3.91 years) during the study period. Of the 66 children, 31 (47%) experienced 45 episodes of peritonitis. The total duration on CAPD was 107.58 years with a peritonitis rate of 0.42 episodes per year. Overall, the mean patient survival was 41 (95% confidence interval (CI) 29–54) months, with mean patient survival of 72% at 12 months, declining to 30% at 36 months and then remaining stable until the end of follow-up (106 months). The overall mean technique survival was 55 (95% CI 40–69) months, with mean technique survival of 69% at 12 months, declining to 44% at 36 months and then remaining stable until the end of follow-up (106 months). Conclusion: CAPD is a viable option for end-stage renal disease in children from developing countries with a lack of access to automated PD and pediatric hemodialysis centers. [ABSTRACT FROM AUTHOR]

The outcomes of the elderly population on peritoneal dialysis (PD) in developing countries are less known. In this study, we intended to study the clinical characteristics and patient and technique survival of elderly patients on PD. In this study, data of 148 elderly patients with end-stage renal disease who initiated PD between January 2001 and December 2015 were collected. Baseline clinical characteristics and events during the study period were recorded. Overall patient and technique survival rates of diabetic and non-diabetic elderly patients on PD were analyzed. Around 128 patients who were initiated PD during the study period were included for final analysis. The mean age of the study group was 70.3 ± 5.1 years, and 94 (80%) were males. Among these, 79 (65.8%) had diabetes. At the end of the study period, only 20 (16.6%) patients were remained on PD. Eighty-four (70%) patients died during PD and 15 (12.5%) patients were transferred to hemodialysis during the study period. The main reasons for death were cardiovascular (56.6%) and sepsis due to peritonitis (18.8%). The mean patient survival time was 38.2 ± 2.6 months. The patient survival rates were 91.2%, 45.3%, and 22.8% at 1, 3, and 5 years, respectively. Predictors of mortality were increased serum phosphorus, peritonitis episodes, urine output <400 mL, and ultrafiltration <1000 mL/day at beginning of PD. The mean technique survival time was 92.0 ± 5.1 months. Technique survival rates at 1, 3, and 5 years were 94.8%, 85.3%, and 71.7%, respectively. None of the factors was found to be predictive of technique survival. We found no significant difference between diabetic and non-diabetic patients in terms of technique and patient survival. Mortality was higher in elderly patients on PD. Factors affecting mortality in elderly patients on PD are low urine output, low ultrafiltration at beginning of PD, high serum phosphorus, and presence of peritonitis episodes. Patient and technique survival rates were comparable between diabetic and non-diabetic elderly patients on PD. [ABSTRACT FROM AUTHOR]

Cardiac angiosarcoma is a rare malignancy with an aggressive course and poor prognosis. We present a 26‐year old man who came to our clinic with shortness of breath and was diagnosed with a right‐sided atrial mass. He underwent urgent resection of the mass. The pathology confirmed the mass to be cardiac angiosarcoma with positive microscopic margins (R1 resection). Since reresection was not feasible, the patient started treatment with concurrent paclitaxel (80 mg/m2 weekly) and proton beam therapy (61 Cobalt equivalent delivered over five weeks). After completing the concurrent chemotherapy and radiation therapy, he was treated with adjuvant chemotherapy using gemcitabine (900 mg/m2 on Days 1 and 8) and docetaxel (100 mg/m2 on Day 8) every three weeks. After three cycles, the patient developed severe dermatitis, and hence further chemotherapy was withheld. The patient is alive at 26 months since receiving his surgery and 18 months since the completion of treatment. Patients with cardiac angiosarcoma who undergo R1 resection have a median survival of six months. More radical approaches such as orthotopic heart‐lung transplant or prolonged durations of chemotherapy lead to minimal improvement in survival at the cost of increased morbidity. Here, we describe a novel approach to a rare disease that resulted in prolonged survival and led to a better quality of life without any long‐term morbidity to the patient. [ABSTRACT FROM AUTHOR]

Early graft dysfunction after renal transplantation manifests as acute rejection (AR) or acute tubular necrosis (ATN). Blood oxygen level-dependent (BOLD) magnetic resonance (MR) imaging is a noninvasive method of assessing tissue oxygenation, which may be useful for predicting acute allograft dysfunction. This was a prospective study involving 40 patients scheduled for renal transplantation from August 2012 to August 2014. In addition, 15 healthy donors were also enrolled in this study. All recipients underwent BOLD MR imaging (MRI) and R2* mapping 10-20 days after transplant, and additionally within 48 h of biopsy if there was any evidence of graft dysfunction. The healthy donors underwent BOLD MRI 1-2 days before surgery. The biopsies were grouped into AR, ATN, and no evidence of AR or ATN. The mean medullary R2*, cortical R2*, corticomedullary gradient, and medullary: cortical R2* ratio were compared between groups using one-way analysis of variance. Spearman's correlation and multinomial linear regression were applied to determine the influence factors of R2* value. Overall, nine patients had graft dysfunction. Six were reported as AR, two as ATN, and one as no evidence of ATN or rejection. The mean medullary and cortical R2* were significantly higher in ATN group compared with AR and normal group, whereas the mean medullary and cortical R2* of AR group were significantly lower than normal group. The corticomedullary gradient of AR group was significantly lower compared with ATN and normal group. Medullary R2*:cortical R2* ratio was significantly lower in AR group compared with normal group. No significant difference was noted between the 15 donors and patients with normal graft function. R2* values on BOLD MRI are significantly decreased in AR allografts and increased in an early stage of ATN allografts, suggesting that BOLD MRI can become a valuable tool for discriminating between AR and ATN. [ABSTRACT FROM AUTHOR]

Aim Treatment of hepatitis C virus (HCV) infection in patients with end-stage renal disease (ESRD) is difficult. Addition of ribavirin to pegylated-interferon (Peg-IFN) may help to improve the treatment response. Further, treatment duration could be shortened using a response-guided treatment (RGT) approach. Methods We retrospectively reviewed records of treatment-naïve adult patients with ESRD and chronic HCV infection who had been treated with Peg-IFN and low-dose ribavirin using a RGT approach. Rapid responders (undetectable HCV-RNA at 4 weeks) received treatment for 12 weeks, and slow responders (HCV-RNA detectable at 4 weeks, but undetectable or with >2.0 log10 reduction at week 12) for 24 (genotype 3; GT3) or 48 (genotype 1; GT1) weeks. In those without such reduction (null responders), treatment was discontinued. Results Of 26 non-cirrhotic patients (GT1 15, GT3 11) treated, four (15%; GT1 3, GT3 1) were null responders. Twenty-two (85%) patients had either rapid ( n = 14 (54%); GT1 10, GT3 4) or slow response ( n = 8 (31%); GT1 2, GT3 6). Of them, 21 patients had undetectable RNA at the end of treatment; one could not complete the treatment and was lost thereafter. There were no deaths during treatment. Three patients relapsed and three others died in 6 months after stopping treatment. Overall, 15/26 (58%) patients attained SVR24. Fourteen patients underwent transplantation beginning one month after treatment completion, and all were relapse-free after 17 (14-24) months of follow-up. Conclusion RGT using Peg-IFN and ribavirin was effective in ESRD patients on maintenance dialysis. Renal transplant was safely done within one month of completing such treatment. [ABSTRACT FROM AUTHOR]

Objective: To compare oral mifepristone (400 mg) with trans-cervical balloon catheter for induction of labor (IOL) in post date women with previous one cesarean section (CS).Methods: In this randomized trial, post date pregnant women (gestation 40 weeks 5 days), with previous one low segment CS (no previous vaginal delivery) were induced either with oral mifepristone (400 mg) or balloon catheter [Foley's catheter (16 Fr); bulb filled with 30 ml normal saline]. They were re-assessed 24 and 48 h later. If at any time Bishop Score was >6; amniotomy was done, followed by oxytocin infusion. Primary outcome of the study was labor onset after first manoeuvre. Secondary outcomes were cervical ripening, need of oxytocin, vaginal delivery and CS, in two groups.Results: From June 2012 to September 2015, we enrolled 107 women. Out of these, 57 received oral tablet mifepristone (400 mg) and 50 were inserted with balloon catheter. Labor onset after first manoeuvre was statistically significantly more in mifepristone group (37/57 vs. 13/50, respectively; p value 0.000). Bishop Score after 24 h was better in balloon catheter (p value 0.000). More women with balloon catheter required oxytocin for IOL (37/50 vs. 20/57, respectively; p value 0.000) along with higher dose [840 (320) mU vs 560 (120) mU, respectively, p value 0.000]. Failure of induction was statistically significantly higher in balloon catheter group (8 out of 50 vs. 2 out of 57, respectively, p value 0.043). There was no statistically significant difference in normal delivery or CS in either group (p value 0.242 and 0.331, respectively).Conclusion: Oral mifepristone (400 mg) is associated with statistically significantly higher incidence of labor onset in post date pregnant women with previous one CS, as compared to balloon catheter. Both methods are primarily for cervical ripening and oxytocin should not be delayed in the absence of onset of labor.Clinical Trial Registration: Clinical Trials Registry-India, www.ctri.nic.in , CTRI/2012/05/003634. [ABSTRACT FROM AUTHOR]

This is the first case report of the Kluth type I-2 variant of esophageal atresia. The peculiar anatomy of this variant does not suit (1) esophageal substitution via posterior mediastinal route, (2) esophageal lengthening for preserving native esophagus and (3) distal esophageal stump stoma for gastric feeds. [ABSTRACT FROM AUTHOR]

Background: Infections by uncommon non-fermenting Gram negative bacteria are on the rise, but little is known about the risk factors and drug resistance in trauma patients in India. This study explored the infections caused by Stenotrophomonas maltophilia and/or Burkholderia cepacia in trauma patients over a period of 5 years. Material and methods: Patients admitted for trauma care with S. maltophilia and/or B. cepacia isolated from clinical specimens were enrolled. Characteristics regarding the strain isolation, drug sensitivity pattern, multidrug resistance (MDR), patient, outcomes, and differentiation of true infection from colonisation were observed. Results: Of the total 233 isolates, 102 were S. maltophilia and 131 were B. cepacia; 4.3% were responsible for polymicrobial infections with other bacteria. There were more B. cepacia MDR isolates than S. maltophilia. Maximum resistance was found to tetracycline (86.7%) and tobramycin (86.7%) in B. cepacia and to co-trimoxazole (68.7%) in S. maltophilia. Of these, 21 (16.03%) had a fatal outcome and the remaining 111 (84.7%) were discharged healthy. The in-hospital mortality rate associated with B. cepacia was much (16%) higher than S. maltophilia (13%) at this centre. Conclusion: The analysis of epidemiology and outcome of these infections will help to inform their management and treatment. [ABSTRACT FROM AUTHOR]

Purpose: We determined the relevance of the biomechanical properties of freshly harvested vaginal tissue during large cystocele repair on clinical outcome at a minimum 1-year followup. Materials and Methods: With institutional review board approval we prospectively studied the biomechanical properties of full thickness vaginal wall tissue from postmenopausal women with symptomatic Baden-Walker prolapse undergoing anterior vaginal wall suspension with cystocele repair from 2002 to 2005. A standardized biomechanical protocol was applied with stress-strain curves for Young''s modulus obtained by blinded investigators. Failed repair was defined as recurrence on examination or reoperation for recurrent anterior prolapse. Results: A total of 32 patients (median age 72 years) had a median followup of 34 months (range 12 to 62). Median Young''s modulus was statistically different in tissue samples transported in immersed vs moistened media (median 3.8 vs 7.6, p = 0.008). Associations between Young''s modulus and clinical variables were described. On followup 7 patients experienced failure of the repair. After controlling for tissue transport protocol no association was seen between Young''s modulus and failures (HR 1.1, p = 0.34). Conclusions: This study found no association between Young''s modulus and clinical results at long-term followup. This finding suggests that retropubic scarring and pelvic floor muscle properties may be more important for a successful reparative outcome than the intrinsic properties of the vaginal wall. [Copyright &y& Elsevier]

Background: There is a paucity of good quality evidence regarding the best therapeutic option for acute control of blood pressure during acute hypertensive emergency of pregnancy.Objective: We sought to compare the efficacy of intravenously administered hydralazine and oral nifedipine for acute blood pressure control in acute hypertensive emergency of pregnancy.Study Design: In this double-blind, randomized, controlled trial, pregnant women (≥24 weeks period of gestation) with sustained increase in systolic blood pressure of ≥160 mm Hg or diastolic blood pressure of ≥110 mm Hg were randomized to receive intravenous hydralazine injection in doses of 5, 10, 10, and 10 mg and a placebo tablet or oral nifedipine (10 mg tablet up to 4 doses) and intravenous saline injection every 20 minutes until the target blood pressure of 150 mm Hg systolic and ≤100 mm Hg diastolic was achieved. Crossover treatment was administered if the initial treatment failed. The primary outcome of the study was time necessary to achieve target blood pressure. The secondary outcomes were the number of dosages required, adverse maternal and neonatal effects, and perinatal outcome.Results: From December 2014 through September 2015, we enrolled 60 patients. The median time to achieve target blood pressure was 40 minutes in both groups (intravenous hydralazine and oral nifedipine) (interquartile interval 5 and 40 minutes, respectively, P = .809). The median dose requirement in both groups was 2 (intravenous hydralazine and oral nifedipine) (interquartile range 1 and 2 doses, respectively, P = .625). Intravenous hydralazine was associated with statistically significantly higher occurrence of vomiting (9/30 vs 2/30, respectively, P = .042). No serious adverse maternal or perinatal side effects were witnessed in either group.Conclusion: Both intravenous hydralazine and oral nifedipine are equally effective in lowering of blood pressure in acute hypertensive emergency of pregnancy. [ABSTRACT FROM AUTHOR]

In children, epidural hematomas (EDHs) constitute around 2% to 3% of all head traumas. The aim of this study is to compare the manifestation, prognostic factors, and outcome of surgically treated supratentorial with infratentorial EDHs in pediatric patients. This is a hospital-based single-center, retrospective study of 350 pediatric patients admitted between January 2016 and December 2021. All pediatric patients to 18 years of age with posttraumatic EDHs with or without other intracranial/extracranial injuries who underwent surgical evacuation were included in the study. Posttraumatic EDHs treated conservatively during the hospital stay and any EDH unrelated to head trauma were excluded. Glasgow Outcome Scale (GOS) score was used to assess functional outcomes at discharge. The status of the patients at 3-month follow-up was assessed by using the pediatric version of the Glasgow Outcome Scale-Extended (GOS-E Peds) Score. Out of 350 patients, 310 had supratentorial EDH and 40 had infratentorial EDH. In supratentorial EDH, the volume of hematoma, mass effect, and the time interval between trauma and surgery correlated with functional outcome (GOS) at discharge. Anisocoria, hypotension, and intradural injury were associated with functional as well as behavioral outcomes (GOS-E Peds) in the supratentorial EDH group. The severity of the injury was correlated with the functional and behavioral outcomes in both groups. Infratentorial EDH has better clinical outcomes than supratentorial EDH in surgically treated pediatric patients. The most significant and consistent factor influencing the outcome in both groups was the Glasgow Coma Score on admission. [ABSTRACT FROM AUTHOR]

Background: Despite the acceptance of non-operative management (NOM), there is no consensus on the optimal length of hospital stay in patients with blunt liver and splenic injury (BLSI). Recent studies on pediatric patients have demonstrated the safety of early discharge following NOM for BLSI. We aimed at evaluating the feasibility and safety of early discharge in adult patients with BLSI following NOM in a randomized controlled trial.Materials and Methods: After initial assessment and management, patients aged 18-60 years with BLSI planned for NOM were randomized into 2 groups: Group A (test group; discharge day 3), and Group B (control group; discharge day 5). Standard NOM protocol was followed. These patients were discharged on the proposed day if they met the pre-defined discharge criteria. All patients were followed at days 7, 15, and 30 of discharge.Results: Sixty patients were recruited, 30 randomized to each arm. Most patients were males and aged less than 30 years. Road traffic injury was the most common mode of injury. Both groups were comparable in demography and injury-related parameters. 27 patients (90%) from group A and 28 patients (93%) from group B were discharged on the proposed day. Three patients had unplanned hospital visits for reasons unrelated to BLSI. All patients were asymptomatic and had a normal examination during their scheduled follow-up visits.Conclusion: Adult patients undergoing NOM for BLSI can be safely discharged after 48 h of in-hospital observation, provided other injuries precluding discharge do not exist. [ABSTRACT FROM AUTHOR]

Purpose: To look for incidence of pregnancy associated TMA, clinical presentation and impact of early diagnosis and institution of plasma exchange on overall renal outcomes METHODS: -This is a retrospective study among all female patients who presented with acute kidney injury post pregnancy between October 2002 to April 2016 in department of nephrology in a tertiary care hospital in northern India and diagnosed as pregnancy induced TMA. The patient were assessed for duration of onset of renal failure to time of diagnosis of TMA, role of modality of treatment ie plasmpaharesis to outcome. These patients were assessed for complete, partial or no recovery in renal functions at 60 days after admission.Results: Patients whose time of onset of renal failure to a correct diagnosis of TMA was ≤15 days and age less than 30 years was also associated with good prognosis. The patients who received plasma exchange and that to within 72 h of admission had more chances of recovery.Conclusions: Early diagnosis of disease and early institution of plasma exchange therapy improves renal outcomes in postpartum TMA. [ABSTRACT FROM AUTHOR]

Chest trauma causes substantial morbidity and mortality and its severity is assessed using clinical diagnosis or scoring systems like Injury severity score (ISS) and thoracic trauma severity score (TTSS). Association of inflammatory cytokines with severity of disease and final clinical outcome is not clearly defined in patients with chest trauma. In this study, we thought to evaluate the inflammatory response in serum and bronchoalveolar lavage fluid (BALF) in chest trauma patients and correlate the level of extracellular cytokines with diseases severity and final outcome. A total of 65 patients with blunt chest trauma and 30 healthy controls were enrolled in this prospective observational study. Assessment of inflammatory cytokines such as Interleukin (s) - IL-5, IL-13, IL-2, IL-6, IL-9, IL-1β, IFN-γ, TNF-α, IL-17A, IL-17F,IL-4, IL-21 and IL-22 was performed in both serum and bronchoalveolar lavage fluid using 13-plex multiplex kit using fluorescence–encoded bead based immunoassays. A significantly higher level of IL-13, IL-2, IL-6, IL-9, IL-1β, IFN-γ, TNF-α, IL-17A, IL-17F, IL-21 and IL-22 cytokines were observed in patients with blunt chest trauma compared to healthy controls. Level of IL-2, IL-6, IL-1β and IL-17A was significantly raised in the patients with blunt chest trauma who had a fatal outcome during the hospital stay. An elevated cytokine response of IL-13, IL-4, and IL-21 was noted in the group of patients with high (>5) thoracic trauma severity score. Routine monitoring of the inflammatory cytokine level in patients with chest trauma may be used routinely. Longer prospective studies should be encouraged to determine the role of cytokines in patients with chest trauma in predicting the patient final clinical outcome. [ABSTRACT FROM AUTHOR]