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Background: Interest in natural orifice transluminal endoscopic surgery (NOTES) has expanded, and the first experiences with patients using different techniques have been reported. However, no work has addressed the learning process or the limitations of the procedures. The relation between inexperience and complications became a major concern after the introduction of laparoscopic surgery. This study investigates the learning process for a new technique using specially designed instruments in an ex vivo model before clinical application.Methods: Specially designed instruments and a single-port technique using the Tuebingen Trainer were used to evaluate instrument and surgeon performance (learning curve) in terms of time and errors. A total of 90 procedures performed by three surgeons were evaluated. Group and individual learning curves were plotted.Results: All the surgeons showed a reduction in both mean cholecystectomy time (subject A: 27.2 vs 16.6 min; subject B: 21.4 vs 19.22 min; subject C: 21 vs 19.7 min) and mean errors (subject A: 2.8 vs 1.6; subject B: 3.5 vs 2.6; subject C: 3.5 vs 2). A plateau was reached after approximately 15 procedures. Group learning curve analysis showed a significant reduction in time between the first group (mean, 24.97 +/- 5.8 min) and last group (mean, 19.30 +/- 3.09 min; F[1,28] = 11.83; p = 0.001) for 15 procedures, as well as reduced technical errors in the fifth group, from 3.7 +/- 1.65 to 1.6 +/- 1.04 (F[1,28] = 8.90; p < 0.01), demonstrating a learning effect. The number of optic and access port position changes were recorded, setting a standard for normal instrument performance.Conclusion: This study shows that the tasks of cholecystectomy can be learned safely in a reasonable number of simulations with the new instruments. Although this is a new technique, prior laparoscopic surgery experience is helpful. The technique offers an advantage over those using flexible endoscopes. [ABSTRACT FROM AUTHOR]

Background Trained doctors and para-medical personnel in accident and emergency services are scant in India. Teaching and training in trauma and emergency medical system (EMS) as a specialty accredited by the Medical Council of India is yet to be started as a postgraduate medical education program. The MI and CMO (casualty medical officer) rooms at military and civilian hospitals in India that practice triage, first-aid, medico-legal formalities, reference and organize transport to respective departments leads to undue delays and lack multidisciplinary approach. Comprehensive trauma and emergency infrastructure were created only at a few cities and none in the rural areas of India in last few years. Aim To study the infrastructure, human resource allocation, working, future plans and vision of the established trauma centers at the 3 capital cities of India DL Delhi (2 centres), Lucknow and Mumbai. Setting and design Participant observer structured open ended qualitative research by 7 days direct observation of the facilities and working of above trauma centers. Material and methods Information on, 1. Infrastructure; space and building, operating, ventilator, and diagnostic and blood bank facilities, finance and costs and pre-hospital care infrastructure, 2. Human resource; consultant and resident doctors, para-medical staff and specialists and 3. Work style; first responder, type of patients undertaken, burn management, surgical management and referral system, follow up patient management, social support, bereavement and postmortem services were recorded on a pre-structured open ended instrument interviewing the officials, staff and by direct observation. Data were compressed, peer-analyzed as for qualitative research and presented in explicit tables. Results Union and state governments of Delhi, Maharashtra and Uttar Pradesh have spent heavily to create trauma and emergency infrastructure in their capital cities. Mostly general and orthopedics surgeons with their resident staff were managing the facilities. Comprehensively trained accident and emergency (AandE) personnel were not available at any of the centers. Expert management of cardiac peri-arrest arrhythmias, peripheral and microvascular repair were occasionally available. Maxillo-facial, dental and prosthodontic facilities, evenomation grading and treatment of poisoning DL anti venom were not integrated. Ventilators, anesthetist, neuro and plastic surgeons were available on call for emergency care at all the 4 centers. Emergency diagnostic radiology (X-ray, CT scan, and ultrasound) and pathology were available at all the 4 centers. On the spot blood bank and component blood therapy was available only at the Delhi centers. Pre-hospital care, though envisioned by the officials, was lacking. Comprehensively trained senior A and E personnel as first responders were unavailable. Double barrier nursing for burn victims was not witnessed. Laparoscopic and fibreoptic endoscopic emergency procedures were also available only at Delhi. Delay in treatment on account of incomplete medico-legal formalities was not seen. Social and legal assistance, bereavement service and cold room for dead body were universally absent. Free treatment at Delhi and partial financial support at Lucknow were available for poor and destitute. Conclusion Though a late start, evolution of trauma services was observed and huge infrastructure for trauma have come up at Delhi and Lucknow. Postgraduate accreditation in Trauma and EMS and creation of National Injury Control Program must be mandated to improve trauma care in India. Integration of medical, non traumatic surgical and pediatric emergency along with pre-hospital care is recommended. [ABSTRACT FROM AUTHOR]

Back Ground Deep vein thrombosis (DVT) is still an underestimated complication in trauma patients. Only 10 percent of individuals who require DVT prophylaxis receive it; the remaining 90 percent of individuals are deprived of DVT prophylaxis because of ignorance and lack of awareness. Aims & Objectives - To assess awareness in hospital staff (nurses and doctors) regarding DVT and its prophylaxis using 14 point Questionnaire - To assess patient comfort with the DVT pump Methodology A 14 point Questionnaire was randomly distributed to 100 staff personnel who included doctors of various disciplines and nurses of wards and intensive care units of multispecialty tertiary trauma centre. Results were evaluated and studied. Observations and Results 100% of personnel's were aware that DVT pump was useful. The compliance of using DVT pump while at work was 0-30%, 30-60% and 60-100% in 6%, 28% and 66% staff respectively. The reason for noncompliance in 36% staff members was busy schedule and 32% staff stated that they were not advised by the treating physician.4% personnel's had doubt regarding the site of application of DVT pump. 72% staff believed that DVT cannot occur in upper limb and 8% stated that DVT pump cannot be applied on single limb. 6% mentioned that it cannot be used in hemodynamically unstable patients while 2% stated that it cannot be used in patients on ventilator. 36% of staff was not aware that fracture pelvis and spine are high risk for DVT. 6% believed that with low molecular heparin prophylaxis DVT pump is not required even in high risk patients. 24% patients complained that DVT pump was uncomfortable. Conclusions Despite the availability of resources for DVT prophylaxis, there is still ignorance regards its use in medics and paramedics. There is a need to increase the awareness of DVT, individual's risk factors and triggering events so that we can reduce the number of patients that die every year from DVT and its complications. [ABSTRACT FROM AUTHOR]

Introduction: Trans-abdominal pre-peritoneal (TAPP) repair is one of the standard techniques for laparoscopic repair of groin hernias. Literature has shown that both total extraperitoneal (TEP) and TAPP are equally effective with similar outcomes but TAPP has an advantage over TEP as there is more working space, and it provides access to the opposite side for repair of occult hernias. We reviewed our experience of TAPP repair in complicated groin hernias and compared the outcomes with uncomplicated groin hernia., Methods: Patients undergoing TAPP repair from January 2004 to December 2019 were analyzed, and divided into two groups-I uncomplicated and II complicated groin hernia., Results: TAPP repair was performed in 820 patients, of which 70.3% had uncomplicated and 29.7% patients had complicated hernias. Occult hernia was detected in 61 patients. The intra-operative complications (16.8% vs 1.3%) and conversions (2.4%) were higher in complicated hernias. Laparoscopic assisted repair was used in 16.8% patients with complicated hernias. The incidence of post-operative complications (62.1% vs 17.3%; P value <.01) were significantly higher in complicated groin hernia patients. The median follow-up was 15 months; only three patients in the uncomplicated hernia group developed recurrence, and chronic groin pain was higher in the complicated hernia repair patients (P > .05) at 6 months., Conclusion: Although operative time, incidence of intra-operative and post-operative complications (albeit minor in nature), and conversions to open are higher after TAPP repair for complicated groin hernias, the short-term outcomes (hematoma, mesh infection) as well as long-term outcomes (chronic groin pain, port site hernia and recurrence) are not different when compared with uncomplicated hernias. TAPP repair can be used in both complicated and uncomplicated groin hernias with similar short-term and long-term outcomes, albeit with a slightly higher incidence of minor complications in complicated hernias. This can be taken into consideration while operating on patients with complicated hernias and taking informed consent., (© 2023 Asia Endosurgery Task Force and Japan Society of Endoscopic Surgery and John Wiley & Sons Australia, Ltd.)

Due to lack of well-designed trials, there is no good evidence on the efficacy of stem cells in spinal cord injury. We aim to study the efficacy and outcome of bone marrow derived stem cells (BMSCs) in acute complete spinal cord injury (SCI). In this prospective study over a 3-year period, 27 patients with acute, complete SCI were randomized to receive BMSCs or placebo (intramedullary route) intraoperatively. Institutional ethics approval was taken and informed consent was taken from all patients. Functional outcome was assessed using ASIA scale, SCIM score and SSEP responses preoperatively, three and six months after surgery. Thirteen patients were available for final analysis of which six were in the stem cell group and seven received placebo. 6 patients had improvement by at least one grade in ASIA score in the stem cell group as compared to only one patient in the placebo group. However, no functional motor improvement in any of the patients. ASIA sensory score improved from a preoperative mean of 124 to 224 at 6 months compared to the static mean of 115 in the control group. Absent SSEP waveform converted to abnormal waveform at 6 months in 3 patients in the stem cell group and one patient in the control group. There was no significant difference in the SCIM scores between the groups at last follow-up. All patients in the stem cell group reported improved bladder sensation, decreased spasticity and improved posture control as compared to nine in the placebo group. BMSCs through intramedullary route are a potential therapy for acute complete SCI and more research is required in this area., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Laparoscopic donor nephrectomy (LDN) has advantages over open donor nephrectomy (ODN), with less bleeding and pain, and earlier discharge. However, the quality of life (QOL) has not been compared between these techniques. All consecutive donors undergoing left LDN or ODN from 2013 to 2015 at our center were included. The donors' QOL was measured with the brief World Health Organization QOL (WHOQOL-BREF) and the Hospital Anxiety and Depression Scale (HADS) questionnaires preoperatively and at 3 and 6 months postoperatively. Cosmesis was measured by the body image questionnaire, and patient satisfaction was scored on a verbal rating scale at 3 and 6 months. Of the 264 donors, 228 met the inclusion criteria (100 - LDN and 128 - ODN). The LDN group showed no difference in WHOQOL-BREF scores at 3 months, and significant improvements in the psychological and social domains at 6 months versus the baseline. The ODN group showed a significant decrease in the physical, psychological, and environmental domains at 3 and 6 months versus the baseline. Compared with the ODN group, the LDN group had better QOL scores at 3 and 6 months in all domains. The responses to the HADS questionnaire were similar between the groups at all time points. The mean body image, cosmesis, and satisfaction scores were significantly better in the LDN group. LDN minimized the negative effects of surgery on the donors' QOL, with improvements in the long-term psychological and social aspects versus the baseline. LDN was more cosmetic and was associated with higher satisfaction than ODN.

Objective: The intramedullary route holds the potential to provide the most concentration of stem cells in cases of spinal cord injury (SCI). However, the safety and feasibility of this route need to be studied in human subjects. The aim of this study was to evaluate the safety and feasibility of intramedullary injected bone marrow-derived mesenchymal stem cells (BM-MSCs) in acute complete SCI., Methods: In this prospective study conducted over a 2-year period, 27 patients with acute (defined as within 1 week of injury) and complete SCI were randomized to receive BM-MSC or placebo through an intramedullary route intraoperatively at the time of spinal decompression and fusion. Institutional ethics approval was obtained, and informed consent was obtained from all patients. Safety was assessed using laboratory and clinicoradiological parameters preoperatively and 3 and 6 months after surgery., Results: A total of 180 patients were screened during the study period. Of these, 27 were enrolled in the study. Three patients withdrew, 3 patients were lost to follow-up, and 8 patients died, leaving a total of 13 patients for final analysis. Seven of these patients were in the stem cell group, and 6 were in the control group. Both groups were well matched in terms of sex, age, and weight. No adverse events related to stem cell injection were noted for laboratory and radiological parameters. Five patients in the control group and 3 patients in the stem cell group died during the follow-up period., Conclusions: Intramedullary injection of BM-MSCs was found to be safe and feasible for use in patients with acute complete SCI.

Background: Studies evaluating the efficacy of ATLS in low- and middle-income countries are limited. We followed up ATLS providers certified by the ATLS India program over a decade (2009 to 2019), aiming to measure the benefits in knowledge, skills, attitude and their attrition over time., Methods: The survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email as a Google form, along with a statement of purpose. Results are presented descriptively., Results: ATLS India trained 7,847 providers over the study period. 2500 providers were selected for the survery using computer-generated random number table. One thousand and thirty doctors (41.2%) responded. Improvement in knowledge (n = 1,013 [98.3%]), psychomotor skills (n = 986 [95.7%]), organizational skills (n = 998 [96.9%]), overall trauma management (n = 1,013 [98.7%]) and self-confidence (n = 939 [91%]) were reported. Majority (904 [87.8%]) started ATLS promulgation at workplace in personal capacity. These benefits lasted beyond 2 years in majority (>60%) of respondents. More than 40% reported cognitive (n = 492 [47.8%]), psychomotor (n = 433 [42%]), and organizational benefits (n = 499 [48.4%]) lasting beyond 3 years. Improvement in self-confidence, ATLS promulgation at the workplace, and retention of organizational skills were more pronounced in ATLS faculties than providers. All other benefits were found to be comparable in both sub-groups. Lack of trained staff (n = 660 [64.1%]) and attitude issues (n = 495 [48.1%]) were the major impediments in implementing ATLS at the workplace. More than a third of respondents (n = 373 [36.2%]) could enumerate one or more incidents where ATLS principles were life- or limb- saving., Conclusions: Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Until formal trauma systems are established, ATLS remains the best hope for critically injured patients in resource-contrained settings., (Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Trauma is a global cause of death and disability, and trauma systems are not well developed in low- and middle-income countries. Training of nurses in trauma care is of utmost importance to improve the organization and delivery of trauma care., Objective: This study aimed to identify common knowledge gaps and develop study aids to improve nurses' performance taking the Advanced Trauma Care for Nurses (ATCN) course., Methods: This is a descriptive, single-center study of the multiple-choice final examinations of the ATCN course conducted over 1 year in the All India Institute of Medical Sciences, Rishikesh, Level I trauma center. The questions missed by candidates were compiled, and the wrong options were tabulated. The most commonly missed questions were identified, and the most commonly marked wrong option was analyzed vis-a-vis the correct answer. Each error was classified into either a theoretical error or a practice-based error., Results: Ninety-six nurses attended 6 courses from June 2019 to June 2020. Of the theoretical-based questions, the top 3 categories of most missed questions were geriatric trauma (n = 13; 81.2%), massive transfusion (n = 35; 72.9%), and traumatic brain injury (n = 35; 72.9%). Of the practice-based questions, the top 3 categories of most missed questions were dislocated extremity management (n = 54; 79.4%), basic airway (n = 31; 64.5%), and shock management (n = 30; 62.5%)., Conclusions: Periodic identification and categorization of the ATCN course examination's most frequent knowledge gaps allow instructors to develop teaching aids to enhance instructor teaching and improve trauma nurses' knowledge., Competing Interests: The authors declare no conflicts of interest., (Copyright © 2021 Society of Trauma Nurses.)

This study aimed to assess the neurocognitive outcomes and their diffusion tensor imaging correlates in children (aged 6-16 years) with mild traumatic brain injury. This prospective analysis included 74 children with mild traumatic brain injury (52 boys; mean age: 9.5 [±2.7] years). Wechsler Intelligence Scale for Children-Indian adaptation (WISC-IV), Child Behavior Checklist, and Children's Sleep Habits Questionnaire were administered for 57 cases (at 3 months postinjury) and 51 controls of similar age. The findings of diffusion tensor imaging (done within 7 days of injury) were correlated with various WISC-IV indices. The presenting features at the time of injury were loss of consciousness (53%), confusion or disorientation (47%), and post-traumatic amnesia (10%). Other features in the acute phase included drowsiness (86%), headache (78%), balance problems (62%), nausea (47%), fatigue (45%), vomiting (35%), nasal or ear bleed (12%), sensitivity to sound and light (12%), etc. At 3 months postinjury, the children with mild traumatic brain injury performed poorly in terms of Intelligence Quotient, perceptual reasoning index, and processing speed index as compared to controls. Based on the Child Behavior Checklist, 17% of children with mild traumatic brain injury had internalizing behavioral problems in comparison with 4% of controls. Prevalence of poor sleepers in the mild traumatic brain injury cohort and controls was 12.3% and 2% respectively. Headache, reduced attention span, and fatigue were common postconcussion symptoms. There was a positive correlation between right uncinate fasciculus fractional anisotropy and verbal comprehension index ( r = 0.32; P < .05).

Background: With standardization of laparoscopic technique of groin hernia repair, the focus of surgical outcome has shifted to lesser studied parameters like sexual function and fertility., Methods: This prospective randomized study was conducted in a single surgical unit at a tertiary care hospital. A sample size of 144 was calculated with 72 in each group (Group 1 TEP and Group 2 TAPP). Primary outcomes measured included comparison of sexual function using BMFSI, qualitative semen analysis and ASA levels between patients undergoing TEP or TAPP repair. Semen analysis and ASA was measured pre-operatively and 3 months post-operatively., Results: A total of 145 patients were randomized into two groups, TAPP (73) and TEP (72) patients. Both the groups were comparable in terms of demographic profile and hernia characteristics with majority of the patients in both the groups having unilateral inguinal hernia (89.0% in TAPP group and 79.2% in TEP group). Both the groups showed statistically significant improvement in overall sexual function score (BMFSI) at 3 months; however, there was no inter group difference. Both the groups were also comparable in terms of ASA and qualitative semen analysis., Conclusion: Both TEP and TAPP repair are comparable in terms of sexual function and effect on semen analysis. Laparoscopic repair improves the overall sexual functions in patients with groin hernia.

Background: Trauma is slowly regaining its pre-COVID-19 status in terms of prevalence. Advanced trauma training cannot be deferred indefinitely in the current pandemic owing to defense requirements and disaster preparedness in vulnerable regions. Advanced Trauma Life Support (ATLS) India resumed ATLS and Advanced Trauma Care For Nurses (ATCN) courses at one civilian and one military site., Methods: Stakeholders of respective centers for advanced trauma training deliberated over safe means to resume ATLS and ATCN. Meticulous screening of all participants and pre- and post-course tracking were deemed the most important components for the safe resumption of courses. 'Paperless' course, 'open-air' skill stations, 'payment protection', 'buddy system', point of care sanitizer installation, packed food, and potable beverages were major organizational changes. Participants above 60 years and with uncontrolled comorbidities were not enrolled., Results: Two ATCN, one ATLS (civilian), and one combined ATLS-ATCN (military) were conducted. 78 delegates trained by 32 faculties and 13 personnel. All underwent daily thermal scanning and smartphone application-based COVID-19 tracking. Manikins were utilized instead of moulages and instructors took up the role of nursing assistants in Initial Assessment. Exit exams were conducted with full PPE precautions at the military site and mask-distancing precautions at the civilian site. High fidelity simulator was used at one station at the civilian site. Expenses at the civilian site per course were USD 570 lower than conventional courses. There was no incidence of COVID-19 in any of the 123 participants at 14 days follow up., Conclusion: With stringent participant selection and moderate precautions, ATLS and ATCN can be resumed safely in the current COVID-19 pandemic. To the best of our knowledge and after a thorough search of published English literature, this is the first paper reporting on resuming Advanced trauma training in the COVID-19 era., Competing Interests: The authors have none to declare., (© 2021 Director General, Armed Forces Medical Services. Published by Elsevier, a division of RELX India Pvt. Ltd.)

Traumatic brain injury is an important cause of acquired brain injury. The current study brings to light the clinicoepidemiologic profile of pediatric traumatic brain injury in India. Retrospective record analysis of children (aged ≤ 16 years) with traumatic brain injury presenting to an apex-trauma-center in North India over 4 years was done. Of more than 15 000 patients with a suspected head injury, 4833 were children ≤16 years old. Of these, 1074 were admitted to the inpatient department; 65% were boys with a mean age at presentation being 6.6 years. Most patients (85%) had a Glasgow Coma Scale score of 13 to 15 at presentation while Glasgow Coma Scale scores of ≤8 was seen in 10% of patients. Neuroimaging (computed tomography [CT]) abnormalities were seen in 12% of patients, with the commonest abnormality being skull fracture, followed by contusions, and extradural hemorrhage. Around 2% of patients required decompressive craniotomy whereas 3% of patients succumbed to their illness.Among the inpatients with pediatric traumatic brain injury, two-thirds were boys with a mean age at presentation of 7.6 years. Severity of traumatic brain injury varied as mild (64%), moderate (11%), and severe (25%). The most common mode of injury was accidental falls (59%) followed by road traffic and rail accidents (34%). Neuroimaging abnormalities were seen in half of inpatients with pediatric traumatic brain injury, with the commonest abnormality being skull fracture. Pediatric head injuries are an important public health problem and constitute a third of all head injuries. They are more common in boys, and the most common modes of injury are accidental falls, followed by road traffic accidents.

Introduction: Primary closure of common bile duct (CBD) after laparoscopic common bile duct exploration (LCBDE) is now becoming the preferred technique for closure of choledochotomy. Primary CBD closure not only circumvents the disadvantages of an external biliary drainage but also adds to the advantage of LCBDE. Here, we describe our experience of primary CBD closure following 355 cases of LCBDE in a single surgical unit at a tertiary care hospital., Materials and Methods: All patients undergoing LCBDE in a single surgical unit were included in the study. Preoperative and intraoperative parameters including the technique of CBD closure were recorded prospectively. The postoperative recovery, complications, hospital stay, antibiotic usage, and postoperative intervention, if any, were also recorded., Results: Three hundred fifty-five LCBDEs were performed from April 2007 to December 2018, and 143 were post-endoscopic retrograde cholangiopancreatography failures. The overall success rate was 91.8%. The mean operative time was 98±26.8 minutes (range, 70 to 250 min). Transient bile leak was seen in 10% of patients and retained stones in 3 patients. Two patients required re-exploration and 2 patients died in the postoperative period. Follow-up ranged from 6 months to 10 years, with a median follow-up of 72 months. No long-term complications such as CBD stricture or recurrent stones were noted., Conclusions: Primary closure of CBD after LCBDE is safe and associated with minimal complications and no long-term problems. The routine use of primary CBD closure after LCBDE is recommended based on our experience.

Introduction: Internal drainage of walled of necrosis of pancreas has been considered as the standard of care. For symptomatic walled off necrosis (WON) of pancreas with the advent of laparoscopy and refinement of techniques and instrumentation, laparoscopic internal drainage is becoming the standard surgical drainage procedure for these patients. However, there is a dearth of literature regarding outcomes following laparoscopic drainage. Most of the studies have small number of patients with limited follow-up. We in this study describe our experience of laparoscopic internal drainage of walled off necrosis over the last 13 years., Materials and Methods: This is a retrospective analysis of a prospectively maintained database. All patients with WON undergoing laparoscopic internal drainage between January 2005 and December 2018 were included. Primary outcome measure was successful drainage. Secondary outcome measures included morbidity, hospital stay, re-intervention rate and mortality. Patients were followed up post-operatively at 1 week, 4 weeks, 3 months and then annually thereafter. Ultrasonography was done periodically for the assessment of cyst resolution., Results: Between 2005 and 2018, 154 surgical drainage procedures were performed for symptomatic pseudocyst/walled off necrosis. Out of these, 134 underwent laparoscopic drainage; 129 patients (96.3%) underwent laparoscopic cystogastrostomy and 5 (3.7%) underwent laparoscopic cystojejunostomy. Majority of the patients were male (male:female = 6:1) with a mean age of 36 ± 12.9 years (range 15-58 years). The mean operative time was 94 min (range 64-144 min). There were three conversions because of intra-operative bleeding. The overall post-operative morbidity was 8.9%. The average hospital stay was 4.4 days (2-19 days). The mean duration of follow-up was 5.5 years (range 6 months-13 years). Complete cyst resolution was achieved in 95.5% (n = 128) patients. There has been no mortality till date., Conclusion: In conclusion, laparoscopic internal drainage is a very effective technique for drainage of WON with an excellent success rate.

Background: The management of geriatric trauma patients is challenging because of the altered physiology and co-existent medical conditions. To study the in-hospital mortality profile of geriatric trauma victims and the parameters associated with the mortality, we conducted this retrospective analysis., Methods: In a retrospective review of geriatric trauma admissions (above 60 years) over a 3-year period, we studied the association of age, gender, comorbidities, mechanism of injury (MOI), Glasgow coma score (GCS), injury severity score (ISS), systolic blood pressure, and hemoglobin (Hb) level on admission with hospital mortality. Univariate and Multivariable logistic regression was used to estimate odds and find independent associated parameters. P < 0.05 was considered as statistically significant., Results: Out of 881 patients, 208 (23.6%) patients died in hospital. The most common MOI was fall (53.3%) followed by motor vehicle collision (31.1%) and other mechanisms (14.5%). The in-hospital mortality was significantly higher and adjusted odds ratio (OR) for mortality were higher for male gender (2.11 [1.04-4.26]), higher ISS (6.75 [2.07-21.95] for ISS >30), low GCS (<8) (4.6 [2.35-8.97]), low Hb (<9) (1.68 [0.79-3.55]), hypotension on admission (32.42 [10.89-96.52]) as compared to other groups. Adjusted OR was 3.19 (1.55-6.56); 7.67 (1.10-53.49); 1.13 (0.08-17.12) for co-existent cardiovascular, renal, and hepatic comorbidities, respectively., Conclusion: Male gender, higher ISS, low GCS, low Hb, hypotension on admission, co-existent cardiovascular, renal and hepatic comorbidities are associated with increased mortality in geriatric trauma patients., Competing Interests: There are no conflicts of interest., (Copyright: © 2020 Journal of Emergencies, Trauma, and Shock.)

Objectives: To assess the effect of a mobile phone application for prehospital notification on resuscitation and patient outcomes., Design: Longitudinal prospective cohort study with preintervention and postintervention cohorts., Setting: Major trauma centre in India., Participants: Injured patients being transported by ambulance and allocated to red (highest) and yellow (medium) triage categories., Intervention: A prehospital notification application for use by ambulance and emergency clinicians to notify emergency departments (EDs) of an impending arrival of a patient requiring advanced lifesaving care., Main Outcome Measures: The primary outcome was the proportion of eligible patients arriving at the hospital for which prehospital notification occurred. Secondary outcomes were the availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray, and ED and in-hospital mortality., Results: Data from January 2017 to January 2018 were collected with 208 patients in the preintervention and 263 patients in the postintervention period. The proportion of patients arriving after prehospital notification improved from 0% to 11% (p<0.001). After the intervention, more patients were managed with a trauma call-out (relative risk (RR) 1.30; 95% CI: 1.10 to 1.52); a trauma bay was ready for more patients (RR 1.47; 95% CI: 1.05 to 2.05) and a trauma team leader present for more patients (RR 1.50; 95% CI: 1.07 to 2.10). There was no difference in time to the initial chest X-ray (p=0.45). There was no association with mortality at hospital discharge (RR 0.94; 95% CI: 0.72 to 1.23), but the intervention was associated with significantly less risk of patients dying in the ED (RR 0.11; 95% CI: 0.03 to 0.39)., Conclusions: The prehospital notification application for severely injured patients had limited uptake but implementation was associated with improved trauma reception and reduction in early deaths. Quality improvement efforts with ongoing data collection using the trauma registry are indicated to drive improvements in trauma outcomes in India., Trial Registration Number: NCT02877342., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Pancreatic fluid collections (PFC) may develop following acute pancreatitis (AP). Endoscopic and laparoscopic internal drainage are accepted modalities for drainage of PFCs but have not been compared in a randomized trial. Our objective was to compare endoscopic and laparoscopic internal drainage of pseudocyst/walled-off necrosis following AP., Patients and Methods: Patients with symptomatic pseudocysts or walled-off necrosis suitable for laparoscopic and endoscopic transmural internal drainage were randomized to either modality in a randomized controlled trial. Endoscopic drainage comprised of per-oral transluminal cystogastrostomy. Additionally, endoscopic lavage and necrosectomy were done following a step-up approach for infected collections. Surgical laparoscopic cystogastrostomy was done for drainage, lavage, and necrosectomy. Primary outcome was resolution of PFCs by the intended modality and secondary outcome was complications., Results: Sixty patients were randomized, 30 each to laparoscopic and endoscopic drainage. Both groups were comparable for baseline characteristics. The initial success rate was 83.3% in the laparoscopic and 76.6% in the endoscopic group (p = 0.7) after the index intervention. The overall success rate of 93.3% (28/30) and 90% (27/30) in the laparoscopic and endoscopic groups respectively was also similar (p = 1.0). Two patients in the laparoscopic group required endoscopic cystogastrostomy for persistent collections. Similarly, two patients in the endoscopic group required laparoscopic drainage. Postoperative complications were comparable between the groups except for higher post-procedure infection in the endoscopic group (19 vs. 9; p = 0.01) requiring endoscopic re-intervention., Conclusions: Endoscopic and laparoscopic techniques have similar efficacy for internal drainage of suitable pancreatic fluid collections with < 30% debris. The choice of procedure should depend on available expertise and patient preference.

Background: Each year approximately five million people die from injuries. In countries where systems of trauma care have been introduced, death and disability have decreased. A major component of developed trauma systems is a trauma quality improvement (TQI) program and trauma quality improvement meeting (TQIM). Effective TQIMs improve trauma care by identifying and fixing problems. But globally, TQIMs are absent or unstructured in most hospitals providing trauma care. The aim of this study was to implement and evaluate a checklist for a structured TQIM., Methods: This project was conducted as a prospective before-and-after study in four major trauma centres in India. The intervention was the introduction of a structured TQIM using a checklist, introduced with a workshop. This workshop was based on the World Health Organization (WHO) TQI Programs short course and resources, plus the developed TQIM checklist. Pre- and post-intervention data collection occurred at all meetings in which cases of trauma death were discussed. The primary outcome was TQIM Checklist compliance, defined by the discussion of, and agreement upon each of the following: preventability of death, identification of opportunities to improve care and corrective actions and a plan for closing the loop., Results: There were 34 meetings in each phase, with 99 cases brought to the pre-intervention phase and 125 cases brought to the post-intervention phase. There was an increase in the proportion of cases brought to the meeting for which preventability of death was discussed (from 94% to 100%, p = 0.007) and agreed (from 7 to 19%, OR 3.7; 95% CI:1.4-9.4, p = 0.004) and for which a plan for closing the loop was discussed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001) and agreed (from 2% to 18%, OR 10.9; 95% CI:2.5-47.6, p < 0.001)., Conclusion: This study developed, implemented and evaluated a TQIM Checklist for improving TQIM processes. The introduction of a TQIM Checklist, with training, into four Indian trauma centres, led to more structured TQIMs, including increased discussion and agreement on preventability of death and plans for loop closure. A TQIM Checklist should be considered for all centres managing trauma patients., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Introduction: There are 2 standard techniques of laparoscopic groin hernia repair, totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). TEP has the advantage that the peritoneal cavity is not breached but is, however, considered to be more difficult to master when compared with TAPP. We describe herein our experience of TEP repair of inguinal hernia over the last 14 years., Materials and Methods: This study is a retrospective analysis of a prospectively maintained database of all patients with groin hernia who underwent TEP repair in a single surgical unit between January 2004 and January 2018. Patients' demographic profile and hernia characteristics (duration, side, extent, content, and reducibility) were noted in the prestructured proforma. Clinical outcomes included the operation time, intraoperative and postoperative complications, length of postoperative hospital stay, hernia recurrence, chronic pain, recurrence, seroma, and wound infections. Long-term follow-up was carried out in the outpatient department., Results: Over the last 14 years, TEP repair was performed in 841 patients and a total of 1249 hernias were repaired. The mean age of patients was 50.7 years. There were 748 primary and 345 unilateral hernias. The majority were direct (61%) inguinal hernias. Telescopic dissection was the commonest method of space creation. The average operating time was 54.8 and 77.9 minutes for unilateral and bilateral hernias, respectively. With 81 conversions, the success rate for TEP was 93.5%. Seroma was the most common postoperative complication seen in 81 patients. The incidence of chronic groin pain was 1.4%. The follow-up ranged from 3 months to 10 years, and there were only 3 recurrences (<1%)., Conclusion: In conclusion, TEP repair is an excellent technique of laparoscopic inguinal hernia repair with acceptable complications after long-term follow-up.

Scrub typhus is largely ignored in India particularly during outbreaks of viral fever. The disease course is often complicated leading to fatalities in the absence of treatment. However, if diagnosed early and a specific treatment is initiated, the cure rate is high. We report here five cases of scrub typhus to highlight the fact that high clinical suspicion for such a deadly disease is an absolute necessity., Competing Interests: None

Introduction: Abdominal trauma is one of the preventable causes of death in polytrauma patients. Decision and timing of laparotomy is a major challenge. Rate of nontherapeutic laparotomy is still high. Laparoscopy can avoid nontherapeutic laparotomy and also provide a reliable and accurate diagnosis of injury., Materials and Methods: This ambispective observational study was conducted in the division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute Medical Sciences, New Delhi. Retrospective analysis of prospectively maintained data of cases from January 1, 2008 through April 30, 2013 and prospective analysis of cases from May 1, 2013 through March 31, 2015 was done using appropriate measures. Hemodynamically stable or responders fulfilling inclusion criteria were included. Selected patients underwent the laparoscopic procedure and if required converted to laparotomy., Results: Of the 3610 patients of abdominal trauma, laparotomy was done in 1666 (46.14%) patients and laparoscopy was done in 119 (3.29%) patients. Rate of reduction of nontherapeutic laparotomy in patients with abdominal trauma using diagnostic laparoscopy was 55.4%. However laparotomy could be avoided in 59.7%. Laparoscopy was 100% accurate in identifying injuries in our study. No injuries were missed in these patients. Fever and wound infection were significantly higher in laparotomy group. Chest infection and sepsis were also higher in laparotomy group but the difference was not statistically significant. Median length of hospital stay in laparoscopy group was 4 days (range: 1 to 28 d) and in laparotomy group was 9.5 days (range: 2 to 55 d) with P-value of 0.001., Conclusions: Laparoscopy has a role in management of hemodynamically stable patients with suspected abdominal injury to prevent nontherapeutic laparotomies, and thereby decreasing postoperative complications.

Chest trauma is an important public health problem accounting for a substantial proportion of all trauma admissions and deaths. It directly account for 20-25 % of deaths due to trauma. Therefore, this study was conducted to analyze the presentation, patterns, and outcome of chest trauma in a level-1 urban trauma center. It was a prospective observational study of all patients presented with chest trauma to an urban level 1-trauma center over a period of 3 years. Demographic profile, mechanism of injury, injury severity scores (ISS), associated injuries, hospital stay, etc. were recorded. Morbidity and mortality rates were analyzed and compared with the published literature. Chest injuries comprised 30.9 % of all trauma admissions and the mechanism was blunt in majority (83.5 %) of the cases. Vehicular crashes (59.7 %) followed by assault were the most common modes of injury. Rib fracture was the most common chest injury seen in 724 of the 1258 patients while abdominal visceral injuries were the commonest associated injuries in polytrauma cases. Majority of the patients were managed non-operatively. Inter costal tube drainage (ICD) was the main stay of treatment in 75 % of the cases, whereas, thoracotomy was required only in 5.56 % of the patients. Overall mortality was 11 % and it was found to be significantly higher following blunt chest trauma. We observed that associated extra thoracic injuries resulted in higher mortality as compared to isolated chest injuries. Thoracic injuries can be readily diagnosed in the emergency department by meticulous and repeated clinical evaluation and majority require simple surgical procedures to prevent immediate mortality and long-term morbidity., Competing Interests: Compliance with Ethical StandardsNo funding received from any source.Obtained from the Institutional Ethics Committee.Rajasekhar Narayanan, Subodh Kumar, Amit Gupta, Virinder Kumar Bansal, Sushma Sagar, Maneesh Singhal, Biplab Mishra, Sanjeev Bhoi, Babita Gupta, Shivanand Gamangatti, Adarsh Kumar, and Mahesh Chandra Misra do not have any conflict of interest.

Background & Objectives: The incidence and severity of invasive and non-invasive infections demonstrate variability over time. The emerging resistance of Group A streptococci (GAS) to commonly used antibiotics is of grave concern. This study was conducted to assess the antimicrobial resistance of beta-haemolytic streptococci (βHS) in India and to ascertain the molecular mechanisms of resistance., Methods: All isolates of βHS from the Trauma Centre of All India Institute of Medical Sciences (AIIMS) (north India), and heavily populated area of old Delhi from 2010 to 2014 and Yashoda Hospital, Secunderabad (in south India, 2010-2012) and preserved isolates of βHS at AIIMS (2005-2009) were included. Phenotypic confirmation was done using conventional methods and the Vitek 2. Antibiotic sensitivity testing was done by disc diffusion and E-test. Detection of resistance genes, erm(A), erm(B), mef(A), tet(M) and tet(O), was done by polymerase chain reaction (PCR)., Results: A total of 296 isolates of βHS (240 from north and 21 from south India) were included in the study. Of the 296 βHS, 220 (74%) were GAS, 52 (17.5%) were Group G streptococci and 11 (3.7%), 10 (3.3%) and three (1%) were Group B streptococci, Group C streptococci and Group F streptococci, respectively. A total of 102 (46%) and 174 (79%) isolates were resistant to tetracycline and erythromycin, respectively; a lower resistance to ciprofloxacin (21, 9.5%) was observed. A total of 42 (14%) and 30 (10%) isolates, respectively, were positive for tet(M) and erm(B) genes. Only 13 (5%) isolates were positive for mef(A). None of the isolates were positive for erm(A) and tet(O). There was discordance between the results of E-test and PCR for erythromycin and tetracycline., Interpretation & Conclusions: A high level of resistance to erythromycin and tetracycline was seen in βHS in India. Discordance between genotypic and phenotypic results was reported. Absence of erm(A) and tet(O) with high prevalence of tet(M) and erm(B) was observed., Competing Interests: None