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Glasgow Coma Scale (GCS) is one of the most commonly used trauma scores and is a good predictor of outcome in traumatic brain injury (TBI) patients. There are other more complex scores with additional physiological parameters. Whether they discriminate better than GCS in predicting mortality in TBI patients is debatable. The aim of this study was to compare the discrimination of GCS with that of MGAP, GAP, RTS and KTS for 24-hour and 30-day in-hospital mortality in adult TBI patients, in a resource limited LMIC setting.We analysed data from the multicentre, observational trauma cohort Towards Improved Trauma Care Outcome (TITCO) in India. We included all patients 18 years or older, admitted from the emergency department with TBI. The Area Under the Receiver Operating Characteristic (AUROC) curve was used to quantify and compare the discrimination of all scores: GCS; Revised Trauma Score (RTS); mechanism, GCS, age, systolic blood pressure (MGAP); GCS, age, systolic blood pressure (GAP) and Kampala Trauma Score (KTS) in the prediction of 24-hour and 30-day in-hospital mortality.A total of 3306 TBI patients were included in this study. The majority were within the GCS range 3-8. The commonest mechanism of injury was road traffic injuries [1907(58.0%)]. In-hospital mortality was 27.2% (899). There was no significant difference in discrimination in 24-hour in-hospital mortality when comparing GCS with MGAP and GAP. While GCS performed better than KTS, RTS performed better than GCS. For 30-day in-hospital mortality, GCS discriminated significantly better compared with KTS, but there was no significant difference when compared to MGAP and RTS. GAP discriminated significantly better when compared with GCS.This study shows that the discrimination of GCS is comparable to that of more complex trauma scores in predicting 24-hour and 30-day in-hospital mortality in adult TBI patients in a resource limited LMIC setting.

Background It is well established that disease-free survival and overall survival after breast conservation surgery (BCS) followed by radiotherapy are equivalent to that after mastectomy. However, in Asian countries, the rate of BCS continues to remain low. The cause may be multifactorial including the patient’s choice, availability and accessibility of infrastructure, and surgeon’s choice. We aimed to elucidate the Indian surgeons’ perspective while choosing between BCS and mastectomy, in women oncologically eligible for BCS. Methods We conducted a survey-based cross-sectional study in January–February 2021. Indian surgeons with general surgical or specialised oncosurgical training, who consented to participate were included in the study. Multinomial logistic regression was performed to assess the effect of study variables on offering mastectomy or BCS. Results A total of 347 responses were included. The mean age of the participants was 43 ± 11 years. Sixty-three of the surgeons were in the 25–44 years age group with the majority (80%) being males. 66.4% of surgeons ‘almost always’ offered BCS to oncologically eligible patients. Surgeons who had undergone specialised training in oncosurgery or breast conservation surgery were 35 times more likely to offer BCS (p p Conclusion Two-thirds of Indian surgeons preferred BCS over mastectomy. Lack of radiotherapy facilities and specialised surgical training were deterrents to offering BCS to eligible women.

Abdominal trauma management has seen a paradigm shift over the last few decades. There is wide variation in the treatment depending on the level of healthcare facilities available. With an aim to standardise the treatment of solid organ injuries in blunt abdominal trauma, Indian Society for Trauma and Acute Care (ISTAC®) formulated consensus guidelines to benefit doctors engaged in trauma care in the country.

ObjectiveTo compare experts’ perceived usefulness of audit filters from Ghana, Cameroon, WHO and those locally developed; generate context-appropriate audit filters for trauma care in selected hospitals in urban India; and explore characteristics of audit filters that correlate to perceived usefulness.DesignA mixed-methods approach using a multicentre online Delphi technique.SettingTwo large tertiary hospitals in urban India.MethodsFilters were rated on a scale from 1 to 10 in terms of perceived usefulness, with the option to add new filters and comments. The filters were categorised into three groups depending on their origin: low and middle-income countries (LMIC), WHO and New (locally developed), and their scores compared. Significance was determined using Kruskal-Wallis test followed by Wilcoxon rank-sum test. We performed a content analysis of the comments.Results26 predefined and 15 new filter suggestions were evaluated. The filters had high usefulness scores (mean overall score 9.01 of 10), with the LMIC filters having significantly higher scores compared with those from WHO and those newly added. Three themes were identified in the content analysis relating to medical relevance, feasibility and specificity.ConclusionsAudit filters from other LMICs were deemed highly useful in the urban India context. This may indicate that the transferability of defined trauma audit filters between similar contexts is high and that these can provide a starting point when implemented as part of trauma quality improvement programmes in low-resource settings.

Objectives Delayed primary closure (DPC) of the skin has been suggested to decrease superficial surgical site infection (SSSI) in patients undergoing surgery for peritonitis secondary to hollow viscus perforation, but there is no consensus. The aim of this study was to compare the outcomes of primary closure (PC) and DPC of the skin in terms of SSSI, fascial dehiscence and length of hospital stay (LOS). Material and methods Sixty patients, undergoing emergency surgery for perforation peritonitis, were randomized to PC (n= 30) and DPC (n= 30). Patients in the DPC group underwent skin closure four or more days after surgery when the wound was clinically considered appropriate for closure. Patients in the PC group had skin closure at the time of surgery. Results Incidence of SSSI was significantly less in the DPC group (7.4%) compared to the PC (42.9%) (p= 0.004). However, the median time of DPC was the 10th POD, i.e., these wounds required considerable time to become clinically suitable for closure. Incidence of fascial dehiscence was comparable between the two groups (p= 0.67). Length of hospital stay (LOS) was 13.8 days in the DPC group compared to 13.5 days in PC; the difference was not significant (p= 0.825). Conclusion DPC of the skin incision resulted in the reduction of SSSI. However, this did not translate into a reduction in hospital stay, as it took considerable time for these wounds to become appropriate for DPC, thus bringing into question any real advantage of DPC over PC.

Fall is the second most common mechanism of trauma worldwide after road traffic injuries. Data on fall predominantly comes from the high-income countries (HICs) and mostly includes injuries in children and elderly. There are very few studies from low- and middle-income countries(LMICs) that describe fall related injuries other than fragility fractures in elderly. This study describes the profile of poly-trauma patients admitted with a history of 'fall' and assesses the variables associated with mortality.We analyzed data from the 'Towards Improved Trauma Care Outcome' (TITCO) database which prospectively collected data of poly-trauma patients admitted to four major tertiary care hospitals of India between 2013 to 2015. Patients across all age groups admitted to hospital with the history of 'fall'; were included in our study. Single bone fractures were excluded. The Kaplan Meier survival analysis was used to estimate the survival probability in different age groups.A total of 3686 patients were included in our study. The median age of the patients was 28 years (IQR: 9, 47) with the majority being males (73.6%). Almost one-third of the patients were within the age group of 0-14 (30.4%). Most of the patients (79.9%) had a diagnosis of traumatic brain injury (TBI). The overall in-hospital mortality was 18% (664), but higher at 39.0% among patients over 65 years of age. Probability of survival decreased with increase of age.Falling from height is a common injury mechanism in India, occurring more in young males and usually associated with TBI. Isolated TBI and TBI associated with other injuries are the main contributors of mortality in fall injuries. Mortality from these injuries increased with age and ISS.

Outcomes in patients with isolated traumatic brain injury (iTBI) have not been evaluated comprehensively in low-income and middle-income countries. We aimed to study the in-hospital iTBI mortality and its associated risk factors in a prospective multicenter Indian trauma registry.Patients with iTBI (head and neck Abbreviated Injury Score ≥2 and other region Abbreviated Injury Score ≤2) were included. Study variables comprised age, gender, mechanism of injury, systolic blood pressure (SBP) at arrival, Glasgow Coma Scale (GCS) score - classified as mild (13-15), moderate (9-12), and severe (3-8), transfer status, and time to presentation at any participating hospital. A multivariable logistic regression was performed to assess the impact of these factors on 24-h and 30-d mortality following iTBI.Among 5042 included patients, 24-h and 30-d in-hospital mortalities were 5.9% and 22.4%. On a regression analysis, 30-d mortality was associated with age ≥45 y (odds ratio [OR] = 2.1 [1.6-2.7]), railway injury mechanisms (OR = 2.1 [1.3-3.5]), SBP90 mmHg (OR = 2.6 [1.6-4.1]), and moderate (OR = 3.8 [3.0-5.0]) to severe (OR = 21.1 [16.8-26.7]) iTBI based on GCS scores. 24-h mortality showed similar trends. Patients transferred to the participating hospitals from other centers had higher odds of 30-d mortality (OR = 1.4 [1.2-1.8]) compared to those arriving directly. Those who received neurosurgical intervention had lower odds of 24-h mortality (0.3 [0.2-0.4]).Age ≥45 y, GCS score ≤12, and SBP90 mmHg at arrival increased the risk of in-hospital mortality from iTBI.

Haemophilic pseudotumours (HPT) are rare, but are seen in severe haemophiliacs due to spontaneous bleeding into joints and muscles. They are known to affect the musculoskeletal more, but rare incidence of intra-abdominal HPT has been reported. Intra-abdominal HPT arising from the mesentery has not been reported in literature. A high clinical suspicion and detailed imaging can help in diagnosis, though they are commonly mistaken for chronic abscesses. Needle aspiration/biopsy are contraindicated to avoid severe bleeding. Early institution of Factor VIII replacement is the cornerstone of treatment. Surgical excision, though risky, is indicated if there are symptoms due to progressive enlargement of the HPT or complications due to it. Radiotherapy and angioembolization are other treatment options that can be considered in selective cases.We report the case of a previously undiagnosed young, moderate haemophiliac male who presented with features of acute intestinal obstruction due to HPT of the mesentery.

Cutaneous metastasis (CM) from pancreatic adenocarcinoma is very rare. They often present as an umbilical nodule and are associated with other evidence of distant metastasis. We present the case of a 60-year-old male who presented with multiple non-umbilical cutaneous nodules, in an undiagnosed case of pancreatic adenocarcinoma, with no other evidence of distant metastasis.

Primary angiosarcoma of spleen is a rare and aggressive tumour arising from the endothelial lining of the splenic sinuses, with very poor outcome. Due to similarity in clinical and radiological features, they are often mistaken for benign splenic lesions and misdiagnosed. We present two cases where they were misdiagnosed as splenic haemangioma and splenic abscess. Both patients ultimately underwent splenectomy but succumbed to this aggressive disease.

Objective: The aim of our study was to evaluate whether insertion of a subcutaneous closed suction vacuum drain at incisional surgical site reduces the incidence of surgical site infection (SSI) in post operative cases of exploratory laparotomy for perforative peritonitis. Methods: An institutional based randomized control study was performed with two hundred patients each included in the study (with drain) and control (without drain) group. Both groups were statistically similar in terms of various variables and thus comparable. All continuous variables were reported as mean ± SD and compared across groups using unpaired t-test. All categorical variables were reports as n (%) compared across groups using Chi-square test for independence of attributes. Result: Use of a subcutaneous closed suction vacuum drain results in statistically significant reduction in wound infection (58% vs 16%; p < 0.001). The most common organism causing SSI was found to be Escherichia Coli accounting for 62.5% and 62.7% of cases in drain group and control group respectively, followed by Klebsiella (12.5% vs 24.14%). Conclusion: Use of a subcutaneous closed suction vacuum drain is effective in reducing SSI in contaminated surgery like that for perforative peritonitis and also leads to reduction in SSI related complications like wound disruption, patient discomfort, bad cosmesis, prolonged hospital stay, antibiotic use and increased cost. Bangladesh Journal of Medical Science Vol.16(1) 2017 p.85-90

Adult presentation of congenital diaphragmatic hernia (CDH) is rare. Out of the three varieties of CDH, Morgagni hernia is the rarest of all. Though most of them are asymptomatic and may be incidentally detected, they may also present in the emergency setting with respiratory or gastrointestinal features like obstruction or strangulation. Gastric outlet obstruction is a rare manifestation of adult Morgagni hernia. We present a case of adult left-sided Morgagni hernia with features of gastric outlet obstruction complicated with perforation.

Internal herniation is a rare cause of small bowel obstruction, with an incidence of 0.2-0.9%. Obstruction due to congenital internal hernias is even rarer. The commonest type of congenital internal hernia is the paraduodenal or the mesocolic hernia. The left and right mesocolic hernias constitute 75% and 25% of the mesocolic hernias respectively. Middle mesocolic hernias are an extremely rare and unusual variant of mesocolic hernia, and literature search revealed only three reported cases. In view of its rarity, a high level of clinical suspicion, supported by radiological evidence is required to diagnose it preoperatively. Prompt surgical management is mandatory to reduce complications and their associated morbidity and mortality.

Background Seroma formation is a well-known complication after modified radical mastectomy (MRM) for breast cancer. Another well known complication is shoulder movement dysfunction following the same operation. Traditionally, patients were asked to perform exercises of the shoulders as early as possible after surgery in the belief that it reduces subsequent shoulder dysfunction. The aim of this study was to evaluate whether delayed shoulder exercises after MRM could reduce seroma formation without compromising the outcome of shoulder mobility.

Subcutaneous and deep fungal infections in the hand are rare among children. These are usually found in immunocompromised adults or in persons engaged in soil handling activities, due to direct exposure, especially in the tropics. Delay in diagnosis is usual because pyogenic and other granulomatous infections are considered first.The authors present the case of a healthy, immunocompetent 2½-year-old child who presented with progressive swelling of the right hand mimicking a localized gigantism of the entire hand. Multiple operative drainage procedures done previously had failed to resolve the condition. A biopsy established the presence of fungal hyphae, thus confirming the diagnosis of deep fungal infection of the hand and guided proper therapeutic intervention. A strong index of suspicion needs to be maintained in cases not responding to conventional antibacterial therapy, and both microbiologic and histopathologic samples need to be obtained to establish the diagnosis.

Aim The aim of the study is to evaluate the results of the multimodality approach to diabetic limb ulcers.

A diaphragmatic hernia is defined as a communication between the abdominal and thoracic cavities, with or without abdominal contents in the thorax. It is usually diagnosed among newborns, but late presentation of congenital diaphragmatic hernias has also been reported with an incidence of 5 to 25%. Intestinal obstruction due to obstructed diaphragmatic hernia is very rare and represents a considerable diagnostic challenge. Herein, we report the case of an obstructed diaphragmatic Bochdalek-type hernia complicated by acute intestinal obstruction.

Though lipomas are one of the commonest mesenchymal tumours in adults, a lipoma of the head and neck region is relatively rare. Among those lipomas that develop in the neck, the posterior triangle is the most common location; occurrence in the anterior triangle is very rare. Though most lipomas are 10cm have also been reported in different parts of the body. Giant lipomas of the neck, particularly those >20cm, are extremely rare. Most patients of giant lipoma of the neck either present with complaints of cosmetic disfigurement or features of compression on deeper structures. Most lipomas do not pose any diagnostic dilemma. However, when a patient presents with a large, rapidly progressing lipoma of the head and neck region, the possibility of malignancy should be kept in mind. Surgical excision remains the treatment of choice.

Background and Purpose There are different methods and materials for closing a surgical wound by subcuticular stitch but controversy prevails as concerns the appropriate material for this stitch. This study aims to investigate the different suture materials and compare their technical accessibility, usefulness, complication rates, patient satisfaction and, above all, the general outcome.

Subcuticular sutures have been extensively used for closure of wounds, particularly when good cosmesis is required. Both absorbable and nonabsorbable sutures are used in subcuticular sutures. Nonabsorbable sutures have some distinct advantages over absorbable sutures from cosmetic point of view, when used in subcuticular sutures. The challenge remains in keeping the nonabsorbable suture secure and in situ. We present six different methods of securing the suture in position while closing the wound with a nonabsorbable suture (2-0/3-0 polypropylene, polyamide, or polyethylene).

Leiomyoma of the urinary bladder is a rare neoplasm of the bladder and accounts for 0.04 - 0.5% of bladder neo- plasms. Though most patients present with obstructive or irritative urinary symptoms, dyspareunia may be an un- usual presentation that should be kept in mind to avoid missing the diagnosis. Though MRI is considered to be the imaging modality of choice, cystourethroscopy with guided biopsy usually clinches the diagnosis. Surgical excision is the treatment of choice in this prognostically favourable tumour.

Parathyroid carcinoma is a rare disease. But multiglandular parathyroid neoplasm is even rarer. A high level of suspicion, on the basis of clinical, hematological tests and intraoperative findings is necessary to treat this disease entity, particularly in the absence of palpable neck masses. Preoperative localization is important. Bilateral neck exploration should be done routinely and all 4 glands seen to avoid missing out other pathological glands.

Unilateral renal agenesis is usually asymptomatic and may be found incidentally during examination for other causes. The incidence of testicular tumors arising from cryptorchidism is well established, but if it is coexistent with ipsilateral renal agenesis, the diagnosis and management becomes a challenge. Only three cases of such association have been reported in literature so far. This association has to be kept in mind when dealing with a case of testicular tumor arising from abdominal cryptorchidism, so that the function of the other kidney can be assessed before surgery, and protection given to it in the event of using radiotherapy in an adjuvant setting.

Congenital anomalies are frequently encountered in surgery. They pose a dilemma in surgical decision-making and if undetected, they may lead to surgical complications. Gallbladder duplication is a rare anomaly with an incidence of 1 in 3000-4000. Preoperative imaging is often the only modality of diagnosis, as there are no specific symptoms for the pathology. Preoperative diagnosis and appreciation and of this anomaly is especially important to prevent possible surgical complications.

Laparoscopic splenectomy (LS) is emerging as the treatment of choice over open splenectomy (OS) in cases of idiopathic (immune) thrombocytopenic purpura (ITP) that is either steroid resistant or steroid unresponsive.The aim of the present study is to compare therapeutic response and outcome of patients with ITP undergoing LS with a similar group undergoing OS.The study was performed on 63 patients with ITP attending Medical College and Hospital, Kolkata, a tertiary level referral centre in Eastern India during 2005-2009.Twenty-seven patients with ITP underwent LS and the rest underwent OS. Twenty-eight patients were steroid resistant whereas the rest were diagnosed to be refractory to steroids. Parameters assessed were demographic characteristics of patients, peri-operative data, complications and haematological outcome.The patients were followed up for a mean period of 40 months.Demographic characteristics of the patients in LS and OS group were comparable. Patients undergoing LS were found to require a longer operative time but had lower intra-operative blood loss, less postoperative pain, decreased incidence of complications, reduced hospital stay and comparable haematological response as compared to that for patients undergoing OS. LS for ITP is a safe technique associated with lower morbidity and faster convalescence and similar haematological response when compared to OS.

Before any systematic attempt was made in the Indian subcontinent to impart instruction in western medicine, two systems were already existent in the region: the Hindu or Ayurvedic system and the Arabic or Unani system. Although history was witness to the remarkable progress made by ancient physicians and surgeons in ancient India, there came a period when this progress stagnated. In the early nineteenth century, when the science and art of healing was making remarkable progress in the western world, no corresponding development was taking place in the Indian subcontinent. The British Government was loath to entrust the health of its officers in the hands of the ‘native’ doctors, and had to get ‘suitably’ trained medical personnel from Europe. After a point, they realized that this was not a practical solution to the problem and a system of imparting education in western medicine had to be started in the Indian subcontinent. This led to the publication of an order on June 21, 1822, to start the first medical school in British India, exclusively for the Europeans.

Internal herniation of small intestine is a very rare entity, and it poses a real diagnostic challenge clinically. Recurrent entrapment of the bowel may lead to partial to complete intestinal obstruction and eventually strangulation of the small bowel. Of this rare clinical entity, left paraduodenal hernia is more common. High index of suspicion with prompt management may prevent bowel strangulation and gangrene. We present a case of acute intestinal obstruction due to left paraduodenal hernia with malrotation of midgut in a 55-year-old male patient.

Chronic calculous cholecystitis is quite a common disease entity today. However, advances in diagnostic imaging and use of broad-spectrum antibiotics have facilitated its early detection and treatment. Hence complications of untreated calculous cholecystitis have shown a steady decline. Spontaneous cholecystocutaneous fistula is one such rare complication. A 45-year-old female presented with acute onset of pain and swelling in the right hypochondrium. She had leucocytosis. The swelling ruptured spontaneously and 200 ml frank yellow pus along with multiple stones were expelled from the site. Completion drainage was done. A fistulogram confirmed the diagnosis of a cholecystocutaneous fistula. The patient underwent open cholecystectomy and excision of the fistulous tract.

Gallstone ileus is an uncommon cause of small bowel obstruction and is rarely suspected preoperatively. Patients are usually elderly and present with features of small bowel obstruction. Commonest site of impaction of the gallstone is the terminal ileum. We report a case of gallstone ileus in a 37-year-old female who presented with vomiting and anuria, and without any symptoms of intestinal obstruction. Intraoperatively the gallstone was found impacted at the duodeno-jejunal flexure. Impaction of gallstone at the duodeno-jejunal flexure is yet to be reported in literature.