Publications by authors named "Mahesh C Misra"

80 Publications

Advanced Trauma Care for Nurses (ATCN): A Single-Center Analysis of Trauma Nurses Knowledge Gaps.

J Trauma Nurs 2021 Jul-Aug 01;28(4):258-264

AIIMS Rishikesh, Rishikesh, Uttarakhand, India (Mss Kaur and Rao and Messrs Rattan, Kumar, and Kant); and ATLS India, Indian Society for Trauma and Acute Care, New Delhi, India (Mr Misra).

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.
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http://dx.doi.org/10.1097/JTN.0000000000000594DOI Listing
September 2021

Does ATLS Training Work? 10-Year Follow-Up of ATLS India Program.

J Am Coll Surg 2021 08 3;233(2):241-248. Epub 2021 May 3.

Sharda Hospital and School of Medical Sciences & Research, Greater Noida, Uttar Pradesh, India.

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.
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http://dx.doi.org/10.1016/j.jamcollsurg.2021.04.022DOI Listing
August 2021

Neurocognitive Outcomes and Their Diffusion Tensor Imaging Correlates in Children With Mild Traumatic Brain Injury.

J Child Neurol 2021 07 24;36(8):664-672. Epub 2021 Feb 24.

Child Neurology Division, Center of Excellence & Advanced Research on Childhood Neurodevelopmental Disorders, Department of Pediatrics, 29751All India Institute of Medical Sciences, New Delhi, India.

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 ( = 0.32; < .05).
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http://dx.doi.org/10.1177/0883073821996095DOI Listing
July 2021

Embracing the change: Resuming advanced trauma training in the COVID-19 era.

Med J Armed Forces India 2021 Feb 2;77(Suppl 1):S140-S145. Epub 2021 Feb 2.

Program Director & Chair, ATLS, Ex-President & Vice Chancellor, Mahatma Gandhi University of Medical Sciences & Technology, Jaipur, Formerly Director, AIIMS, New Delhi, India.

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.
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http://dx.doi.org/10.1016/j.mjafi.2020.12.033DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7873696PMC
February 2021

Long-term Outcomes Following Primary Closure of Common Bile Duct Following Laparoscopic Common Bile Duct (CBD) Exploration: Experience of 355 Cases at a Tertiary Care Center.

Surg Laparosc Endosc Percutan Tech 2020 Dec;30(6):504-507

Departments of Surgical Disciplines.

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.
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http://dx.doi.org/10.1097/SLE.0000000000000830DOI Listing
December 2020

Prehospital notification of injured patients presenting to a trauma centre in India: a prospective cohort study.

BMJ Open 2020 06 21;10(6):e033236. Epub 2020 Jun 21.

National Trauma Research Institute, The Alfred Hospital, Melbourne, VIC, Australia.

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.
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http://dx.doi.org/10.1136/bmjopen-2019-033236DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7311027PMC
June 2020

Assessment of core capacities for antimicrobial stewardship practices in indian hospitals: Report from a multicentric initiative of global health security agenda.

Indian J Med Microbiol 2019 Jul-Sep;37(3):309-317

Department of Microbiology, King George's Medical University, Lucknow, Uttar Pradesh, India.

Introduction: Antimicrobial-resistant HAI (Healthcare associated infection) are a global challenge due to their impact on patient outcome. Implementation of antimicrobial stewardship programmes (AMSP) is needed at institutional and national levels. Assessment of core capacities for AMSP is an important starting point to initiate nationwide AMSP. We conducted an assessment of the core capacities for AMSP in a network of Indian hospitals, which are part of the Global Health Security Agenda-funded work on capacity building for AMR-HAIs.

Subjects And Methods: The Centers for Disease Control and Prevention's core assessment checklist was modified as per inputs received from the Indian network. The assessment tool was filled by twenty hospitals as a self-administered questionnaire. The results were entered into a database. The cumulative score for each question was generated as average percentage. The scores generated by the database were then used for analysis.

Results And Conclusion: The hospitals included a mix of public and private sector hospitals. The network average of positive responses for leadership support was 45%, for accountability; the score was 53% and for key support for AMSP, 58%. Policies to support optimal antibiotic use were present in 59% of respondents, policies for procurement were present in 79% and broad interventions to improve antibiotic use were scored as 33%. A score of 52% was generated for prescription-specific interventions to improve antibiotic use. Written policies for antibiotic use for hospitalised patients and outpatients were present on an average in 72% and 48% conditions, respectively. Presence of process measures and outcome measures was scored at 40% and 49%, respectively, and feedback and education got a score of 53% and 40%, respectively. Thus, Indian hospitals can start with low-hanging fruits such as developing prescription policies, restricting the usage of high antibiotics, enforcing education and ultimately providing the much-needed leadership support.
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http://dx.doi.org/10.4103/ijmm.IJMM_19_445DOI Listing
June 2020

Totally Extraperitoneal Repair in Inguinal Hernia: More Than a Decade's Experience at a Tertiary Care Hospital.

Surg Laparosc Endosc Percutan Tech 2019 Aug;29(4):247-251

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

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.
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http://dx.doi.org/10.1097/SLE.0000000000000682DOI Listing
August 2019

Antimicrobial resistance in beta-haemolytic streptococci in India: A four-year study.

Indian J Med Res 2018 Jan;147(1):81-87

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

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.
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http://dx.doi.org/10.4103/ijmr.IJMR_1517_16DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5967222PMC
January 2018

Damage control surgery: 6 years of experience at a level I trauma center.

Ulus Travma Acil Cerrahi Derg 2017 Jul;23(4):322-327

Division of Trauma Surgery & Critical Care, J P N Apex Trauma Center, All India Institute of Medical Sciences, New Delhi-India.

Background: Damage control surgery (DCS) has been a well-established practice in the management of trauma victims for more than 2 decades now. The primary aim of this study was to review and analyze the presentation and outcome of patients with torso trauma who underwent DCS at Level I trauma center.

Methods: Retrospective study was conducted using database records prospectively maintained over period of 6 years from 2008 through 2013 at an urban Level I trauma center. Data available from hospital medical records were analyzed to study presentation, mechanism of injury, organs injured, associated injuries, and outcome in patients who underwent DCS following torso trauma. Primary outcome measure was survival.

Results: Total of 61 patients were identified who had undergone DCS during the study period. Majority of these patients were males (n=59), had sustained blunt trauma as result of road traffic injury, and had presented with shock (n=49). The 30-day mortality rate was 54%. Mortality was significantly associated with shock (63% cases died; p=0.008), and with Glasgow Coma scale ≤8 (85% died; p=0.001). Injuries significantly associated with high mortality were hepatic injury (n=15; 11 died), major vascular injury (n=10; 3 died), cardiac injury (n=5; 3 died), and pelvic fracture (n=17; 10 died). Re-exploration was required in 28 cases with 13 deaths. Mesh laparostomy was performed in 24 cases, with mortality in 58%.

Conclusion: In the absence of more effective alternative, especially at facilities with limited resources, DCS may be appropriate in critically injured patients; however, it continues to be associated with significant morbidity and high mortality, even at tertiary care centers.
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http://dx.doi.org/10.5505/tjtes.2016.03693DOI Listing
July 2017

Prehospital notification for major trauma patients requiring emergency hospital transport: A systematic review.

J Evid Based Med 2017 Aug;10(3):212-221

National Trauma Research Institute, Melbourne, Australia.

Objective: This systematic review aimed to determine the effect of prehospital notification systems for major trauma patients on overall (<30 days) and early (<24 hours) mortality, hospital reception, and trauma team presence (or equivalent) on arrival, time to critical interventions, and length of hospital stay.

Methods: Experimental and observational studies of prehospital notification compared with no notification or another type of notification in major trauma patients requiring emergency transport were included. Risk of bias was assessed using the Cochrane ACROBAT-NRSI tool. A narrative synthesis was conducted and evidence quality rated using the GRADE criteria.

Results: Three observational studies of 72,423 major trauma patients were included. All were conducted in high-income countries in hospitals with established trauma services, with two studies undertaking retrospective analysis of registry data. Two studies reported overall mortality, one demonstrating a reduction in mortality; (adjusted odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39 to 0.94, 72,073 participants); and the other demonstrating a nonsignificant change (OR 0.61, 95% CI 0.23 to 1.64, 81 participants). The quality of this evidence was rated as very low.

Conclusion: Limited research on the topic constrains conclusive evidence on the effect of prehospital notification on patient-centered outcomes after severe trauma. Composite interventions that combine prehospital notification with effective actions on arrival to hospital such as trauma bay availability, trauma team presence, and early access to definitive management may provide more robust evidence towards benefits of early interventions during trauma reception and resuscitation.
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http://dx.doi.org/10.1111/jebm.12256DOI Listing
August 2017

Clinical characteristics and prognostic factors of patients with infections.

J Lab Physicians 2017 Apr-Jun;9(2):132-135

Department of Surgery, All India Institute of Medical Sciences, New Delhi, India.

Introduction: earlier had limited pathogenic potential, but now with growing degree of immunosuppression in general population, it is being recognized as an important nosocomial pathogen.

Methodology: A retrospective 7 years study was carried out to determine the clinical characteristics of all patients with infections, antibiotic resistance pattern, and risk factors associated with hospital mortality. All patients with culture positivity were identified and their medical records were reviewed. Risk factor associated with hospital mortality was analyzed.

Results: A total of 123 samples obtained from 88 patients were culture positive. Most patients presented with bacteremia (45, 51%) followed by pneumonia (37, 42%) and skin and soft tissue infections (6, 7%). About 23 of 88 infected patients had co-infection. Percentage resistance to cotrimoxazole; 8 (5.4%) was lower than that for levofloxacin; 18 (12%). Twenty-eight patients died during hospital stay. Intensive Care Unit admission ( = 0.0002), mechanical ventilation ( = 0.0004), central venous catheterization ( = 0.0227), urethral catheterization ( = 0.0484), and previous antibiotic intake ( = 0.0026) were independent risk factors associated with mortality.

Conclusion: Our findings suggest that can cause various infections irrespective of patient's immune status and irrespective of potential source. Thus, should be thought of as potential pathogen and its isolation should be looked with clinical suspicion.
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http://dx.doi.org/10.4103/0974-2727.199639DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5320877PMC
April 2017

Role of Laparoscopy in Patients With Abdominal Trauma at Level-I Trauma Center.

Surg Laparosc Endosc Percutan Tech 2018 Feb;28(1):20-25

JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

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.
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http://dx.doi.org/10.1097/SLE.0000000000000379DOI Listing
February 2018

Comparison of Absorbable Versus Nonabsorbable Tackers in Terms of Long-term Outcomes, Chronic Pain, and Quality of Life After Laparoscopic Incisional Hernia Repair: A Randomized Study.

Surg Laparosc Endosc Percutan Tech 2016 Dec;26(6):476-483

Departments of *Surgical Disciplines †Anaesthesia ‡Psychiatry, All India Institute of Medical Sciences, New Delhi, India.

Background: Laparoscopic incisional and ventral hernia repair (LIVHR) has been associated with a high incidence acute and chronic pain due to use of nonabsorbable tackers. Several absorbable tackers have been introduced to overcome these complications. This randomized study was done to compare 2 techniques of mesh fixation, that is, nonabsorbable versus absorbable tackers for LIVHR.

Materials And Methods: Ninety patients admitted for LIVHR repair (defect size <15 cm) were randomized into 2 groups: nonabsorbable tacker fixation (NAT group, 45 patients) and absorbable tacker fixation (AT group, 45 patients). Intraoperative variables and postoperative outcomes were recorded and analyzed.

Results: Patients in both the groups were comparable in terms of demographic profile and hernia characteristics. Mesh fixation time and operation time were also comparable. There was no significant difference in the incidence of immediate postoperative and chronic pain over a mean follow-up of 8.8 months. However, cost of the procedure was significantly higher in AT group (P<0.01) and NAT fixation was more cost effective as compared with AT. Postoperative quality of life outcomes and patient satisfaction scores were also comparable.

Conclusions: NAT is a cost-effective method of mesh fixation in patients undergoing LIVHR with comparable early and late postoperative outcomes in terms of pain, quality of life, and patient satisfaction scores.
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http://dx.doi.org/10.1097/SLE.0000000000000347DOI Listing
December 2016

Outcomes of Laparoscopic Common Bile Duct Exploration After Failed Endoscopic Retrograde Cholangiopancreatography in Patients with Concomitant Gall Stones and Common Bile Duct Stones: A Prospective Study.

J Laparoendosc Adv Surg Tech A 2016 Dec 9;26(12):985-991. Epub 2016 Nov 9.

1 Department of Surgical Disciplines, All India Institute of Medical Sciences , New Delhi, India .

Introduction: The aim of the present study was to compare the outcomes of secondary laparoscopic CBD exploration (LCBDE) following failed endoscopic retrograde cholangiopancreatography (ERCP) and primary laparoscopic common bile duct (CBD) exploration.

Materials And Methods: One hundred eighty-five patients undergoing LCBDE were divided into Group I consisting of patients undergoing a primary LCBDE (n = 102) and Group II consisting of patients undergoing LCBDE after failure of ERCP to clear the CBD stones (n = 83). Primary outcome measure was successful laparoscopic CBD clearance. The secondary outcome measures were degree of difficulty, operative time, complications, hospital stay, and the cost of treatment.

Results: Success rate was similar in both groups (85.3% versus 80.7%). Mean operative time, degree of difficulty, hospital stay, and cost of procedure were significantly higher in Group II (P value <.05).

Conclusion: It may be prudent to consider ERCP failure patients for primary LCBDE than risk the complications of ERCP if they are suitable for primary surgery.
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http://dx.doi.org/10.1089/lap.2016.0272DOI Listing
December 2016

Is Interleukin 10 (IL10) Expression in Breast Cancer a Marker of Poor Prognosis?

Indian J Surg Oncol 2016 Sep 20;7(3):320-5. Epub 2016 Feb 20.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Interleukin 10 (IL10) is a poor prognostic marker in several cancers. Its role in breast cancer is not well elucidated. The present study is designed to see the expression of IL10 in breast cancer tissue and to evaluate its correlation with the established markers of prognosis. Sixty female patients who underwent surgery for breast cancer were enrolled for the study. Immediately after surgery, 2-5 g of tumour tissue and similar volume of peritumoural normal breast tissue were collected for IL10 assay. IL10 expression was assayed by immunohistochemistry. IL10 expressing tumours and IL10 non expressing tumours were compared. Chi square/Fisher exact test and student's t test were used to compare the data. p- valueless than 0.05 was considered as statistically significant. Thirty six patients (60 %) of carcinoma breast showed IL 10 expression in tumour tissue as compared to no IL 10 expression in any peritumouralnormal breast tissue (p < 0.01). IL10 expression had statistically significant correlation with locally advanced disease, tumour grade, HER2 + ve tumours and ER-ve, PR-ve, HER2 + ve breast cancer subtypes (p = 0.001, 0.001, 0.001 and 0.01 respectively). No correlation could be found with patient's age, tumour size, tumour histology and ER and PR status. Correlation of IL10 expressing tumours with several established poor prognostic markers of breast cancer may indicate the possible association of IL10 expression with poor prognosis. Large studies with long term follow up are needed to substantiate the association of IL10 with poor prognosis.
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http://dx.doi.org/10.1007/s13193-016-0512-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5016330PMC
September 2016

Patterns of injury among motorized two-wheeler pillion riders in New Delhi, India.

J Surg Res 2016 09 17;205(1):142-6. Epub 2016 Jun 17.

Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Background: Motorized two-wheelers (MTWs) such as scooters and motorcycles place drivers and passengers at significant risk of injury and death in the event of a road traffic accident. In India, where road traffic is poorly regulated and consists of vehicles ranging from semitrucks to animal carts, the MTW pillion rider (backseat passenger) is particularly vulnerable. Annually, approximately 140,000 Indians are injured or killed in MTW road traffic accidents. In 2011, the city of New Delhi renewed a mandatory helmet use exemption for its 8 million women. We sought to identify the patterns of injury among MTW pillion riders in the city of New Delhi, including differences between helmeted and unhelmeted male and female pillion riders.

Methods: All records of incoming trauma patients to the Jai Prakash Narayan Apex Trauma Center, New Delhi, were reviewed for the 23-mo period from April 1, 2009 until March 1, 2011. More than 3000 charts were reviewed selecting for patients who were MTW pillion riders involved in road traffic accidents. Data including Glasgow Coma Scale score, number of surgical procedures performed, length of stay, and demographic information were collected from charts that met the criteria. Fisher's exact test was used for categorical variables and Kruskal-Wallis test for continuous variables.

Results: A total of 466 charts of MTW pillions in road traffic accidents were identified with 108 helmeted males, 161 unhelmeted males, three helmeted females, and 194 unhelmeted females. Females, both unhelmeted and helmeted, were more likely to have head and neck injury than unhelmeted males or helmeted males (66.0% and 66.7% versus 53.4% and 27.8%, P < 0.001). Unhelmeted females were most likely to suffer inhospital mortality (17.6%, P = 0.008) and require intensive care unit admission (40.0%, P = 0.004). Unhelmeted pillions, both male and female, had significantly lower Glasgow Coma Scale scores than helmeted pillions (12.6 and 12.8 versus 13.8 and 15, P = 0.04).

Conclusions: Female pillions are more likely to have head and neck injury than male pillions, and unhelmeted pillions are more likely to have injuries resulting in their death. This firmly establishes the protective benefit of helmet use for pillions. Encouraging helmet use among all pillions may prevent a significant number of injuries and deaths, and mandatory helmet laws may decrease morbidity and mortality of MTW road traffic accidents for the women of New Delhi and all of India.
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http://dx.doi.org/10.1016/j.jss.2016.06.033DOI Listing
September 2016

Transversus abdominis plane block for laparoscopic inguinal hernia repair: a randomized trial.

J Clin Anesth 2016 Sep 28;33:357-64. Epub 2016 May 28.

Department of Surgery, All India Institute of Medical Sciences, New Delhi, India.

Background: Pain after laparoscopic inguinal hernia surgery can be moderate to severe, interfering with return to normal activity. The study aimed to assess the efficacy of bilateral ultrasound-guided (USG) transversus abdominis plane (TAP) block for relieving acute pain after laparoscopic hernia repair as T10-L1 nerve endings are anesthetized with this block.

Methods: Seventy-one American Society of Anesthesiologists I to II patients, aged 18 to 65 years, undergoing unilateral/bilateral laparoscopic hernia repair were randomized to port site infiltration (control, 36) and TAP block groups (35). All patients received general anesthesia (fentanyl 2 μg/kg intravenously at induction, 0.5 μg/kg on 20% increase in heart rate or mean blood pressure) and paracetamol 6 hourly. Postintubation, TAP group received bilateral USG TAP block (15-20 mL 0.5% ropivacaine, maximum 3 mg/kg) with 18-G Tuohy needle. Control group had 20 to 30 mL 0.5% ropivacaine infiltrated preincision, at port sites from skin to peritoneum. Postoperative patient-controlled analgesia fentanyl was provided for 6 hours; pain was assessed using 0- to 100-mm visual analog scale (VAS) at 0, 1, 2, 4, 6, and 24 hours and telephonically at 1 week and 3 months.

Results: Demographic profile of the 2 groups was comparable. Significantly more number of patients required intraoperative fentanyl in the control group (24/36) than in the TAP group (13/35); VAS at rest was lower in TAP than control patients in postanesthesia care unit at 0, 2, 6, and 24 hours (median VAS TAP group: 0, 0, 0, and 0; control: 10, 20, 10, and 10; P= .002, P= .001, P= .001, and P= .006, respectively); P< .01 was considered statistically significant. TAP group had significantly lower VAS on deep breathing at 6 hours and on knee bending and walking at 24 hours and lesser patient-controlled analgesia fentanyl requirement. No significant difference in pain scores was observed at 1 week and 3 months.

Conclusion: TAP block reduced postoperative pain up to 24 hours after laparoscopic hernia repair.
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http://dx.doi.org/10.1016/j.jclinane.2016.04.047DOI Listing
September 2016

Why are we Poor Organ Donors: A Survey Focusing on Attitudes of the Lay Public From Northern India.

J Clin Exp Hepatol 2016 Jun 30;6(2):81-6. Epub 2016 Apr 30.

Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi, India.

Background: Knowledge, sociocultural views, and awareness about organ donation in the general population are important for the success of deceased organ donation. There is an urgent need to gather this information in order to find out the reasons for poor organ donation rates in India.

Methods: A 30-item questionnaire was designed in the English and Hindi language and was administered to the lay people in order to assess their knowledge, views, and attitude regarding brain death and organ donation.

Results: Three hundred and fifty-two people (male:female = 202:150; mean age = 30.6 ± 13.9 years) completed the questionnaire. Only 70% of the people were aware that the organs can be donated after brain death and only 44% thought that they understood the meaning of brain death. Media and Internet were the preferred sources for seeking information on brain death and organ donation. The majority of people (81.2%) were willing to donate organs after brain death but only 1.4% had registered for organ donation. Lack of awareness (80.1%), religious beliefs and superstitions (63.4%), and lack of faith in the healthcare system (40.3%) were believed to be the most important reasons for poor deceased organ donation rates in India. The survey also highlighted the importance of the opinion of family members and the religious leaders in making the decision for organ donation. Educational qualification above matriculation was significantly associated with the knowledge of brain death and the willingness for organ donation.

Conclusion: Lack of awareness appears to be the most important factor for low donation rates in India. Educating people by using media and Internet and conducting awareness programs may help in improving the donation rates.
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http://dx.doi.org/10.1016/j.jceh.2016.04.001DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4963316PMC
June 2016

Learning Curve in Laparoscopic Inguinal Hernia Repair: Experience at a Tertiary Care Centre.

Indian J Surg 2016 Jun 12;78(3):197-202. Epub 2015 Sep 12.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India.

One of the major reasons for laparoscopy not having gained popularity for repair of groin hernia is the perceived steep learning curve. This study was conducted to assess the learning curve and to predict the number of cases required for a surgeon to become proficient in laparoscopic groin hernia repair, by comparing two laparoscopic surgeons. The learning curve evaluation parameters included operative time, conversions, intraoperative complications and postoperative complications, and these were compared between the senior and the junior surgeon. One hundred thirty-eight cases were performed by the senior surgeon, and 63 cases by the junior surgeon. Both were comparable in terms of intraoperative and postoperative complications. Using the moving average method, minimum of 13 laparoscopic hernia repairs are required to reach at par the operating time of an experienced surgeon. For total extraperitoneal (TEP) repair, the number of cases was 14; and for transabdominal preperitoneal (TAPP) repair, this number was 13.
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http://dx.doi.org/10.1007/s12262-015-1341-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4907907PMC
June 2016

Aeromonas spp.: An Emerging Nosocomial Pathogen.

J Lab Physicians 2016 Jan-Jun;8(1):1-4

Surgery, JPNA Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

Aeromonads are hallophillic, nonacid fast, nonspore forming, Gram-negative rods which are widely distributed in the soil, foodstuffs, and aquatic environment. Since times immemorial, they are important zoonotic pathogens of poikilotherms but are now emerging as important human pathogens. These emerging enteric pathogens flourish in the water distribution system by forming biofilms. They possess large number of virulence factors including inherent resistance to various antibiotics and ability to form biofilms using quorum sensing. These properties make them easy pathogens for human infections. Aeromonads are important enteric pathogens, but, with the growing level of immunosuppression in the population, they have been associated with various extraintestinal infections, such as skin and soft-tissue infections, traumatic wound infections, and lower respiratory tract/urinary tract infections. The average annual incidence of bacteremia in Southern Taiwan due to Aeromonas spp. was 76 cases/million inhabitants between 2008 and 2010. However, the incidence reported from Western countries is much lower. The case fatality rate among patients with Aeromonas bacteremia ranges from 27.5 to 46%. Aeromonads are universally resistant to the narrow-spectrum penicillin group of antibiotics such as penicillin, ampicillin, carbenicillin, and ticarcillin. They are however susceptible to piperacillin, azlocillin, second and third generation cephalosporins, and carbapenems. Most of the Aeromonas species are susceptible to aminoglycosides, tetracycline, chloramphenicol, trimethoprim-sulfamethoxazole, quinolones, and monobactams. This manuscript is a comprehensive systematic review of the literature available on Aeromonas spp.
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http://dx.doi.org/10.4103/0974-2727.176234DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4785759PMC
March 2016

Prospective Case-Control Study to Evaluate the Role of Glutathione S Transferases (GSTT1 and GSTM1) Gene Deletion in Breast Carcinoma and Its Prognostic Significance.

Indian J Surg 2015 Dec 5;77(Suppl 3):1067-72. Epub 2014 Aug 5.

Department of Anatomy, All India Institute of Medical Sciences, New Delhi, India.

Breast cancer is the most common cause of cancer death in women with the incidence rising in young women. GST gene polymorphisms are significant because of their role in the detoxification of both environmental carcinogens and also cytotoxic drugs used in therapy for breast cancer. The present study has been designed to identify the role of polymorphisms in GSTT1 and GSTM1 genes in the risk of development of breast cancer, in the prognostication of breast cancer, and in the prediction of response towards chemotherapy. Ninety-nine patients with breast cancer and 100 healthy controls with no history of cancer were taken from blood donors after informed consent. Epidemiological and clinical data was collected from participants and 5 ml of peripheral venous blood was collected for genotype analysis. Null genotype of GSTT1 was detected in 51.04 % of the controls in comparison to 20.2 % of patients with carcinoma breast, which was found to be statistically significant (OR 4.18; 95 % CI 2.01-8.75; P = 0.0001). GSTM1 gene deletion was also significantly more common among controls (60 %) than in patients with breast cancer (33 %) (OR 4.57; 95 % CI 2.20-9.51; P = 0.0001). Tumors more than 5 cm in size had greater tendency for GSTM1 gene expression (P value = 0.019), but other clinicopathological parameters did not show any correlation. GSTT1 and GSTM1 genes status did not show any association with response to chemotherapy. The results indicated the null genotype of both GSTT1 and GSTM1 to be protective for the development of carcinoma breast. None of the known etiological factors have any correlation with GSTT1 and GSTM1 gene deletion. Patients with small tumor size expressed GSTM1 gene deletion. Other tumor characteristics and clinicopathological parameters did not have any correlation with gene deletion.
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http://dx.doi.org/10.1007/s12262-014-1152-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4775586PMC
December 2015

Preventing Delayed Gastric Emptying After Whipple's Procedure-Isolated Roux Loop Reconstruction With Pancreaticogastrostomy.

Indian J Surg 2015 Dec 12;77(Suppl 2):703-7. Epub 2013 Nov 12.

Department of Surgical Disciplines, All India Institute of Medical Sciences, Room No. 5021, 5th Floor Teaching Block, New Delhi, India.

Although delayed gastric emptying (DGE) after Whipple's pancreaticoduodenectomy is not life-threatening and can be treated conservatively, it results in discomfort and significant prolongation of the hospital stay and adds on to the hospital costs. To overcome this problem, we started using the isolated loop technique of reconstruction along with pancreaticogastrostomy and we present our series using this technique. All consecutive patients undergoing Whipple's pancreaticoduodenectomy in a single surgical unit from January 2009 until December 2012 were included. In the absence of hepatic and peritoneal metastasis, resection (Whipple's procedure) with curative intent was done using isolated loop technique with pancreaticogastrostomy. Delayed gastric emptying was assessed clinically and on oral gastrograffin study. Bile reflux was also assessed on clinical parameters and evidence of beefy friable gastric mucosa on upper GI endoscopy and presence of reflux on hepatobiliary scintigraphy. A total of 52 patients were operated using this technique from January 2009 to October 2012. The mean operative time was 260.8 ± 50.3, and the mean operative blood loss was 1,068.0 ± 606.1 ml. Mean gastric emptying time 106.0 ± 6.1 min (89-258 min). Three out of the 52(5.7 %) patients had persistent vomiting in the post-operative period requiring reinsertion of NG tube. A HIDA scan done on POD7 for all patients did not show any evidence of bile reflux in any of the patients. Pancreatogastrostomy with isolated loop in pancreaticoduodenal resection markedly reduces the post-operative incidence of alkaline reflux gastritis and DGE.
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http://dx.doi.org/10.1007/s12262-013-0992-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692950PMC
December 2015

Traumatic Diaphragmatic Injury: A Marker of Serious Injury Challenging Trauma Surgeons.

Indian J Surg 2015 Dec 5;77(Suppl 2):666-9. Epub 2013 Sep 5.

Department of Surgical Disciplines, Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

The objectives of this study are (1) to evaluate prevalence of traumatic diaphragmatic injury (TDI), (2) identify the predictors of mortality, and (3) study the accuracy of investigations in survivors of TDI. Retrospective analysis of prospectively maintained database of TDI from January 2007 to December 2011. Emergency department (ED) records, operative details, and autopsy reports were reviewed to determine injury characteristics, treatment provided, and outcome. Statistical analyses were performed using the SPSS ver.15 software. TDI was identified in 75 individuals. Thirty-two of 75 (42.6 %) cases were brought dead to the hospital, and 43/75 (57.3 %) were survivors presented to emergency department, diagnosed to have TDI intraoperatively. Seven of 43 (16.3 %) died postoperatively. Mortality in TDI was significantly related to age (p = 0.001), injury severity (p < 0.001), site of TDI (p = 0.002), and associated injuries (p = 0.021, odds ratio of 9). Death increased with increase in the number of organ injured (p < 0.001, odds ratio of 12). Multi-detector computer tomography (MDCT) detected TDI in 23/26 (88.5 %) cases preoperatively. Laparotomy (p < 0.001, odds ratio of 22) and thoracotomy (p = 0.021, with odds ratio of 9) were associated with survival benefit when compared to minimal invasive surgery in injured cases. The prevalence of TDI was 2.67 %, TDI's mark severity of injury. Mortality increases with increasing number of organ injured. Right-sided or bilateral injury of diaphragm is associated with increased mortality.
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http://dx.doi.org/10.1007/s12262-013-0970-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692852PMC
December 2015

Factors Affecting Short-Term and Long-Term Outcomes After Bilioenteric Reconstruction for Post-cholecystectomy Bile Duct Injury: Experience at a Tertiary Care Centre.

Indian J Surg 2015 Dec 13;77(Suppl 2):472-9. Epub 2013 Feb 13.

Department of Anaesthesiology, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, 110029 India.

Bile duct injury following cholecystectomy is an iatrogenic catastrophe associated with significant perioperative morbidity, reduced long-term survival and quality of life. There has been little literature on the long-term outcomes after surgical reconstruction and factors affecting it. The aim of this study was to study factors affecting long-term outcomes following surgical repair of iatrogenic bile duct injury being referred to a tertiary care centre. Between January 2005 to December 2011, 138 patients with bile duct injury were treated in a single surgical unit in a tertiary care referral hospital. Preoperative details were recorded. After initial resuscitation, any intra-abdominal collection was drained and an imaging of biliary anatomy was done. Once the general condition of the patient improved, patients were taken up for a side-to-side extended left duct hepaticojejunostomy. The post-operative outcomes were recorded and a hepatobiliary iminodiacetic acid scan and liver function tests were done, and then the patients were followed up at regular intervals. Clinical outcome was evaluated according to clinical grades described by Terblanche and Worthley (Surgery 108:828-834, 1990). The variables were compared using chi-square, unpaired Student's t test and Fisher's exact test. A two-tailed p value of <0.05 was considered significant. One hundred thirty-eight patients, 106 (76.8 %) females and 32 (23.2 %) males with an age range of 20-63 years (median 40.8 ± SD) with bile duct injury following open or laparoscopic cholecystectomy, were operated during this period. Majority of the patients [83 (60.1 %)] had a delayed presentation of more than 3 months. Based on imaging, Strasburg type E1 was seen in 17 (12.5 %), type E2 in 30 (21.7 %), type E3 in 85 (61.5 %) and type E4 in 6 (4.3 %). On multivariate analysis, only level of injury, longer duration of referral and associated vascular injury were independently associated with an overall poor long-term outcome. This study demonstrates level of injury at or above the confluence; associated vascular injury and delay in referral were associated with poorer outcomes in long-term follow-up; however, almost all patients had excellent outcome in long-term follow-up.
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http://dx.doi.org/10.1007/s12262-013-0880-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692855PMC
December 2015

Accuracy of Focused Assessment with Sonography for Trauma (FAST) in Blunt Trauma Abdomen-A Prospective Study.

Indian J Surg 2015 Dec 31;77(Suppl 2):393-7. Epub 2013 Jan 31.

Department of Forensic Medicine, All India Institute of Medical Sciences, New Delhi, India.

Focused assessment with sonography for trauma (FAST) is a limited ultrasound examination, primarily aimed at the identification of the presence of free intraperitoneal or pericardial fluid. In the context of blunt trauma abdomen (BTA), free fluid is usually due to hemorrhage, bowel contents, or both; contributes towards the timely diagnosis of potentially life-threatening hemorrhage; and is a decision-making tool to help determine the need for further evaluation or operative intervention. Fifty patients with blunt trauma abdomen were evaluated prospectively with FAST. The findings of FAST were compared with contrast-enhanced computed tomography (CECT), laparotomy, and autopsy. Any free fluid in the abdomen was presumed to be hemoperitoneum. Sonographic findings of intra-abdominal free fluid were confirmed by CECT, laparotomy, or autopsy wherever indicated. In comparing with CECT scan, FAST had a sensitivity, specificity, and accuracy of 77.27, 100, and 79.16 %, respectively, in the detection of free fluid. When compared with surgical findings, it had a sensitivity, specificity, and accuracy of 94.44, 50, and 90 %, respectively. The sensitivity of FAST was 75 % in determining free fluid in patients who died when compared with autopsy findings. Overall sensitivity, specificity, and accuracy of FAST were 80.43, 75 and 80 %, respectively, for the detection of free fluid in the abdomen. From this study, we can safely conclude that FAST is a rapid, reliable, and feasible investigation in patients with BTA, and it can be performed easily, safely, and quickly in the emergency room with a reasonable sensitivity, specificity, and accuracy. It helps in the initial triage of patients for assessing the need for urgent surgery.
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http://dx.doi.org/10.1007/s12262-013-0851-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692944PMC
December 2015

Improving Trauma Care in India: the Potential Role of the Rural Trauma Team Development Course (RTTDC).

Indian J Surg 2015 Dec 8;77(Suppl 2):227-31. Epub 2012 Dec 8.

Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India.

The Rural Trauma Team Development Course (RTTDC) was devised to optimize trauma resuscitation training in under-resourced rural institutions. This program appears ideal for India because of its dense traffic, large population, and high frequency of rural trauma. We report on the feasibility and desirability of introducing RTTDC in India. An instructor course for 20 faculties and a provider course for 23 were conducted in New Delhi, India. The courses were evaluated by multiple choice question (MCQ) performance, by rating the modules on a three-point scale (1 = very relevant, 2 = relevant, and 3 = not relevant) for communication skills, principles of performance improvement and patient safety (PIPS), and clinical scenarios. Evaluation questionnaires including desirability of promulgation in India were completed using a five-point Likert Scale (1 = strongly agree, 2 = agree, 3 = neutral, 4 = disagree, and 5 = strongly disagree). Overall written comments were also provided. Both faculty and providers improved post-course MCQ scores (p < 0.05) with lower scores in the provider group. Seventy-eight percent faculty and 74 % providers rated the communication module very relevant. PIPS was rated very relevant by 72 % faculty and 65 % providers. There were over 150 comments, generally positive with over 90 % of both faculty and providers rating strongly agree to agree that the course be promulgated widely in India. The RTTDC including plans for promulgation was enthusiastically received in India, and its potential for improving trauma care including communication skills and PIPS appears excellent.
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http://dx.doi.org/10.1007/s12262-012-0775-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4692915PMC
December 2015
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