Incidence and Risk Factors of Postoperative Complications in General Surgery Patients.

Background Postoperative complications, which are undesirable consequences of surgery, need to be minimized to ensure the quality of surgical care. In this study, we aimed to estimate the incidence and identify the risk factors for postoperative complications which may help in planning appropriate preventive measures. Methodology A prospective observational study was conducted in the general surgery department of a tertiary care hospital in a metropolitan city in India. Patients undergoing elective or emergency surgery were included. Patients transferred postoperatively from other hospitals and those undergoing day-care operations or endoscopic procedures were excluded. Age, gender, body mass index (BMI), comorbidities, surgical risk as per American Society of Anesthesiologists (ASA) grading, scheduling of surgery (emergency, semi-emergency, or elective), approach (open or laparoscopic), intraoperative complications, operative blood loss, the extent of surgery (superficial or deep cavity), indication (diagnostic, therapeutic, or palliative), duration of surgery, wound class (clean, clean-contaminated, contaminated, or dirty), and duration of hospital stay in days were recorded. Patients were followed up for 30 days postoperatively for complications (defined as any undesirable, unintended event as a direct result of an operation). Clavien-Dindo classification was used to grade the severity of complications. The chi-square test was used for categorical data, and the t-test was used for numerical data. P-values <0.05 were considered significant. Results Postoperative complications were observed in 31.50%; minor complications (Grade I and II) in 19.75% and major complications (Grade III and IV) in 8.0% of patients. Postoperative mortality (Grade V) was 3.75%. Significant risk factors were the presence of comorbidities, higher ASA grade, higher BMI, emergency surgery, open surgery, palliative surgery, deeper cavity surgery, higher intraoperative blood loss, prolonged surgical duration, intraoperative complications, and contaminated surgical wounds. Postoperative complications significantly prolonged the hospital stay. Conclusions Understanding risk factors can guide surgeons to adopt appropriate strategic measures to reduce postoperative complications and improve the quality of surgical care. Three key measures emerging from this study are (1) preoperative patient optimization; (2) diligence during surgery to reduce operative time, blood loss, and intraoperative complications; and (3) implementation of infection control practices.

A cohort study of differences in trauma outcomes between females and males at four Indian Urban Trauma Centers.

Background Studies from high income countries suggest improved survival for females as compared to males following trauma. However, data regarding differences in trauma outcomes between females and males is severely lacking from low- and middle-income countries. The objective of this study was to determine the association between sex and clinical outcomes amongst Indian trauma patients using the Australia-India Trauma Systems Collaboration database. Methods A prospective multicentre cohort study was performed across four urban public hospitals in India April 2016 through February 2018. Bivariate analyses compared admission physiological parameters and mechanism of injury. Logistic regression assessed association of sex with the primary outcomes of 30-day and 24-hour in-hospital mortality. Secondary outcomes included ICU admission, ICU length of stay, ventilator requirement, and time on a ventilator. Results Of 8,605 patients, 1,574 (18.3%) were females. The most common mechanism of injury was falls for females (52.0%) and road traffic injury for males (49.5%). On unadjusted analysis, there was no difference in 30-day in-hospital mortality between females (11.6%) and males (12.6%, p = 0.323). However, females demonstrated a lower mortality at 24-hours (1.1% vs males 2.1%, p = 0.011) on unadjusted analysis. Females were also less likely to require a ventilator (17.3% vs 21.0% males, p = 0.001) or ICU admission (34.4% vs 37.5%, p = 0.028). Stratification by age or by ISS demonstrated no difference in 30-day in-hospital mortality for males vs females across age and ISS categories. On multivariable regression analysis, sex was not associated significantly with 30-day or 24-hour in-hospital mortality. Conclusion This study did not demonstrate a significant difference in the 30-day trauma mortality or 24-hour trauma mortality between female and male trauma patients in India on adjusted analyses. A more granular data is needed to understand the interplay of injury severity, immediate post-traumatic hormonal and immunological alterations, and the impact of gender-based disparities in acute care settings.

Associations of On-arrival Vital Signs with 24-hour In-hospital Mortality in Adult Trauma Patients Admitted to Four Public University Hospitals in Urban India: A Prospective Multi-Centre Cohort Study.

INTRODUCTION: In India, more than a million people die annually due to injuries. Identifying the patients at risk of early mortality (within 24 hour of hospital arrival) is essential for triage. A bilateral Government Australia-India Trauma System Collaboration generated a trauma registry in the context of India, which yielded a cohort of trauma patients for systematic observation and interventions. The aim of this study was to determine the independent association of on-arrival vital signs and Glasgow Coma Score (GCS) with 24-hour mortality among adult trauma patients admitted at four university public hospitals in urban India. METHODS: We performed an analysis of a prospective multicentre observational study of trauma patients across four urban public university hospitals in India, between April 2016 and February 2018. The primary outcome was 24-hour in-hospital mortality. We used logistic regression to determine mutually independent associations of the vital signs and GCS with 24-hour mortality. RESULTS: A total of 7497 adult patients (18 years and above) were included. The 24-hour mortality was 1.9%. In univariable logistic regression, Glasgow Coma Score (GCS) and the vital signs systolic blood pressure (SBP), heart rate (HR), respiratory rate (RR) and peripheral capillary oxygen saturation (SpO2) had statistically significant associations with 24-hour mortality. These relationships held in multivariable analysis with hypotension (SBP<90mm Hg), tachycardia (HR>100bpm) and bradycardia (HR<60bpm), hypoxia (SpO2<90%), Tachypnoea (RR>20brpm) and severe (3-8) and moderate (9-12) GCS having strong association with 24-hour mortality. Notably, the patients with missing values for SBP, HR and RR also demonstrated higher odds of 24-hour mortality. The Injury Severity Scores (ISS) did not corelate with 24-hour mortality. CONCLUSION: The routinely measured GCS and vital signs including SBP, HR, SpO2 and RR are independently associated with 24-hour in-hospital mortality in the context of university hospitals of urban India. These easily measured parameters in the emergency setting may help improve decision-making and guide further management in the trauma victims. A poor short-term prognosis was also observed in patients in whom these physiological variables were not recorded.

Does in-hospital trauma mortality in urban Indian academic centres differ between "office-hours" and "after-hours"?

INTRODUCTION: Trauma services within hospitals may vary considerably at different times across a 24 h period. The variable services may negatively affect the outcome of trauma victims. The current investigation aims to study the effect of arrival time of major trauma patients on mortality and morbidity. METHOD: Retrospective analysis of the Australia-India Trauma Systems Collaboration (AITSC) registry established in four public university teaching centres in India Based on hospital arrival time, patients were grouped into "Office-hours" and "After-hours". Outcome parameters were compared between the above groups. RESULTS: 5536 (68.4%) patients presented "after-hours" (AO) and 2561 (31.6%) during "office-hours" (OH). The in-hospital mortality for "after-hours" and "office-hours" presentations were 12.1% and 11.6% respectively. On unadjusted analysis, there was no statistical difference in the odds of survival for OH versus AH presentations. (OR,1.05, 95% CI 0.9-1.2). Adjusting for potential prognostic factors (injury severity, presence of shock on arrival, referral status, sex, or extremes of age), there was no statistically significant odds of survival for OH versus AH presentations (OR,1.02, 95%CI 0.9-1.2).ICU length of stay and duration of mechanical ventilation was longer in the AH group. CONCLUSION: The in-hospital mortality did not differ between trauma patients who arrived during "after-hours" compared to '"office-hours".

An Analysis of 30-Day in-Hospital Trauma Mortality in Four Urban University Hospitals Using the Australia India Trauma Registry.

BACKGROUND: India has one-sixth (16%) of the world's population but more than one-fifth (21%) of the world's injury mortality. A trauma registry established by the Australia India Trauma Systems Collaboration (AITSC) Project was utilized to study 30-day in-hospital trauma mortality at high-volume Indian hospitals. METHODS: The AITSC Project collected data prospectively between April 2016 and March 2018 at four Indian university hospitals in New Delhi, Mumbai, and Ahmedabad. Patients admitted with an injury mechanism of road or rail-related injury, fall, assault, or burns were included. The associations between demographic, physiological on-admission vitals, and process-of-care parameters with early (0-24 h), delayed (1-7 days), and late (8-30 days) in-hospital trauma mortality were analyzed. RESULTS: Of 9354 patients in the AITSC registry, 8606 were subjected to analysis. The 30-day mortality was 12.4% among all trauma victims. Early (24-h) mortality was 1.9%, delayed (1-7 days) mortality was 7.3%, and late (8-30 days) mortality was 3.2%. Abnormal physiological parameters such as a low SBP, SpO2, and GCS and high HR and RR were observed among non-survivors. Early initiation of trauma assessment and monitoring on arrival was an important process of care indicator for predicting 30-day survival. CONCLUSIONS: One in ten admitted trauma patients (12.4%) died in urban trauma centers in India. More than half of the trauma deaths were delayed, beyond 24 h but within one week following injury. On-admission physiological vital signs remain a valid predictor of early 24-h trauma mortality.

Management of liver trauma in urban university hospitals in India: an observational multicentre cohort study.

BACKGROUND: Low- and middle-income countries (LMICs) contribute to 90% of injuries occurring in the world. The liver is one of the commonest organs injured in abdominal trauma. This study aims to highlight the demographic and management profile of liver injury patients, presenting to four urban Indian university hospitals in India. METHODS: This is a retrospective registry-based study. Data of patients with liver injury either isolated or concomitant with other injuries was used using the ICD-10 code S36.1 for liver injury. The severity of injury was graded based on the World Society of Emergency Surgery (WSES) grading for liver injuries. RESULTS: A total of 368 liver injury patients were analysed. Eighty-nine percent were males, with road traffic injuries being the commonest mechanism. As per WSES liver injury grade, there were 127 (34.5%) grade I, 96 (26.1%) grade II, 70 (19.0%) grade III and 66 (17.9%) grade IV injuries. The overall mortality was 16.6%. Two hundred sixty-two patients (71.2%) were managed non-operatively (NOM), and 106 (38.8%) were operated. 90.1% of those managed non-operatively survived. CONCLUSION: In this multicentre cohort of liver injury patients from urban university hospitals in India, the commonest profile of patient was a young male, with a blunt injury to the abdomen due to a road traffic accident. Success rate of non-operative management of liver injury is comparable to other countries.

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

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.

Predicting mortality with the international classification of disease injury severity score using survival risk ratios derived from an Indian trauma population: A cohort study.

BACKGROUND: Trauma is predicted to become the third leading cause of death in India by 2020, which indicate the need for urgent action. Trauma scores such as the international classification of diseases injury severity score (ICISS) have been used with great success in trauma research and in quality programmes to improve trauma care. To this date no valid trauma score has been developed for the Indian population. STUDY DESIGN: This retrospective cohort study used a dataset of 16047 trauma-patients from four public university hospitals in urban India, which was divided into derivation and validation subsets. All injuries in the dataset were assigned an international classification of disease (ICD) code. Survival Risk Ratios (SRRs), for mortality within 24 hours and 30 days were then calculated for each ICD-code and used to calculate the corresponding ICISS. Score performance was measured using discrimination by calculating the area under the receiver operating characteristics curve (AUROCC) and calibration by calculating the calibration slope and intercept to plot a calibration curve. RESULTS: Predictions of 30-day mortality showed an AUROCC of 0.618, calibration slope of 0.269 and calibration intercept of 0.071. Estimates of 24-hour mortality consistently showed low AUROCCs and negative calibration slopes. CONCLUSIONS: We attempted to derive and validate a version of the ICISS using SRRs calculated from an Indian population. However, the developed ICISS-scores overestimate mortality and implementing these scores in clinical or policy contexts is not recommended. This study, as well as previous reports, suggest that other scoring systems might be better suited for India and other Low- and middle-income countries until more data are available.

Bilobed gallbladder: a rare congenital anomaly.

Bilobed gallbladder is a rare form of duplication of gallbladder. Preoperative diagnosis is important to avoid peroperative complications; however, it is also a challenge as imaging reports are often confounding. A case of bilobed gallbladder managed successfully laparoscopically is presented.

Protocol for a prospective observational study to improve prehospital notification of injured patients presenting to trauma centres in India.

INTRODUCTION: Prehospital notification of injured patients enables prompt and timely care in hospital through adequate preparation of trauma teams, space, equipment and consumables necessary for resuscitation, and may improve outcomes. In India, anecdotal reports suggest that prehospital notification, in those few places where it occurs, is unstructured and not linked to a well-defined hospital response. The aim of this manuscript is to describe, in detail, a study protocol for the evaluation of a formalised approach to prehospital notification. METHODS AND ANALYSIS: This is a longitudinal prospective cohort study of injured patients being transported by ambulance to major trauma centres in India. In the preintervention phase, prospective data on patients will be collected on prehospital assessment, notification, inhospital assessment, management and outcomes and recorded in a new tailored multihospital trauma registry. All injured patients arriving by ambulance and allocated to a red or yellow priority category will be eligible for inclusion. The intervention will be a prehospital notification application to be used by ambulance clinicians to notify emergency departments of the impending arrival of a patient. The proportion of eligible patients arriving to hospital after notification will be the primary outcome measure. Secondary outcomes evaluated will be availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray and inhospital mortality. PROGRESS: Ethical approval has been obtained from the All India Institute of Medical Sciences, New Delhi and site-specific approval granted by relevant trauma services. The trial has also been registered with the Monash University Human Research and Ethics Committee; Project number: CF16/1814 - 2016000929. Results will be fed back to prehospital and hospital clinicians via a series of reports and presentations. These will be used to facilitate discussions about service redesign and implementation. It is expected that evidence for improved outcomes will enable widespread adoption of this intervention among centres in all settings with less established tools for prehospital assessment and notification. TRIAL REGISTRATION NUMBER: NCT02877342; Pre-results.

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

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.

An observational study of incidence, risk factors & outcome of systemic inflammatory response & organ dysfunction following major trauma.

BACKGROUND & OBJECTIVES: Trauma is known to lead to systemic inflammatory response syndrome (SIRS) and multiple organ dysfunction syndrome (MODS), which is often a cause of late deaths after injury. SIRS and MODS have been objectively measured using scoring systems. This prospective observational study was carried out in a tertiary care hospital in India to evaluate SIRS and MODS following trauma in terms of their incidence, the associated risk factors and the effect on the outcome. METHODS: All adult patients with major life- and limb-threatening trauma were included. Patients who died within 24 h, those with severe head injury, known comorbidity, immunocompromised state, on immunosuppressants or pregnancy were excluded. SIRS and MODS scores were recorded after initial management (baseline score), on days 3 and 6 of admission. SIRS was defined as SIRS score of ≥2 and MODS was defined as MODS score of ≥1. RESULTS: Two hundred patients were enrolled. SIRS was noted in 156 patients (78%). MODS was noted in 145 (72.5%) patients. Overall mortality was 39 (19.5%). Both SIRS and MODS scores were significantly associated with age >60 yr, blunt injury, (lower) revised trauma score hypotension on admission and (higher) injury severity score, but not with gender, pre-hospital time or operative treatment. INTERPRETATION & CONCLUSIONS: Both SIRS and MODS scores were associated with longer Intensive Care Unit (ICU) stay, more ICU interventions and higher mortality. Incidence of MODS was significantly higher in patients with SIRS. Both scores showed rising trend with time in non-survivors and a decreasing trend in survivors. The serial assessment of scores can help prognosticate outcome and also allocate appropriate critical care resources to patients with rising scores.

Implementation of the World Health Organization Trauma Care Checklist Program in 11 Centers Across Multiple Economic Strata: Effect on Care Process Measures.

BACKGROUND: Trauma contributes more than ten percent of the global burden of disease. Initial assessment and resuscitation of trauma patients often requires rapid diagnosis and management of multiple concurrent complex conditions, and errors are common. We investigated whether implementing a trauma care checklist would improve care for injured patients in low-, middle-, and high-income countries. METHODS: From 2010 to 2012, the impact of the World Health Organization (WHO) Trauma Care Checklist program was assessed in 11 hospitals using a stepped wedge pre- and post-intervention comparison with randomly assigned intervention start dates. Study sites represented nine countries with diverse economic and geographic contexts. Primary end points were adherence to process of care measures; secondary data on morbidity and mortality were also collected. Multilevel logistic regression models examined differences in measures pre- versus post-intervention, accounting for patient age, gender, injury severity, and center-specific variability. RESULTS: Data were collected on 1641 patients before and 1781 after program implementation. Patient age (mean 34 ± 18 vs. 34 ± 18), sex (21 vs. 22 % female), and the proportion of patients with injury severity scores (ISS) ≥ 25 (10 vs. 10 %) were similar before and after checklist implementation (p > 0.05). Improvement was found for 18 of 19 process measures, including greater odds of having abdominal examination (OR 3.26), chest auscultation (OR 2.68), and distal pulse examination (OR 2.33) (all p < 0.05). These changes were robust to several sensitivity analyses. CONCLUSIONS: Implementation of the WHO Trauma Care Checklist was associated with substantial improvements in patient care process measures among a cohort of patients in diverse settings.

Validation of international trauma scoring systems in urban trauma centres in India.

INTRODUCTION: In the Lower-Middle Income Country setting, we validate trauma severity scoring systems, namely Injury Severity Score (ISS), New Injury Severity Scale (NISS) score, the Kampala Trauma Score (KTS), Revised Trauma Score (RTS) score and the TRauma Injury Severity Score (TRISS) using Indian trauma patients. PATIENTS AND METHODS: From 1 September 2013 to 28 February 2015, we conducted a prospective multi-centre observational cohort study of trauma patients in four Indian university hospitals, in three megacities, Kolkata, Mumbai and Delhi. All adult patients presenting to the casualty department with a history of injury and who were admitted to inpatient care were included. The primary outcome was in-hospital mortality within 30-days of admission. The sensitivity and specificity of each score to predict inpatient mortality within 30days was assessed by the areas under the receiver operating characteristic curve (AUC). Model fit for the performance of individual scoring systems was accomplished by using the Akaike Information criterion (AIC). RESULTS: In a registry of 8791 adult trauma patients, we had a cohort of 7197 patients eligible for the study. 4091 (56.8%)patients had all five scores available and was the sample for a complete case analysis. Over a 30-day period, the scores (AUC) was TRISS (0.82), RTS (0.81), KTS (0.74), NISS (0.65) and ISS (0.62). RTS was the most parsimonious model with the lowest AIC score. Considering overall mortality, both physiologic scores (RTS, KTS) had better discrimination and goodness-of-fit than ISS or NISS. The ability of all Injury scores to predict early mortality (24h) was better than late mortality (30day). CONCLUSION: On-admission physiological scores outperformed the more expensive anatomy-based ISS and NISS. The retrospective nature of ISS and TRISS score calculations and incomplete imaging in LMICs precludes its use in the casualty department of LMICs. They will remain useful for outcome comparison across trauma centres. Physiological scores like the RTS and KTS will be the practical score to use in casualty departments in the urban Indian setting, to predict early trauma mortality and improve triage.

Non Operative Approach to Isolated Traumatic Pancreatic Duct Disruption.

Management of isolated traumatic pancreatic duct disruption remains challenging due to associated morbidity and mortality. Two children with isolated pancreatic ductal disruption were treated conservatively. Both developed a pseudocyst which resolved spontaneously due to the atrophy of the distal pancreas in a five-year-old girl while remained persistent and was treated by endoscopic cystogastrostomy in an eight-year-old boy. Non-operative management may be pursued in patients with pancreatic ductal injury in the hope of a pseudocyst formation which may spontaneously resolve or may be treated later with a minimally invasive procedure. However, the literature review precludes its practice as a standard due to high incidence of associated complications of non-operative management.

Scoring system to preoperatively predict choledocholithiasis.

BACKGROUND: The incidence of common bile duct (CBD) calculi has been reported to be 8 % to 20 % among the patients with cholelithiasis. Failure to detect CBD stones on the part of the surgeon not only fails to relieve symptoms but also subjects them to potentially life-threatening complications such as cholangitis, pancreatitis or obstructive jaundice. Modalities for detection of CBD stones have evolved over time from CBD exploration based on clinical and operative findings to intraoperative cholangiography (IOC), to endoscopic retrograde cholangiopancreaticography (ERCP) and, recently, to magnetic resonance cholangiopancreaticography (MRCP) and endoscopic ultrasonography (EUS). We felt a need for a scoring system to predict a patient population having a higher risk of choledocholithiasis so that these modern interventions can be selectively utilized. SETTING: This study was performed in a tertiary care medical college hospital in a metropolitan city. DESIGN: This is a prospective observational study. METHODS: All patients with symptomatic cholelithiasis admitted to the hospital were included. Patients were diagnosed as having choledocholithiasis either by ultrasonography (USG), computed tomography scan, MRCP, EUS or ERCP and were followed up for at least 6 weeks. RESULTS: The prevalence of choledocholithiasis among the 275 patients with symptomatic biliary colic in our study was 18.9 % (n = 77). On bivariate analysis, dilated bile duct on USG (>6 mm), raised total bilirubin, raised alkaline phosphatase (ALP), raised amylase, raised SGPT and SGOT were significantly associated with choledocholithiasis (p < 0.05). On multivariate analysis also, all these factors except amylase and SGPT showed a significant correlation with choledocholithiasis (p < 0.05). These observations were used to build a scoring system consisting of four factors: dilated bile duct on USG (>6 mm), total bilirubin >2 mg/dL, ALP >190 IU/L and SGOT >40 IU/L. CONCLUSION: A positive predictive value of 3 or more factors was over 95 %, necessitating an endoscopic intervention. A negative predictive value of the absence of any factor was 100 %, which ruled out CBD calculi. If only one or two factors are positive, then further evaluation is recommended preferably using non-minimal or minimal invasive investigations like EUS or MRCP.

Laparotomy for blunt abdominal trauma-some uncommon indications.

Trauma laparotomy after blunt abdominal trauma is conventionally indicated for patients with features of hemodynamic instability and peritonitis to achieve control of hemorrhage and control of spillage. In addition, surgery is clearly indicated for the repair of posttraumatic diaphragmatic injury with herniation. Some other indications for laparotomy have been presented and discussed. Five patients with blunt abdominal injury who underwent laparotomy for nonroutine indications have been presented. These patients were hemodynamically stable and had no overt signs of peritonitis. Three patients had solid organ (spleen, kidney) infarction due to posttraumatic occlusion of the blood supply. One patient had mesenteric tear with internal herniation of bowel loops causing intestinal obstruction. One patient underwent surgery for traumatic abdominal wall hernia. In addition to standard indications for surgery in blunt abdominal trauma, laparotomy may be needed for vascular thrombosis of end arteries supplying solid organs, internal or external herniation through a mesenteric tear or anterior abdominal wall musculature, respectively.

Traumatic transfers: calibration is adversely affected when prediction models are transferred between trauma care contexts in India and the United States.

OBJECTIVE: We evaluated the transferability of prediction models between trauma care contexts in India and the United States and explored updating methods to adjust such models for new contexts. STUDY DESIGN AND SETTINGS: Using a combination of prospective cohort and registry data from 3,728 patients of Towards Improved Trauma Care Outcomes in India (TITCO) and from 18,756 patients of the US National Trauma Data Bank (NTDB), we derived models in one context and validated them in the other, assessing them for discrimination and calibration using systolic blood pressure, heart rate, and Glasgow coma scale as candidate predictors. RESULTS: Early mortality was 8% in the TITCO and 1-2% in the NTDB samples. Both models discriminated well, but the TITCO model overestimated the risk of mortality in NTDB patients, and the NTDB model underestimated the risk in TITCO patients. CONCLUSION: Transferability was good in terms of discrimination but poor in terms of calibration. It was possible to improve this miscalibration by updating the models' intercept. This updating method could be used in samples with as few as 25 events.

Blunt Cardiac Rupture: A Diagnostic Challenge.

Blunt Cardiac Rupture (BCR) is a life threatening injury. Majority of patients do not reach the hospital and in those who reach the emergency department, timely diagnosis and treatment is a challenge. The case is about a patient with multiple blunt injuries who presented in shock. Cardiac tamponade was suspected on clinical grounds and on evidence of mediastinal widening on radiograph. In the absence of songography, the diagnosis was confirmed by subxiphoid pericardial window. Emergency thoracotomy revealed a right atrial appendage rupture which was surgically corrected. The patient also underwent splenectomy for grade IV splenic injury. Liver injury, pubic diastasis and tibial spine avulsion fracture was managed conservatively. He recovered well. Systematic observance of trauma resuscitation guidelines can help salvage patients with life threatening complex injuries even in the absence of specialized imaging investigations.