Role of intra-abdominal pressure measurement in patients with acute abdomen requiring exploratory laparotomy.

<b>Introduction:</b> Acute abdomen is one of the most common surgical emergencies faced by a surgeon. Monitoring Intra-Abdominal Pressure (IAP) in patients with acute abdomen referred for exploratory laparotomy may help guide the need for early intervention. </br></br> <b>Aim:</b> This study was performed to determine whether preoperative IAP had any significant association with organ failure as assessed using SOFA score. Furthermore, effect of IAP on patient outcome in terms of hospital stay, mortality was also evaluated. </br></br> <b>Materials and methods:</b> 60 patients above 18 years of age presenting with acute abdomen requiring exploratory laparotomy were included in this prospective observational study from November 2013 until March 2015. IAP and SOFA scores were calculated at the time of admission. The outcome of patients was assessed in terms of hospital stay, morbidity and mortality. The correlation between IAP and SOFA scores was also assessed to determine the risk of organ failure. The inferences were drawn with the use of SPSS v22.0 statistical software. ANOVA, Chi-square and Student's t-test were used in the analysis. </br></br> <b> Results:</b> There was a positive correlation between SOFA score and IAP; and this correlation was found to be statistically significant with Pearson's correlation coefficient being 0.6247 and significance levels being <0.0001. Both hospital stay and mortality positively correlated with the degree of IAP. </br></br> <b> Conclusions:</b> IAP should be routinely measured in patients with acute abdomen requiring exploratory laparotomy. Patients with preoperatively raised IAP should be referred for emergency surgery as soon as possible for better outcome.

Updated greenhouse gas inventory estimates for Indian underground coal mining based on the 2019 IPCC refinements.

Underground coal mining has been known as a significant source of fugitive greenhouse gas emissions. Past analyses of these emissions in India used deterministic emission factors and predominantly focused on methane emissions with reporting of CO2 emissions remaining limited to a few sites. This study addresses these gaps via field measurements on 108 underground mines (out of a total 338) to evolve greenhouse gas reporting in this sector. Results show large heterogeneity across "degrees" of mines as categorized by the Indian government. In addition, CO2 emissions are found to be significant in shallower mines of lower gassiness. Overall, the emissions from underground mining have reduced from 2.6 to 8.3 Mt-CO2e to 1.3-3.6 Mt-CO2e during 1980-2019. These emissions might remain significant by 2050 under a 2-2.5°C constraint or may decline below 100,000 t-CO2e under a 1.5°C constraint. We also discuss several generalizable outcomes and approaches to make inventories in this sector more robust.

Effect of Mastectomy Flap Fixation on Post-operative Fluid Drainage and Seroma Formation in Breast Cancer Patients A Double-blinded Randomised Control Trial.

<b> Introduction:</b> Post-operative seroma formation is one of the most common complications following modified radical mastectomy (MRM). Quilting is a technique where the mastectomy flaps are sutured to the underlying chest wall muscles with sutures, obliterating the dead space. The authors hypothesised that post-mastectomy dead space obliteration by intermittent mastectomy flap fixation leads to decreased drain output and seroma formation. </br></br> <b> Material and methods: </b> A double-blinded randomised control trial with two arms was conducted from November 2019 to March 2021 in our institute located in India. Patients with non metastatic breast carcinoma planned for MRM were randomly categorised into two groups of 35 patients each. In the test group, each flap was fixed to the underlying muscle using four intermittent 3-0 polyglactin sutures, which was followed by skin closure, and only skin closure was done in the control group. </br></br> <b>Results:</b> The test and control groups did not differ significantly with respect to demographic and tumour characteristics. The average drain output of the test group (155.43 ml) was significantly less than of the control group (206.29 ml). The overall incidence of seroma formation is lower in the test group (5.7%) when compared to the control group (28.6%). The duration of hospital stay in the test group (4.63 days) was significantly shorter when compared to the control group (6.66 days). There was no significant increase in the overall operating time or complications like surgical site infection or skin dimpling due to flap fixation. </br></br> <b>Conclusions:</b> Fixation of MRM flaps is associated with better post-operative outcomes related to drain output and seroma formation without a significant increase in other morbidities or usage of resources.

Evaluation of ISS, RTS, CASS and TRISS scoring systems for predicting outcomes of blunt trauma abdomen.

PURPOSE: Trauma is the leading cause of mortality in people below the age of 45 years. Abdominal trauma constitutes one-fourth of the trauma burden. Scoring systems in trauma are necessary for grading the severity of the injury and prior mobilization of resources in anticipation. The aim of this study was to evaluate RTS, ISS, CASS and TRISS scoring systems in blunt trauma abdomen. MATERIALS AND METHODS: A prospective single-center study was conducted on 43 patients of blunt trauma abdomen. Revised trauma score (RTS), Injury Severity Score (ISS), Clinical Abdominal Scoring System (CASS) and Trauma and Injury Severity Score (TRISS) were calculated and compared with the outcomes such as need for surgical intervention, post-operative complications and mortality. RESULTS: The majority of the study subjects were males (83.7%). The most common etiology for blunt trauma abdomen as per this study was road traffic accident (72.1%). Spleen was the most commonly injured organ as per the study. CASS and TRISS were significant in predicting the need for operative intervention. Only ISS significantly predicted post-operative complications. All scores except CASS significantly predicted mortality. CONCLUSIONS: Among the scoring systems studied CASS and TRISS predicted the need for operative intervention with good accuracy. For the prediction of post-operative complications, only the ISS score showed statistical significance. ISS, RTS and TRISS predicted mortality with good accuracy but the superiority of one score over the other couldn't be proved.

A Prospective Randomised Controlled Study Comparing Ultrasonic Dissector with Electrocautery for Axillary Dissection in Patients of Carcinoma Breast.

BACKGROUND: Axillary dissection is one of the important components of modified radical mastectomy (MRM). The present study was conducted to compare surgical outcomes by using monopolar electrocautery and ultrasonic dissector for axillary dissection in MRM. METHODS: A parallel randomised controlled single blinded study was conducted with a sample size of 70 patients who were randomised into two groups. One group underwent MRM using ultrasonic dissector (Group A) and the other one using electrocautery (Group B). Intra- and post-operative outcomes were compared. RESULTS: Group A had an average operating time of 30.86 min, which was statistically less than that of Group B. The mean mop count and the daily drain output in Group A were less as compared to Group B and the differences were statistically significant. Drain was removed early in Group A as compared to Group B. However, post-operative pain scores and seroma formation were not statistically significant among the two groups. CONCLUSION: Ultrasonic dissector group had significantly lesser intra-operative bleeding, operating time and post-operative drain output when compared to electrocautery group. However, the two groups had no significant difference in post-operative pain scores and seroma formation.

Pharmacokinetics and Pharmacodynamic Herb-Drug Interaction of Piperine with Atorvastatin in Rats.

Herbals that are widely consumed as therapeutic alternatives to conventional drugs for cardiovascular diseases, may lead to herb-drug interactions (HDIs). Atorvastatin (ATR) is drug of choice for hyperlipidemia and is extensively metabolized through CYP3A4 enzyme. Thus, we postulate that concomitant administration of ATR with piperine (PIP, potent inhibitor of CYP3A4 enzyme)/ridayarishta (RID, cardiotonic herbal formulations containing PIP) may lead to potential HDI. A simple, accurate, sensitive high-performance liquid chromatography-photodiode array detection method using Kromasil-100 C18 column, mobile phase acetonitrile: 30 mM phosphate buffer (55:45 v/v) pH 4.5 with flow rate gradient programming was developed to study the potential HDI in rats. Method was found to be linear (2-100 ng/mL) with Lower Limit of Detection (LLOD) 2 ng/mL. The precision (%CV < 15%), accuracy (-1.0 to -10% R.E) with recoveries above 90% from rat plasma of ATR and IS were obtained. The pharmacokinetic (PK) interactions studies on co-administration of ATR (8.4 mg/kg, p.o.) with PIP (35 mg/kg, p.o.), demonstrated a threefold increase in Cmax of ATR (P < 0.01) with significant increase in AUC0-t/AUC0-∞ compared to ATR alone indicating potential PK-HDI. However co-administration of RID (4.2 mL/kg, p.o.) showed less significant changes (P > 0.05) indicating low HDI. The pharmacodynamic effects/interactions study (TritonX-100 induced hyperlipidemic model in rats) suggested no significant alterations in the lipid profile on co-administration of PIP/RID with ATR, indicating that there may be no significant pharmacodynamic interactions.

Evaluation of risk factors for prognosticating blunt trauma chest.

<b>Introduction:</b> Blunt trauma chest contributes to significant number of trauma admissions globally and is a cause of major morbidity and mortality. Many scoring systems and risk factors have been defined in past for prognosticating blunt trauma chest but, none is considered to be gold standard. </br> <b>Aim:</b> This study was conducted to reassess the significance of available scoring systems and others indicators of severity in prognosticating blunt trauma chest patients. </br> <b>Materials and Methods:</b> In this prospective observational study from November 2016 till March 2018, 50 patients with age more than 12 years with blunt chest trauma who required hospitalization were included. Nine risk factors were assessed namely- age of the patient, duration of presentation after trauma, number of ribs fractured, bilateral thoracic injury, evidence of lung contusion, associated extra thoracic injury, need for mechanical ventilation, Revised trauma Score (RTS) and Modified Early Warning Sign Score (MEWS). Severity of blunt thoracic trauma was assessed on following outcomes-SIRS, ARDS and Death. The inferences were drawn with the use of statistical software package SPSS v22.0. </br> <b>Results:</b> The age of 50 patients included in our study with a range of 15 to 76 years, the median age was 35.5 years. Statistically significant association was observed between occurrence of SIRS and multiple ribs fractured (p-value- 0.049), associated extra-thoracic injury (p-value-0.016) and higher MEWS score (p-value-0.025). ARDS occurrence was statistically significantly associated with all the risk factors except age.Death occurred more in patients with delayed duration of presentation to hospital (p-value <0.001), multiple ribs fractured (p-value-0.001), bilateral thoracic injury(p-value<0.001), associated extra-thoracic injury (p-value-0.004), patients who required ventilatory support (p-value<0.001), low RTS (p-value-0.006) and high MEWS (p-value-0.005) on admission. This association was found statistically significant. </br> <b>Conclusion:</b> High MEWS, associated extra-thoracic injuries and multiple rib fractured can very well predict poor outcome in terms of SIRS, ARDS and death. Aggressive treatment protocols should be established for better outcome in these patients with blunt trauma chest.

Comparative study between P- POSSUM and Apache II scores in predicting outcomes of perforation peritonitis: Prospective observational cohort study.

BACKGROUND: Scoring systems are needed to prognosticate, compare and audit surgical procedures. Portsmouth Physiological and Operative Severity Score for the Enumeration of Mortality and morbidity (P-POSSUM) and Acute Physiological and Chronic Health Evaluation II (APACHE II) are well known and validated scores to predict surgical outcomes. The objective of this study was to compare P-POSSUM and APACHE II scores in predicting morbidity and mortality of patients who underwent emergency surgery for perforation peritonitis. MATERIALS AND METHODS: A prospective single-center cohort study was conducted with a sample size of 56 patients of perforation peritonitis from November 2018 to March 2020. All patients were followed up prospectively for a period of 30 days to monitor the primary outcome variable mortality and secondary outcome variables such as wound infection, wound dehiscence, anastomotic leak, respiratory complications, Intensive Care Unit (ICU) stay and hospital stay. RESULTS: Mean age of patients was 37.1 years and 67.86% were males. Ileum was the most common site of perforation followed by the stomach. The most common post-operative complication was wound infection (71.43%) followed by respiratory complications (64.29%) and wound dehiscence (35.71%). ICU stay was required for a majority of patients (74.42%). The mean hospital stay was 8.93 days and the mortality rate was 23.21% in this study. P-POSSUM and APACHE II scores had a good association with mortality, post-operative wound dehiscence, respiratory complications, ICU stay and hospital stay. However, there was no statistical difference between the two scores in predicting the above outcomes. Post-operative wound infection and anastomotic leak had no association with P-POSSUM or APACHE II scores. CONCLUSION: As the APACHE II score is based only on preoperative parameters and is easier to calculate we recommend its use for patients of perforation peritonitis over the P-POSSUM score as both have similar predictability.

Surgical Triage of Breast Disorders During the COVID-19 Pandemic: An Indian Perspective.

Breast complaints are a very common cause of healthcare visits in the female population. They range in severity from benign to malignant, and treatment options vary from simple observation to mastectomy. As healthcare facilities are overburdened with coronavirus disease 2019 (COVID-19) patients, properly triaging patients diagnosed with breast disorders is necessary for the optimal use of limited resources in developing countries. We are proposing a concise triage system for timely intervention among patients with breast disorders during the havoc of the COVID-19 pandemic.

Isolated Epitrochlear Filarial Lymphadenopathy: Cytomorphological Diagnosis of an Unusual Presentation.

Filariasis is a major public health problem in tropical countries like India. Despite the large number of people at risk, detection of eggs with or without larva (microfilaria) on fine-needle aspiration cytology is very unusual, especially in an uncommon site or incidentally detected in clinically unsuspected cases of filariasis with the absence of microfilariae in the peripheral blood. A 19-year-old male presented with swelling over medial aspect of left arm (just above the elbow), with no other specific signs and symptoms. Fine needle aspiration cytology revealed an adult gravid female filarial worm in a background of reactive lymphoid cells and lymphohistiocytic clusters. We report a case with elaborate fine needle aspiration cytology findings of filarial worm infestation with unusual presentation of isolated epitrochlear lymph node involvement in a clinically unsuspected case and recommend clinicians and pathologists to consider a high index of suspicion for such infections at uncommon sites especially in endemic territories, as early diagnosis and treatment prevent the more severe manifestations of disease.

Primary cutaneous non-Hodgkin's lymphoma, clinically mimicking a soft tissue sarcoma.

Primary cutaneous B-cell lymphomas (PCBCL) are a heterogeneous group of neoplasms with distinct biology and clinical course when compared to their nodal counterparts. They usually present as violaceous, erythematous plaques, and nonulcerated nodules, which are confined to skin at the time of presentation. We present an unusual case of primary cutaneous diffuse large B-cell lymphoma, clinically mimicking a sarcoma. This case highlights the uncommon aggressive behavior and ulcerated type of nodular lesions seen in PCBCL and also revisits the cytomorphological findings of the same.

Transmural Migration of Gossypiboma: a Rare Cause of Acute Abdomen.

Gossypiboma is the retained foreign body which is generally a cotton sponge/gauze after surgery. Incidence of gossypiboma is around one in 3000 to 5000 surgeries. This low incidence is mainly attributed to a low case reporting due to an associated medicolegal aspect. We are reporting a case of a 38 years old male, who presented with signs and symptoms of peritonitis. The patient had a history of open cholecystectomy 2 years back. A working diagnosis of perforation peritonitis was made, and the patient underwent exploratory laparotomy. Intraoperatively, a surgical sponge was present inside the ileal lumen causing intestinal obstruction with dense adhesion of bowel loops proximal to the site of obstruction with multiple ileal perforations. Even though the incidence of gossypiboma is very low, it should always be kept in mind as a cause of chronic abdominal pain and abdominal discomfort in a patient with previous abdominal surgery.

Large-scale HFMD epidemics caused by Coxsackievirus A16 in Bangalore, India during 2013 and 2015.

Hand foot and mouth disease (HFMD) is a relatively unreported disease in India. This study was undertaken to characterize the enterovirus type/s associated with two unexpectedly-massive epidemics that occurred in Bangalore, India in 2013 and 2015. Stool samples of 229 children with HFMD living in Northern and Southern areas of Bangalore were tested by RT-PCR; 189 (82.5%) were enterovirus positive. The Indian CV-A16 strains exhibited 98-99% sequence identity with those reported in France and China in the 5' untranslated region. BLAST and phylogenetic analyses of complete genomes of representative Indian isolates revealed that the 2015 epidemic was predominated by an inter-species recombinant between CV-A16 and coxsackievirus B5. The 2013 epidemic was primarily caused by nonrecombinant strains. The CV-A16 strains circulated in India since 2007 and phylogeographic analyses indicated imported cases in France and China. In conclusion, CV-A16-associated HFMD epidemics should be recognized as an emerging public health problem in India.

A Prospective Randomized Study Comparing Fibrin Glue Versus Prolene Suture for Mesh Fixation in Lichtenstein Inguinal Hernia Repair.

The aim of this study is to assess the advantages of fibrin glue over Prolene suture in fixation of the mesh in open inguinal hernia repair. Sixty-four cases of inguinal hernia underwent hernia repair by the Lichtenstein method in the department of surgery in PGIMER & Dr. RML Hospital, New Delhi. The patients were randomized prospectively into group A (fibrin glue group) and group B (Prolene suture group). In group A, fibrin glue was used for mesh fixation, and in group B, Prolene suture was used for mesh fixation. The mean age of patients in group A was 44.5 years and that of group B patients was 44.2 years. There was a significant difference in the duration of surgery, with the mean duration in fibrin glue group being 30.6 min and that of the suture group was 43.3 min. The mean visual analogue pain score of postoperative pain at 1, 6, 12, and 24 h was significantly higher in the suture group than in the fibrin glue group (p < 0.001). The mean total dose of analgesia in ampoules of tramadol was significantly less in the fibrin glue group (1.56 ampoules) than that in the suture group (4.125 ampoules) with p = 0.000. At the end of the first month, 25 % of subjects in the suture group presented with mild groin pain (p value = 0.0048). At the end of the second and third month, 22 % (p 68 value = 0.0048) and 12.5 % (p value = 0.1132) of subjects respectively presented with mild groin pain in the suture group. The present study demonstrates that the use of fibrin glue in place of Prolene suture for mesh fixation in open inguinal hernia repair can help decreasing the time required for surgery, reduce the intensity of postoperative pain, shorten the duration of hospital stay, and prevent the incidence of chronic groin pain.

Non-polio enterovirus association with persistent diarrhea in children as revealed by a follow-up study of an Indian cohort during the first two years of life.

BACKGROUND: We recently reported significant association of non-polio enteroviruses (NPEVs) with acute diarrhea in children. Persistent diarrhea (PD) remains a major cause of morbidity and mortality in infants below two years of age in developing countries. Understanding age-dependent frequency and duration of NPEV infections is important to determine their association with persistent diarrhea and disease burden. OBJECTIVES: A cohort of 140 infants was followed for 6 months to 2 years of age to determine the frequency, duration, and association with PD of NPEV infections in comparison with rotavirus and other agents. STUDY DESIGN: Stool samples were collected every 14 days, and diarrheal episodes and their duration were recorded. Enteroviruses were characterized by RT-PCR and VP1 gene sequence analysis, rotavirus by electropherotyping, and other agents by PCR. RESULTS: Of 4545 samples, negative for oral polio vaccine strains, 3907 (85.96%) and 638 (14.04%) were NPEV-negative and NPEV-positive, respectively, representing 403 (8.87%) infection episodes. About 68% of NPEV infections occurred during the first year with every child having at least one episode lasting between four days and four months. Approximately 38% and 22% of total diarrheal episodes were positive for NPEV and RV, respectively. While about 18% of NPEV infection episodes were associated with diarrhea, 6% being persistent, 13% of total diarrheal episodes were persistent involving infections by monotype NPEV strains or sequential infections by multiple strains and other agents. CONCLUSIONS: This is the first report revealing NPEVs as the single most frequently and persistently detected viral pathogen in every PD episode.