Estimation of Time Since Death Using Biochemical Markers in Synovial Fluid.

ABSTRACT: In the field of forensic medicine, estimating time since death plays an important role in helping the investigative organizations unravel the mystery of crime. Presently, many less reliable subjective parameters are being used to measure it, necessitating the need to have more specific and objective parameters. This cross-sectional comparative study was conducted at the Department of Forensic Medicine and Toxicology, All India Institute of Medical Sciences, Bhopal, India on 60 deceased bodies to determine the correlation between known time since death and biochemical parameters in the synovial fluid specifically sodium, potassium, lactate, and total proteins, analyzed using random access fully automated chemical analyzer (Beckman Coulter Au680) followed by estimation of correlation using Spearman correlation test.All the biochemical parameters that were tested in the synovial fluid except for sodium showed a significant correlation. The potassium and lactate showed a significant positive correlation (P < 0.001), and on the contrary, the total protein level showed a significant negative correlation with time since death (P < 0.001). This study shows usefulness of these markers in estimating the time since death. The smaller sample size and the unavailability of the results of effect of cold storage on these parameters necessitate the need of further similar studies to uncover the real practical application.

Study of Demographics, Clinical Profile and Risk Factors of Inguinal Hernia: A Public Health Problem in Elderly Males.

BACKGROUND: Inguinal hernia repair is the most commonly performed elective surgery in India draining significant healthcare resources. This observational study was conducted at a tertiary-level institute in northern India to look into the demographics, clinical profile and risk factors of inguinal hernia. METHOD:  This study was conducted as an observational study at the tertiary care centre of northern India, including 110 patients who had come to the surgical outpatient department for inguinal hernia repair. After obtaining informed consent from all the participants, demographic details, history and clinical examination were recorded. This was a prospective, single-centre, non-randomized, observational study. RESULTS AND DISCUSSION:  In our study, 43 patients (39%) were >50 years of age. One hundred and seven patients (97.27%) were males, and three (2.72%) were females. Male: Female ratio was 32:1. The preponderance of males was due to their involvement in more strenuous exercises and lifting weights and the anatomical differences between them. The main risk factor in the present study was lifting heavy weights 55%, followed by altered bowel habits 36.36% and respiratory disease (chronic obstructive airway disease). Smoking and diabetes were also associated as risk factors for the hernia. In this study, the most common side of hernia was on the right side, 63%, on the left, 33% and bilateral in 4% of patients. The indirect hernia was the most common type. CONCLUSION: Inguinal hernia is a surgical problem found commonly in the male elderly. Right-sided inguinal hernia is common, with the indirect type being more frequent. Heavy weight lifting and strenuous exercises were commonly found risk factors.

Comparison of Postoperative Chronic Groin Pain After Repair of Inguinal Hernia Using Nonabsorbable Versus Absorbable Sutures for Mesh Fixation.

BACKGROUND: Inguinal hernia repair is one of the most common operations performed in general surgery. Lichtenstein mesh hernioplasty is a commonly practiced technique for open inguinal hernia repair. Out of many other complications postoperatively, chronic groin pain is one of the patients' most common postoperative complaints. There is no direct evidence to explain the cause of post-mesh hernioplasty pain. Only a few studies have been done to judge the effect of suture material used for mesh fixation on chronic groin pain. AIMS AND OBJECTIVES: To compare the postoperative groin pain level in mesh hernioplasty using nonabsorbable versus absorbable sutures for mesh fixation at predetermined intervals using a visual analog scale (VAS) score. METHODS:  A prospective, single-center, non-randomized, observational study was conducted. All patients per inclusion and exclusion criteria of inguinal hernia planned for surgery were admitted electively on the day of surgery and were operated on in minor OT under local anesthesia for open mesh hernioplasty. The VAS score assessed the postoperative pain level. RESULTS:  This observational study was done to look for any difference in postoperative chronic groin pain after mesh fixation with either nonabsorbable, prolene sutures (PS) or absorbable vicryl sutures (VS). One hundred and ten patients fulfilling the department of general surgery inclusion criteria were admitted to the study. In our study, postoperatively, the incidence of chronic groin pain was assessed and followed up to six months. After six months, 25%of patients had pain. Of this 25%, the majority (70%) of patients had mild pain, 15% had moderate pain, and 15% had severe pain. There was no statistically significant difference between the two groups of mesh fixation by nonabsorbable versus absorbable sutures. CONCLUSION: Inguinal hernia is one of the most typical conditions seen in general surgery clinics with male predominance. Definitive management of inguinal hernia is surgery. There is no difference in postoperative chronic groin pain with either type of suture material i.e., nonabsorbable or absorbable (prolene vs vicryl) sutures. To conclude, fixation material for mesh does not influence chronic inguinodynia. However, further studies are required for the same.

Comparison Between Closed and Open Methods for Creating Pneumoperitoneum in Laparoscopic Cholecystectomy.

Background: To study the efficacy of closed and open methods for creating pneumoperitoneum in laparoscopic cholecystectomy by comparing the two in terms of their outcome and complication. Study Design: Single-centre, prospective, observational study. Materials and study: Purposive sampling method where the inclusion criteria were all patients with cholelithiasis who were advised and consented to laparoscopic cholecystectomy of age 18-70 years were included in the study group. Exclusion criteria include patients with a paraumbilical hernia, a history of upper abdominal surgery, uncontrolled systemic illness, and local skin infection. Sixty cases of cholelithiasis satisfying exclusion and inclusion criteria who underwent elective cholecystectomy during the study period were included. Thirty-one of these cases underwent the closed method, while in the remaining 29 patients open method was adopted. Cases in which pneumoperitoneum created by closed technique were grouped as group A and those by open technique as group B. Parameters comparing the safety and efficacy of the two methods were studied. The parameters were access time, gas leak, visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia. Patients were assessed on the first postoperative day, the seventh postoperative day, and then two months after surgery. Some follow-ups were done telephonically. Results: Out of 60 patients, 31 underwent the closed method, while 29 underwent the open method. Minor complications like gas leak during the procedure was observed more in the open method. The mean access time in the open-method group was less than in the closed-method group. Other complications like visceral injury, vascular injury, need for conversion, umbilical port site hematoma, umbilical port site infection, and hernia were not observed in either group during the allocated follow-up period in the study. Conclusion: Open technique for pneumoperitoneum is as safe and effective as the closed technique.

Agenesis of gall bladder: Diagnosed before it is an unpleasant laparoscopic surprise-clinical case report and review.

INTRODUCTION & BACKGROUND: Agenesis of gall bladder is a rare congenital anomaly and incidence is 0.007-0.0027%. Even though gall bladder is absent, clinical presentation of 50% cases, mimic biliary colic. This combined with inconclusive radiological findings leads to wrong preoperative diagnosis and patients are subjected to unnecessary surgery causing complications like injury to biliary tract. Except for few cases where a preoperative diagnosis of absent gall bladder was made in majority of cases, agenesis of the gallbladder is described as an incidental finding during surgery. The work has been reported in line with the SCARE criteria (Agha et al., 2018). CASE PRESENTATION: This article will share our experience about two cases who presented with complains of pain in right upper quadrant and USG examination revealed inconclusive reports as cholelethiasis with contracted or shrunken gall bladder in first case and in second case as cholelethiasis with non-visualisation of gall bladder. On further imaging with MR cholangiogram diagnosis of agenesis of gall bladder was made and unnecessary surgery was avoided. DISCUSSION: Ultrasound is the imaging technique of choice to assess the gallbladder; but difficulty arises when gallbladder is either contracted or atrophic. Magnetic cholangioresonance is a non-invasive modality which can describe anatomy of biliary apparatus. So Magnetic cholangiogram should be combined with inconclusive USG studies for gall bladder agenesis. CONCLUSION: With better imaging modalities, it has been possible to diagnose gallbladder agenesis before surgery. And so inconclusive US reports of gall bladder should be combined with MR imaging. In Perioperative scenario on suspicion of gall bladder agenesis present norm is to quit laparoscopy and resort to MR cholangiogram to reduce exploration complications.

A combined approach in prolonged COVID-19 pandemic to teach undergraduate surgery students-future primary care physicians.

Our aim during prolonged COVID-19 pandemic, is to keep the training of undergraduate surgery students rolling as they may be future GPs (general practitioners) or primary care physicians of tomorrow. World Health Organization (WHO) in its public advisory for COVID-19 pandemic has stressed on physical distancing and this has resulted in discontinuation of in-person undergraduate surgery lectures and demonstrations. Also WHO has laid out directions to deliver only essential health-care services, which has resulted in reduced patient load in didactic surgical clinics and fall in number of planned surgeries and adversely effected the teaching of undergraduate surgery students. So there is an urgent need to reschedule and revise the teaching activities for undergraduate surgery students. Therefore, with this background, we plan to propose certain web-based, distant learning novel strategies to keep the training of undergraduate surgery students rolling. These novel strategies include adopting social media platforms and flip classroom concept to replace in-person lectures, involvement of undergraduate surgery students in telemedicine consultation to substitute didactic clinics, use of multimodal computer-based programs, and use of high-end surgical videos for learning of basic surgical skills. These web-based, distance training modalities can be collaged to form training modules for undergraduate surgery students, and as they are GPs or primary care physician of tomorrow, they can use these e-technologies for patient care and patient education also. It was concluded that proposed web-based strategies may be of use to role training of undergraduate surgery students. As some of them may be future GPs/primary care physicians of tomorrow, they can use this concept of e-technology in patient care and patient education in difficult time. Although these virtual technologies can compensate for gap in learning in times of crisis, these cannot replace real-time experience of learning.

Dermatoses of nipple as molluscum contagiosum - Clinical dilemma.

Molluscum contagiosum is a very common skin and mucosal disease of viral origin, caused by molluscum contagiosum virus (MCV) 0 of poxvirus family. With the eradication of smallpox, MCV is the only member of the poxvirus family that causes substantial disease in humans. Although frequently reported, its unusual clinical presentation makes its diagnosis a challenging task.