Performance of the T2Bacteria Panel for Diagnosing Bloodstream Infections: A Diagnostic Accuracy Study.

Background: Blood cultures, the gold standard for diagnosing bloodstream infections (BSIs), are insensitive and limited by prolonged time to results. The T2Bacteria Panel (T2 Biosystems) is a direct-from-blood, nonculture test that identifies the most common ESKAPE bacteria (Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, and Escherichia coli). Objective: To assess performance of the T2Bacteria Panel in diagnosing suspected BSIs in adults. Design: Prospective patient enrollment (8 December 2015 through 4 August 2017). Setting: Eleven U.S. hospitals. Patients: 1427 patients for whom blood cultures were ordered as standard of care. Intervention: Paired blood culture and T2Bacteria testing. Measurements: Performance of T2Bacteria compared with a single set of blood cultures in diagnosing proven, probable, and possible BSIs caused by T2Bacteria-targeted organisms. Results: Blood culture and T2Bacteria results were positive for targeted bacteria in 3% (39 of 1427) and 13% (181 of 1427) of patients, respectively. Mean times from start of blood culture incubation to positivity and species identification were 38.5 (SD, 32.8) and 71.7 (SD, 39.3) hours, respectively. Mean times to species identification with T2Bacteria were 3.61 (SD, 0.2) to 7.70 (SD, 1.38) hours, depending on the number of samples tested. Per-patient sensitivity and specificity of T2Bacteria for proven BSIs were 90% (95% CI, 76% to 96%) and 90% (CI, 88% to 91%), respectively; the negative predictive value was 99.7% (1242 of 1246). The rate of negative blood cultures with a positive T2Bacteria result was 10% (146 of 1427); 60% (88 of 146) of such results were associated with probable (n = 62) or possible (n = 26) BSIs. If probable BSIs and both probable and possible BSIs were assumed to be true positives missed by blood culture, per-patient specificity of T2Bacteria was 94% and 96%, respectively. Limitation: Low prevalence of positive blood cultures, collection of a single set of culture specimens, and inability of T2Bacteria to detect nontargeted pathogens. Conclusion: The T2Bacteria Panel rapidly and accurately diagnoses BSIs caused by 5 common bacteria. Primary Funding Source: T2 Biosystems.

Management of Wounds with Exposed Bones or Tendons in Children by Vacuum-Assisted Closure Therapy: A Prospective Study.

Background The management of complex soft tissue defects with exposed bones/tendons is always a challenging task for the surgeon and the problem becomes more pronounced when it comes to the management of these wounds in children. Though flap procedures are considered the standard for managing the complex soft tissue defects with exposed bones/tendons yet small blood vessels for anastomosis, long operative period, increased chances of perioperative thrombosis, and difficult perioperative management in children add to the difficulty in performing flap procedures in children. The vacuum-assisted closure (VAC) therapy has emerged as a novel modality for the management of the difficult wounds with added advantages, especially in children. Objective To evaluate the efficacy of VAC in the management of wounds with exposed bones/tendons in children. Patients and Method Forty-six children of complex wounds with exposed bones/tendons were included in the study from July 2016 to June 2018. Results Out of 46 patients, 31 were male; the patients had a mean age of 8.4 years. Road traffic accident was the most common mode of injury (54%), with most of the wounds located over extremities. The mean duration of VAC therapy was 12 days. More than 90% coverage of the exposed structure was seen in 89% of patients. The wounds were definitively managed by split-thickness skin graft in 89% of patients and flap cover in 6.5% of patients. The mean cost of the VAC therapy at our government run hospital was 187 Indian rupees per day. No significant major complications were seen during the treatment. Conclusion VAC therapy is an efficient, safe, and cost-effective modality of treatment for the management of complex wounds in the pediatric population.

Contralateral lumbo-umbilical flap: A versatile technique for volar finger coverage.

BACKGROUND: While contemplating any difficult soft tissue reconstruction, patient comfort and compliance is of paramount importance. Reconstruction of the volar aspect of fingers and hand by the ipsilateral pedicled flaps (groin flap, abdominal flaps) is demanding as the flap inset is difficult for the surgeon and very uncomfortable for the patient. This often leads to flap complications. For the comfort of the patient, better compliance and ease of complete inset, we planned to manage soft tissue defects of the volar aspect of fingers and hand by a new contralateral pedicled lumbo-umbilical flap. This flap is based on the paraumbilical perforators of deep inferior epigastric artery. MATERIALS AND METHODS: The contralateral pedicled lumbo-umbilical flap was used in eight patients with high-tension electrical burn injuries involving the volar aspect of fingers and hand. The patients were closely observed for first 6 weeks for any flap or donor site complications and then followed monthly to assess donor and recipient site characteristics for 6 months to 2 years. RESULTS AND CONCLUSION: Large flaps up to 8 cm × 16 cm were raised. All but one flaps survived completely. All patients were mobilised within 48 h and five were discharged in less than a week after initial inset. The flap is reliable, easy to harvest and easy to inset on the volar aspect of fingers. The arm is positioned in a very comfortable position. The main disadvantage, however, is a conspicuous abdominal scar.

Role of customised negative-pressure wound therapy in the integration of split-thickness skin grafts: A randomised control study.

BACKGROUND: Split-thickness skin grafting (STSG) is a time-tested technique in wound cover, but many factors lead to suboptimal graft take. Role of custom-made negative-pressure wound therapy (NPWT) is compared with conventional dress in the integration of STSG and its cost is compared with widely used commercially available NPWT. MATERIALS AND METHODS: This is a parallel group randomised control study. Block randomisation of 100 patients into one of the two groups (NPWT vs. non-NPWT; 50 patients each) was done. Graft take/loss, length of hospital stay post-grafting, need for regrafting and cost of custom-made negative pressure wound therapy (NPWT) dressings as compared to widely used commercially available NPWT were assessed. RESULTS: Mean graft take in the NPWT group was 99.74% ± 0.73% compared to 88.52% ± 9.47% in the non-NPWT group (P = 0.004). None of the patients in the NPWT group required second coverage procedure as opposed to six cases in the non-NPWT group (P = 0.035). All the patients in the NPWT group were discharged within 4-9 days from the day of grafting. No major complication was encountered with the use of custom-made NPWT. Custom-made NPWT dressings were found to be 22 times cheaper than the widely used commercially available NPWT. CONCLUSIONS: Custom-made NPWT is a safe, simple and effective technique in the integration of STSG as compared to the conventional dressings. We have been able to reduce the financial burden on the patients as well as the hospital significantly while achieving results at par with other studies which have used commercially available NPWT.

'Pheran' Induced Fourth Degree Friction Burn of the Brain.

Friction burns result from the rubbing between the skin and any other rough surface. We present a case of fourth degree friction burn of the brain, which was predisposed due to the wearing of traditional long loose clothing known as 'Pheran'. The patient was pillion riding a motor bike on a highway and was wearing a Pheran. The loose arm sleeves of the pheran were hanging by the side. The bike met with a side-on collision with a load-carrier lorry. The patient fell down and the left loose arm sleeve of the pheran was trapped in the axle of the lorry. He was dragged on the road for about half a km before the fast moving lorry stopped, the driver being oblivious of the accident. The patient developed friction injury to various parts of the body in addition to a severe fourth degree friction burn to brain and a fracture shaft of left femur.

Bear maul craniocerebral trauma in Kashmir Valley.

Craniocerebral injuries constitute the bulk of the trauma patients in all the tertiary-care hospitals. Bear attacks as a cause of trauma to the brain and its protective covering are rare. This was a hospital-based retrospective (January 1990 to July 2005) and prospective study (August 2005 to December 2010). Craniocerebral trauma was seen in 49 patients of bear maul injuries. Loss of scalp tissue was seen in 17 patients, 13 of whom had exposed pericranium and needed split-thickness skin grafting, while 4 patients with exposed skull bones required scalp transposition flaps as an initial procedure. Skull bone fractures without associated brain injury were observed in 24 cases. Frontal bone was the site of fracture in the majority of cases (95%). Surgical intervention was needed in 18 patients for significantly depressed fractures. Three of these patients had depressed frontal bone fractures with underlying contusions and needed brain debridement and duraplasty. Injury to the brain was observed in 8 patients. Trauma to the brain and its protective coverings as a result of bear attacks is rarely known. Brain injury occurs less commonly as compared to soft tissue and bony injury. Craniocerebral trauma as a result of bear assaults has been a hitherto neglected area of trauma as the past reported incidence has been very low. Of late, the incidence and severity of such attacks has assumed grave proportions in areas adjacent to known bear habitats. An innocuous-looking surface wound might be the only presentation of an underlying severe brain trauma. Public awareness has to be generated to protect the people living in hilly areas.

Unstable metacarpal and phalangeal fractures: treatment by internal fixation using AO mini-fragment plates and screws.

BACKGROUND: Accurate open reduction and internal fixation for metacarpal and phalangeal fractures of the hand is required in less than 5% of the patients; otherwise, closed treatment techniques offer satisfactory results in most of these cases as these fractures are stable either before or after closed reduction. AO mini-fragment screws and plates, when used in properly selected cases, can provide rigid fixation, allowing early mobilization of joints and hence good functional results while avoiding problems associated with protruding K-wires and immobilization. The advantages of such internal fixation urged us to undertake such a study in our state where such hand injuries are commonly seen. METHODS: Forty patients with 42 unstable metacarpal and phalangeal fractures were treated with open reduction and internal fixation using AO mini-fragment screws and plates over a period of three years in a prospective manner. RESULTS: The overall results were good in 78.5% of cases, fair in 19% of cases and poor in 2.5% of cases, as judged according to the criteria of the American Society for Surgery of the Hand. CONCLUSION: This technique is a reasonable option for treating unstable metacarpal and phalangeal fractures as it provides a highly rigid fixation, which is sufficient to allow early mobilization of the adjacent joints, thus helping to achieve good functional results.

Footboards: Indigenous and Novel Method of Screening for Diabetes Peripheral Neuropathy - A Pilot Study.

BACKGROUND: To validate the effectiveness of indigenously designed "footboard (FB)" in early diagnosis of diabetic peripheral neuropathy (PNP) by comparing it with Semmes-Weinstein monofilament (SWM) and vibration perception (VP). MATERIALS AND METHODS: Two hundred and forty-four patients with diabetes were examined for PNP using SWM and 128 Hz tuning fork. The findings were compared with indigenously designed FBs with 1, 2, and 3 mm elevations. RESULTS: Out of 108 patients who did not have protective sensation as per SWM, only 10 (9.2%) felt 1 mm board bearings, and out of 72 patients who did not feel vibration, only 8 (11.1%) felt 1 mm board bearings. Out of 136 patients who had protective sensation, 128 (94.11%) felt 2 mm elevated board bearings, and out of 172 patients who had VP, only 152 patients (88.3%) felt 2 mm board bearings. With SWM as standard, the sensitivities and specificities, respectively, were 63% and 90% (1 mm board), and 94% and 60% (2 mm board). With VP, the sensitivities and specificities, respectively, were 59% and 90% (1 mm board), and 88% and 61% (2 mm board). CONCLUSIONS: FB, which simultaneously tests touch and pressure sensation, shows a high level of performance in detecting at-risk feet. FB may be simple, time-efficient, and inexpensive test for detection of neuropathy and needs further validation in a larger study.

Vacuum-assisted closure versus conventional dressings in the management of diabetic foot ulcers: a prospective case-control study.

OBJECTIVE: To compare the effectiveness of vacuum-assisted closure (VAC) versus conventional dressings in the healing of diabetic foot ulcerations (DFUs) in terms of healing rate (time to prepare the wound for closure either spontaneously or by surgery), safety, and patient satisfaction. METHODS: Randomized case-control study enrolling 56 patients, divided into two groups. Group A (patients treated with VAC) and Group B (patients treated with conventional dressings), with an equal number of patients in each group. DFUs were treated until wound closure, either spontaneously, surgically, or until completion of the 8-week period. RESULTS: Granulation tissue appeared in 26 (92.85%) patients by the end of Week 2 in Group A, while it appeared in 15 (53.57%) patients by that time in Group B. 100% granulation was achieved in 21 (77.78%) patients by the end of Week 5 in Group A as compared to only 10 (40%) patients by that time in Group B. Patients in Group A had fewer number of positive blood cultures, secondary amputations and were satisfied with treatment as compared to Group B. CONCLUSION: VAC appears to be more effective, safe, and patient satisfactory compared to conventional dressings for the treatment of DFUs.

Outcome of wide local excision in dermatofibrosarcoma protuberans and use of radiotherapy for margin-positive disease.

PURPOSE: Wide local excision (WLE) is the preferred treatment of dermatofibrosarcoma protuberans (DFSP). The aim is to achieve negtive margins. We followed the impact of radiotherapy used postoperatively for both margin-negative and margin-positive DFSP tumors. MATERIALS AND METHODS: Outcome of treatment of 36 patients of DFSP treated at our hospital was assessed. Thirty patients received radiotherapy postoperatively and six patients received radiotherapy alone. The maximum dimension of the lesion was 15 cm(2). Patients were followed up for varying periods of time for any recurrence. RESULTS: 10-year actuarial local control rate was determined. Local control was realized in six patients who were treated with radiotherapy alone. 30 patients were treated by radiotherapy and surgery. Out of these 30 patients, there were 6 local failures (failure rate 10%). Actuarial control rate was 82%. The failures were among patients who had positive margins. CONCLUSION: Radiotherapy is effective, and it decreases the recurrence rate in the treatment of DFSP. It is especially helpful in margin-positive disease. This appears true for patients treated with radiotherapy alone or radiotherapy used postoperatively.

Incidence and pattern of bear maul injuries in Kashmir.

BACKGROUND: Injuries due to mauling by bears are rarely reported in the literature. The high incidence of such injuries in Kashmir, India, which is a valley surrounded by dense forests and is a habitat of Asiatic Black bears, urged us to undertake such a study in our department. MATERIALS AND METHODS: The study was conducted both retrospectively (January 1990-July 2005) and prospectively (August 2005-December 2007). RESULTS: A total of 417 cases were recorded and all the injuries were caused by black bears alone. Majority of the patients were young to middle-aged (96.8% of cases) and predominantly males (80.33%). The incidence was highest during July to November (76.82%), and most of the attacks (97%) occurred during daytime. Soft-tissue injury occurred in all 417 cases, bones were involved in 131 (31.41%) while the visceral organs were injured in four (12.94%) patients. The face (80.57%) was most common part of the body injured, followed by the head (54.67%), and all the patients had soft-tissue injury (100%). In spite of devastating injuries caused by bear maulings, the mortality rate was only 2.39%. CONCLUSION: Injuries due to mauling by black bear occur mainly between July and November. The young and middle-aged men have a higher tendency to be wounded. The face and head were the most commonly affected sites, while visceral injuries were rare. Mortality was low, and reconstruction of many of the injuries was challenging, often necessitating a staged procedure. Those living in villages close to black bear habitats may benefit from education related to the risk and severity of the attacks in the hope of reducing the number of injuries seen.

Isolated aglossia in a six year old child presenting with impaired speech: a case report.

INTRODUCTION: The most mobile organ of the body, the tongue is associated with various congenital anomalies; most of which are in association with many other systemic abnormalities. Rarely do they occur in isolation. Isolated aglossia, that we presented, is one of the more rare presentations. CASE PRESENTATION: Our patient is a 6-year-old male child of Asiatic origin from Kashmir (India), who was physically well built and mentally sound and presented with history of impaired speech. The patient had normal velopharangeal competence but absence of tongue which was replaced by a small mucus membrane projection near the floor of oropharangeal isthmus. The patient had no difficulty in feeding or taste sensation but he was unable to pronounce lingual consonants. CONCLUSION: Isolated aglossia is very rare condition explained on the basis of growth failure of lateral lingual swellings and tubercular impar. Such patients do not usually need reconstruction of tongue; as feeding, swallowing and taste sensations are usually intact and speech cannot be improved by reconstruction. However, malocclusion of teeth needs to be taken care of.

Surgeon and human immunodeficiency virus infection.

HIV infection has attained extraordinary attention among surgeons and other health care workers as a potential source of occupational infection. Disease is usually blood-borne and transmissible, and due to the nature of surgical work, surgical community has become involved and is developing sterile surgical barriers, and improved surgical techniques and procedures.

An unusual case of frost bite autoamputation of toes.

BACKGROUND: We report a case of a 15 year old young female who suffered autoamputation of left mid foot and four digits of right foot following repeated application of snow to relieve the pain in her frost bitten feet. CASE PRESENTATION: The sociodemographic background, cause, resulting injury and subsequent management are discussed. CONCLUSION: Such injuries are relatively rare but awareness of the risk of this type of injury is important.