Better among the two for Burn Mortality Prediction in Developing Nations: Revised Baux or Modified Abbreviated Burn Severity Index?

Background: Burns is one of the leading causes of mortality in developing countries like India. Most of the major burns requiring hospital care are not triaged adequately for the use of medical resources. An efficient mortality predicting scale would not only help in better care to those who will benefit the most but also make it easy to explain to patient's attendants. Among the various tools, revised Baux (rBaux) and modified Abbreviated Burn Severity Index (ABSI) are two most commonly used scales in developed nations. We proposed this study to analyze the reliability of these two scoring scales in our burn population. Aim: This study aimed to retrospectively study the two scoring systems and analyze them for their reliability in predicting mortality compared to actual observed mortality in each case. Materials and Methods: This study was conducted on all burn patients admitted to the intensive care unit of our hospital. Data on their demographic profile, total burn surface area, thickness of burns, inhalational injury, and other comorbidities were collected from files. rBaux and modified ABSI (mABSI) were calculated. The end result in the form of survival or nonsurvival was also recorded. Appropriate statistical analysis using Mann-Whitney U-test, Chi-square test, and receiver operator characteristic curve was done to look for a better scoring system out of the two. Results: A total of 504 patients were included in the study, out of which 337 were survivors. Female gender was not a risk factor for mortality in our study. The median rBaux score in the survivor group was 100 (80-110) and in nonsurvivor group was 111 (103-123). The median mABSI score in the survivor group was 8 (7-9) and in nonsurvivor group was 10 (9-11). The area under the receiver operating characteristic curve shows mABSI having better specificity for predicting mortality. rBAUX, though more sensitive, overestimates mortality than actual observed mortality. Conclusion: mABSI predicts mortality better than rBaux. A multicentric prospective study is recommended for mABSI to be used as a standard mortality predictor in burns in India.

Role of Lactate Measurement in Flap Monitoring: An Useful Adjunct.

Background Detection of vascular compromise in flap is often a challenging task for reconstructive surgeons. A timely salvage procedure depends on objectivity and reliability of postoperative flap monitoring. This study determined if flap capillary lactate helps in prediction of flap viability in first 48 postoperative hours of surgery. Methods We conducted this study on all flaps with accessible skin paddle where capillary lactate values were assessed along with clinical observation to check viability of flap at 0, 1, 6, 12, 24 and 48 hours of surgery. The data was statistically analyzed for significance and area under the receiver operating characteristic curve was used for calculating cutoff value for lactate. Results Out of a total of 30 patients included in this study, 25 were males and the mean age was 45.03 years. Fifteen patients underwent free flap and rest pedicled. Highly significant association of role of clinical observation in the outcome of flap was found. The average of lactate values for survived and distally ischemic flap was 5.32 ± 1.91 and 8.38 ± 1.81, respectively, which was highly significant. The cutoff value of lactate below which all flaps survived was found to be 6.09 mmol/L. Conclusion Flap capillary lactate measurement is an easy, quick, cost-effective, and objective tool for checking viability of flaps.

Evaluation of Preoperative Scoring System for Predicting Difficult Laparoscopic Cholecystectomy.

Context: Laparoscopic cholecystectomy (LC) is established as the gold standard for benign gallbladder disease. This study was done for the evaluation of preoperative scoring system given by Randhawa and Pujahari considering various preoperative parameters to predict difficulty in LC. Aims: Preoperative prediction of difficult LC using a scoring system considering various preoperative factors in elective/interval LC to predict difficult gallbladder. Settings and Design: A prospective study of 120 patients admitted for LC from January 2020 to June 2021 was analyzed. Subjects and Methods: All the patients were evaluated on the basis of Randhawa and Pujahari scoring system with the following variables: age >50 years, male sex, body mass index 25.1-27.5 and >27.5 kg/m2, previous abdominal surgery, prior hospitalization for gallstone disease, palpable gallbladder, gallbladder wall thickening, impacted stone, and pericholecystic collection. Each variable had given a score. Based on these findings, the surgical procedure was defined as easy, difficult, and very difficult. Results: One hundred and twenty cases satisfying the inclusion criteria were studied comparing different variables and assigned preoperative scoring. A score >5 was considered significant and compared with intraoperative findings. Out of 53 patients having preoperative scores >5, 40 were difficult gallbladders and 13 were easy to operate. Prediction came true in 93.0% of difficult cases and 83.1% of easy cases. Conclusions: From this study, we can conclude that the preoperative scoring system is statistically reliable to predict difficulty in LC in the majority of the cases (area under receiver operator characteristics = 0.935).

Comparative Efficacy of Intralesional Triamcinolone Acetonide and 5-Fluorouracil for Keloid Scars.

Intralesional triamcinolone acetonide (TAC; a synthetic corticosteroid) and 5-fluorouracil (5-FU; a cytotoxic chemotherapy drug) are the medications most commonly used to treat keloid scars. We investigated the clinical efficacy of TAC compared with 5-FU. We included 40 patients in the study and divided them into two equal groups ( n = 20 Group A; n = 20 Group B). Group A patients received 4 mg/cm 2 or 0.1 ml/cm 2 of intralesional TAC (40 mg/ml) at 3-week intervals. Group B patients received 10 mg/cm 2 or 0.2 ml/cm 2 of intralesional 5-FU (50 mg/ml) at 3-week intervals. We assessed the scar using the Vancouver Scar Scale (VSS), visual analog scale (VAS), and patient satisfaction score (PSS). We found that Group A patients had a lower VAS than Group B patients (2.09 vs. 3.18). We saw a reduction in the VSS in both treatment arms; however, we found that Group B patients had a more marked reduction in the VSS compared with Group A patients (2.57 vs. 2.68). The PSS was higher in Group A than in Group B (1.97 vs. 1.78). We concluded that intralesional 5-FU elicits a better response than intralesional TAC. Although 5-FU is less well tolerated and has more side effects than TAC, we found that 5-FU was more effective in resolving keloid scars. Notably, the PSS was higher in the TAC group, but the VSS and VAS were better in Group B.

Grinder Injury of the Hand: A Rare but Devastating Occupational Hazard.

Food handlers and workers are exposed to several occupational hazards not frequented by the general population. Grinder injuries of the hand present a devastating consequence of industrial food processing that is infrequently described. Herein, we describe two cases that presented to our department with meat grinder injuries of the hand.

Evaluation of the Component Separation Technique for the Treatment of Patients with Large Incisional Hernia.

BACKGROUND: Incisional hernia remains a frequent complication of abdominal surgery. Results of surgical repair are disappointing with recurrence rates of suture repair being in the range of 5%-63% depending on the type of repair used, with better results using mesh implantation. For the management of such large hernias, interest has been generated in the Component Separation Technique. This technique relaxes abdominal wall by translation of muscular layers without severing the innervation and blood supply, with or without the mesh augmentation. This can accommodate for defects up to 25-30 cm in the waistline. MATERIALS AND METHODS: The study was conducted on 20 patients with "Large Incisional Hernia" with defect size >5 cm at its maximum width or with a surface area >50 cm2 operated upon with Component Separation. Clinical outcome was measured over a follow-up period of 3 months from the surgery in terms of recurrence and other local complications. RESULTS: There were 20 patients (3 men and 17 women; 70% of cases above the age of 50 years). Mean defect size was 9.5 cm (range = 6-20 cm). Average body mass index was 28.97 kg/m2 (range = 22-37 kg/m2). Mean duration of hospital stay was 9 days (range = 5-21 days). Early complications occurred in 15% (3/20) cases and postoperative abdominal compartment or recurrence was not reported over a follow-up period of 3 months. CONCLUSIONS: Component Separation Technique is a safe, easy, and quick option for patients with large hernias.

A statistical analysis of incidence, etiology, and management of palatal fistula.

OBJECTIVE: The purpose of this study was to retrospectively review the incidence, profile, and the management of palatal fistula occurring in patients operated for cleft palate in our institute. MATERIALS AND METHODS: A retrospective analysis was performed on all cleft palatal fistula patients who presented during the period from August 2007 to October 2017, to classify their site, age of presentation, surgery performed, and outcome. A record of the type of cleft palate and previous palatoplasty was also obtained. The outcome in terms of incidence and fistula formation depending on Veau's classification was analyzed. RESULTS: Twenty-two patients reported with palatal fistula during this period. The incidence of fistula formation of our institute was 9.6%. Incisive foramen (13/22) was the most common site of fistula formation. Among various techniques used, local and buccal flaps were found to be useful in a maximum number of cases (14/22). The rate of fistula recurrence was 18.2% (4/22). On retrospective analysis of our institutional data, it was found that the incidence of cleft palate fistula was significantly higher in clefts with Veau Types III and IV (13/18) as compared to Veau Types I and II (5/18). CONCLUSION: This study shows that the fistula rate of our institution was 9.6%. Complete clefts (unilateral or bilateral) involving both primary and secondary palates predispose more to fistula formation.

Diagnostic tools in maxillofacial fractures: Is there really a need of three-dimensional computed tomography?

INTRODUCTION: Because of its functional and cosmetic importance, facial injuries, especially bony fractures are clinically very significant. Missed and maltreated fractures might result in malocclusion and disfigurement of the face, thus making accurate diagnosis of the fracture very essential. In earlier times, conventional radiography along with clinical examination played a major role in diagnosis of maxillofacial fractures. However, it was noted that the overlapping nature of bones and the inability to visualise soft tissue swelling and fracture displacement, especially in face, makes radiography less reliable and useful. Computed tomography (CT), also called as X-ray computed radiography, has helped in solving this problem. This clinical study is to compare three-dimensional (3D) CT reconstruction with conventional radiography in evaluating the maxillofacial fractures preoperatively and effecting the surgical management, accordingly. MATERIALS AND METHODS: Fifty patients, with suspected maxillofacial fractures on clinical examination, were subjected to conventional radiography and CT face with 3D reconstruction. The number and site of fractures in zygoma, maxilla, mandible and nose, detected by both the methods, were enumerated and compared. The final bearing of these additional fractures, on the management protocol, was analysed. RESULTS: CT proved superior to conventional radiography in diagnosing additional number of fractures in zygoma, maxilla, mandible (subcondylar) and nasal bone. Coronal and axial images were found to be significantly more diagnostic in fracture sites such as zygomaticomaxillary complex, orbital floor, arch, lateral maxillary wall and anterior maxillary wall. CONCLUSION: 3D images gave an inside out picture of the actual sites of fractures. It acted as mind's eye for pre-operative planning and intra-operative execution of surgery. Better surgical treatment could be given to 33% of the cases because of better diagnostic ability of CT.

Sub mucous cleft palate with fenestration.

Congenital fenestration in sub mucous cleft palate is not a common identity. This patient is a 16-year-old female who presented with nasal speech. On examination, she had associated microform cleft lip with nasal deformity. Successful palatoplasty with intra velar veloplasty was done.

Efficacy of topical application of beta urogastrone (recombinant human epidermal growth factor) in Wagner's Grade 1 and 2 diabetic foot ulcers: Comparative analysis of 50 patients.

INTRODUCTION: Diabetes mellitus is growing at epidemic proportions world wide and associated with this is an increase in incidence of diabetic foot ulcers. For better understanding and ease of management, diabetic foot ulcer severity is often classified using the Wagner system. In recent times, various treatment modalities have been put to test for getting early wound healing, including growth factors like human epidermal growth factor. MATERIALS AND METHODS: The present study was conducted in the Department of Surgery, Dayanand Medical College and Hospital, Ludhiana. The patients were divided into two groups of 25 patients each. Group 1 was the study group and patients in this group received topical application of beta urogastrone (rhEGF) gel. Group 2 was the control group and patients in this group received betadine dressing. The patients were followed up after every two weeks for eight weeks. RESULTS: The age and sex were comparable in both groups. Mode of onset was either spontaneous or posttraumatic or following debridement. Initially in group A, 12 patients each had serous and seropurulent discharge respectively. I patient did not have any discharge. In group B, 15 patients had sero purulent discharge, 9 patients had serous discharge and 1 patient had purulent discharge. Initially, 13 patients in group A and 15 patients in group B had granulation tissue. Mean size at the beginning of the study in-group A was 19.56 sq cm and 21.20 sq cm in group B. Two patients from group A had incomplete healing at the end of the study as compared to 14 patients from group B. CONCLUSIONS: The application of rhEGF shortens the wound healing time significantly and the mean closure was significantly higher in the EGF group compared with placebo.

Experience with uroflowmetry in evaluation of lower urinary tract symptoms in patients with benign prostatic hyperplasia.

INTRODUCTION: Uroflowmetry is a non- invasive urodynamic tool which is widely used for most of the patients with suspected lower urinary tract dysfunction. The severity of lower urinary tract symptoms (LUTS) can be measured reliably by using a number of validated questionnaires, like International Prostate Symptom Score (IPSS). This study was designed to determine the relationship between the parameters of uroflowmetry and symptom severity. MATERIALS AND METHODS: Fifty patients with LUTS caused by benign prostatic hyperplasia were evaluated by using uroflowmetry, IPSS, prostate volume estimation. The correlations between these parameters were quantified by means of Spearman correlation co-efficients. RESULTS: Statistically significant correlations were found between the IPSS and results of uroflowmetry (peak flow rate and average flow rate) and post void residual urine. No correlation was found between the IPSS and results of prostate volume measurements. CONCLUSION: There was a positive correlation between peak flow rate, as was measured by uroflowmetry and lower urinary tract symptom severity.

Study of the relation of clinical and demographic factors with morbidity in a tertiary care teaching hospital in India.

BACKGROUND: The emergency department of every tertiary care teaching hospital is the backbone of community health care service. AIMS: This study was undertaken to identify the pattern of emergencies in the hospital, and to identify the risk factors associated with these emergencies. MATERIALS AND METHODS: This was a retrospective record analysis of the emergency department from Jan 2010 to Dec 2010. The data were analyzed for various types of medical emergencies presented at the hospital at Guru Gobind Singh Medical College and Hospital, Faridkot. RESULTS: A total of 2310 patients presented in the emergency department of which nearly half were males; a great majority were in the age group of 15-40 years. The diseases related to the cardiovascular system, 367 (15.89%), topped the list of which hypertension was noted in 267 (11.56%) cases. This was followed by morbidities related to the neurological system, diabetes, hepatobiliary, respiratory, renal 168 (7.27%), poisoning, pyrexia of unknown origin, and multi-organ involvement. With regard to the specific diseases, the majority were contributed by coronary artery disease 217 (9.39%), stroke 178 (7.71%), alcoholic liver disease 160 (6.93%), and chronic obstructive lung diseases 90 (3.90%). In our series, we noted that a great majority of cases were in the 41-60 age groups except poisoning (majority less than 40 years). The age groups were significantly related with selected morbidities. CONCLUSIONS: There are transparent evidence that we need an organized emergency care system in India as relatively the younger age group (15-40 years) comprised nearly half cases.

Demographic profile of hand injuries in an industrial town of north India: a review of 436 patients.

There are not many injuries that rival the injured hand in complexity. A better understanding of biologic, behavioral, and socioeconomic risk factors potentially associated with hand injuries can help identify those individuals most at risk and define potential preventative measures to help reduce the incidence. We present a prospective study of 436 consecutive patients of hand and forearm injury treated over a period of 2 years. A serial recording of the demographic profile of the patient along with the type & cause of injury sustained, hand dominance, duration of hospital stay, time lag between injury and admission, type surgery preformed with intra-operative findings and the cost analysis was done. An expected male dominance in economically viable individuals of 21 to 30 years formed 50 % of the patients of which 22.9 % were labourers and students each. The malady was altercation (27.5 %) followed by industrial & road accidents. Post prandial period was most notorious with multiple neuro (27.05 %) vasculo (39.34 %) tendinous (60.66 %) injury common with even simple lacerations. Dominant hand injury was commonest. It is challenging to assess and treat an injured hand. This study defines the demography and the etiology behind the various cases of hand and forearm injury with the detailed trauma profile. The limitation of the study was absence of functional outcome. The necessity of hand trauma registry is a pre-requisite to quantify the burden of hand injuries and formulate a prevention strategy.

Palatoplasty in a patient with Seckel syndrome.

We report a rare case of a patient of Seckel syndrome having cleft palate born to nonconsanguineous married parents. This 8-year-old male child underwent successful palatoplasty under general anesthesia. Till date there are approximately 60 cases of Seckel syndrome reported in the literature. The syndrome which has autosomal recessive inheritance is characterized by Intra Uterine Growth Retardation, microcephaly, dwarfism, and bird-like face. The associated features of the syndrome and technical details of surgery and anesthesia are discussed.

Evaluation of trauma and prediction of outcome using TRISS method.

INTRODUCTION: Trauma and injury severity score (TRISS), introduced in 1981 is a combination index based on revised trauma score (RTS), injury severity score (ISS) and patient's age. In this study we have used TRISS method to predict the outcome in trauma cases. MATERIALS AND METHODS: 1000 consecutive cases of trauma of adult age group admitted in casualty of Dayanand Medical College and Hospital Ludhiana, from 1/7/2000 onwards. Revised Trauma Score, Injury Severity Score and Age Index were recorded from which TRISS was determined. The performance of TS, ISS and TRISS as predictors of survival was evaluated using the misclassification rate, the information gain and the relative information gain. RESULTS: The majority of the patients were men (83.7%) and in the age group of 20-50 years. Road traffic collisions (72%) were the most common cause of trauma. The mortality rate was 4.1%. Using PER method, the TRISS method was found to have information gain of 0.049 and a relative information gain of 0.41. CONCLUSIONS: The revised trauma score (RTS) ranged from 2.746 to 7.8408.There was a graded increase in mortality with decreasing RTS score.

Role of negative pressure wound therapy in healing of diabetic foot ulcers.

INTRODUCTION: Foot disorders such as ulceration, infection and gangrene are the most common, complex and costly sequelae of diabetes mellitus.[1-3] Even for the most superficial wounds, treatment is often difficult with poor healing responses and high rates of complications. The purpose of this study is to compare the rate of ulcer healing with the negative pressure dressing technique to conventional moist dressings in the treatment of diabetic foot ulcers. MATERIALS AND METHODS: The study was conducted on 30 patients, which were divided into two groups. One group received negative pressure dressing while other group received conventional saline moistened gauze dressing. Results were compared for rate of wound healing. RESULTS: There was a statistically significant difference in the rate of appearance of granulation tissue between the two groups; with granulation tissue appearing earlier in the study group. The study group promised a better outcome (80% complete responders) as compared to the control group (60% complete responders). CONCLUSIONS: Negative pressure wound therapy has a definitive role in healing of diabetic foot ulcers.