Diabetic foot ulcers, their characteristics, and trends in survival: Real world outcomes at a tertiary care facility in India.

AIMS: Characteristics of diabetes-related foot ulcers (DFU), association with recurrence and amputation are poorly described in the Asian Indian population. METHODS: A prospectively maintained database was reviewed to characterize DFU and its association with amputation and recurrence. RESULTS: Of 200 patients, 63.5 % were male, the median age was 62 years (Min-Max:40-86), and median BMI was 27.90 kg/m2 (Min-Max:18.5-42.7). Median duration of Diabetes mellitus was 15 years (Min-Max:2-43). Complete healing occurred at a median of three months (Min-Max:0.23-37.62). Amputation for the current ulcer was required in 43.4 % of individuals. Ulcer recurrence was documented in 42.4 % instances, 66.1 % evolving on the ipsilateral side. Previous amputation was associated with the risk of subsequent amputation (Adjusted OR-3.08,p-0.047). Median time to ulcer recurrence was 4.23 years among those with amputation, in contrast to 9.61 years in those with healing. Cardiovascular death was the commonest cause of mortality, followed by sepsis. At a median follow up of 6.08 years, mortality at 1,3,5 and 10 years was 2.5 %,2.5 %,8.2 % and 30.9 % respectively among those who underwent amputation versus 0 %,0 %,10.1 % and 24.5 % respectively for those who achieved healing. CONCLUSIONS: Patients with DFU in India incur amputations at rates higher than conventionally described. With previous amputation, subsequent amputation risk triples. Ten-year mortality is 25%-30 %. Underestimates of the burden of recurrence and mortality are consequential of limited follow-up.

Pseudomyxoma Peritonei Arising from Urachal Mucinous Neoplasms: a Case Series and Updated Literature Review.

To report a case series of patients with pseudomyxoma peritonei (PMP) from urachal mucinous neoplasm (UMN) treated with CRS and HIPEC at a high-volume referral centre, along with an updated literature review. Retrospective review of cases treated between 2000 and 2021. A literature review using MEDLINE and Google Scholar databases was performed. Clinical presentation of PMP from UMN is heterogeneous, and common symptoms are abdominal distension, weight loss, fatigue and haematuria. At least one tumour marker among CEA, CA 19.9, and CA 125 was elevated in the six cases reported, and 5/6 had a preoperative working diagnosis of urachal mucinous neoplasm suspected on detailed cross-sectional imaging. Complete cytoreduction was achieved in five cases, while one patient underwent maximal tumour debulking. Histological findings mirrored the findings of PMP from appendiceal mucinous neoplasms (AMN). Overall survival ranged between 43 and 141 months after complete cytoreduction. On literature review, 76 cases have been reported to date. Complete cytoreduction is associated with good prognosis for patients with PMP from UMN. A definitive classification system is still not available. Supplementary Information: The online version contains supplementary material available at 10.1007/s13193-022-01694-5.

Inter- and Intra-rater Reliability of Modified House-Brackmann and Sunnybrook Facial Nerve Grading Systems in Post Parotidectomy Patients.

To compare inter-rater, intra-rater and inter-system reliability of modified House-Brackmann and Sunnybrook grading systems. The study was conducted in a tertiary care hospital with a single cohort of 20 patients and 3 raters. The patients, eligible to be included for the study, were those over 18 years of age planned for nerve sparing parotidectomy. In the postoperative period, patients were video recorded performing specific movements according to the requirements of modified House-Brackmann and Sunnybrook systems. These recordings were used for the grading once recruitment was completed. The inter-rater, intra-rater and inter-system reliability of modified House-Brackmann and Sunnybrook systems were assessed using the intraclass coefficient. The intra-rater reliability was good-to-excellent for both groups with Intra-Class coefficient (ICC) ranging from 0.902 to 0.958 in modified House-Brackmann and in 0.802 to 0.957 Sunnybrook system. The inter-rater reliability was good-to-excellent with ICC ranging from 0.806 to 0.906 in modified House-Brackmann and 0.766 to 0.860 in Sunnybrook system. The inter-system reliability was good-to-excellent with ICC ranging from 0.892 to 0.937. There was no significant difference in the reliability of modified House-Brackmann and Sunnybrook systems. Thus, an interval scale accomplishes the task of grading facial nerve palsy in a reliable way, and the choice of the specific instrument will be based on other factors like expertise involved, ease of administration and generalisability to the incumbent clinical scenario.

Breast reconstruction following mastectomy in Indian women: a neglected entity.

Phyllodes tumour is a rapidly growing neoplasm with a propensity to involve the entire breast tissue. In large tumours, the treatment comprises a wide local excision or a mastectomy. A woman in her 20s from rural India presented with complaints of a recurrent left breast lump. The lump progressed to a large size, limiting her social activities and causing depression. On examination, she had a mass occupying almost the entire left breast, with stretched skin, dilated veins and pressure necrosis. There were no palpable axillary nodes. She was offered a wide local excision and reconstruction with a latissimus dorsi pedicled flap. After much discussion and clarification of some misconceptions around breast reconstruction, she underwent the planned surgery. This was followed by adjuvant radiation therapy as the histopathology was consistent with a complex phyllodes tumour with close margins. She was well at 1-year follow-up and led a good family and social life. Breast conservation and reconstruction are seldom offered as part of cancer treatment in India. All women should be offered surgical options that are oncologically safe while preserving body image, and hence healthcare providers must work towards breaking the barriers that prevent breast reconstruction.

Assessment of laparoscopic instrument reprocessing in rural India: a mixed methods study.

BACKGROUND: Laparoscopy is a minimally-invasive surgical procedure that uses long slender instruments that require much smaller incisions than conventional surgery. This leads to faster recovery times, fewer post-surgical wound infections and shorter hospital stays. For these reasons, laparoscopy could be particularly advantageous to patients in low to middle income countries (LMICs). Unfortunately, sterile processing departments in LMIC hospitals are faced with limited access to equipment and trained staff which poses an obstacle to safe surgical care. The reprocessing of laparoscopic devices requires specialised equipment and training. Therefore, when LMIC hospitals invest in laparoscopy, an update of the standard operating procedure in sterile processing is required. Currently, it is unclear whether LMIC hospitals, that already perform laparoscopy, have managed to introduce updated reprocessing methods that minimally invasive equipment requires. The aim of this study was to identify the laparoscopic sterile reprocessing procedures in rural India and to test the effectiveness of the sterilisation equipment. METHODS: We assessed laparoscopic instrument sterilisation capacity in four rural hospitals in different states in India using a mixed-methods approach. As the main form of data collection, we developed a standardised observational checklist based on reprocessing guidelines from several sources. Steam autoclave performance was measured by monitoring the autoclave cycles in two hospitals. Finally, the findings from the checklist data was supported by an interview survey with surgeons and nurses. RESULTS: The checklist data revealed the reprocessing methods the hospitals used in the reprocessing of laparoscopic instruments. It showed that the standard operating procedures had not been updated since the introduction of laparoscopy and the same reprocessing methods for regular surgical instruments were still applied. The interviews confirmed that staff had not received additional training and that they were unaware of the hazardous effects of reprocessing detergents and disinfectants. CONCLUSION: As laparoscopy is becoming more prevalent in LMICs, updated policy is needed to incorporate minimally invasive instrument reprocessing in medical practitioner and staff training programmes. While reprocessing standards improve, it is essential to develop instruments and reprocessing equipment that is more suitable for resource-constrained rural surgical environments.

Amyand's Hernia: Case Report -Current Dilemma in Diagnosis and Management.

Amyand's hernia is an extremely rare condition, often misdiagnosed as a strangulated inguinal hernia, in which the inguinal hernial sac contains the vermiform appendix. It is often a surgical surprise. The reported incidence is approximately 1% of all adult inguinal hernia cases. Acute appendicitis in the Amyand's hernia is even less common. We report a rare presentation of acute appendicitis associated with Amyand's hernia managed by en masse reduction of the hernia followed by laparoscopic appendicectomy and open Lichtenstein's tension free inguinal hernioplasty.