A comparative analysis of trans-abdominal pre-peritoneal repair in uncomplicated vs complicated inguinal hernia repair.

INTRODUCTION: Trans-abdominal pre-peritoneal (TAPP) repair is one of the standard techniques for laparoscopic repair of groin hernias. Literature has shown that both total extraperitoneal (TEP) and TAPP are equally effective with similar outcomes but TAPP has an advantage over TEP as there is more working space, and it provides access to the opposite side for repair of occult hernias. We reviewed our experience of TAPP repair in complicated groin hernias and compared the outcomes with uncomplicated groin hernia. METHODS: Patients undergoing TAPP repair from January 2004 to December 2019 were analyzed, and divided into two groups-I uncomplicated and II complicated groin hernia. RESULTS: TAPP repair was performed in 820 patients, of which 70.3% had uncomplicated and 29.7% patients had complicated hernias. Occult hernia was detected in 61 patients. The intra-operative complications (16.8% vs 1.3%) and conversions (2.4%) were higher in complicated hernias. Laparoscopic assisted repair was used in 16.8% patients with complicated hernias. The incidence of post-operative complications (62.1% vs 17.3%; P value <.01) were significantly higher in complicated groin hernia patients. The median follow-up was 15 months; only three patients in the uncomplicated hernia group developed recurrence, and chronic groin pain was higher in the complicated hernia repair patients (P > .05) at 6 months. CONCLUSION: Although operative time, incidence of intra-operative and post-operative complications (albeit minor in nature), and conversions to open are higher after TAPP repair for complicated groin hernias, the short-term outcomes (hematoma, mesh infection) as well as long-term outcomes (chronic groin pain, port site hernia and recurrence) are not different when compared with uncomplicated hernias. TAPP repair can be used in both complicated and uncomplicated groin hernias with similar short-term and long-term outcomes, albeit with a slightly higher incidence of minor complications in complicated hernias. This can be taken into consideration while operating on patients with complicated hernias and taking informed consent.

A Prospective Study Comparing Quality of Life after Laparoscopic Donor Nephrectomy versus Open Donor Nephrectomy.

Laparoscopic donor nephrectomy (LDN) has advantages over open donor nephrectomy (ODN), with less bleeding and pain, and earlier discharge. However, the quality of life (QOL) has not been compared between these techniques. All consecutive donors undergoing left LDN or ODN from 2013 to 2015 at our center were included. The donors' QOL was measured with the brief World Health Organization QOL (WHOQOL-BREF) and the Hospital Anxiety and Depression Scale (HADS) questionnaires preoperatively and at 3 and 6 months postoperatively. Cosmesis was measured by the body image questionnaire, and patient satisfaction was scored on a verbal rating scale at 3 and 6 months. Of the 264 donors, 228 met the inclusion criteria (100 - LDN and 128 - ODN). The LDN group showed no difference in WHOQOL-BREF scores at 3 months, and significant improvements in the psychological and social domains at 6 months versus the baseline. The ODN group showed a significant decrease in the physical, psychological, and environmental domains at 3 and 6 months versus the baseline. Compared with the ODN group, the LDN group had better QOL scores at 3 and 6 months in all domains. The responses to the HADS questionnaire were similar between the groups at all time points. The mean body image, cosmesis, and satisfaction scores were significantly better in the LDN group. LDN minimized the negative effects of surgery on the donors' QOL, with improvements in the long-term psychological and social aspects versus the baseline. LDN was more cosmetic and was associated with higher satisfaction than ODN.

Advanced Trauma Care for Nurses (ATCN): A Single-Center Analysis of Trauma Nurses Knowledge Gaps.

BACKGROUND: Trauma is a global cause of death and disability, and trauma systems are not well developed in low- and middle-income countries. Training of nurses in trauma care is of utmost importance to improve the organization and delivery of trauma care. OBJECTIVE: This study aimed to identify common knowledge gaps and develop study aids to improve nurses' performance taking the Advanced Trauma Care for Nurses (ATCN) course. METHODS: This is a descriptive, single-center study of the multiple-choice final examinations of the ATCN course conducted over 1 year in the All India Institute of Medical Sciences, Rishikesh, Level I trauma center. The questions missed by candidates were compiled, and the wrong options were tabulated. The most commonly missed questions were identified, and the most commonly marked wrong option was analyzed vis-a-vis the correct answer. Each error was classified into either a theoretical error or a practice-based error. RESULTS: Ninety-six nurses attended 6 courses from June 2019 to June 2020. Of the theoretical-based questions, the top 3 categories of most missed questions were geriatric trauma (n = 13; 81.2%), massive transfusion (n = 35; 72.9%), and traumatic brain injury (n = 35; 72.9%). Of the practice-based questions, the top 3 categories of most missed questions were dislocated extremity management (n = 54; 79.4%), basic airway (n = 31; 64.5%), and shock management (n = 30; 62.5%). CONCLUSIONS: Periodic identification and categorization of the ATCN course examination's most frequent knowledge gaps allow instructors to develop teaching aids to enhance instructor teaching and improve trauma nurses' knowledge.

Does ATLS Training Work? 10-Year Follow-Up of ATLS India Program.

BACKGROUND: Studies evaluating the efficacy of ATLS in low- and middle-income countries are limited. We followed up ATLS providers certified by the ATLS India program over a decade (2009 to 2019), aiming to measure the benefits in knowledge, skills, attitude and their attrition over time. METHODS: The survey instrument was developed taking a cue from published literature on ATLS and improvised using the Delphi method. Randomly selected ATLS providers were sent the survey instrument via email as a Google form, along with a statement of purpose. Results are presented descriptively. RESULTS: ATLS India trained 7,847 providers over the study period. 2500 providers were selected for the survery using computer-generated random number table. One thousand and thirty doctors (41.2%) responded. Improvement in knowledge (n = 1,013 [98.3%]), psychomotor skills (n = 986 [95.7%]), organizational skills (n = 998 [96.9%]), overall trauma management (n = 1,013 [98.7%]) and self-confidence (n = 939 [91%]) were reported. Majority (904 [87.8%]) started ATLS promulgation at workplace in personal capacity. These benefits lasted beyond 2 years in majority (>60%) of respondents. More than 40% reported cognitive (n = 492 [47.8%]), psychomotor (n = 433 [42%]), and organizational benefits (n = 499 [48.4%]) lasting beyond 3 years. Improvement in self-confidence, ATLS promulgation at the workplace, and retention of organizational skills were more pronounced in ATLS faculties than providers. All other benefits were found to be comparable in both sub-groups. Lack of trained staff (n = 660 [64.1%]) and attitude issues (n = 495 [48.1%]) were the major impediments in implementing ATLS at the workplace. More than a third of respondents (n = 373 [36.2%]) could enumerate one or more incidents where ATLS principles were life- or limb- saving. CONCLUSIONS: Cognitive, psychomotor, organizational, and affective impact of ATLS is overwhelmingly positive in the Indian scenario. Until formal trauma systems are established, ATLS remains the best hope for critically injured patients in resource-contrained settings.

Neurocognitive Outcomes and Their Diffusion Tensor Imaging Correlates in Children With Mild Traumatic Brain Injury.

This study aimed to assess the neurocognitive outcomes and their diffusion tensor imaging correlates in children (aged 6-16 years) with mild traumatic brain injury. This prospective analysis included 74 children with mild traumatic brain injury (52 boys; mean age: 9.5 [±2.7] years). Wechsler Intelligence Scale for Children-Indian adaptation (WISC-IV), Child Behavior Checklist, and Children's Sleep Habits Questionnaire were administered for 57 cases (at 3 months postinjury) and 51 controls of similar age. The findings of diffusion tensor imaging (done within 7 days of injury) were correlated with various WISC-IV indices. The presenting features at the time of injury were loss of consciousness (53%), confusion or disorientation (47%), and post-traumatic amnesia (10%). Other features in the acute phase included drowsiness (86%), headache (78%), balance problems (62%), nausea (47%), fatigue (45%), vomiting (35%), nasal or ear bleed (12%), sensitivity to sound and light (12%), etc. At 3 months postinjury, the children with mild traumatic brain injury performed poorly in terms of Intelligence Quotient, perceptual reasoning index, and processing speed index as compared to controls. Based on the Child Behavior Checklist, 17% of children with mild traumatic brain injury had internalizing behavioral problems in comparison with 4% of controls. Prevalence of poor sleepers in the mild traumatic brain injury cohort and controls was 12.3% and 2% respectively. Headache, reduced attention span, and fatigue were common postconcussion symptoms. There was a positive correlation between right uncinate fasciculus fractional anisotropy and verbal comprehension index (r = 0.32; P < .05).

Embracing the change: Resuming advanced trauma training in the COVID-19 era.

BACKGROUND: Trauma is slowly regaining its pre-COVID-19 status in terms of prevalence. Advanced trauma training cannot be deferred indefinitely in the current pandemic owing to defense requirements and disaster preparedness in vulnerable regions. Advanced Trauma Life Support (ATLS) India resumed ATLS and Advanced Trauma Care For Nurses (ATCN) courses at one civilian and one military site. METHODS: Stakeholders of respective centers for advanced trauma training deliberated over safe means to resume ATLS and ATCN. Meticulous screening of all participants and pre- and post-course tracking were deemed the most important components for the safe resumption of courses. 'Paperless' course, 'open-air' skill stations, 'payment protection', 'buddy system', point of care sanitizer installation, packed food, and potable beverages were major organizational changes. Participants above 60 years and with uncontrolled comorbidities were not enrolled. RESULTS: Two ATCN, one ATLS (civilian), and one combined ATLS-ATCN (military) were conducted. 78 delegates trained by 32 faculties and 13 personnel. All underwent daily thermal scanning and smartphone application-based COVID-19 tracking. Manikins were utilized instead of moulages and instructors took up the role of nursing assistants in Initial Assessment. Exit exams were conducted with full PPE precautions at the military site and mask-distancing precautions at the civilian site. High fidelity simulator was used at one station at the civilian site. Expenses at the civilian site per course were USD 570 lower than conventional courses. There was no incidence of COVID-19 in any of the 123 participants at 14 days follow up. CONCLUSION: With stringent participant selection and moderate precautions, ATLS and ATCN can be resumed safely in the current COVID-19 pandemic. To the best of our knowledge and after a thorough search of published English literature, this is the first paper reporting on resuming Advanced trauma training in the COVID-19 era.

Long-term Outcomes Following Primary Closure of Common Bile Duct Following Laparoscopic Common Bile Duct (CBD) Exploration: Experience of 355 Cases at a Tertiary Care Center.

INTRODUCTION: Primary closure of common bile duct (CBD) after laparoscopic common bile duct exploration (LCBDE) is now becoming the preferred technique for closure of choledochotomy. Primary CBD closure not only circumvents the disadvantages of an external biliary drainage but also adds to the advantage of LCBDE. Here, we describe our experience of primary CBD closure following 355 cases of LCBDE in a single surgical unit at a tertiary care hospital. MATERIALS AND METHODS: All patients undergoing LCBDE in a single surgical unit were included in the study. Preoperative and intraoperative parameters including the technique of CBD closure were recorded prospectively. The postoperative recovery, complications, hospital stay, antibiotic usage, and postoperative intervention, if any, were also recorded. RESULTS: Three hundred fifty-five LCBDEs were performed from April 2007 to December 2018, and 143 were post-endoscopic retrograde cholangiopancreatography failures. The overall success rate was 91.8%. The mean operative time was 98±26.8 minutes (range, 70 to 250 min). Transient bile leak was seen in 10% of patients and retained stones in 3 patients. Two patients required re-exploration and 2 patients died in the postoperative period. Follow-up ranged from 6 months to 10 years, with a median follow-up of 72 months. No long-term complications such as CBD stricture or recurrent stones were noted. CONCLUSIONS: Primary closure of CBD after LCBDE is safe and associated with minimal complications and no long-term problems. The routine use of primary CBD closure after LCBDE is recommended based on our experience.

Prehospital notification of injured patients presenting to a trauma centre in India: a prospective cohort study.

OBJECTIVES: To assess the effect of a mobile phone application for prehospital notification on resuscitation and patient outcomes. DESIGN: Longitudinal prospective cohort study with preintervention and postintervention cohorts. SETTING: Major trauma centre in India. PARTICIPANTS: Injured patients being transported by ambulance and allocated to red (highest) and yellow (medium) triage categories. INTERVENTION: A prehospital notification application for use by ambulance and emergency clinicians to notify emergency departments (EDs) of an impending arrival of a patient requiring advanced lifesaving care. MAIN OUTCOME MEASURES: The primary outcome was the proportion of eligible patients arriving at the hospital for which prehospital notification occurred. Secondary outcomes were the availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray, and ED and in-hospital mortality. RESULTS: Data from January 2017 to January 2018 were collected with 208 patients in the preintervention and 263 patients in the postintervention period. The proportion of patients arriving after prehospital notification improved from 0% to 11% (p<0.001). After the intervention, more patients were managed with a trauma call-out (relative risk (RR) 1.30; 95% CI: 1.10 to 1.52); a trauma bay was ready for more patients (RR 1.47; 95% CI: 1.05 to 2.05) and a trauma team leader present for more patients (RR 1.50; 95% CI: 1.07 to 2.10). There was no difference in time to the initial chest X-ray (p=0.45). There was no association with mortality at hospital discharge (RR 0.94; 95% CI: 0.72 to 1.23), but the intervention was associated with significantly less risk of patients dying in the ED (RR 0.11; 95% CI: 0.03 to 0.39). CONCLUSIONS: The prehospital notification application for severely injured patients had limited uptake but implementation was associated with improved trauma reception and reduction in early deaths. Quality improvement efforts with ongoing data collection using the trauma registry are indicated to drive improvements in trauma outcomes in India. TRIAL REGISTRATION NUMBER: NCT02877342.

Totally Extraperitoneal Repair in Inguinal Hernia: More Than a Decade's Experience at a Tertiary Care Hospital.

INTRODUCTION: There are 2 standard techniques of laparoscopic groin hernia repair, totally extraperitoneal repair (TEP) and transabdominal preperitoneal repair (TAPP). TEP has the advantage that the peritoneal cavity is not breached but is, however, considered to be more difficult to master when compared with TAPP. We describe herein our experience of TEP repair of inguinal hernia over the last 14 years. MATERIALS AND METHODS: This study is a retrospective analysis of a prospectively maintained database of all patients with groin hernia who underwent TEP repair in a single surgical unit between January 2004 and January 2018. Patients' demographic profile and hernia characteristics (duration, side, extent, content, and reducibility) were noted in the prestructured proforma. Clinical outcomes included the operation time, intraoperative and postoperative complications, length of postoperative hospital stay, hernia recurrence, chronic pain, recurrence, seroma, and wound infections. Long-term follow-up was carried out in the outpatient department. RESULTS: Over the last 14 years, TEP repair was performed in 841 patients and a total of 1249 hernias were repaired. The mean age of patients was 50.7 years. There were 748 primary and 345 unilateral hernias. The majority were direct (61%) inguinal hernias. Telescopic dissection was the commonest method of space creation. The average operating time was 54.8 and 77.9 minutes for unilateral and bilateral hernias, respectively. With 81 conversions, the success rate for TEP was 93.5%. Seroma was the most common postoperative complication seen in 81 patients. The incidence of chronic groin pain was 1.4%. The follow-up ranged from 3 months to 10 years, and there were only 3 recurrences (<1%). CONCLUSION: In conclusion, TEP repair is an excellent technique of laparoscopic inguinal hernia repair with acceptable complications after long-term follow-up.

Antimicrobial resistance in beta-haemolytic streptococci in India: A four-year study.

BACKGROUND & OBJECTIVES: The incidence and severity of invasive and non-invasive infections demonstrate variability over time. The emerging resistance of Group A streptococci (GAS) to commonly used antibiotics is of grave concern. This study was conducted to assess the antimicrobial resistance of beta-haemolytic streptococci (ßHS) in India and to ascertain the molecular mechanisms of resistance. METHODS: All isolates of ßHS from the Trauma Centre of All India Institute of Medical Sciences (AIIMS) (north India), and heavily populated area of old Delhi from 2010 to 2014 and Yashoda Hospital, Secunderabad (in south India, 2010-2012) and preserved isolates of ßHS at AIIMS (2005-2009) were included. Phenotypic confirmation was done using conventional methods and the Vitek 2. Antibiotic sensitivity testing was done by disc diffusion and E-test. Detection of resistance genes, erm(A), erm(B), mef(A), tet(M) and tet(O), was done by polymerase chain reaction (PCR). RESULTS: A total of 296 isolates of ßHS (240 from north and 21 from south India) were included in the study. Of the 296 ßHS, 220 (74%) were GAS, 52 (17.5%) were Group G streptococci and 11 (3.7%), 10 (3.3%) and three (1%) were Group B streptococci, Group C streptococci and Group F streptococci, respectively. A total of 102 (46%) and 174 (79%) isolates were resistant to tetracycline and erythromycin, respectively; a lower resistance to ciprofloxacin (21, 9.5%) was observed. A total of 42 (14%) and 30 (10%) isolates, respectively, were positive for tet(M) and erm(B) genes. Only 13 (5%) isolates were positive for mef(A). None of the isolates were positive for erm(A) and tet(O). There was discordance between the results of E-test and PCR for erythromycin and tetracycline. INTERPRETATION & CONCLUSIONS: A high level of resistance to erythromycin and tetracycline was seen in ßHS in India. Discordance between genotypic and phenotypic results was reported. Absence of erm(A) and tet(O) with high prevalence of tet(M) and erm(B) was observed.

Role of Laparoscopy in Patients With Abdominal Trauma at Level-I Trauma Center.

INTRODUCTION: Abdominal trauma is one of the preventable causes of death in polytrauma patients. Decision and timing of laparotomy is a major challenge. Rate of nontherapeutic laparotomy is still high. Laparoscopy can avoid nontherapeutic laparotomy and also provide a reliable and accurate diagnosis of injury. MATERIALS AND METHODS: This ambispective observational study was conducted in the division of Trauma Surgery and Critical Care, JPN Apex Trauma Centre, All India Institute Medical Sciences, New Delhi. Retrospective analysis of prospectively maintained data of cases from January 1, 2008 through April 30, 2013 and prospective analysis of cases from May 1, 2013 through March 31, 2015 was done using appropriate measures. Hemodynamically stable or responders fulfilling inclusion criteria were included. Selected patients underwent the laparoscopic procedure and if required converted to laparotomy. RESULTS: Of the 3610 patients of abdominal trauma, laparotomy was done in 1666 (46.14%) patients and laparoscopy was done in 119 (3.29%) patients. Rate of reduction of nontherapeutic laparotomy in patients with abdominal trauma using diagnostic laparoscopy was 55.4%. However laparotomy could be avoided in 59.7%. Laparoscopy was 100% accurate in identifying injuries in our study. No injuries were missed in these patients. Fever and wound infection were significantly higher in laparotomy group. Chest infection and sepsis were also higher in laparotomy group but the difference was not statistically significant. Median length of hospital stay in laparoscopy group was 4 days (range: 1 to 28 d) and in laparotomy group was 9.5 days (range: 2 to 55 d) with P-value of 0.001. CONCLUSIONS: Laparoscopy has a role in management of hemodynamically stable patients with suspected abdominal injury to prevent nontherapeutic laparotomies, and thereby decreasing postoperative complications.

Damage control surgery: 6 years of experience at a level I trauma center.

BACKGROUND: Damage control surgery (DCS) has been a well-established practice in the management of trauma victims for more than 2 decades now. The primary aim of this study was to review and analyze the presentation and outcome of patients with torso trauma who underwent DCS at Level I trauma center. METHODS: Retrospective study was conducted using database records prospectively maintained over period of 6 years from 2008 through 2013 at an urban Level I trauma center. Data available from hospital medical records were analyzed to study presentation, mechanism of injury, organs injured, associated injuries, and outcome in patients who underwent DCS following torso trauma. Primary outcome measure was survival. RESULTS: Total of 61 patients were identified who had undergone DCS during the study period. Majority of these patients were males (n=59), had sustained blunt trauma as result of road traffic injury, and had presented with shock (n=49). The 30-day mortality rate was 54%. Mortality was significantly associated with shock (63% cases died; p=0.008), and with Glasgow Coma scale ≤8 (85% died; p=0.001). Injuries significantly associated with high mortality were hepatic injury (n=15; 11 died), major vascular injury (n=10; 3 died), cardiac injury (n=5; 3 died), and pelvic fracture (n=17; 10 died). Re-exploration was required in 28 cases with 13 deaths. Mesh laparostomy was performed in 24 cases, with mortality in 58%. CONCLUSION: In the absence of more effective alternative, especially at facilities with limited resources, DCS may be appropriate in critically injured patients; however, it continues to be associated with significant morbidity and high mortality, even at tertiary care centers.

Prehospital notification for major trauma patients requiring emergency hospital transport: A systematic review.

OBJECTIVE: This systematic review aimed to determine the effect of prehospital notification systems for major trauma patients on overall (<30 days) and early (<24 hours) mortality, hospital reception, and trauma team presence (or equivalent) on arrival, time to critical interventions, and length of hospital stay. METHODS: Experimental and observational studies of prehospital notification compared with no notification or another type of notification in major trauma patients requiring emergency transport were included. Risk of bias was assessed using the Cochrane ACROBAT-NRSI tool. A narrative synthesis was conducted and evidence quality rated using the GRADE criteria. RESULTS: Three observational studies of 72,423 major trauma patients were included. All were conducted in high-income countries in hospitals with established trauma services, with two studies undertaking retrospective analysis of registry data. Two studies reported overall mortality, one demonstrating a reduction in mortality; (adjusted odds ratio (OR) 0.61, 95% confidence interval (CI) 0.39 to 0.94, 72,073 participants); and the other demonstrating a nonsignificant change (OR 0.61, 95% CI 0.23 to 1.64, 81 participants). The quality of this evidence was rated as very low. CONCLUSION: Limited research on the topic constrains conclusive evidence on the effect of prehospital notification on patient-centered outcomes after severe trauma. Composite interventions that combine prehospital notification with effective actions on arrival to hospital such as trauma bay availability, trauma team presence, and early access to definitive management may provide more robust evidence towards benefits of early interventions during trauma reception and resuscitation.

Clinical characteristics and prognostic factors of patients with Stenotrophomonas maltophilia infections.

INTRODUCTION: Stenotrophomonas maltophilia earlier had limited pathogenic potential, but now with growing degree of immunosuppression in general population, it is being recognized as an important nosocomial pathogen. METHODOLOGY: A retrospective 7 years study was carried out to determine the clinical characteristics of all patients with Stenotrophomonas infections, antibiotic resistance pattern, and risk factors associated with hospital mortality. All patients with Stenotrophomonas culture positivity were identified and their medical records were reviewed. Risk factor associated with hospital mortality was analyzed. RESULTS: A total of 123 samples obtained from 88 patients were culture positive. Most patients presented with bacteremia (45, 51%) followed by pneumonia (37, 42%) and skin and soft tissue infections (6, 7%). About 23 of 88 Stenotrophomonas infected patients had co-infection. Percentage resistance to cotrimoxazole; 8 (5.4%) was lower than that for levofloxacin; 18 (12%). Twenty-eight patients died during hospital stay. Intensive Care Unit admission (P = 0.0002), mechanical ventilation (P = 0.0004), central venous catheterization (P = 0.0227), urethral catheterization (P = 0.0484), and previous antibiotic intake (P = 0.0026) were independent risk factors associated with mortality. CONCLUSION: Our findings suggest that Stenotrophomonas can cause various infections irrespective of patient's immune status and irrespective of potential source. Thus, Stenotrophomonas should be thought of as potential pathogen and its isolation should be looked with clinical suspicion.

Comparison of Absorbable Versus Nonabsorbable Tackers in Terms of Long-term Outcomes, Chronic Pain, and Quality of Life After Laparoscopic Incisional Hernia Repair: A Randomized Study.

BACKGROUND: Laparoscopic incisional and ventral hernia repair (LIVHR) has been associated with a high incidence acute and chronic pain due to use of nonabsorbable tackers. Several absorbable tackers have been introduced to overcome these complications. This randomized study was done to compare 2 techniques of mesh fixation, that is, nonabsorbable versus absorbable tackers for LIVHR. MATERIALS AND METHODS: Ninety patients admitted for LIVHR repair (defect size <15 cm) were randomized into 2 groups: nonabsorbable tacker fixation (NAT group, 45 patients) and absorbable tacker fixation (AT group, 45 patients). Intraoperative variables and postoperative outcomes were recorded and analyzed. RESULTS: Patients in both the groups were comparable in terms of demographic profile and hernia characteristics. Mesh fixation time and operation time were also comparable. There was no significant difference in the incidence of immediate postoperative and chronic pain over a mean follow-up of 8.8 months. However, cost of the procedure was significantly higher in AT group (P<0.01) and NAT fixation was more cost effective as compared with AT. Postoperative quality of life outcomes and patient satisfaction scores were also comparable. CONCLUSIONS: NAT is a cost-effective method of mesh fixation in patients undergoing LIVHR with comparable early and late postoperative outcomes in terms of pain, quality of life, and patient satisfaction scores.

Outcomes of Laparoscopic Common Bile Duct Exploration After Failed Endoscopic Retrograde Cholangiopancreatography in Patients with Concomitant Gall Stones and Common Bile Duct Stones: A Prospective Study.

INTRODUCTION: The aim of the present study was to compare the outcomes of secondary laparoscopic CBD exploration (LCBDE) following failed endoscopic retrograde cholangiopancreatography (ERCP) and primary laparoscopic common bile duct (CBD) exploration. MATERIALS AND METHODS: One hundred eighty-five patients undergoing LCBDE were divided into Group I consisting of patients undergoing a primary LCBDE (n = 102) and Group II consisting of patients undergoing LCBDE after failure of ERCP to clear the CBD stones (n = 83). Primary outcome measure was successful laparoscopic CBD clearance. The secondary outcome measures were degree of difficulty, operative time, complications, hospital stay, and the cost of treatment. RESULTS: Success rate was similar in both groups (85.3% versus 80.7%). Mean operative time, degree of difficulty, hospital stay, and cost of procedure were significantly higher in Group II (P value <.05). CONCLUSION: It may be prudent to consider ERCP failure patients for primary LCBDE than risk the complications of ERCP if they are suitable for primary surgery.

Patterns of injury among motorized two-wheeler pillion riders in New Delhi, India.

BACKGROUND: Motorized two-wheelers (MTWs) such as scooters and motorcycles place drivers and passengers at significant risk of injury and death in the event of a road traffic accident. In India, where road traffic is poorly regulated and consists of vehicles ranging from semitrucks to animal carts, the MTW pillion rider (backseat passenger) is particularly vulnerable. Annually, approximately 140,000 Indians are injured or killed in MTW road traffic accidents. In 2011, the city of New Delhi renewed a mandatory helmet use exemption for its 8 million women. We sought to identify the patterns of injury among MTW pillion riders in the city of New Delhi, including differences between helmeted and unhelmeted male and female pillion riders. METHODS: All records of incoming trauma patients to the Jai Prakash Narayan Apex Trauma Center, New Delhi, were reviewed for the 23-mo period from April 1, 2009 until March 1, 2011. More than 3000 charts were reviewed selecting for patients who were MTW pillion riders involved in road traffic accidents. Data including Glasgow Coma Scale score, number of surgical procedures performed, length of stay, and demographic information were collected from charts that met the criteria. Fisher's exact test was used for categorical variables and Kruskal-Wallis test for continuous variables. RESULTS: A total of 466 charts of MTW pillions in road traffic accidents were identified with 108 helmeted males, 161 unhelmeted males, three helmeted females, and 194 unhelmeted females. Females, both unhelmeted and helmeted, were more likely to have head and neck injury than unhelmeted males or helmeted males (66.0% and 66.7% versus 53.4% and 27.8%, P < 0.001). Unhelmeted females were most likely to suffer inhospital mortality (17.6%, P = 0.008) and require intensive care unit admission (40.0%, P = 0.004). Unhelmeted pillions, both male and female, had significantly lower Glasgow Coma Scale scores than helmeted pillions (12.6 and 12.8 versus 13.8 and 15, P = 0.04). CONCLUSIONS: Female pillions are more likely to have head and neck injury than male pillions, and unhelmeted pillions are more likely to have injuries resulting in their death. This firmly establishes the protective benefit of helmet use for pillions. Encouraging helmet use among all pillions may prevent a significant number of injuries and deaths, and mandatory helmet laws may decrease morbidity and mortality of MTW road traffic accidents for the women of New Delhi and all of India.

Is Interleukin 10 (IL10) Expression in Breast Cancer a Marker of Poor Prognosis?

Interleukin 10 (IL10) is a poor prognostic marker in several cancers. Its role in breast cancer is not well elucidated. The present study is designed to see the expression of IL10 in breast cancer tissue and to evaluate its correlation with the established markers of prognosis. Sixty female patients who underwent surgery for breast cancer were enrolled for the study. Immediately after surgery, 2-5 g of tumour tissue and similar volume of peritumoural normal breast tissue were collected for IL10 assay. IL10 expression was assayed by immunohistochemistry. IL10 expressing tumours and IL10 non expressing tumours were compared. Chi square/Fisher exact test and student's t test were used to compare the data. p- valueless than 0.05 was considered as statistically significant. Thirty six patients (60 %) of carcinoma breast showed IL 10 expression in tumour tissue as compared to no IL 10 expression in any peritumouralnormal breast tissue (p < 0.01). IL10 expression had statistically significant correlation with locally advanced disease, tumour grade, HER2 + ve tumours and ER-ve, PR-ve, HER2 + ve breast cancer subtypes (p = 0.001, 0.001, 0.001 and 0.01 respectively). No correlation could be found with patient's age, tumour size, tumour histology and ER and PR status. Correlation of IL10 expressing tumours with several established poor prognostic markers of breast cancer may indicate the possible association of IL10 expression with poor prognosis. Large studies with long term follow up are needed to substantiate the association of IL10 with poor prognosis.