Assessment of the Diagnostic Reliability of Modified Alvarado Scores and Abdominal Ultrasonography in Acute Appendicitis.

Introduction Acute appendicitis is a common surgical emergency. Clinical assessment plays a major role; however, subtle clinical features in early stages and atypical presentation makes diagnosis challenging. Ultrasonography (USG) of the abdomen is a usual investigation that aids in diagnosis, however, it is operator dependent. A contrast-enhanced computed tomography (CECT) of the abdomen is more accurate; however, it exposes the patient to hazardous radiation. The study aimed to combine clinical assessment and USG abdomen in the reliable diagnosis of acute appendicitis. Objectives The objective of this study was to assess the diagnostic reliability of the Modified Alvarado Score and ultrasonography of the abdomen in acute appendicitis. Material and methods All patients with right iliac fossa pain, clinically suspected of having acute appendicitis, admitted to the department of general surgery, Kalinga Institute of Medical Sciences (KIMS), Bhubaneswar, between January 2019 and July 2020, who gave consent were included. Clinically, Modified Alvarado Score (MAS) was calculated, after which patients were subjected to USG abdomen, where findings were noted and a sonologic score was calculated. The study group was the patients who needed appendicectomy (n=138). Operative findings were noted. Histopathological diagnosis of acute appendicitis was deemed as confirmatory in these cases and was correlated with MAS and USG scores to determine diagnostic accuracy. Results A combined clinicoradiological (MAS + USG) score of seven showed a sensitivity of 81.8% and a specificity of 100%. The specificity of score seven or above was 100%; however, the sensitivity at 81.8%. The diagnostic accuracy of the clinicoradiological was 87.5%. The negative appendicectomy rate was 4.34%, with a diagnosis of acute appendicitis being confirmed for 95.7% of patients upon histopathological examination. Conclusion The MAS and USG of the abdomen, which is an affordable and non-invasive tool, showed increased diagnostic reliability, and hence it can help reduce the use of CECT abdomen, as CECT abdomen is considered as a gold standard for confirmation or exclusion of diagnosis of acute appendicitis. Use of the combined scoring system of MAS and USG abdomen can be used as a cost-effective alternative.

A Clinical Significance of Fungal Infections in Diabetic Foot Ulcers.

BACKGROUND: Diabetic foot ulcers (DFUs) are the most common and serious complications in uncontrolled diabetes. Infections are predominantly polymicrobial, with aerobic Gram-positive, anerobic, and fungal infections. Early detection of fungal infection and initiation of appropriate treatment in DFUs may lead to better healing and avoid amputations. The primary objective was to find out the prevalence of DFUs getting infected with fungus and the secondary objective was to identify the appropriate methodology for the detection of the fungus in DFUs. MATERIALS AND METHODS:  This was a cross-sectional observational study carried out in a tertiary care hospital with a sample size of 60 DFUs. Microbiological analysis was done by swab culture and deep tissue culture. Observational data were collected and the significance level was statistically analyzed. RESULTS:  In the present study, the prevalence of fungal infections in DFUs was 31.7%. Only fungal tissue was positive in 15%, the fungal swab was positive in 8.33%, and both tissue and swab were positive in 8.33%. All these patients were treated with antifungal treatment as per the culture report in addition to appropriate antimicrobial therapy. CONCLUSION:  A fungal culture should be done in all patients with non-healing DFUs. Both fungal swab and tissue culture testing should be advocated in patients with DFUs for better mycological evaluation. The addition of antifungal medications may provide better outcomes in selected cases.

Intraoperative Findings of Elective Laparoscopic Cholecystectomy in Diabetics Versus Nondiabetics: A Comparative Study.

Objectives Diabetes mellitus predisposes to the formation of gallstones. Surgery for gallstone disease (GSD) in diabetic patients also carries more risk compared with nondiabetic patients. The objective of the present study was to evaluate the intraoperative findings of elective laparoscopic cholecystectomy in diabetics and nondiabetics. Methods This study was carried out for two years in the department of general surgery as a prospective observational study. Two groups of patients with uncomplicated gallstone disease were recruited: one group included 75 diabetics and the other one included 75 nondiabetics. The two study groups were matched by age and gender. Detailed history and intraoperative findings and their outcomes were recorded. Patients with emergencylaparoscopiccholecystectomy for acute cholecystitis and its complications and cholecystectomy associated with common bile duct (CBD) stones were excluded from the study. Results The results of elective laparoscopic cholecystectomy in the groups were compared. No demographic differences were found between the groups. Adverse intraoperative findings such as thick-walled gallbladder (GB), pericholecystic collections, and adhesions to the surrounding structures, surgical difficulties, modification to subtotal cholecystectomy, and open conversion were more frequent in diabetic patients than in nondiabetic patients. Conclusion Laparoscopic cholecystectomy in diabetic patients had more adverse intraoperative findings in comparison to nondiabetic patients. However, in elective laparoscopic cholecystectomy, good preoperative preparation and meticulous surgical technique are mandatory to achieve similar outcomes between the groups.

Efficacy and Cost-Effectiveness of Laparoscopic Transversus Abdominis Plane (TAP) Block in Laparoscopic Cholecystectomy: A Comparison With the Non-TAP Group.

BACKGROUND: Postoperative pain caused by laparoscopic cholecystectomy can be controlled by different methods. The study aimed to observe the efficacy of laparoscopic transversus abdominis plane (TAP) block in laparoscopic cholecystectomy and to analyze the cost-effectiveness of the procedure in comparison to the non-TAP method. METHODS:  In this double-blinded randomized clinical trial, the subjects who had come for cholecystectomy were randomly divided into two groups (n = 43 in each group). Group A received laparoscopy-guided subcostal TAP block bilaterally (0.25% bupivacaine, 20 ml each) along with parenteral analgesics (100 mg tramadol injection in 100 ml normal saline IV) SOS as rescue analgesia, and group B received parenteral analgesics (injection paracetamol 1 gm IV) eight hourly and injection tramadol 100 mg in 100 ml normal saline IV SOS as rescue analgesia. RESULT:  A bulge was visualized by the surgeon through a laparoscope as a signature view for confirming the placement of local anesthetic in TAP. Based on the Visual Analog Scale (VAS) for assessment of postoperative pain and the Numeric Rating Scale (NRS) for assessment of pain at 30 minutes, four hours, eight hours, 12 hours, and 24 hours postoperatively, patients of both groups were assessed. According to the VAS, the pain assessment was better in the TAP block group at 30 minutes post-surgery than in the non-TAP group. As a primary outcome, 37% of TAP block group cases were recovered without any rescue analgesia. VAS score revealed a significant difference in postoperative nausea and vomiting (PONV) among the TAP block and non-TAP groups. PONV at four hours, eight hours, and 12 hours showed significantly lesser incidences in the TAP group as compared to the non-TAP group (p-value: 0.015, 0.028, and 0.055, respectively). CONCLUSION:  The cost-effectiveness of the TAP block method is 20 times lesser than the non-TAP method. Thus, a laparoscopic-guided TAP block could offer better postoperative analgesia at a low cost with a similar advantage to a USG-guided TAP block.

Periplaneta americana L. a potential source of traditional medicine: chemometric analysis, in vitro and in silico study.

'Mayurbhanj is the ethnic dominant tribal population district in Odisha, India. The triabl's of Mayurbhanj depends on traditional medicines since time immemorial for health-related issues. Due to the imperative ethnic claim of traditional healers, the financial stringency of the patient community and the necessity to produce a better therapeutic effect has led to investigate ethno zoological sources and to find out the biochemical moiety responsible for the healing process. Considering the ethnic communities' acceptability of the zoological source as traditional medicine, the current evidence-based research study is conducted to investigate the biochemical moiety present in Periplaneta americana, responsible for therapeutic activity. The whole powdered Periplaneta americana was extracted using maceration techniques with n-hexane and methanol as solvent. The obtained extracts were subjected to GC-MS analysis to identify the biochemical moiety. To check the potential biological activity, an in-vitro antimicrobial test was carried out in both turbidimetry and a viable count method against E. coli. Moreover, the obtained biochemical molecules were exposed to in silico studies for their binding modes and their affinity using Discovery studio software. The major compounds were found to be hexadecanoic acid, methyl ester, n-hexadecanoic acid, oleic acid, octadecanoic acid along with other minor constituents. The maximum inhibitory activity of n-hexane and methanol extract against S. aureus at a concentration of 400 µg/mL was found to be 89 and 87%, respectively. The binding models of almost all identified compounds confer very good binding affinities with some key and strong non-covalent interactions with various amino acid residues of receptor active site pocket, which predict the compounds to be potent inhibitors of various infectious bacteria. These findings suggested that the hexane extract of P. americana could be exploited as a potential natural source. Communicated by Ramaswamy H. Sarma.

Waugh's Syndrome: Blessing in Disguise.

Waugh's syndrome is the association between intestinal malrotion and intussusceptions. We report a case of Waugh's syndrome in a one year old child who presented to us with acute bowel obstruction and bleeding per rectum. Due to malrotation, there was easy prolapsing of ileocolic region into the nonfixed ascending colon and the intussusceptum advanced into the descending colon and rectum without compromising vascularity of the bowel. In most of the cases the intussusceptum advancing into the rectum is associated with bowel gangrene even when ceacum is mobile. But in our case, mobile caecum with malrotation proved to be blessing in disguise in preventing such a complication. A Meckel's diverticulum was also an incidental finding in this case. Waugh's syndrome is missed in cases of close reduction of intussusception and may be a reason for recurrence. Though a rare entity, the probability of Waugh's syndrome should be kept in mind during surgery, during hydrostatic reduction of intussusceptions, and in case of recurrent ileocolic intussusceptions.