Hop, skip and a thump: Kangaroo inflicted trauma.

Although hospital presentations from kangaroo-related injuries commonly stem from motor vehicle collisions, a lesser-known subset involves assaults by kangaroos. In an Australian study over 10 years, only 40 attacks on humans were reported (Herbert et al., 2021). The rate of human injury from kangaroos has speculatively increased, attributed to changes in its natural habitat from fires and urbanisation (Hardy et al., 2021). We present the case of a 75-year-old gentleman who sustained multiple injuries, including a scrotal tear and hemopneumothorax, from a kangaroo-related assault. This case highlights the diverse nature of kangaroo-related injuries and underscores the need for public safety campaigns and comprehensive reporting mechanisms to capture injury rates from incidents involving kangaroos, especially in the setting of climate change-altering environments and increasing human-wildlife contact.

Experience of damage control trauma laparotomy in a limited resource healthcare setting: A retrospective Cohort Study.

INTRODUCTION: Damage control surgery (DCS) is an established option for managing severely injured trauma patients. However, its role in the management of similar patients in the developing world is debatable. The purpose of this study is to describe characteristics and outcomes of patients undergoing DCS. METHODS: All trauma patients requiring laparotomies from 1996 to 2011 at a tertiary care hospital in South Asia were reviewed. DCS was defined in a patient who underwent a truncated laparotomy where the fascia was primarily left open, with the intention of physiological optimization in the Intensive Care Unit, followed by definitive surgery. The primary outcome was in-hospital mortality. Multivariate logistic regression was used to determine the independent predictors of mortality after adjustment for potential confounders. RESULTS: Of 258 patients, 47 underwent DCS. 40% patients were transferred from other hospitals. The time between injury and operation was 152 minutes (IQR: 90-330). Intra-operative laboratory parameters revealed a median pH of 7.16 (IQR: 7.10-7.27), median temperature of 34.7 (IQR: 34.0-35.4) and median PT of 15.9 (IQR: 12.4-21.2). 55% of the patients survived to discharge from hospital. Of those who died, 86% died before the first take back operation. Packed red blood cell transfusion and vascular injury were independently associated with mortality. DISCUSSION: Damage control surgery is feasible in developing countries, with more than 50% survival reported at one hospital. Future research should focus on critical care management. CONCLUSION: Damage Control trauma laparotomy is feasible in tertiary care hospitals with multidisciplinary trauma teams in lesser-developed countries.

Blunt Traumatic Abdominal Wall Hernias: A Surgeon's Dilemma.

BACKGROUND: Traumatic abdominal wall hernias (TAWH) have been recognized for more than a century since they were first reported by Selby (JAMA 47:1485-1486, 1906). They continue to be a rare diagnosis, encountered in approximately 1% blunt trauma admissions. The present study is a 10-year retrospective review of patients presenting with TAWH to a State Major Trauma Unit in Western Australia. We hypothesized that the timing of the repair of TAWH was dependent on the severity of the abdominal wall injury, as well as associated injuries, and in turn, this may affect patient outcomes. MATERIALS AND METHODS: The Trauma Registry at Royal Perth Hospital (the only Level I Trauma Centre for adults in Western Australia) was scrutinized for TAWH, between 2003 and 2013. The injuries were graded by the classification system of Dennis et al. (Am J Surg 197:413-417, 2009). Patients with TAWH following penetrating trauma were excluded. RESULTS: During the study period, 44 patients were diagnosed to have TAWH accounting for 0.08% of admissions. Thirty (68%) of the patients were male and the median age was 36 years (IQR 24-54). The median BMI was between 25 and 30. The majority of the patients sustained trauma secondary to motor vehicle crashes and the commonest associated injury was a pelvic fracture. Grades 3 and 4 injuries were found to have an association with a pelvic fracture (p < 0.001). No association was seen in the present study between seat belt use and the development of TAWH or between the location of TAWH and seat belt pattern. The median time of diagnosis of TAWH following arrival to hospital was 18 hours while the median time of surgery from diagnosis was 15.5 hours. Forty-one (93%) of the patients underwent surgery. Of these, 8 (20%) were emergent due to a simultaneous bowel perforation and another five had primary mesh repairs. Three of the patients suffered superficial complications (7.5%) and there were 3 (7%) recurrences at a mean time of 7.25 months from the first repair. The follow-up period ranged from 1 to 51 months with an average time of 16 months. CONCLUSION: This series is the largest single institution study conducted on TAWH to date. Despite its retrospective nature and small numbers, it has generated some important questions. A larger prospective study with a longer follow-up period is required to generate reliable treatment algorithms as well as to standardize the management of TAWH.

Office hours vs after-hours. Do presentation times affect the rate of missed injuries in trauma patients?

BACKGROUND: A number of studies have investigated the effect of presentation time on the outcome of patients presenting following trauma. However, it is uncertain whether there is a difference in the incidence of missed injuries between patients presenting during 'office hours' to those presenting in the 'after-hours' period. MATERIALS AND METHODS: We analysed all patients recorded in the Trauma Registry of Royal Perth Hospital (a Level I Trauma Centre for adults in Western Australia) between 2003 and 2013. Patients were divided into 3 groups i.e. those presenting during office hours, those presenting 'after-hours' on a weekday and those presenting on a weekend. In 2008, the State Major Trauma Unit (SMTU) at RPH was initiated following which in-hospital cover by the Trauma Fellows was extended to 11 PM on weekdays. The study was therefore divided into two time periods i.e. pre-SMTU (2003-2007) and post-SMTU (2008-2013). RESULTS: 53,030 patients were recorded in the Trauma Registry in the 10-year period (major and minor trauma). There were 2519 missed injuries in 1262 patients (2.4%). Of these, 2.2% patients presented during office hours, 2.6% 'after-hours on a weekday' and 2.5% on weekends. The odds of missing an injury were 1.2 times higher if the patient presented after-hours (p=0.048). Missed injury rates were found to have increased over the past 10 years (p=0.0179). The odds of missing an injury in 2013 were 1.34 times higher than in 2003. Most of the missed injuries were AIS 1 and 2 (19.8 and 59%) and 55% had no clinical impact on the patients. Thoracic Spine and abdominal injuries were most commonly missed. The only region to show a significant difference between the 3 groups of patients studied was the abdomen (5.3% vs 11.1% vs 6.3%; p=0.004). It was also seen that a larger number of hollow viscus abdominal injuries (5.2%) were missed when compared to solid organs (3.2%; p<0.001). CONCLUSION: Injuries in patients sustaining trauma are more likely to be missed 'after-hours' than during 'office hours'. T-spine and abdominal injuries are more likely to be missed when compared to other anatomical regions of the body.

Diltiazem vs. glyceryl tri-nitrate for symptomatic relief in anal fissure: a randomised clnical study.

OBJECTIVE: To further resolve the clinical equipoise on the choice of chemical sphincterotomy agent for early symptomatic relief of anal fissure by comparing the effectiveness of 2% Diltiazem gel with 0.2% Glyceryl TriNitrate. METHODS: The randomized clinical trial was conducted at Aga Khan University Hospital, Karachi, from February 1, to July 30, 2008, and comprised 60 adult patients with anal fissure who were equally randomised to either Diltiazem or Glyceryl TriNitrate after taking informed consent. The creams were applied locally; the former twice daily, and the latter three times a day for a period of two weeks. The rest of the treatment was standard. Patients were followed up in clinic by the principal investigator at two weeks for primary outcome i.e. self-reported symptomatic relief on Visual Analogue Scale, and secondary outcomes i.e. side effects and the overall cost of treatment. RESULTS: Of the total, 31 (52%) patients were males and the overall mean age was 37 +/- 11 years. Patients, who used Diltiazem reported more symptomatic relief than Glyceryl TriNitrate (p < 0.01). Side effects were found more in Glyceryl TriNitrate than Diltiazem (p < 0.01), and most common side effect in the former group was headache in 12 (40%) patients. Cost of the treatment was not significantly different between both treatment arms (p < 0.28). CONCLUSION: Chemical sphincterotomy with topical 2% Diltiazem gel is an effective first-line treatment for early symptomatic relief of anal fissures, owing to negligible side effects.

Outcomes of splenectomy for idiopathic thrombocytopenic purpura in adults: a developing country perspective.

OBJECTIVE: To determine the outcome of splenectomy done in adult patients of Idiopathic Thrombocytopenic Purpura over a period of 10 years and, secondarily, to determine the predictors of complete response to therapy. METHODS: The retrospective review comprised of adult patients over 14 years of age who underwent open or laparoscopic splenectomy for Idiopathic Thrombocytopenic Purpura at Aga Khan University Hospital, Karachi, from January 2000 to December 2010. Data was reviewed in January 2011 by a surgical resident. Outcome was the response to splenectomy as per new definition of response set by the American Society of Haematology 2011 evidence based practice guidelines for Idiopathic Thrombocytopenic Purpura. Assessment of response was done within 1 to 2 months of splenectomy and after withholding concomitant treatment. SPSS 17 was used for statistical analysis. RESULTS: A total of 27 patients were found eligible. Of them, 2 (7.4%) were males and 25 (92.6%) were females with an overall mean age at the time of splenectomy of 30.8±6.3 years (range: 15-55 years). Out of 27 cases, 23 (85.18%) patients underwent open splenectomy, 3 (11%) laparoscopic and 1 (3.7%) had laparoscopic converted to open splenectomy. Complete response was achieved in 20 (74.1%) patients, whereas 5 (18.5%) had response and 2 (7.4%) had no response. None of the predictors of response to splenectomy were found significant. CONCLUSION: Response to splenectomy in adult Idiopathic Thrombocytopenic Purpura patients was comparable to reported rate in literature with relatively lower morbidity and mortality. Splenectomy is a safe treatment option especially in patients who succumb to adverse effects of medical therapy.

Conservative management of an abdominal gunshot injury with a peritoneal breach: wisdom or absurdity?

Surgical exploration has been the standard of care for abdominal gunshot injuries. The authors report a case of a 28-year-old man who sustained a transabdominal gunshot injury, which entered the anterior abdominal wall and exited adjacent to the T12 vertebra posteriorly with a tangential trajectory. On presentation, the patient was haemodynamically stable with no peritoneal signs. Based on trajectory of the bullet, intra-abdominal injury was suspected. Therefore a CT scan abdomen with intravenous and rectal contrast was performed. The CT scan revealed no extravasation of the rectal contrast but showed free air specks behind the descending colon. Delayed renal images of the left ureter were also normal. Based on the clinical findings, the patient was managed non-operatively with nothing per oral, intravenous antibiotics and frequent abdominal assessments. He made an uneventful recovery without necessitating laparotomy.

Surgical site infection following hernia repair in the day care setting of a developing country: a retrospective review.

OBJECTIVE: To determine the incidence proportion of surgical site infection following hernia repair in a daycare setting at a tertiary care hospital of a low-income country. METHODS: The retrospective audit was done at the Aga Khan University Hospital, Karachi, from June 1, 2008 to May 30, 2009. Patients with age >15 years who underwent Lichenstein's open mesh repair in daycare were included. Surgical Site Infection was labelled if the records revealed any of the following: opening of the wound by the primary surgeon; pain, tenderness and raised temperature of skin; purulent discharge from the wound; if the surgeon had documented it as a surgical site infection. SPSS 16 was used for data analysis. RESULTS: After reviewing the retrieved files, 104 patients were found eligible. Of them, 102 (98%) were males. Overall wound-related complications were found in 13 (12.5%), whereas surgical site infection was found in 8 (7.7%) patients. The mean age of those with infections was 38.7+/-8 year, while that of those with no surgical site infection was 47.8+/-18 years. Smoking was found significantly associated with surgical site infection with 5.8 times higher incidence as compared to the non-smokers [OR with 95% CI: 5.6 (1.2, 25.3)]. CONCLUSIONS: The incidence of surgical site infection after hernia repair with mesh in a daycare setting at a tertiary care hospital of a low-income country was higher than internationally reported incidence. Smoking was found to be a significant risk factor.

Morbidity meetings: what makes it to; what stays out of the forum.

OBJECTIVES: To review the utility of morbidity and mortality forum in General Surgery at a tertiary care hospital in Karachi, Pakistan. METHODS: The retrospective study was conducted at the Aga Khan University Hospital and reviewed morbidity data from March to May 2009. Case notes of all patients admitted to the General Surgical service during the study period were reviewed to identify in-hospital morbidities. RESULTS: There were a total of 340 inpatients during this period. Case notes identified 61 (17.94%) patients with morbidities; 35 (57.37%) males and 26 (42.62%) females. The morbidity record for the same period identified 32 (52.5%) patients, while 29 (47.5%) morbidities were missed. Of the total morbidities, 32 (52.5%) patients were admitted to the general ward, and 29 (47.5%) to high dependency areas. Nine (28%) morbidities identified in the general ward, and 23 (79%) in high dependency areas were formally presented. Morbidities related to the abdominal cavity were the commonest (n = 22; 36%). Wound-related (n = 17; 28%) and cardio-pulmonary (n = 8; 13%) complication were the next most frequent. CONCLUSIONS: Abdominal cavity morbidities were the most common in this review followed by wound related and cardiopulmonary complications. The morbidity and mortality forum is an educational activity that has stood the test of time and continues to be the cornerstone of post-graduate education. It should be considered a mandatory activity in all postgraduate training programmes.

Abdominal tuberculosis with massive jejunal haemorrhage.

Jejunum is a rare site of involvement in intestinal tuberculosis (TB) and massive lower gastrointestinal haemorrhage is an even rare reported condition. The authors report a 15-year-old female student, who presented with fever, anaemia, hypoalbunemia and developed massive lower gastrointestinal haemorrhage during hospital stay. The diagnosis of abdominal TB was established on tissue biopsy; tissue culture was positive for Mycobacterium TB. Optimal outcome was achieved with aggressive resuscitation, repeated mesenteric angio-embolization and anti-tuberculosis chemotherapy.

Hospital-based trauma quality improvement initiatives: first step toward improving trauma outcomes in the developing world.

BACKGROUND: Injuries remain a leading cause of death in the developing world. Whereas new investments are welcome, quality improvement (QI) at the currently available trauma care facilities is essential. The objective of this study was to determine the effect and long-term sustainability of trauma QI initiatives on in-hospital mortality and complications at a large tertiary hospital in a developing country. METHODS: In 2002, a specialized trauma team was formed (members trained using advanced trauma life support), and a western style trauma program established including a registry and quality assurance program. Patients from 1998 onward were entered in to this registry, enabling a preimplementation and postimplementation study. Adults (>15 years) with blunt or penetrating trauma were analyzed. The main outcomes of interest were (1) in-hospital mortality and (2) occurrence of any complication. Multiple logistic regression was performed to assess the impact of formalized trauma care on outcomes, controlling for covariates reaching significance in the bivariate analyses. RESULTS: A total of 1,227 patient records were analyzed. Patient demographics and injury characteristics are described in Table 1. Overall in-hospital mortality rate was 6.4%, and the complication rate was 11.1%. On multivariate analysis, patients admitted during the trauma service years were 4.9 times less likely to die (95% confidence interval, 1.77-13.57) and 2.60 times (odds ratio; 95% confidence interval, 1.29-5.21) less likely to have a complication compared with those treated in the pretrauma service years. CONCLUSION: Despite significant delays in hospital transit and lack of prehospital trauma care, hospital level implementation of trauma QI program greatly decreases mortality and complication rates in the developing world. LEVEL OF EVIDENCE: Care management study, level IV.

Laparoscopic splenectomy for haematological disorder: our experience.

Laparoscopic splenectomy has universal acceptance due to less morbidity and decreased incidence of peroperative and postoperative complication. It is not a popular procedure in Pakistan due to technical challenges. Here, we are presenting our experience of laparoscopic splenectomy for haematological disorders at Aga Khan University Hospital. A total of seven cases, underwent elective laparoscopic splenectomy for haematological disorders. The operative time was less than 3 hours with minimal blood loss with rapid and uneventful recovery. There was no procedure related morbidity or mortality; however, one patient expired due to overwhelming post splenectomy sepsis. Our initial report highlights the safety of laparoscopic splenectomy and we propose it to be the procedure of choice in elective splenectomy.