EFFICACY AND SAFETY OF KNOTLESS BARBED SUTURES IN CAPSULAR CLOSURE FOLLOWING DISTAL FEMUR FRACTURE FIXATION

ABSTRACT Introduction: Good wound closure is an important step in management of distal femur fracture to prevent infection and faster rehabilitation. Knotless barbed sutures can save time and distribute wound tension evenly. However, its role in terms of functional outcome, closure time, and postoperative complications has not been studied in a distal femur fracture. Material and methods: A total of 47 patients aged more than 18 years of distal femur fracture treated with distal femur locking plate were randomized either into either barbed or traditional suture groups. in the barbed group, capsular wound closure was carried out with 2-0 bidirectional barbed knotless sutures (Quill SRS® PDO, Angiotech, Vancouver, BC, Canada). In patients assigned to group B, capsular closure was done with 1-0 Vicryl® (Ethicon inc. Somerville, NJ) and 5-0 Ethibond® alternatively. Results: The mean flexion at the knee joint was 105.7±15.6 degrees in the study group while it was 110.4±13.7 in the control group (p= 0.2133). Mean estimated closure time was significantly shorter in the study group as compared to the control group (p<0.05). Cases of needle prick injury were higher in traditional suture group. Patients developed stitch abscess and superficial infection in both groups. However, the difference in incidence between the two was not statistically significant Conclusion: Barbed suture is an efficient method of wound closure. It reduces wound closure time with similar complication rate as with use of conventional sutures. Evidence Level II; Randomized Clinical Trial

A study of empyema thoracis and role of intrapleural streptokinase in its management

BACKGROUND: Clinical spectrum, microbiology and outcome of empyema thoracis are changing. Intrapleural instillation of fibrinolytic agents is being increasingly used for management of empyema thoracis. The present study was carried out to describe the clinical profile and outcome of patients with empyema thoracis including those with chronic empyema and to study the efficacy and safety of intrapleural streptokinase in its management. METHODS: Clinical profile, etiological agents, hospital course and outcome of 31 patients (mean age 40 ± 16 years, M: F 25: 6) with empyema thoracis treated from 1998 to 2003 was analyzed. All patients were diagnosed on the basis of aspiration of frank pus from pleural cavity. Clinical profile, response to therapy and outcome were compared between the patients who received intrapleural streptokinase (n = 12) and those who did not (n = 19). RESULTS: Etiology was tubercular in 42% of the patients (n = 13) whereas the rest were bacterial. Amongst the patients in which organisms could be isolated (n = 13, 42%) Staphylococcus aureus was the commonest (n = 5). Intrapleural streptokinase was instilled in 12 patients. This procedure resulted in increase of drainage of pleural fluid in all patients. Mean daily pleural fluid drainage after streptokinase instillation was significantly higher for patients who received intrapleural streptokinase than those who did not (213 ml vs 57 ml, p = 0.006). Only one patient who was instilled streptokinase eventually required decortication, which had to be done in five patients (16.1%). Mean hospital stay was 30.2 ± 17.6 days whereas two patients died. CONCLUSIONS: Tubercular empyema is common in Indian patients. Intrapleural streptokinase appears to be a useful strategy to preserve lung function and reduce need for surgery in patients with late stage of empyema thoracis

Predictors of mortality of patients with acute respiratory failure secondary to chronic obstructive pulmonary disease admitted to an intensive care unit: A one year study

BACKGROUND: Patients with acute exacerbation of chronic obstructive pulmonary disease (COPD) commonly require hospitalization and admission to intensive care unit (ICU). It is useful to identify patients at the time of admission who are likely to have poor outcome. This study was carried out to define the predictors of mortality in patients with acute exacerbation of COPD and to device a scoring system using the baseline physiological variables for prognosticating these patients. METHODS: Eighty-two patients with acute respiratory failure secondary to COPD admitted to medical ICU over a one-year period were included. Clinical and demographic profile at the time of admission to ICU including APACHE II score and Glasgow coma scale were recorded at the time of admission to ICU. In addition, acid base disorders, renal functions, liver functions and serum albumin, were recorded at the time of presentation. Primary outcome measure was hospital mortality. RESULTS: Invasive ventilation was required in 69 patients (84.1%). Fifty-two patients survived to hospital discharge (63.4%). APACHE II score at the time of admission to ICU {odds ratio (95 % CI): 1.32 (1.138–1.532); p < 0.001} and serum albumin (done within 24 hours of admission) {odds ratio (95 % CI): 0.114 (0.03-0.432); p = 0.001}. An equation, constructed using the adjusted odds ratio for the two parameters, had an area under the ROC curve of 91.3%. For the choice of cut-off, sensitivity, specificity, positive and negative predictive value for predicting outcome was 90%, 86.5%, 79.4% and 93.7%. CONCLUSION: APACHE II score at admission and SA levels with in 24 hrs after admission are independent predictors of mortality for patients with COPD admitted to ICU. The equation derived from these two parameters is useful for predicting outcome of these patients

Spectrum of clinical disease in a series of 135 hospitalised HIV-infected patients from north India

BACKGROUND: Literature on the spectrum of opportunistic disease in human immunodeficiency virus (HIV)-infected patients from developing countries is sparse. The objective of this study was to document the spectrum and determine the frequency of various opportunistic infections (OIs) and non-infectious opportunistic diseases, in hospitalised HIV-infected patients from north India. METHODS: One hundred and thirty five consecutive, HIV-infected patients (age 34 ± 10 years, females 17%) admitted to a tertiary care hospital in north India, for the evaluation and management of an OI or HIV-related disorder between January 2000 and July 2003, were studied. RESULTS: Fever (71%) and weight loss (65%) were the commonest presenting symptoms. Heterosexual transmission was the commonest mode of HIV-acquisition. Tuberculosis (TB) was the commonest OI (71%) followed by candidiasis (39.3%), Pneumocystis jiroveci pneumonia (PCP) (7.4%), cryptococcal meningitis and cerebral toxoplasmosis (3.7% each). Most of the cases of TB were disseminated (64%). Apart from other well-recognised OIs, two patients had visceral leishmaniasis. Two cases of HIV-associated lymphoma were encountered. CD4+ cell counts were done in 109 patients. Majority of the patients (82.6%) had CD4+ counts <200 cells/μL. Fifty patients (46%) had CD4+ counts <50 cells/μL. Only 50 patients (37%) received antiretroviral therapy. Twenty one patients (16%) died during hospital stay. All but one deaths were due to TB (16 patients; 76%) and PCP (4 patients; 19%). CONCLUSIONS: A wide spectrum of disease, including both OIs and non-infectious opportunistic diseases, is seen in hospitalised HIV-infected patients from north India. Tuberculosis remains the most common OI and is the commonest cause of death in these patients

Noninvasive ventilation in patients with chronic obstructive airway disease

Gopi C Khilnani, Amit BangaDepartment of Medicine, All India Institute of Medical Sciences, Ansari Nagar, New Delhi, IndiaAbstract: Recent years have seen the emergence of noninvasive ventilation (NIV) as an important tool for management of patients with acute exacerbation of chronic obstructive pulmonary disease (COPD). Several well conducted studies in the recent years have established its role in the initial, as well as later management of these patients. However, some grey areas remain. Moreover, data is emerging on the role of long term nocturnal NIV use in patients with very severe stable COPD. This review summarizes the evidence supporting the use of NIV in various stages of COPD, discuss the merits as well as demerits of this novel ventilatory strategy and highlight the grey areas in the current body of knowledge.Keywords: noninvasive ventilation, nocturnal, COPD, ventilatory strateg

Diagnostic utility of pleural fluid IFN-γ in tuberculosis pleural effusion

Pleural fluid interferon-γ (IFN-γ) levels are increased in patients with tuberculosis (TB) pleural effusion. Recent studies from the west have found that estimation of pleural fluid IFN-γ levels is an excellent diagnostic strategy for these patients. The diagnostic utility of pleural effusion IFN-γ level estimation has not been evaluated in patients from developing countries, however. This work was carried out to study the diagnostic utility of IFN-γ level estimation in patients with TB pleural effusion and to define the best cutoff of IFN-γ for diagnosis TB pleural effusion. We studied 101 patients with pleural effusion. Of these, 64 were found to have a TB etiology, established by means of various conventional modalities. Measurement of pleural fluid IFN-γ levels was done by ELISA technique. The median value of pleural fluid IFN-γ levels in patients with TB (1480 pg/ml, range 3-14000 pg/ml) was significantly higher (p &lt; 0.001) compared with the non-TB group (3 pg/ml, range 0-900 pg/ml). The receiver operator characteristic (ROC) curve for IFN-γ showed an area under the curve (AUC) value of 0.954, and the best cutoff was computed to be 138 pg/ml. Using this cutoff for IFN-γ levels in pleural fluid for the diagnosis of TB, sensitivity, specificity, negative predictive value, and positive predictive value were found to be 90.2%, 97.3%, 85.7%, and 98.3%, respectively. Estimation of IFN-γ levels in pleural fluid is a useful diagnostic modality for TB pleural effusion. A cutoff of 138 pg/ml provides the best sensitivity and specificity for diagnosis of TB

Pleural fluid interferon-γ and adenosine deaminase levels in tuberculosis pleural effusion: a cost-effectiveness analysis

Pleural fluid levels of interferon-&#947; (IFN-&#947; ) and adenosine deaminase (ADA) have been found to be high in patients with tuberculosis (TB). The present study was carried out to compare the diagnostic utility of these two markers and to carry out a cost-effectiveness analysis of performing IFN-&#947; estimation in comparison to ADA. A total of 52 patients with pleural effusion, 35 of which were found to have TB etiology, were prospectively included for estimation of ADA and IFN-&#947; levels. The difference in the cost of performing the two diagnostic tests was compared with the cost of the treatment for a patient with TB. Pleural fluid IFN-&#947; (median [range]: 2,100 [70-14,000] vs. 3 [0-160]; P&#60;0.001) as well as ADA levels (mean [SD]: 93.1 [62.3] vs 15.4 [8.7]; P&#60;0.001) were significantly higher in patients with TB effusion. Even though IFN-&#947; estimation was more sensitive (97.1 vs. 91.4%), the extra cost of IFN-&#947; estimation for detecting one patient with TB was found to be equivalent to the cost of a complete course of antituberculosis treatment for six patients. In developing countries, where TB is rampant and cost is a major concern, pleural fluid IFN-&#947; estimation does not seem to be a cost-effective investigation method for differentiating TB from non-TB pleural effusion

A study of empyema thoracis and role of intrapleural streptokinase in its management

Abstract Background Clinical spectrum, microbiology and outcome of empyema thoracis are changing. Intrapleural instillation of fibrinolytic agents is being increasingly used for management of empyema thoracis. The present study was carried out to describe the clinical profile and outcome of patients with empyema thoracis including those with chronic empyema and to study the efficacy and safety of intrapleural streptokinase in its management. Methods Clinical profile, etiological agents, hospital course and outcome of 31 patients (mean age 40 ± 16 years, M: F 25: 6) with empyema thoracis treated from 1998 to 2003 was analyzed. All patients were diagnosed on the basis of aspiration of frank pus from pleural cavity. Clinical profile, response to therapy and outcome were compared between the patients who received intrapleural streptokinase (n = 12) and those who did not (n = 19). Results Etiology was tubercular in 42% of the patients (n = 13) whereas the rest were bacterial. Amongst the patients in which organisms could be isolated (n = 13, 42%) Staphylococcus aureus was the commonest (n = 5). Intrapleural streptokinase was instilled in 12 patients. This procedure resulted in increase of drainage of pleural fluid in all patients. Mean daily pleural fluid drainage after streptokinase instillation was significantly higher for patients who received intrapleural streptokinase than those who did not (213 ml vs 57 ml, p = 0.006). Only one patient who was instilled streptokinase eventually required decortication, which had to be done in five patients (16.1%). Mean hospital stay was 30.2 ± 17.6 days whereas two patients died. Conclusions Tubercular empyema is common in Indian patients. Intrapleural streptokinase appears to be a useful strategy to preserve lung function and reduce need for surgery in patients with late stage of empyema thoracis.</p