External fixation of “intertrochanteric” fractures

In developing countries, due to limited availability of modern anesthesia and overcrowding of the hospitals with patients who need surgery, high-risk patients with “intertrochanteric” fractures remain unsuita ble for open reduction and internal fixation

Acute disseminated encephalomyelitis as the first presentation of CNS tuberculosis: report of a case with brief review

Acute disseminated encephalomyelitis (ADEM) also known as post infectious encephalomyelitis is a demyelinating disease of the central nervous system (CNS) that typically presents as a monophasic disorder associated with multifocal neurological symptoms and disability. It may follow vaccination in children or infection. Viral infection like measles, rubella, influenza, Epstein bar, HIV, herpes, cytomegalusvirus (CMV) and West Nile virus have been implicated in the causation. Among bacteria, group A hemolytic streptococcus, mycoplasma pneumonia, Chlamydia, Rickettesia and leptospira have been shown to cause ADEM. There are few reports of ADEM due to tuberculosis (TB). We describe acute disseminated encephalomyelitis due to tuberculosis in a 35 year old female who initially started with neuropsychiatric manifestations and later developed florid neurological deficit and classical magnetic resonance imaging (MRI) lesions suggestive of the disease. The patient recovered completely after antitubercular therapy and is following our clinic for the last 12 months now

Reconstruction of soft tissue defects in Fournier’s gangrene at a tertiary care centre

Background: Fournier’s gangrene is an acute and potentially lethal multi-bacterial necrotizing infection that primarily involves the scrotum but may extend beyond its confines to perineum and abdominal wall. The disease may result in sepsis and death if treatment is delayed. Management consists of timely diagnosis, aggressive debridement, broad-spectrum antibiotics followed by reconstruction which still remains a surgical challenge.Methods: It is a prospective study conducted from Jan 2006 to Dec 2015 on 29 patients of Fournier’s gangrene who were referred to the department of Plastic and Reconstructive Surgery, Sheri-Kashmir Institute of Medical Sciences, Srinagar, Kashmir, for reconstruction after initial debridement by general surgeon/urologist. The patient’s age, predisposing factors, site and the size of the defects, reconstructive options used and outcome were evaluated. Assessment of testicular function was done at 6 months by sperm count and morphology.Results: A total of 29 patients of Fournier’s gangrene consisting of 28 males and one female were included in the study. The mean age was 37 years and the most common comorbidity was diabetes mellitus in 18 patients (62%). Wounds were allowed to heal by secondary intension in 8 patients. Scrotal advancement flap was done in seven patients. Split thickness skin grafting (STSG) of extensive wounds was done in 11 patients and testes were placed in medial thigh subcutaneous pocket in one patient. Two elderly diabetic patients succumbed to sepsis and multi organ failure. Overall complication rate was 18.5%.Conclusions: Thorough debridement and early wound cover are essential in the management of Fournier’s gangrene for successful rehabilitation. Various reconstructive options are available with no conclusive evidence to support flap rather than skin graft and most of the procedures result in preservation of testicular function in the long term

Negative pressure wound therapy: eleven-year experience at a tertiary care hospital

Background: Management of complicated wounds is a reconstructive challenge. A reconstructive surgeon has to be ready to face new challenges every day. Negative pressure wound therapy has revolutionized the management of complex wounds. We are presenting our experience with this wound care modality in the past 11 years.Methods: It was a prospective study conducted from January 2006 to December 2016 on patients having wounds of varied etiologies, who consented to participate in this study. Custom made low cost NPWT was used till definitive wound closure.Results: A total of 568 patients consented to participate in the study during these 11 years. No major complications were seen. Most of these were males (60.73%) in their 3rd and 4th decade. Trauma was the leading cause of wounds in 38.14%, followed by diabetic foot wounds in 21.5%. Ankle and foot was the most common site of wounds (30.92%) followed by leg (24.01%). A total of 322 small, 218 medium and 97 large size dressings were used. Most of the patients improved with the NPWT.  No major complications were seen.Conclusions: NPWT is safe, effective and has proved to be revolutionary in managing difficult wounds. With the use of customized low cost NPWT the benefit can be extended to underprivileged population in under developed nations too

Early results after transatrial repair of RVOT obstruction including teratology of fallot

Background: Right ventricular (RV) dysfunction is a significant cause of morbidity and mortality after surgical correction of RVOT obstruction including tetralogy of Fallot (TOF). Transatrial repair avoids a ventriculotomy (in contrast to the transventricular approach) emphasizing maximal preservation of RV structure and function. We have adopted this technique as less traumatic for the right ventricle. This study evaluates the early surgical results of our approach.Methods: Between January 2005 to January 2014, 77 consecutive patients with RVOT obstruction were referred to our unit for surgical therapy. Of these, 14 were unsuitable for repair and underwent aortopulmonary shunting. In the remaining 63 patients (mean age of 2.67±0.38 years), complete transatrial/transpulmonary repair was performed. Previously placed shunts (four patients) were taken down. In all cases, subpulmonary resection and ventricular septal defect (VSD) closure were accomplished transatrially. In 51 patients, the main pulmonary artery was augmented with an autologous pericardial patch.Results: There were 7 (9%) deaths in this series. No patient required permanent pacemaker. Median ICU and hospital stay were 91 hours and 14 days, respectively. At median follow up of 54 (mean 51±12) months, all patients are asymptomatic, with no significant residual lesion.Conclusions: Transatrial/transpulmonary repair of TOF is associated with remarkably low morbidity and mortality in our early experience

Closure of anterior palatal fistula using tongue flap: our experience

Background: Palatal fistula is one of the most common complications following cleft palate repair. It occurs mostly due to tip necrosis of palatal flaps. Small palatal fistulas are usually closed by transposition of adjacent tissues, however these local tissues are not sufficient for the closure of bigger fistulas. The tongue flap serves as a reliable and most easily obtainable local flap for closure of large sized palatal fistulas.Methods: This is a prospective study conducted from Aug 2006 to July 2015 in the department of Plastic & Reconstructive Surgery, SKIMS, Srinagar, Jammu Kashmir, India. A total of 25 patients with large anterior palatal fistula were treated using anteriorly based tongue flap. Patients were selected on the basis of size of fistula (> 1x1 cm), scarred local palatal tissue or history of fistula recurrence after previous attempts of closure using local palatal tissues.Results: In present study 25 patients of palatal fistula were treated using tongue flap. Eighty percent patients were in the age group of 3 to 5 years. Male-to-female ratio was 2:3. The largest dimension of treated fistula was 4x3 cm. There was partial dehiscence of flap suture line in two patients while remnant fistula was observed in three patients. None of our patients had flap necrosis.Conclusions: Tongue flap is an excellent and versatile option for closure of large palatal fistulas with high success rate and least morbidity

Two stage flexor tendon reconstruction in hand: our experience

Background: Flexor tendon injuries in the digital flexor sheath area (zone II) are the most difficult to treat and remain a focus of both clinical attention and basic investigations. This prospective study was designed to evaluate the results of staged zone II flexor tendon repair.Methods: Seventy digits in thirty five patients were treated by Two Stage flexor tendon reconstruction and followed for an average of one and a half year. The procedure included placing a silicone catheter (cut to desire size) as an active implant and reconstruction of A2, A4 or both pulleys if damaged in first stage. During the second stage (performed three to eight months later), tendon graft replaced the silicone catheter in the pseudo sheath formed around the catheter. The proximal end of the transplanted tendon was fixed with flexor digitorum profundus tendon of respective finger using the Pulvertaft method, and the distal end of the graft was fixedwith the distal stump of respective flexor digitorum profundus tendon. Early controlled motion protocol was instituted in all cases.Results: As per Buck Gramcko scale total active motion obtained was Excellent in 70%, Good in 20%, Fair in 7.1%, and Poor in 2.9% of patients.Conclusions: Flexor tendon reconstruction using two stage tendon reconstructions is an effective way to restore digital tendon function in delayed zone II flexor tendon injuries

Quantitative response of wheat to sowing dates and irrigation regimes using ceres-wheat model

An experiment was conducted at Punjab Agricultural University, Ludhiana during 2014–15 and 2015–16, keeping four sowing dates {25th Oct (D1), 10th Nov (D2), 25th Nov (D3) and 10th Dec (D4)} in main plots and five irrigation schedules {irrigation at 15 (FC15), 25 (FC25), 35 (FC35) and 45 (FC45) % depletion of soil moisture from field capacity (FC) and a conventional practice} in sub plots. The objective of the study was to evaluate the performance of CERES-Wheat model for simulating yield and water use under varying planting and soil moisture regimes. The simulated and observed grain yield was higher in D1, with irrigation applied at FC15 as compared to all other sowing date and irrigation regime combinations. Simulated grain yield decreased by 19% with delay in sowing from 25th October to 10th December because of 8% reduction in simulated crop evapotranspiration. Simulated evapotranspiration decreased by 16%, wheat grain yield by 23% and water productivity by 15% in drip irrigation at 45% depletion from field capacity as compared to drip irrigation at 15% of field capacity. It was further revealed that the model performed well in simulating the phenology, water use and yield of wheat

Laparoscopy in management of appendicitis in high-, middle-, and low-income countries: a multicenter, prospective, cohort study.

BACKGROUND: Appendicitis is the most common abdominal surgical emergency worldwide. Differences between high- and low-income settings in the availability of laparoscopic appendectomy, alternative management choices, and outcomes are poorly described. The aim was to identify variation in surgical management and outcomes of appendicitis within low-, middle-, and high-Human Development Index (HDI) countries worldwide. METHODS: This is a multicenter, international prospective cohort study. Consecutive sampling of patients undergoing emergency appendectomy over 6 months was conducted. Follow-up lasted 30 days. RESULTS: 4546 patients from 52 countries underwent appendectomy (2499 high-, 1540 middle-, and 507 low-HDI groups). Surgical site infection (SSI) rates were higher in low-HDI (OR 2.57, 95% CI 1.33-4.99, p = 0.005) but not middle-HDI countries (OR 1.38, 95% CI 0.76-2.52, p = 0.291), compared with high-HDI countries after adjustment. A laparoscopic approach was common in high-HDI countries (1693/2499, 67.7%), but infrequent in low-HDI (41/507, 8.1%) and middle-HDI (132/1540, 8.6%) groups. After accounting for case-mix, laparoscopy was still associated with fewer overall complications (OR 0.55, 95% CI 0.42-0.71, p < 0.001) and SSIs (OR 0.22, 95% CI 0.14-0.33, p < 0.001). In propensity-score matched groups within low-/middle-HDI countries, laparoscopy was still associated with fewer overall complications (OR 0.23 95% CI 0.11-0.44) and SSI (OR 0.21 95% CI 0.09-0.45). CONCLUSION: A laparoscopic approach is associated with better outcomes and availability appears to differ by country HDI. Despite the profound clinical, operational, and financial barriers to its widespread introduction, laparoscopy could significantly improve outcomes for patients in low-resource environments. TRIAL REGISTRATION: NCT02179112