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For residents or fellows outside anesthesiology and critical care training programs, formal training in managing critically sick patients does not exist in India either at the undergraduate level, or at postgraduate level. Acute critical care course (ACCC) is a simulation-based skills development course that has been developed indigenously to address this lacuna in training of interns and residents in surgical specialties and emergency medicine in India. This study is aimed to find out and to assess the effectiveness of this course. This is a prospective interventional study using low-fidelity simulation-based courses. As many as 1036 candidates (interns and residents) were trained in 40 ACCC provider courses, and 165 instructor candidates in 9 instructor courses in 16 teaching hospitals in India in 2014–2021. However, in this report, the authors have analyzed the feedback (verbal and written) from 487 candidates of 19 ACCC provider courses conducted in 14 teaching hospitals in India between 2014 and 2018. Analysis of data was performed by thematic analysis for qualitative data and descriptive analysis for quantitative data. All the 487 candidates in 19 courses over 5 years replied either as very good (above expectations) or as good (as per expectations). In response to the question of the effectiveness of a lecture or skill station, none of them chose the options fair (below expectations) or poor (unacceptable). Fifteen out of 18 interns replied their emails that were sent 3 weeks after ACCC to find out if there was an improvement in their clinical application on a scale of 1–10. The response to the question in regards to improvement in their own ability 'to assess a sick patient', 'in treating a sick patient', 'communication skills with a colleague', and 'confidence in breaking bad news to patient or relatives', respectively, was 7.5, 7.8, 8.3 and 8.3. Mean scores out of 5 in response to content of ACCC course for clarity, utility, adequacy of content, understandable and interaction during course were 4.59, 4.81, 4,78, 4.86 and 4.97 respectively. Qualitative analysis led to 5 themes described in the manuscript. Low fidelity simulation using role-play appeals to the adult learners, breaks the monotony of classroom teaching, encourages interactive learning, and facilitates active participation in skill development necessary for critical care training of residents in surgical specialties and in emergency medicine. Sharing the vision document of ACCC with the deans of medical colleges is the crucial step in implementing applied physiology in step-wise logical approach in managing a sick patient. [ABSTRACT FROM AUTHOR]

Burst abdomen is a grave complication of laparotomy. X-suturing has been developed as a new method for reducing risk of burst abdomen. Five randomised controlled trials were conducted comparing X-suture with continuous suture in patients undergoing emergency laparotomy. The analysis of pooled data is presented. Data from five randomised controlled trials were collated. Data on individual patients were obtained from each centre on an Excel database format. A total of 1005 patients undergoing emergency laparotomy were studied. Of these 494 patients were randomised to X-suture arm and 511 to the continuous suture arm. The occurrence of burst abdomen was the main outcome of interest and the suture technique the main predictor of burst. The continuous suture group was considered the reference category. Risk ratio, risk difference, attributable proportion in exposed and prevented fraction in the exposed were calculated. Burst abdomen occurred in 9.31% patients in the X-suture group and in 20.35% patients in the continuous suture group. The risk difference (11%) and relative risk = 0.45 were highly significant (p = 0.0001) with a prevented fraction = 54%. Presence of diabetes, intraperitoneal sepsis, uraemia, and raised serum bilirubin were associated with increased risk of burst abdomen. The risk of burst abdomen can be substantially reduced with the use of X-suture in patients undergoing emergency laparotomy. [ABSTRACT FROM AUTHOR]

Cholecystectomy is one of the commonest general surgical procedures performed all over India. The risk of bile duct injury (BDI) during laparoscopic cholecystectomy is two to three times higher than during open cholecystectomy. The worldwide incidence of bile duct injury is 0.5% or 1 in 200 cases. BDI and its consequences result in significant morbidity and may even cause mortality. BDI increases the cost of treatment and is a common reason for a medicolegal suit against the surgeons. To minimize the incidence of BDI and to manage it timely and appropriately, a set of guidelines was deemed necessary by a group of senior surgeons during a Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) meeting in 2016. Guidelines for "Safe Laparoscopic Cholecystectomy" and bile duct injury management formulated by other international societies are already available. The applicability of these guidelines to Indian subjects especially in small peripheral centers was limited. Hence, a decision was taken to form a set of guidelines for general surgeons with basic laparoscopic skills with little or no advanced laparoscopic skills. Those working in a solo practice, nursing homes, and small private hospitals at talukas or districts should have "Safe Cholecystectomy" guidelines and management of BDI suitable to their situation. These guidelines were formed after three consensus meetings and have been approved by a SELSI Expert Group. [ABSTRACT FROM AUTHOR]

Cholecystectomy is one of the most common general surgical operations performed worldwide. The risk of bile duct injury (BDI) during laparoscopic cholecystectomy is two to three times higher than during open cholecystectomy. The worldwide incidence of bile duct injury is 0.5% or 1 in 200 cases. BDI and its consequences result in significant morbidity and may even cause mortality; it also increases the cost of treatment and can be a common reason for medico-legal suits against the surgeons. To minimize the incidence of BDI and to manage it timely and appropriately, a set of guidelines was deemed necessary by a group of senior surgeons during a Society of Endoscopic and Laparoscopic Surgeons of India (SELSI) meeting in 2016. Guidelines for "Safe Laparoscopic Cholecystectomy" and bile duct injury management formulated by other international societies are already available. The applicability of these guidelines to Indian subjects, especially in small peripheral centers, was limited. Hence, a decision was taken to form a set of guidelines for general surgeons with basic laparoscopic skills with little or no advanced laparoscopic skills. Those working in a solo practice, nursing homes, and small private hospitals at talukas or districts should have "Safe Cholecystectomy" guidelines and management of BDI suitable to their situation. These guidelines were formed after three consensus meetings and have been approved by a SELSI Expert Group. [ABSTRACT FROM AUTHOR]

Injury from motor vehicle accidents remains a leading cause of death in India with increasing number of fatalities. Timely delivery of lifesaving interventions is critical for survival and in restoring physical functioning. As a part of the Australia India Trauma Systems Collaboration, the Trauma Reception and Resuscitation (TRR©)-computerized decision support system was implemented in a Level 1 Trauma Centre in India in order to determine whether this system would reduce the time in performing lifesaving interventions and improve vital sign data capture and documentation. This prospective cohort study at the Jai Prakash Narayan Apex Center, All India Institute of Medical Science, New Delhi, recruited a total of 106 participants into two groups: TRR© (76) and controls (30). During the first 30 min of resuscitation, the TRR© group recorded greater sets of vital signs in compared to the controls for medical records. More importantly, the real-time documentation of the vital signs for the TRR© group ensured accuracy for medical records. For lifesaving interventions, oxygen was administered in the TRR© group only if SpO2 < 93%, whereas oxygen was administered as standard of care in the controls. There was no statistical difference in the mean times to endotracheal intubation, intercostal catheter insertion or performance of emergency chest x-ray between the control and TRR© groups. Importantly however, these 3 comparable interventions were performed consistently within a smaller timeframe for patients receiving care with TRR© decision prompts. There was a greater variability in the time taken to perform lifesaving interventions in the control group in comparison to the clinicians assisted with computerized decision prompts. This preliminary study was not powered to measure difference in mortality and patient recruitment was limited to 8 am–5 pm when trained staff could attend to operating the TRR© system. [ABSTRACT FROM AUTHOR]

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. 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. 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. 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. [ABSTRACT FROM AUTHOR]

Background: The completeness of a trauma registry's data is essential for its valid use. This study aimed to evaluate the extent of missing data in a new multicentre trauma registry in India and to assess the association between data completeness and potential predictors of missing data, particularly mortality. Methods: The proportion of missing data for variables among all adults was determined from data collected from 19 April 2016 to 30 April 2017. In-hospital physiological data were defined as missing if any of initial systolic blood pressure, heart rate, respiratory rate, or Glasgow Coma Scale were missing. Univariable logistic regression and multivariable logistic regression, using manual stepwise selection, were used to investigate the association between mortality (and other potential predictors) and missing physiological data. Results: Data on the 4466 trauma patients in the registry were analysed. Out of 59 variables, most (n = 51; 86.4%) were missing less than 20% of observations. There were 808 (18.1%) patients missing at least one of the first in-hospital physiological observations. Hospital death was associated with missing in-hospital physiological data (adjusted OR 1.4; 95% CI 1.02–2.01; p = 0.04). Other significant associations with missing data were: patient arrival time out of hours, hospital of care, 'other' place of injury, and specific injury mechanisms. Assault/homicide injury intent and occurrence of chest X-ray were associated with not missing any of first in-hospital physiological variables. Conclusion: Most variables were well collected. Hospital death, a proxy for more severe injury, was associated with missing first in-hospital physiological observations. This remains an important limitation for trauma registries. [ABSTRACT FROM AUTHOR]

Introduction: Few studies have addressed the mid to long term impact of Laparoscopic Sleeve Gastrectomy (LSG) on weight loss and obesity associated co-morbidities, particularly in Indian population. The aim of this study is to assess the efficacy of LSG in morbid obesity over 3-7 years follow up.Materials and Methods: Data of all patients who underwent LSG between January 2008 and March 2015 and completed their at least 1 year follow up till March 2016 was retrospectively reviewed using a prospectively collected database.Results: 424 patients undergoing primary LSG were included. The mean age (±2SD) was 39.8 ± 22.5 years and the mean Body Mass Index (BMI) (±2SD) was 46.67 ± 15.8 kg/m2. 124 patients (29.2%) were super-obese (BMI >50 kg/m2). The percentage follow-up at 1 year, 3 years, 5 years and 7 years was 78.3%, 66.7%, 42.3% and 38.4% respectively. The mean percentage Excess weight Loss (%EWL) (±2SD) at 1year, 3years, 5years, and 7years was 71.8 (±50.5%), 64.95% (±41.8%), 61.7% (±46.2%) and 57.15% (±50.2%) respectively. The preoperative BMI significantly correlated with %EWL at 5 year (r2 = 0.107, p = 0.018). The overall complication rate was 5.8%. Early complications included staple line leak (1.2%), bleeding (1.2%), deep venous thrombosis (0.4%) and 30-day mortality (0.21%). Late complications included stricture formation (0.21%) and new onset Gastro-esophageal Reflux Disease (GERD) (2.8%).At 5 years, 83.3% of diabetic patients showed remission while rest showed improvement in glycemic control with decrease in dosage. 69.3% patients showed improvement in hypertension, 100% patients showed improvement in Obstructive Sleep Apnea Syndrome, 75% patients showed improvement in hypothyroidism after surgery. GERD resolved in 62.8% patients while worsened in 11.4% patients.Conclusions: LSG has durable weight loss at 5 year with %EWL of 61% and significant resolution of obesity associated co-morbidities. [ABSTRACT FROM AUTHOR]

Background and Aims: There is paucity of data regarding some of the lesser known contextual and epidemiological factors with respect to road traffic injuries (RTIs). The objective was to study the epidemiological profile of RTI victims attending an emergency department of a tertiary care trauma center. Methods: The present study was a hospital-based cross-sectional study conducted in the emergency department of a tertiary care trauma center in New Delhi. All patients of RTI attending the emergency department during the designated data collection days were included in the study. Patients brought dead were excluded from the study. A semi-structured interview schedule was developed for collecting data on various domains such as sociodemographic characteristics, vehicle-related factors, accident site-related factors, personal protection measures, contextual factors, and prehospital care-related factors. Results: A total of 984 patients and informants were approached and finally data of 900 participants were analyzed after excluding those who refused participation and those for whom incomplete data were available. Out of 900 RTI victims, 756 were male (84.0%) and 144 (16.0%) were female. Mean age of the victims was 32.7 years. Most of the victims, i.e., 377 out of 900 (41.9%) were occupants rather than drivers. Majority of victim's vehicle meeting accidents were motorized two-wheelers (53.4%), and majority of the colliding vehicle was a four-wheeler (39.3%). Helmet use was found to be low (63.3%), but seat belt use was particularly low (32.4%). Most accidents (28%) happened between midnight and 6 A.M. More than half of the victims were in a hurry on the day of the accident. An ambulance was used to transport the victims in only 14.6% cases. Conclusion: In road traffic accidents some lesser known epidemiological data were generated that may be useful in defining preventive measures. [ABSTRACT FROM AUTHOR]

Liver injury is the major cause of morbidity and mortality in polytrauma patients. This study was conducted to know the burden of hepatobiliary injury and its outcome in our setup. It is a retrospective study of all patients with traumatic hepatobiliary injuries from January 2008 through April 2012 at JPNATC, New Delhi. All patients were resuscitated as per ATLS guidelines. Management of patients was based on hemodynamic status and associated injuries. Liver injury occurred in 7.52 % of all trauma admissions and 20.34 % of total abdominal trauma patients. Most common mechanism of injury was blunt trauma due to road traffic injury among all age groups ( n = 234, 67.83 %). Seventy-five percent of the patients with liver injury were hemodynamically stable at presentation ( n = 262, 75 %). Isolated liver injury was seen in 27 % of the patients. Grade II ( n = 138, 40 %) liver injury was the most common. Of the patients, 68.70 % were managed nonoperatively. Among operatively managed patients ( n = 100, 29 %), 38 % patient underwent immediate laparotomy due to hemodynamic instability. The failure of nonoperative management was in eight (2.32 %) patients with success rate of 96.73 %, i.e., 237 patients out of 245 were successfully managed nonoperatively. Packing was done in 27 % of the patients of high-grade liver injury and was associated with high morbidity and mortality (51 %). The morbidity and mortality of liver trauma were 28.99 % and 12.17 %, respectively. Liver injury is common in abdominal trauma patients. Most of the patients with liver injury are hemodynamically stable and should be managed nonoperatively with careful monitoring. [ABSTRACT FROM AUTHOR]

Introduction: Patients with traumatic brain injury (TBI) need frequent computed tomography (CT) of the head for assessment and management. In view of the associated polytrauma, hemodynamic instability, and various in-dwelling catheters and tubes, shifting of patients for CT scans may be difficult.Aims and Objectives: To assess the role of mobile CT (Ceretom®; NeuroLogica Corporation, Boston, MA, USA) in a trauma center with respect to patient management.Materials and Methods: In this retrospective study over 67 months (June 2009 to January 2015), the number of CT scans done, the time taken for CT and downtime were evaluated. Also, for the first 1000 mobile CT scans, the clinical and radiological records of all patients with TBI who underwent imaging using the mobile CT scanner in the intensive care units (ICUs) were analyzed.Observations and Results: A total of 10,000 mobile CT scans were done on the mobile CT scanner till January 5, 2015. Of the first 1000 patients evaluated, 75.3% had severe TBI, 15.1% had moderate TBI, and 9.6% had mild TBI. 78.1% patients were on ventilator, with 80.2% requiring sedation and 8.4%, an inotropic support. An in situ intracranial pressure monitoring was present in 21.1% of patients. In all, 12.4% of patients had long-bone fractures requiring skeletal traction; and, the tube thoracostomy was in-situ in 7.4%. No adverse events related to line malfunction/pullout occurred. The mean time for the performance of imaging using the mobile CT scan was 11.6 minutes compared with 47.8 minutes when patients were shifted to a conventional CT scan suite. The machine was nonfunctional 94 times, with an average downtime of 4.2 hours (range 2-72 hours). The life-cycle cost per mobile CT scan was Rs. 1340.Conclusions: A mobile CT has considerably changed the management response time in the neurosurgical intensive care unit (ICU) setup and decreased patient transfer times and the associated complications. Inclusion of a mobile CT scanner in the armamentarium of a neurosurgeon as a "bedside tool" can dramatically change decision making and the response time. It should be considered as the standard of care in any large-volume emergency department or neurosurgical facility. [ABSTRACT FROM AUTHOR]

Background: Infections by uncommon non-fermenting Gram negative bacteria are on the rise, but little is known about the risk factors and drug resistance in trauma patients in India. This study explored the infections caused by Stenotrophomonas maltophilia and/or Burkholderia cepacia in trauma patients over a period of 5 years. Material and methods: Patients admitted for trauma care with S. maltophilia and/or B. cepacia isolated from clinical specimens were enrolled. Characteristics regarding the strain isolation, drug sensitivity pattern, multidrug resistance (MDR), patient, outcomes, and differentiation of true infection from colonisation were observed. Results: Of the total 233 isolates, 102 were S. maltophilia and 131 were B. cepacia; 4.3% were responsible for polymicrobial infections with other bacteria. There were more B. cepacia MDR isolates than S. maltophilia. Maximum resistance was found to tetracycline (86.7%) and tobramycin (86.7%) in B. cepacia and to co-trimoxazole (68.7%) in S. maltophilia. Of these, 21 (16.03%) had a fatal outcome and the remaining 111 (84.7%) were discharged healthy. The in-hospital mortality rate associated with B. cepacia was much (16%) higher than S. maltophilia (13%) at this centre. Conclusion: The analysis of epidemiology and outcome of these infections will help to inform their management and treatment. [ABSTRACT FROM AUTHOR]

Background: Bloodstream infection (BSI) and bacteremias due to Enterococcus spp. are increasing worldwide with the current need to understand its causes among hospitalized trauma patients. Hence, the study was conducted. Methodology: A 3-year retrospective laboratory cum clinical based study was performed at a level I trauma center in India. Patients with health care associated enterococcal bacteremia were identified using the hospital database, their episodes of BSI/bacteremia calculated and their clinical records and treatment were noted. Results: A total of 104 nonrepetitive Enterococcus spp. was isolated of which Enterococcus faecium was the most common (52%). High-level resistance to gentamicin high-level aminoglycoside resistance was seen in all the Enterococcus spp. causing bacteremia, whereas a low resistance to vancomycin and teichoplanin was observed. Overall mortality was more in patients infected with vancomycin-resistant Enterococcus (5/11, 46%) compared to those with vancomycin sensitive Enterococcus (9/93, 10%); though no significant association of mortality with Enterococcus spp. bacteremia (P > 0.05) was seen. The rate of bacteremia due to Enterococcus spp. was 25.4 episodes/1,000 admissions (104/4,094) during the study period. Conclusion: Enterococcal bacteremia is much prevalent in trauma care facilities. Here, a microbiologist can act as a sentinel and help in preventing such infections. [ABSTRACT FROM AUTHOR]

Purpose: Bloodstream infections (BSIs) are one of the major life-threatening infections in hospitals. They are responsible for prolonged hospital stays, high healthcare costs, and significant mortality. The epidemiology of BSIs varies between hospitals necessitating analysis of local trends. Few studies are available on trauma patients, who are predisposed due to the presence of multiple invasive devices. Materials and Methods: A prospective surveillance of all BSIs was done at a level 1 trauma center from April, 2011 to March, 2012. All patients admitted to the different trauma intensive care units (ICUs) were monitored daily by attending physicians for subsequent development of nosocomial BSI. An episode of BSI was identified when patients presented with one or more of the following signs/symptoms, that is, fever, hypothermia, chills, or hypotension and at least one or more blood culture samples demonstrated growth of pathogenic bacteria. BSIs were further divided into primary and secondary BSIs as per the definitions of Center for Disease Control and Prevention. All patients developing nosocomial BSIs were followed till their final outcome. Results: A total of 296 episodes of nosocomial BSIs were observed in 240 patients. A source of BSI was identified in 155 (52%) episodes. Ventilator-associated pneumonia was the most common source of secondary BSI. The most common organism was Acinetobacter sp. (21.5%). Candida sp. accounted for 12% of all blood stream organisms. A high prevalence of antimicrobial resistance was observed in Gram-negative and-positive pathogens. Conclusions: Trauma patients had a high prevalence of BSIs. Since secondary bacteremia was more common, a targeted approach to prevention of individual infections would help in reducing the burden of BSIs. [ABSTRACT FROM AUTHOR]

Introduction: Despite the advances in medical sciences, the morbidity and mortality due to sepsis in severe trauma patients remains high; hence the need for early and accurate diagnosis. Very few prospective studies are available in a country like India, which tried to analyze the prediction of sepsis using serum procalcitonin (PCT) in such a large scale among trauma patients. This study explores the role of the biomarker PCT in early diagnosis of sepsis and prediction of outcomes in severe trauma cases. Materials and Methods: We studied the patient population prospectively in two different groups. One with acute trauma but no clinical evidence of sepsis and the second group with clinical evidence of sepsis and are followed. Bronchoalveolar lavage, tracheal aspirates, pus, urine, body fluids from sterile body sites, etc., were collected including blood for culture and serum for PCT assays. Such assays were done on samples collected on days 1 and 4 and then compared. Additionally, C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) levels were also tested. Antimicrobial sensitivity tests were carried out for all the isolates from the clinical samples and correlated with the clinically suspected cases of sepsis. Outcomes of the patients were noted. Results: Patients with high initial PCT levels (>2 ng/ml) in severe trauma cases had poor outcomes and risk of developing complications. Its correlation with severe outcomes was better marked as compared with CRP and ESR levels. The difference in PCT levels between days 1 and 4 in group two patients was statistically significant (P = 0.006) but were not statistically significant for CRP (P = 0.646) and ESR (P = 0.935). The study also shows that PCT levels fall in response to appropriate antimicrobial treatment. Conclusion: PCT is a useful biomarker for early and accurate prediction of sepsis in severe trauma patients. If used in adjunct to clinical findings, it proves to be a good biomarker for early diagnosis, treatment and for monitoring response to therapy in confirmed cases of sepsis. It will prove to be a good supportive indicator of sepsis in early stages for the trauma patients in a low resource country like India. [ABSTRACT FROM AUTHOR]

Context: Over ordering of blood is a common practice in elective surgical practice. Considerable time and effort is spent on cross-matching for each patient undergoing a surgical procedure. Aims: The aim of this study was to compile and review the blood utilization for two key departments (Neurosurgery and Surgery) in a level 1 trauma center. A secondary objective was to formulate a rational blood ordering practice for elective procedures for these departments. Materials and Methods: Analysis of prospectively compiled blood bank records of the patients undergoing elective surgical, neurosurgical procedures was carried out between April 2007 and March 2009. Indices such as the cross-matched/transfused ratio (C/T ratio), transfusion index and transfusion probability were calculated. The number of red cell units required for each procedure was calculated using the equation proposed by Nuttall et al, using preoperative hemoglobin and postoperative hemoglobin for each elective surgical procedure. Results: There were 252 surgery patients (age range: 2-80 years) in the study. One thousand and eighty-eight units of blood were cross-matched, 432 were transfused (CT ratio 2.5). 44.0% patients did not require transfusion during entire hospital stay. Three (50%) elective procedures had CT ratio >2.5and 4 (66.6%) elective procedures had TI <0.5. There were 200 neurosurgery patients (age range: 2-62 years) in the study. Total 717 units of blood were cross-matched and 161 transfused (CT ratio 4.5). Nine elective procedures had CT ratio >2.5, with five of them exceeding 4. In procedures like spinal instrumentation the CT ratio was <2.5 and 10 (90.9%) of elective procedures had TI <0.5. Conclusions: In this study 40% and 22% of cross-matched blood was being utilized for elective general surgery and neurosurgical procedures, respectively. The calculated required blood units for all elective Trauma surgery procedures were more than 2 units. The calculated required blood units were less than 0.5 units in four of the 11 neurosurgical procedures, and hence only one unit should be arranged for them. It is crucial for every institutional blood bank to formulate a blood ordering schedule. Regular auditing and periodic feedbacks are also vital to improve the blood utilization practices. [ABSTRACT FROM AUTHOR]

Deep vein thrombosis [DVT] is one of the most dreaded complications in post-operative patients as it is associated with considerable morbidity and mortality. Majority of patients with postoperative DVT are asymptomatic. The pulmonary embolism, which is seen in 10% of the cases with proximal DVT, may be fatal. Therefore it becomes imperative to prevent DVT rather than to diagnose and treat. Only one randomized trial has been reported from India to assess the effectiveness of low molecular weight heparin in preventing post-operative DVT. To assess the risk of DVT in North Indian patients following major abdominal operations and to evaluate the effectiveness of Nadroparin, A Low Molecular Weight Heparin (LMWH) therapy in preventing post-operative DVT. Sixty five patients were randomised preoperatively into Group-I; Nadroparin prophylaxis and Group-II: No prophylaxis. The primary outcome was the occurrence of DVT, diagnosed by bilateral lower limb venogram performed, seven to ten days after operation. Secondary outcome measures included adverse effects of radio-opaque dye, intra-operative blood loss, operating time, postoperative platelet count, intraoperative blood transfusion requirements and the total duration of postoperative bed rest. No case of DVT occurred in either group. There was no statistical difference in the risk of secondary outcome measures in the two groups. DVT was not observed in any of the patients, even with several high risk factors indicating a possible protective mechanism in the North Indian population. [ABSTRACT FROM AUTHOR]

Scrub typhus is largely ignored in India particularly during outbreaks of viral fever. The disease course is often complicated leading to fatalities in the absence of treatment. However, if diagnosed early and a specific treatment is initiated, the cure rate is high. We report here five cases of scrub typhus to highlight the fact that high clinical suspicion for such a deadly disease is an absolute necessity. [ABSTRACT FROM AUTHOR]

Introduction: Beta-hemolytic streptococci (βHS) cause a diverse array of human infections. Despite the high number of cases of streptococcal carriers and diseases, studies discerning the molecular epidemiology of βHS in India are limited. This study reports the molecular and clinical epidemiology of beta-hemolytic streptococcal infections from two geographically distinct regions of India. Methodology: A total of 186 isolates of βHS from north and south India were included. The isolates were identified to species level and subjected to antimicrobial susceptibility testing. Polymerase chain reaction (PCR) was done to detect exotoxin genes, and emm types of group A streptococci (GAS) strains were ascertained by sequencing. Results: GAS was the most common isolate (71.5%), followed by group G streptococci (GGS) (21%). A large proportion of GAS produced speB (97%), smeZ (89%), speF (91%), and speG (84%). SmeZ was produced by 21% and 50% of GGS and GGS, respectively. A total of 45 different emm types/subtypes were seen in GAS, with emm 11 being the most common. Resistance to tetracycline (73%) and erythromycin (34.5%) was commonly seen in GAS. Conclusions: A high diversity of emm types was seen in Indian GAS isolates with high macrolide and tetracycline resistance. SpeA was less commonly seen in Indian GAS isolates. There was no association between disease severity and exotoxin gene production. [ABSTRACT FROM AUTHOR]

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., (Copyright © 2021 American College of Surgeons. Published by Elsevier Inc. All rights reserved.)

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., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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.

Introduction: Prehospital notification of injured patients enables prompt and timely care in hospital through adequate preparation of trauma teams, space, equipment and consumables necessary for resuscitation, and may improve outcomes. In India, anecdotal reports suggest that prehospital notification, in those few places where it occurs, is unstructured and not linked to a well-defined hospital response. The aim of this manuscript is to describe, in detail, a study protocol for the evaluation of a formalised approach to prehospital notification., Methods and Analysis: This is a longitudinal prospective cohort study of injured patients being transported by ambulance to major trauma centres in India. In the preintervention phase, prospective data on patients will be collected on prehospital assessment, notification, inhospital assessment, management and outcomes and recorded in a new tailored multihospital trauma registry. All injured patients arriving by ambulance and allocated to a red or yellow priority category will be eligible for inclusion. The intervention will be a prehospital notification application to be used by ambulance clinicians to notify emergency departments of the impending arrival of a patient. The proportion of eligible patients arriving to hospital after notification will be the primary outcome measure. Secondary outcomes evaluated will be availability of a trauma cubicle, presence of a trauma team on patient arrival, time to first chest X-ray and inhospital mortality., Progress: Ethical approval has been obtained from the All India Institute of Medical Sciences, New Delhi and site-specific approval granted by relevant trauma services. The trial has also been registered with the Monash University Human Research and Ethics Committee; Project number: CF16/1814 - 2016000929. Results will be fed back to prehospital and hospital clinicians via a series of reports and presentations. These will be used to facilitate discussions about service redesign and implementation. It is expected that evidence for improved outcomes will enable widespread adoption of this intervention among centres in all settings with less established tools for prehospital assessment and notification., Trial Registration Number: NCT02877342; Pre-results., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Health care workers (HCWs) face constant risk of exposure to cuts and splashes as occupational hazard. Hence, a prospective observational study was conducted to observe the exposure of HCWs to various sharp injuries and splashes during health care and to work up a baseline injury rate among HCWs for future comparison in trauma care set ups., Methods: A 2 year and 5 month study was conducted among the voluntarily reported exposed HCWs of the APEX trauma centre. Such reported cases were actively followed for 6 months after testing for viral markers and counselled. The outcomes of such exposed HCWs and rate of seroconversion was noted. To form a future reference point, the injury rate in trauma care HCWs based on certain defined parameters along with the rate of under reporting were also analysed in this study., Results: In our study, doctors were found to have the highest exposure (129, 36.2%), followed by nurses (52, 14.6%) and hospital waste disposal staff (27, 7.6%). Of the source patients, a high number of them were HBV positive (11, 3.1%), followed by HIV positive patients (8, 2.2%). No seroconversion was seen in any of the exposed HCWs. Injuries by sharps (303, 85.1%) outnumber those due to splashes (53, 14.9%) which were much higher in those working in pressing situations. Underreporting was common, being maximally prevalent in hospital waste disposal staff (182, 51.1%)., Conclusions: High rates of exposure to sharp injuries and splashes among HCWs call for proper safety protocols. Proper methods to prevent it, encouraging voluntary reporting and an active surveillance team are the need of the hour., (Copyright © 2014 Elsevier Ltd. All rights reserved.)

The best training method in laparoscopic surgery has not been defined. We evaluated the efficacy of laparoscopic skills acquisition in a short-term focused program. Two hundred fifty-six participants undergoing training on a phantom model were divided into 2 groups. Group 1 had no exposure and group 2 had performed a few laparoscopic surgeries. Acquisition of laparoscopic skills was assessed by operation time and the modified Global Operative Assessment of Laparoscopic Skills (GOALS) scale. A questionnaire was sent to the participants after 3 to 6 months for assessment of impact of training. There was a statistically significant improvement in the assessed parameters and in the mean score of all 5 domains of GOALS. The participants in group 2 performed better than those in group 1 in the first case. The difference between both the groups disappeared after the training. Participants who responded to the questionnaire felt that training helped them in improving their performance in the operation theater.

There is a need to understand the epidemiology and risk factors associated with candidaemia in critically ill trauma patients. The rise in incidence of non-albicans candidaemia and the emergence of antifungal resistance have made such a study necessary. A prospective laboratory-based surveillance study was performed over a period of 21 months (April 2008-December 2009) at a level I trauma centre in New Delhi, India. All blood culture samples positive for Candida were processed for microbial identification by standard methods. Identification was carried out by conventional methods, using chromogenic medium (CHROMagar Candida) and by the automated Vitek 2 system. These isolates were characterized for their susceptibility to amphotericin B, fluconazole, flucytosine and voriconazole. Eighty-nine episodes of candidaemia occurred in 89 patients during the study period. The incidence was 0.71 episodes per 1000 patient days. A total of 136 Candida isolates were obtained, with non-albicans Candida species accounting for over 80 %. Candida rugosa, a rarely isolated pathogen, accounted for 25 (18.4 %) of the isolates, and 5.9 % of the isolates were resistant to fluconazole. None of the isolates showed resistance against amphotericin B, flucytosine or voriconazole. The present study revealed that non-albicans Candida species caused most of the cases of candidaemia in the trauma patients. The isolation of C. rugosa from a large number of cases highlights the ability of this rarely reported pathogen to cause bloodstream infections. The presence of azole resistance among many of the Candida isolates is a matter of concern.

Background: Creation of extraperitoneal space during TEP repair requires an expensive commercially available balloon., Patients and Methods: Fifty-six patients suffering from uncomplicated primary unilateral or bilateral groin hernia were randomized into two groups; group 1--indigenous balloon dissection and group 2--direct telescopic dissection., Results: There were 55 males and 1 female, with an average age of 49 years; 50% of the inguinal hernias were bilateral. Creation of extraperitoneal space was considered as satisfactory in majority of patients (94.6%) with satisfactory anatomical delineation. Peritoneal breach was noticed during dissection in 36 (64.3%) patients. There was one (3.8%) conversion of TEP to TAPP in group 2. Distance between pubic symphysis to umbilicus was an important factor, which affected the easiness of dissection. In patients with this distance