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Women in India, particularly those with amputation, face significant challenges, including but not limited to, unequal prosthetic access and satisfaction, societal discrimination, and the physical and emotional consequences of amputation. These challenges are further exacerbated by gender biases towards access to education and socioeconomic factors, which increases their vulnerability to unemployment and mental health issues. This article emphasizes the urgent need for affordable and customizable prosthetic options tailored to the unique needs of women with amputation, particularly those from low-income backgrounds who often face neglect. Thus, addressing these disparities would significantly enhance their overall well-being and independence. Article PDF Link: https://jps.library.utoronto.ca/index.php/cpoj/article/view/44002/33160 How To Cite: Alam J, Joshi A, Mir N, Chawla N, Sagar S. Invisible struggles: Exploring challenges faced by women with amputation in India. Canadian Prosthetics & Orthotics Journal. 2024; Volume 7, Issue 1, No.5. https://doi.org/10.33137/cpoj.v7i1.44002 Corresponding Author: Professor Sushma Sagar, Division of Trauma Surgery and Critical Care, Jai Prakash Narayan Apex Trauma Centre, AIIMS, New Delhi, India. E-Mails: sagar.sushma@gmail.com; dr.sushma@aiims.gov.in ORCID ID: https://orcid.org/0000-0002-4700-9868

Introduction: Traumatic hemothorax is accounted for about 20% of traumatic chest injuries. Although majority can be managed with the timely placement of intercostal tube (ICT) drainage, the remaining pose a challenge owing to high complication rates associated with retained hemothorax. Although various treatment modalities including intrapleural instillation of fibrinolytics, radioimage guided drainage, VATS guided evacuation and thoractomy do exist to address the retained hemothorax, but indications along with timing to employ a specific treatment option is still unclear and ambiguous. Methods: Patient with residual hemothorax (>200 mL) on ultrasonography after 48 h of indwelling ICT was randomized into either early video-assisted thoracic surgery (VATS) or conventional approach cohort. Early VATS cohort was subjected to video-assisted thoracoscopic evacuation of undrained blood along with normal saline irrigation and ICT placement. The conventional cohort underwent intrapleural thrombolytic instillation for 3 consecutive days. The outcome measures were the duration of indwelling ICT, removal rate of tube thoracostomy, length of hospital stay, duration of intensive care unit (ICU) monitoring, need for mechanical ventilation, incidence of pulmonary and pleural complications, and requirement of additional intervention to address undrained hemothorax and mortality rate. Results: The early VATS cohort had shorter length of hospital stay (7.50 ± 0.85 vs. 9.50 ± 3.03, P = 0.060), reduced duration of indwelling ICT (6.70 ± 1.25 vs. 8.30 ± 2.91, P = 0.127) with higher rate of tube thoracostomy removal (70% vs. 30%, P = 0.003) and lesser need of additional interventions (0% vs. 30%, P = 0.105). Thoracotomy (3 patients) and image-guided drainage (4 patients) were additional interventions to address retained hemothorax in the conventional cohort. However, similar length of ventilator assistance (0.7 ± 0.48 vs. 0.60 ± 1.08, P = 0.791) and prolonged ICU monitoring (1.30 ± 1.06 vs. 0.90 ± 1.45, P = 0.490) was observed in early VATS cohort. Both the cohorts had no mortality. Conclusion: VATS-guided early evacuation of traumatic hemothorax is associated with shorter length of hospital stay along with abbreviated indwelling ICT duration, reduced incidence of complications, lesser readmissions, and improved rate of tube thoracostomy removal. However, the duration of ventilator requirement, ICU stay, and mortality remain unchanged.

Nematophagous fungi are the best alternatives to chemical nematicides for managing nematodes considering environmental health. In the current study, activity of metabolites from ten isolates of Purpureocillium lilacinum (Thom) Luangsa-ard (Hypocreales: Ophiocordycipitaceae) and two isolates of Paecilomyces variotii Bainier (Eurotiales: Trichocomaceae), were examined to inhibit the hatching of Meloidogyne incognita (Kofoid & White) Chitwood (Tylenchida: Heteroderidae) eggs. At 100%, 50%, and 25% concentrations, respectively, the culture filtrate of the isolate P. lilacinum 6887 prevented 97.55%, 90.52%, and 62.97% of egg hatching. Out of all the isolates, Pl 6887, Pl 6553, and Pl 2362 showed the greatest results in the hatching inhibition experiment.Gas chromatography-mass spectrometry (GC-MS) analysis revealed a variety of nematicidal compounds from different isolates. A total of seven nematicidal compounds, including four very potent nematicidal fatty acids were found in the isolate Pl 6553. Secondary metabolites of the same isolate possess the highest M. incognita juvenile mortality, i.e., 43.33% and 92% after 48 hrs of treatment at 100 and 200 ppm concentrations, respectively. Significant difference was observed in juvenile mortality percentage among the isolate having highest and lowest nematicidal compounds. Nematicidal fatty acids like myristic and lauric acid were found for the first time in P. lilacinum. Multiple vacuole-like droplets were found inside the unhatched eggs inoculated with the culture filtrate of isolate Pl 6887, and also in the juveniles that perished in the ethyl acetate extract of isolate Pl 6553.

Background: Yoga is an emerging intervention causing improvement in physical, mental, and spiritual well-being. Its role in improving outcomes in patients with amputation was investigated. Methodology: Patients with traumatic lower limb amputation (n = 50) were enrolled and randomized to the Yoga group (n = 26) against control (n = 24). Sociodemographic details, quality of life (QOL) (World Health Organization QOL-BREF), Depression anxiety stress scale (DASS), Rosenberg self-esteem scale, and amputee body image score were applied at baseline, 6,–18 weeks of amputation. Results: Sociodemographic and clinical variables were comparable between groups. At 18 weeks, the Yoga group had better QOL (P = 0.005) than the control group. Symptoms of depression (0.02) and anxiety (

Introduction: Acute large traumatic wounds require temporary dressing prior to the definitive soft tissue reconstruction, as the physiological derangement during the immediate postinjury period delays the definitive surgical intervention. Selecting an ideal dressing material from numerous available synthetic dressings and skin substitutes poses a challenge. Although amniotic membrane (AM) scaffold has a definitive role in promoting wound healing in burns and chronic wounds, however, its efficacy in acute large traumatic wound is lacking. The present trial aimed to evaluate the safety and efficacy of AM in wound bed preparation before the definitive soft-tissue reconstruction in acute large traumatic wounds. Methods: Sixty patients with acute large traumatic wounds (>10 cm × 10 cm) were divided into two groups (conventional dressing and AM dressing) using simple mixed block randomization. Wounds were assessed using the Bates Jensen Score at various timelines for the signs of early wound healing. The primary outcome was to evaluate the time taken for the wound bed preparation for definitive soft-tissue reconstruction. The secondary outcome was the pain assessment and complications, if any. Results: There was significant reduction in the wound exudate as well as peripheral tissue edema in the intervention group (P = 0.01). AM dressing was significantly less painful (P = 0.01). The incidence of wound infection and need for debridement was decreased in the intervention group. However, the time interval to definitive soft-tissue coverage was statistically insignificant and comparable in both the groups. No adverse reactions were seen in either group. Conclusion: AM dressings are safe and efficacious with significant reduction in wound exudates and peripheral edema. However, these dressings do not hasten the wound maturation as compared to conventional dressings. AM dressings can be used as a less painful alternative to conventional dressing in the management of large acute posttraumatic wounds.

Objective: To describe the restructuring if in-hospital systems of care at a Level -1 trauma center in India and to analyze volume and patterns of injury for future preparedness as well as to institute preventive measures for specific injuries during health emergencies like COVID-19.Methods: The data were extracted from a prospectively managed trauma registry at level-1 trauma center in India. We compared data of lockdown period with data of the same number of days from the pre-lockdown period. Patients were grouped according to age, gender, cause of injury, place of injury, injury severity, and injury outcome for comparative analysis between two periods.Results: Total emergency department (ED) footfall due to trauma decreased significantly by 73% during lockdown period. Injuries resulting due to blunt forces, increased significantly. There was a significant decrease in the percentage of patients having major injury. The road traffic injuries (RTIs) cases were less, but number of falls reported increased significantly during lockdown. Significantly less number of patients presented without receiving primary care. Majority of the patients were transported using private cars, police vehicle, and two wheelers during lockdown, however, as expected significantly less number of patients were transported by three wheelers. The comparative analysis between quantitative data points shows significant difference in median ISS and length of stay during lockdown. Conclusion: This study highlighted that the preparedness during health emergencies should not focus solely on the response to treatment of infectious disease but also on ensuring access and provision of reasonable quality of care for non-infectious illnesses, especially acute conditions like trauma.

Streptococcus pneumoniae is a rare cause of appendicitis, skin soft tissue, and bloodstream infections. The clinical significance of its isolation from samples of skin or soft tissues and pus from the appendix is poorly understood. Invasive pneumococcal disease (IPD) continues to be a problem in India, associated with a high case fatality rate despite treatment facilities available in the hospital settings. In the present study, we report three adult cases, one presented as acute appendicitis, the other had skin and soft tissue infection, and third presented with bloodstream infection caused by Streptococcus pneumoniae from our level 1 trauma center. The patients with acute appendicitis and soft tissue infection recovered when treated with appropriate antimicrobial therapy, however, the one with pneumococcal sepsis could not be revived.

Background The role of enhanced recovery after surgery (ERAS) has been established in elective operations. However, its role in emergency operations especially in trauma is under-recognized. The aim of this study was to explore the safety and efficacy of ERAS program in patients undergoing emergency laparotomy for trauma.Methods In this single-center study, patients who underwent emergency laparotomy after trauma were randomized to the ERAS protocol or conventional care. The ERAS protocol included early removal of catheters, early initiation of diet, use of postoperative prophylaxis and optimal usage of analgesia. The primary endpoint was duration of hospital stay. The secondary endpoints were recovery of bowel function, pain scores, complications and readmission rate.Results Thirty patients were enrolled in each arm. The ERAS group had significant reduction in duration of hospital stay (3.3±1.3 vs. 5.0±1.7; p

Rice sheath blight disease, caused by Rhizoctonia solani Kühn (teleomorph Thanatephorus cucumeris [Frank] Donk), is a serious threat in rice growing countries. R. solani is a soil borne necrotic fungus that survives in plant debris as sclerotia, and is able to infect plants belonging to more than 27 plant families including economic important monocots and dicots. Management of sheath blight requires an integrated strategy based on the population structure, correct identification of pathogen at early stage and molecular aspects of rice defence responses against R. solani. This review summarizes elaborative and updated knowledge on taxonomic classification of the pathogen, disease etiology and economics, molecular aspects of R. solani pathogenicity and strategies for detection and diagnosis of the disease. Up to date information for management of sheath blight using various strategies are discussed Specifically, the effects of popular cultural practices influencing sheath blight incidence, various chemical fungicides, biological control individually and their combined effect on sheath blight are presented. Summarized and updated information of various biotechnological approaches viz., genetic transformation, host-delivered RNAi technology, genome-editing tools and nanotechnological approaches to enhance resistance in rice against sheath blight is mentioned in this review.

Background: The spleen is most the commonly injured solid organ in abdominal trauma. Operative management (OM) has been challenged by several studies favoring successful non-OM (NOM) aided by modern era interventional radiology. The results of these studies are confounded by associated injuries impacting outcome. The aim of this study is to compare NOM and OM for isolated splenic injury in an Indian Level 1 Trauma Center. Materials and Methods: This is a retrospective analysis of prospective database. Results: A total of 1496 patients were admitted with abdominal injuries. One hundred and twenty-nine patients admitted with diagnosis of isolated splenic injury from January 2009 to December 2016 were included in the study. RTIs, followed by falls from height, were the most common mechanisms of injury. Ninety-two (71.3%) patients with isolated splenic trauma were successfully managed nonoperatively. Thirty-seven (28.7%) required surgery, of which three were due to the failure of NOM. Three patients in the nonoperative group underwent splenectomy later, giving an overall success rate of 96.8% for NOM. Patients with isolated splenic trauma requiring OM had higher grade splenic injury (Grade 4/5), higher blood transfusion requirements (P < 0.001), and prolonged Intensive Care Unit and hospital stay in comparison to patients in the nonoperative group. No patient died in the NOM group; two patients died in the splenectomy group due to hemorrhagic shock and acute respiratory distress syndrome, respectively. Conclusion: Although NOM is successful in most patients with blunt isolated splenic injuries, careful selection is the most important factor dictating the success of NOM.

Introduction: Trauma systems vary in performance during different time periods and may affect the patient outcomes, especially in resource-limited settings. The present study was undertaken to study the pattern, epidemiological profile, processes of care variations of trauma victims presenting during-hours and after-hours in a level 1 trauma Center of a lower middle-income country. Methodology: Retrospective analyses of prospectively collected data registry at a single tertiary care center. Data collected from 2013 to 2015 were analyzed. Patients with a history of trauma and admission to the center or death between arrival and admission were included. Isolated limb injury and patients dead on arrival were excluded. Results: Of 4692, 1789 (38.1%) patients arrived and were admitted during-hours and 2903 (61.9%) after-hours. The overall in-hospital mortality was 14.9% in the cohort. Moreover, it was 16.10% during after-hours in comparison to 13.0% during-hours. The Revised Trauma Score was statistically different during-hours and after-hours suggesting patients with greater physiological derangement after-hours. The Kaplan–Meier survival curves for 7 days were comparable in two groups with the log-rank test of 078. The proportion of initial radiological investigations (chest X-ray, focused assessment sonography in trauma [FAST], and computerized tomography [CT] scans) was ranged from 84.9% for CT scans in the cohort to 99.3% for FAST. Conclusions: Processes of care do not differ significantly for the patients admitted at a level 1 trauma center irrespective of time of the day. Although survival probability for the initial 7 days of follow-up is comparable between two groups; however, for 30 and 90 days of follow-up they are significantly different between during-hours and after-hours, likely due to injury severity.

The sessile nature of plants has made them extremely sensitive and flexible toward the constant flux of the surrounding environment, particularly light and dark. The light is perceived as a signal by specific receptors which further transduce the information through the signaling intermediates and effector proteins to modulate gene expression. Signal transduction induces changes in hormone levels that alters developmental, physiological and morphological processes. Importance of light for plants growth is well recognized, but a holistic understanding of key molecular and physiological changes governing plants development under dark is awaited. Here, we describe how darkness acts as a signal causing alteration in hormone levels and subsequent modulation of the gene regulatory network throughout plant life. The emphasis of this review is on dark mediated changes in plant hormones, regulation of signaling complex COP/DET/FUS and the transcription factors PIFs which affects developmental events such as apical hook development, elongated hypocotyls, photoperiodic flowering, shortened roots, and plastid development. Furthermore, the role of darkness in shade avoidance and senescence is discussed.

Background: Postmortem examination is indispensable to ascertain the cause of an unnatural death and as such is mandatory by the law. From ages, traditional autopsy (TA) has proved its worth in establishing the cause of death in the deceased despite some inherent difficulties and challenges and has enjoyed an insurmountable status. The increasing use of application of the modern-day radiology for postmortem examination has however opened a new arena overcoming some of the difficulties of the TA. There are conflicting reports in the published literature regarding superiority of one modality of the postmortem over the other. Objective: The objective of this study was to compare the findings of postmortem computed tomography (CT) scan and TA in the victims of traumatic deaths and to analyze whether postmortem CT can be used to replace TA. Materials and Methods: All patients with a history of trauma that were declared brought dead on arrival in the emergency department were subjected to full-body CT scan. An experienced radiologist reported the findings of CT scan. Subsequently, a forensic expert subjected the patients to TA. The physician who performed autopsy was blinded to the findings of CT scan and vice versa. An individual who was not part of the radiology or forensic team then entered the findings of CT scan and autopsy in a predesigned Pro forma. An unbiased assessor finally compared the findings of the two modalities and analyzed the results. McNemar's test was used to ascertain the level of significance between the findings reported by these two modalities considering P = 0.05 as statistically significant. The agreement or disagreement on cause of death reported by these two modalities was also assessed. Results: About 95% of the deceased were males. The mean age of the corpses was 35 years (range 16–67 years). CT was found superior in picking up most of the bony injuries, air-containing lesions, hemothorax, and hemoperitoneum. However, autopsy was found more sensitive for soft-tissue and solid visceral injuries. Both modalities were equally helpful in identifying extremity fractures. Statistically significant agreement (>95%) on cause of death by both modalities was not achieved in any patient of trauma. Conclusion: Postmortem CT scan is promising in reporting injuries in traumatic deaths and can significantly complement the conventional autopsy. However, at present, it cannot be considered as a replacement for TA.

Introduction: Emergency department (ED) overcrowding with critically ill trauma patients has been a major concern globally. It has been shown that longer stays in the hospital before Intensive Care Unit (ICU) admission have a higher mortality rate. Objective: The objective of this study was to find whether the delay in ICU admission from ED is associated with significant mortality in a trauma patient. Methods: A prospective trauma registry data of 232 patients collected from the ED of JPNATC trauma center between September 2015 and March 2016 were used in the study. The study participants were all admitted trauma patients. Dead-on-arrival patients were excluded from the study. Results: All included patients had a blunt injury at the time of arrival. Of 232 patients, 66 died during treatment and 166 were discharged. Of these, 196 (84.5%) were male and 36 (15.5%) were female. Most of the patients among 66 who died were referred from different hospitals; however, most survivors arrived directly at JPNATC as compared to another group (P < 0.001). Waiting time in ED was calculated by the difference between arrival time and ED disposition time. There was statistically significant difference found in ED waiting time in both the groups (P = 0.015); however, the odds ratio is closer to 1, that is, 0.998. Similarly, age, gender, oxygen saturation, Glasgow Coma Scale, ICU stay days, heart rate, referring status, and injury severity score were found to be significant at the level of 25% under univariate analysis. Conclusion: The ED delay is not associated with adverse outcome in terms of mortality. Other factors may play a much greater role in determining the prognosis.

Abstract Background Studies to identify an ideal trauma score tool representing prediction of outcomes of the pediatric fall patient remains elusive. Our study was undertaken to identify better predictor of mortality in the pediatric fall patients. Methods Data was retrieved from prospectively maintained trauma registry project at level 1 trauma center developed as part of Multicentric Project—Towards Improving Trauma Care Outcomes (TITCO) in India. Single center data retrieved from a prospectively maintained trauma registry at a level 1 trauma center, New Delhi, for a period ranging from 1 October 2013 to 17 February 2015 was evaluated. Standard anatomic scores Injury Severity Score (ISS) and New Injury Severity Score (NISS) were compared with physiologic score Revised Trauma Score (RTS) using receiver operating curve (ROC). Results Heart rate and RTS had a statistical difference among the survivors to nonsurvivors. ISS, NISS, and RTS were having 50, 50, and 86% of area under the curve on ROCs, and RTS was statistically significant among them. Conclusions Physiologically based trauma score systems (RTS) are much better predictors of inhospital mortality in comparison to anatomical based scoring systems (ISS and NISS) for unintentional pediatric falls.

Background: Amputation following trauma is emerging as a major health burden on the medical services and on the families and the society as well. Loss of limbs causes inability to support self and the family that further leads to various psychiatric disorders in many patients. Therefore, the present study is planned to explore psychiatric comorbidity in patients with amputation following trauma. Materials and Methods: Fifty-nine amputees were recruited by consecutive sampling within 6-month period from amputation clinic of a tertiary care hospital. All participants were interviewed on a semi-structured pro forma of sociodemographic and amputation-related parameters and assessed on psychiatric comorbidity using Mini-International Neuropsychiatric Interview scale. Results: Majority of the patients were male (88.1%) and belonged to younger age group of 16–30 years (71.2%). Approximately, 97% of patients had single-limb amputation (96.6), predominantly right limb (55.9%). Lower limb amputation was noted in 79.7% of participants. Motor vehicle accident was the most common mode of injury followed by railway track injury and others. The most common psychiatric comorbidities in our sample were major depressive disorder (71.2%), suicidality (30.5%), and posttraumatic stress disorder (PTSD) (20.3%). PTSD was positively correlated with phantom sensation (rs = 0.295, P = 0.05) and phantom pain (rs = 0.279, P < 0.05). Conclusion: A substantial proportion of amputees had alarming sign of depression, suicidal ideation, and PTSD. Thus, there is a need to form liaison between surgical treatment providers and psychiatrists and psychologists to manage psychiatric comorbidity in amputees.

Purpose: Traumatic cardiac injury (TCI) is a challenge for trauma surgeons as it provides a short therapeutic window and the management is often dictated by the underlying mechanism and hemodynamic status. The current study is to evaluate the factors influencing the outcome of TCI. Methods: Prospectively maintained database of TCI cases admitted at a Level-1 trauma center from July 2008 to June 2013 was retrospectively analyzed. Hospital records were reviewed and statistical analysis was performed using the SPSS version 15. Results: Out of 21 cases of TCI, 6 (28.6%) had isolated and 15 (71.4%) had associated injuries. Ratio between blunt and penetrating injuries was 2:1 with male preponderance. Mean ISS was 31.95. Thirteen patients (62%) presented with features suggestive of shock. Cardiac tamponade was present in 12 (57%) cases and pericardiocentesis was done in only 6 cases of them. Overall 19 patients underwent surgery. Perioperatively 8 (38.1%) patients developed cardiac arrest and 7 developed cardiac arrhythmia. Overall survival rate was 71.4%. Mortality was related to cardiac arrest (p = 0.014), arrhythmia (p = 0.014), and hemorrhagic shock (p = 0.04). The diagnostic accuracy of focused assessment by sonography in trauma (FAST) was 95.24%. Conclusion: High index of clinical suspicion based on the mechanism of injury, meticulous examination by FAST and early intervention could improve the overall outcome.

Amputation is a major health burden on the families, society, and on medical services as well. Traumatic limb amputation is a catastrophic injury and an irreversible act which is sudden and emotionally devastating for the victims. In addition, it causes inability to support self and the family and driving many patients toward various psychiatric disorders. Extensive information regarding the effects of amputation has not been ascertained and therefore it was decided to do a systematic review. The goal of this review was to provide comprehensive information of peer-reviewed papers examining the psychological distress among amputees in India. A search of the literature resulted in a total of 12 articles with varied sample size from 16 to 190. The sample has been largely comprised males with lower limb amputation caused by primarily traumatic ones, i.e., motor vehicle accident, railway track accidents, machinery injury, blasts, etc., The prevalence of psychiatric disorders among amputees has been found to be in the range of 32% to 84% including depression rates 10.4%–63%, posttraumatic stress disorder 3.3%–56.3%, and phantom limb phenomenon 14%–92%. Although the studies reported that symptoms of anxiety and depression become better over the course of time, however surgical treatment providers need to liaise with psychiatrists and psychologists to support and deal with the psychological disturbances.

The management of hemodynamically normal patients with retained intra-pericardial foreign body remains a matter of conjecture. The available literature supports non-operative management of such innocuous foreign bodies. We report our experience of a hemodynamically normal patient with a retained intra-pericardial pellet from a firearm injury. He initially received successful non-operative management but developed fatal hemopericardium 21 days after injury. In this paper, we discussed the pitfalls in the management of such injuries in light of the available literature and summarized the clinical experience.

Neck, being not protected by skeleton, is vulnerable to external trauma and injury which involves blood vessels, trachea, esophagus and other endocrine and nervous system organs. Vascular injuries can not only cause potentially life-threatening hemorrhage but also need profound surgical expertise in management. Development of collateral circulation in neck is well known; however, there is scarcity of literature on the role of collateral formation in neck trauma. Here, we present a unique case of penetrating gunshot injury to neck with right common carotid and right subclavian artery injury with hemorrhagic shock managed with ligation of these vessels as a life-saving procedure. The patient presented with no neurological or motor deficits in immediate postoperative period owing to the collateral circulation between right vertebral artery and right common carotid and right subclavian artery.

Pneumococcal meningitis is a life-threatening infection, requiring prompt diagnosis and effective treatment. The approach to therapy in patients with pneumococcal meningitis has changed considerably over the past 20 years because of emerging penicillin resistant pneumococcal meningitis. We report a case of Penicillin resistant pneumococcal meningitis in a six-year-old child after skull trauma injury. The patient responded well to injection ceftriaxone and injection vancomycin therapy and recovered completely without sequelae.

Objectives: Pressure ulcers are a multifactorial, prevalent, and preventable morbidity. They cause a burden both financially and emotionally, to the individual, their family and doctor, and to society as a whole. Pressure ulcers are extremely difficult to treat; therefore, prevention is key. Methods: We started a Wound Care Surveillance Program in 2012 involving nurses, physiotherapists, and doctors. We intended to prevent the occurrence of pressure ulcers, ensure early detection, and facilitate the healing process. The Braden scale was used to stratify patients’ risk. The number of patients observed in our study was 2,974 over a one-year period. Results: The pressure sore prevalence was 3.1%. Younger and middle-aged patients were most commonly affected; 27% of these patients did not survive. Mortality was not attributed to the pressure ulcer directly. The most common mode of injury was road traffic accidents. Most of our patients had just a single pressure area affected, most commonly the sacrum. Most patients were managed with debridement and dressings while 12% received surgical treatment. Of those with stage one ulcers, 29% healed completely at two months. In stage two and three patients, 17% and 6% healed in two months, respectively, and this number was zero in stage four patients. Conclusion: The Wound Care Surveillance Program has been a very effective strategy for the prevention and management of pressure ulcers. Stage two ulcers were the most common in our setup. Braden scoring, traditionally used to screen these ulcers, can be used as a predictive and prognostic tool to predict healing of pressure ulcers. Poor healing is expected in higher staged ulcers and patients with spinal injury and major solid organ injury and those who need a tracheostomy. Home-based care is not up to mark in our society and accounts for most of the cases in the follow-up.

Context: Treatment of patients with cleft lip and palate (CLP) anomaly requires a multidisciplinary approach from birth until adulthood. Many children with cleft anomaly are born in rural areas where resources for treatment and awareness on cleft care are limited. Consequently, many patients may receive limited or suboptimal care due to multitudes of reasons. Aims: The current study was aimed to record the baseline data on the spectrum of clinical profile of cleft patients, treatment protocols, quality of treatment and the residual treatment needs of patients with CLP anomaly visiting three major hospitals across Delhi and National Capital Region (NCR). The experience gained from the three-center study would be used to lay a framework to conduct a nationwide multicenter study in terms of logistics, feasibility and difficulties. Materials and Methods: The study titled "CLP anomaly in India: Clinical profile Risk factors and current status of treatment: A hospital based study" was started in 2010 as a Task Force project of Indian Council of Medical Research. The Pilot phase, which started in 2012, encompassed three cleft centers across Delhi and NCR, namely, All India Institute of Medical Sciences, Safdarjang Hospital and Medanta - The Medicity. Data for 126 non-syndromic CLP subjects was recorded on a specially designed performa. Each case was evaluated by a team of specialists comprising of a Plastic Surgeon, an Orthodontist, ENT Surgeon, Dental Surgeon, Speech therapist and an Audiologist. Clinical records included profile and intraoral photos, dental study models, audiometric and speech evaluation data. The current paper attempts to highlights a few of relevant observations of the pooled data from three centers. Results and Conclusions: The results indicate a lack of uniform protocol followed in providing care to cleft patients. A great variation was found in the quality of treatment received by many of the patients.

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 2.5, with five of them exceeding 4. In procedures like spinal instrumentation the CT ratio was

Background: There are studies to prove the role of amylase and lipase estimation as a screening diagnostic tool to detect diseases apart from acute pancreatitis. However, there is sparse literature on the role of serum and urine amylase, lipase levels, etc to help predict the specific intra-abdominal injury after blunt trauma abdomen (BTA). Aim: To elucidate the significance of elevation in the levels of amylase and lipase in serum and urine samples as reliable parameters for accurate diagnosis and management of blunt trauma to the abdomen. Materials and Methods: A prospective analysis was done on the trauma patients admitted in Jai Prakash Narayan Apex Trauma Center, AIIMS, with blunt abdomen trauma injuries over a period of six months. Blood and urine samples were collected on days 1, 3, and 5 of admission for the estimation of amylase and lipase, liver function tests, serum bicarbonates, urine routine microscopy for red blood cells, and complete hemogram. Clinical details such as time elapsed from injury to admission, type of injury, trauma score, and hypotension were noted. Patients were divided into groups according to the single or multiple organs injured and according to their hospital outcome (dead/discharged). Wilcoxon′s Rank sum or Kruskal-Wallis tests were used to compare median values in two/three groups. Data analysis was performed using STATA 11.0 statistical software. Results: A total of 55 patients with median age 26 (range, 6-80) years, were enrolled in the study. Of these, 80% were males. Surgery was required for 20% of the patients. Out of 55 patients, 42 had isolated single organ injury [liver or spleen or gastrointestinal tract (GIT) or kidney]. Patients with pancreatic injury were excluded. In patients who suffered liver injuries, urine lipase levels on day 1, urine lipase/amylase ratio along with aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) on days 1, 3, and 5, were found to be significant. Day 1 serum amylase, AST, ALT, hemoglobin, and hematocrit levels were found significant in patients who had spleen injury. Serum amylase levels on day 5 and ALP on day 3 were significant in patients who had GIT injury. Urine amylase levels on day 5 were found to be statistically significant in patients who had kidney injury. In patients with isolated organ injury to the liver or spleen, the levels of urine amylase were elevated on day 1 and gradually decreased on days 3 and 5, whereas in patients with injury to GIT, the urine amylase levels were observed to gradually increase on days 3 and 5. Conclusion: Although amylase and lipase levels in the serum and urine are not cost-effective clinical tools for routine diagnosis of extra-pancreatic abdominal injuries in BTA, but when coupled with other laboratory tests such as liver enzymes, they may be significant in predicting specific intra-abdominal injury.

A 20-year-old female with Proteus syndrome sustained splenic injury after fall from a bike. She was initially managed non-operatively at a different hospital for three days and was then referred to our level I trauma center in view of increasing abdominal pain and distention. On admission in the Emergency Department (ED), her pulse rate was 120 per minute and blood pressure was 108/68 mm Hg. Clinical examination showed a distended abdomen with left hypochondrial pain. Ultrasonogram (USG) and Computed Tomography (CT) of the abdomen showed splenomegaly and grade III splenic injury with significant hemoperitoneum. Her hemoglobin was 2.9 g/dl with packed cell volume (PCV) of 12%. In view of low hemoglobin and possibility of pathologic spleen, splenectomy was done. Microscopic examination of the spleen showed hemangiolymphangioma. The patient was discharged on the 5 th post-operative day and is doing well at 6 months of follow-up.

Pressure sore is tissue ulceration due to unrelieved pressure, altered sensory perception, and exposure to moisture. Geriatric patients with organic problems and patients with spinal cord injuries are the high-risk groups. Soft tissues over bony prominences are the common sites for ulcer development. About 95% of pressure ulcers occur in the lower part of the body. Ischial tuberosity, greater trochanter, sacrum and heel are common sites. In addition to these, pressure sores at unusual sites like nasal alae, malar eminences, cervical region and medial side of knee have also been described. Only 1.6% of the patients present with sores in areas outside the pelvis and lower extremity. In a paraplegic patient, pressure sores are usually over extensor surface of knee and heel but pressure ulcer over popliteal fossa are extremely rare. We herein report a case of a 36-years-old diabetic and paraplegic male, who presented with multiple bed sores involving the sacral area, heels and bilateral popliteal fossa. Popliteal fossa is an unusual site for pressure sores. Only one similar case has been previously reported in the literature.