Brain death: confirmation by radionuclide cerebral angiography

Dynamic radionuclide cerebral angiography was performed in 14 patients with suspected brain death. In 10 of 14 patients, no intracranial arterial perfusion was demonstrable, thus confirming brain death. In four patients, faint venous activity was seen in the sagittal sinus only. All these patients also eventually died. Radionuclide cerebral angiography provides a simple and noninvasive means to confirm brain death in critically ill patients maintained on life support systems particularly when an electroencephalogram and four vessel contrast angiography may be either impractical or equivocal.     

A knee-sparing distal femoral endoprosthesis using hydroxyapatite-coated extracortical plates. Preliminary results

We used a knee-sparing distal femoral endoprosthesis in young patients with malignant bone tumours of the distal femur in whom it was possible to resect the tumour and to preserve the distal femoral condyles. The proximal shaft of the endoprosthesis had a coated hydroxyapatite collar, while the distal end had hydroxyapatite-coated extracortical plates to secure it to the small residual femoral condylar fragment. We reviewed the preliminary results of this endoprosthesis in eight patients with primary bone tumours of the distal femur. Their mean age at surgery was 17.years (14 to 21). The mean follow-up was 24 months (20 to 31). At final follow-up the mean flexion at the knee was 102 degrees (20 degrees to 120 degrees) and the mean Musculoskeletal Tumour Society score was 80% (57% to 96.7%). There was excellent osteointegration at the prosthesis-proximal bone interface with formation of new bone around the hydroxyapatite collar. The prosthesis allowed preservation of the knee and achieved a good functional result. Formation of new bone and remodelling at the interface make the implant more secure. Further follow-up is required to determine the long-term structural integrity of the prosthesis.     

Tuberculous osteomyelitis of tibial diaphysis following saphenous vein graft harvest for coronary artery bypass: a case report

Tuberculosis in the tibial diaphysis following saphenous vein graft harvest for coronary artery bypass grafting has not been reported, to the best of authors’ knowledge. We report the first such clinical case in view of its clinical rarity and as a complication of the simple procedure like saphenous vein graft harvest.     

Kidney recipients with allograft failure,transition of kidney care (KRAFT): A survey of contemporary practices of transplant providers

Kidney allograft failure and return to dialysis carry a high risk of morbidity. A practice survey was developed by the AST Kidney Pancreas Community of Practice workgroup and distributed electronically to the AST members. There were 104 respondents who represented 92 kidney transplant centers. Most survey respondents were transplant nephrologists at academic centers. The most common approach to immunosuppression management was to withdraw the antimetabolite first (73%), while only 12% responded they would withdraw calcineurin inhibitor (CNI) first. More than 60% reported that the availability of a living donor is the most important factor in their decision to taper immunosuppression, followed by risk of infection, risk of sensitization, frailty, and side effects of medications. More than half of respondents reported that embolization was either not available or offered to less than 10% as an option for surgical intervention. Majority reported that ≤50% of failed allograft patients were re-listed before dialysis, and less than a quarter of transplant nephrologists performed frequent visits with their patients with failed kidney allograft after they return to dialysis. This survey demonstrates heterogeneity in the care of patients with a failing allograft and the need for more evidence to guide improvements in clinical practice related to transition of care.     

Novel predictive risk factor for Erectile Dysfunction: Serum folic acid

The purpose of this study was to compare the serum Folic Acid (FA) levels in patients with Erectile Dysfunction (ED) and healthy controls and whether levels vary with its severity. The study was carried out on 77 sexually active individuals, out of which 41 complained of ED and 36 were apparently normal. Patients were excluded if they had any diseases known to cause ED. The severity was further categorised based on IIEF-5 scores. Blood serum levels of testosterone, lipid profile, random blood sugar, liver function test, renal function test and FA levels were obtained in each patient. Independent-samples t test of significance was used when comparing between two means. Pearson's correlation coefficient (r) test was used for correlating data. All clinical and biochemical parameters except FA were comparable in both the groups. FA levels were significantly decreased in ED group (5.29 vs. 10.8; p value = .004). Smoking habits were comparable between the groups, and FA levels did not vary among smokers and nonsmokers (p value = .46). Serum FA levels significantly declined with increasing severity of ED (8.28 vs. 5.56 vs. 4.37 vs. 3.5; p value < .001). Thus, decreased FA might possibly be one of the novel risk factors for ED.     

Managing scaphoid fractures. How we do it?

The scaphoid is the common carpal bone to be fractured. Proper clinical and radiological evaluation is required to establish it's diagnosis. The management of acute fractures includes conservative treatment with cast in minimally displaced to open reduction and internal fixation in case of displaced ones. The established nonunion requires open reduction, bone grafting and internal fixation.     

Congenital right sided ureteropelvic junction obstruction in right crossed fused ectopia with extrarenal calyces masquerading as massive retroperitoneal urinoma in a case of blunt trauma abdomen: A diagnostic enigma and novel approach of management

An 18 years old young male presented with history of blunt trauma to abdomen with mild hematuria. The contrast enhanced computerized tomography of abdomen revealed crossed fused right renal ectopia with distal large fluid filled sac confusing with urinoma. A midline laparotomy revealed it to be case of right hydronephrotic ectopic fused kidney with extrarenal calyces with large midline pelvis in retroperitoneum. Tailoring of renal pelvis with preservation of posterior pelvic wall plate and ureteral reconstruction was done which was anastomosed to native right ureter. The patient is doing well in one year of follow-up.     

Primary vs delayed primary closure in patients undergoing lower limb amputation following trauma: A randomised control study

Lower limb crush injury is a major source of mortality and morbidity in trauma patients. Complications, especially surgical site infections (SSIs) are a major source of financial burden to the institute and to the patient as it delays rehabilitation. As such, every possible attempt should be made to reduce any complications. We, thus, aimed to compare the outcomes in early vs delayed closure of lower extremity stumps in cases of lower limb crush injury requiring amputation, so as to achieve best possible outcome. A randomised controlled study was conducted in the Division of Trauma Surgery & Critical Care at Jai Prakash Narayan Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi from 1 September 2018 to 30 June 2019 and included patients undergoing lower limb amputation below hip joint. Patients were randomised in two groups, in one group amputation stump was closed primarily, while in the second group delayed primary closure of stump was performed. We compared rate of SSI, length of hospital stay, and number of surgeries in both the groups. Fifty‐six patients with 63 amputation stumps were recruited in the study. Mean age of patients in the study was 34 years, of which about 95% patients were males. The most common mechanism of injury was road traffic injury in 66% of patients. Mean injury severity score was 12.28 and four patients had diabetes preoperatively. Total 63 extremities were randomised with 30 cases in group I and 33 cases in group II as per computer‐generated random number. Above knee amputations was commonest (57.14%) followed by below knee amputations (33.3%). Two patients died in the current study. In group I, In‐hospital infection was detected in 7 cases (23.3%) and in group II 9 cases (27.3%) had SSI during hospital admission (P > .05). Mean hospital stay in group I was 10.32 ± 7.68 days and in group II was 11 ± 8.17 days (P > .05). Road traffic injuries and train‐associated injuries are a major cause of lower limb crush injuries, leading to limb loss. Delayed primary closure of such wounds requires extra number of surgical interventions than primary closure. There is no difference in extra number of surgical interventions required in both the groups. Thus, primary closure can be safely performed in patients undergoing lower limb amputations following trauma, provided that a good lavage and wound debridement is performed.     

Thoracic trauma trends in Northern India- single center experience

Introduction

Thoracic trauma comprises 10–15 % of all traumas. The incidence and etiological pattern of chest trauma varies from region to region and is related to cultural and socio-political circumstances. This paper details our experience with thoracic trauma in a North Indian state.

Material & methods

All patients who were hospitalized for thoracic trauma from June 2010 to June 2012 in our hospital were enrolled. Data was collected prospectively and analysed. Factors analysed were age, gender, mode of injury, type of thoracic injury, associated injuries, management modalities, and outcome.

Results

The total number of patients was 250. The male to female ratio was about 10:1. The mean age of patients was 36.62 years. Road Traffic Accident (RTA) was the most common mode of chest injury. Motor-bike accident was the most common type of RTA. Majority of patients were managed with tube thoracostomy (183, 73.2 %). One hundred and eighty nine (75.6 %) patients were discharged after recovery. Ten (4.0 %) patients absconded. In all, 29 (11.6 %) patients died, while 22 (8.8 %) patients left the hospital against medical advice. A significant association between presence of associated injury and outcome was observed (p?<?0.001). We found mortality rate was significantly higher in chest injury associated with neurotrauma and abdominal visceral injury.

Conclusion

Chest trauma is a major health problem since it has high morbidity and mortality rate. The majority of patients with simple chest injuries can be managed by tube thoracostomy. According to our analysis; mortality predictors were: RTAs, blunt chest trauma, unstable hemodynamic status upon arrival, neurotrauma, abdominal visceral injury, flail chest, ventilator use, cardiac contusion and complications of therapy.