Delay In Surgical Treatment Research Articles

An Anatomical Explanation for a Chronic Gastrointestinal Complaint

Introduction: Median Arcuate Ligament Syndrome (MALS) is an anatomic abnormality causing vascular compression. Variation in the location of either the fibrous band of the median arcuate ligament or the origin of the celiac trunk results in stenosis. This causes ischemia and delayed gastric emptying. Our case demonstrates the extensive workup patients endure prior to being accurately diagnosed with MALS. Case: 75 yo female with a 20 year history of chronic dyspepsia, H. pylori, and C. difficile presented to the ED complaining of worsening nausea and two days of hematochezia. The patient stated new onset dysphagia to both solids and liquids. 2 months prior to presentation, she recalls frequent episodes of abdominal pain requiring multiple ED visits and weight loss of 15lbs. On initial examination, the patient was found afebrile, normotensive, with laboratory results showing a WBC count of 19.3x103 cells/μL, hemoglobin of 16.0 g/dL, and platelet count of 307 x 103 cells/ μL. Physical exam showed an abdomen mildly tender to palpation in the LUQ and LLQ without rebound or guarding. Patient was admitted and placed empirically on piperacillin / tazobactam. Abdominal CT demonstrated wall thickening, trace fluid, and adjacent fat stranding involving the distal transverse, descending, and proximal sigmoid colon likely representing an infectious or inflammatory colitis with a patent inferior mesenteric artery. EGD was only positive for mild antral erythema and few duodenal erosions with no ulcers and samples were obtained to test for H. pylori. During colonoscopy, biopsies obtained showed erythema and congestion consistent with ischemic colitis. A duplex ultrasound was performed, revealing a peak systolic velocity (PSV) within the celiac artery of 285 cm/s, correlating to >70% occlusion. The previous CT results were examined retrospectively and mild compression of the celiac trunk by the median arcuate ligament was noted. A diagnosis of median arcuate ligament syndrome (MALS) was made. Conclusions: We present a case of MALS which depicts a rare diagnosis, initially presenting with vague symptoms such as postprandial epigastric pain and weight loss. These non-specific complaints mimic more common conditions, delaying proper diagnosis and treatment.It is prudent to consider MALS as a cause of chronic mesenteric ischemia when evaluating patients with unresolved abdominal pain and weight loss to prevent delay in curative surgical treatment.

The use of pH to determine the depth of dermal burns and treatment choice

The aim — to increase the effectiveness of treatment in patients with dermal burns by applying pH meters to determine the depth of dermal burns and the choice treatment.Materials and methods. The results of examination and treatment of 170 patients with dermal burns with the 5 — 40 % TBSA have been analyzed. During the first, second and third day, a series of pH meters were performed: pH meter on the unharmed skin of the homologous segment, pH meter on different sites of the wound, around the wound. The pH of the wound was measured by a pH meter with a flat electrode for the skin. Clinical, biochemical, statistical methods of study were carried out. The accuracy, sensitivity and specificity of the tested method has been proved.Results and discussion. A series of pH meters were used as the basis for calculating the constant pH for each degree of burn. The values of burn depth parameters were compared with the histopathological assessment and the clinical outcome at patient discharge. The average pH after the first day for epidermal burns, which healed for 7 — 10 days, was 7.6 ± 0.1 units, for dermal superficial burns healed within 3 weeks — 8.3 ± 0.2 units and for deep dermal burns that did not heal on their own during the study period — 8.9 ± 0.3 units. The pH difference in more than 3 units was detected in 80 patients from the main group with dermal burn, pain was absent in these areas of wounds in the pain test, deep necrosis was determined visually, indicating the presence of deep dermis burns among these patients. All patients underwent early excision of necrotic tissues with plastic wounds. 20 % of the comparison group lacked the objective diagnostics at the early stage leading to delay in surgical intervention, which in turn caused a prolonged duration of a hospital stay. The high sensitivity of the pH test was determined 24 hours after the injury. Probability of the diagnosing the depth of a burn wound 24 hours after the injury by the pH metric test was equal to 84 %. Specificity of the test — 95 %.Conclusions. The contact pH metric for wounds in patients with dermal burns is an objective method to determine the depth of thermal damage in the early stages after the injury as well as predict the course of the wound process. The difference in the pH of the homologous segments one day after the injury (D pH) equal to 2 units is a clear indication for the presence of superficial dermal burns. The pH difference D pH іn 4 units demonstrates the presence of deep dermal burns and is an indication for early surgical treatment.

Treatment Delay Impact on Open Reduction Internal Fixation of Mandibular Fractures: A Systematic Review.

Background:The impact of mandible fracture treatment delay has been contested in the literature for decades, with conventional wisdom favoring earlier surgical treatment to prevent postoperative complications, primarily infection. Through a systematic review of all available evidence, this study aims to determine whether delay to open reduction and internal fixation of traumatic mandibular fractures influences outcomes.Methods:MEDLINE, EMBASE, CINAHL, and Web of Science were systematically searched for English language literature pertaining to the above research question and screened in duplicate. Methodological quality scoring was performed using MINORS criteria. Qualitative and quantitative findings from relevant studies are presented.Results:Twenty eligible studies including 2,671 patients had open reduction internal fixation, with or without adjunct mandibulomaxillary fixation. All studies were observational cohort or case-control studies of low methodological quality with a mean MINORS score of 6.5 of 16 (40.6%) for noncomparative studies and 11.2 of 24 (46.7%) for comparative studies. Only 5 of 20 (25%) studies recommended earlier treatment. Due to insufficient reporting of data and study heterogeneity, the impact of treatment delay on complications could not be quantitatively analyzed.Conclusions:There is substantial heterogeneity and no consensus on the definition of “early” versus “delayed” surgical treatment for patients with traumatic mandibular fractures. The majority of included studies do not make a recommendation for earlier treatment. Future, well-designed prospective studies are essential to determine if there is an optimal surgical treatment delay of mandibular fractures that mitigates the risk of infectious and noninfectious complications.

Reasons for delay of surgical treatment among patients with senile mature cataract in Goa

Background:Cataract accounts for about 81% of blindness in India. By 2020, the elderly population is expected to double, further increasing the number of visually impaired. Effective strategies to reduce cataract backlog include increasing the number of cataract surgeries performed. Despite significant efforts to increase accessibility of cataract surgeries, particularly in developing countries, studies reveal that availability of eye care services in such communities may not necessarily translate into their appropriate utilisation. Even with government funded and private hospitals offering cataract surgeries being present, we see many patients with advanced unilateral or bilateral cataract. The reasons for this need to be evaluated. A hospital based cross sectional survey was aimed to determine the socioeconomic and demographic factors responsible for delay of cataract surgeries in patients with senile mature cataracts in Goa. Methods:This study was conducted over 6 months in 200 patients presenting to the Department of Ophthalmology, Goa Medical College with a senile mature cataract, with a pearly white lens and visual acuity of hand movements close to face projection of rays accurate. Patients were interviewed regarding reasons for delay in cataract treatment, covering awareness and attitude about cataract, misinformation, barriers to affordability, accessibility, and personal reasons. Results:Chief reason observed was good vision in one eye, others being unawareness about presence and treatment of cataract, distrust in surgery and economical and conveyance challenges. Conclusions: Based on this study, better public education, regular ocular examination and increasing accessibility and affordability of surgery will provide a solution to the challenge of delayed cataract treatment.

Evaluation of waiting times for breast cancer diagnosis and surgical treatment.

To analyse any delays in breast cancer diagnosis and surgical treatment, influence of clinical and biological factors and influence of delays on survival. A descriptive, observational, and retrospective study was conducted between 2006 and 2016 on stages I-III breast cancer patients. This is a retrospective review of health records to collect data on delays, patients' clinical data, biological features of the tumour and information on treatment. Mortality data from the National Death Index. In 493 evaluable patients, the median of days from the first symptom to mammography, biopsy, and surgery was 41, 57, and 92, respectively. The median of days from screening mammography to biopsy and surgery was 10 and 51, respectively. From biopsy to surgery, the median was 34days in every case. Over the last 5years, an increase in biopsy-surgery delay has been observed (p = 0.0001). Tumour stages I and II vs. stage III (RR 1.74. 95% CI 1.08-2.80, p = 0.027), diagnosis in screening (RR 0.66. 95% CI 0.45-0.96, p = 0.030), and use of magnetic resonance imaging (RR 2.08. 95 CI 1.21-3.56, p = 0.008) condition a greater biopsy-surgery delay. No influence of delays on survival has been identified. Delays in diagnosis and surgery in the case of women diagnosed on the basis of symptoms may be improved. There is a temporary tendency to a greater delay in surgery. Some clinical and biological factors must be taken into account to optimise delays. Survival results are not adversely affected by delays.

Acute Invasive Fungal Rhinosinusitis in Immunocompromised Patients: Role of an Early Diagnosis.

Objective The aims of the present study were to evaluate the clinical significance of the delay for surgical treatment and the prognostic value of other clinical, pathologic, and microbiological variables among hematologic patients affected by acute invasive fungal rhinosinusitis (AIFRS). Furthermore, we propose our early diagnosis and treatment protocol, reporting its 10-year results. Study Design Monocentric retrospective analysis. Setting The study was conducted from 2001 to 2017 at the University Hospital of Bologna, Italy. Subjects and Methods The impact of time to treatment and clinical, pathologic, and microbiological variables were analyzed among patients with histologically and microbiologically proven AIFRS. The outcomes of patients treated before the introduction of the early diagnosis protocol were compared with those treated afterward. Results Nineteen patients affected by AIFRS were eligible for the study. Treatment delay >4 days ( P = .002), infection caused by Mucorales ( P = .015), and extension of the disease were negative prognostic variables ( P = .017). The application of our protocol significantly reduced the delay for diagnosis and appropriate treatment by an average of 7.3 days ( P = .02). Conclusion The promptness of the diagnosis and surgical treatment may play a significant role in the management of AIFRS, as it appears to be significantly associated with the disease outcome. Our protocol may help to reduce the time required for diagnosis of high-risk hematologic patients.

Osteonecrosis and nonunion as complication of fracture neck femur

Nonunion and osteonecrosis are two major problems that lead to revision surgery after treatment of intracapsular femoral neck fractures. Fixation failure and nonunion are the main modes of failure following fixation of displaced or undisplaced femoral neck fractures. The two problems are difficult to distinguish as most displaced fractures take a long time to heal after fixation, which increases the risk of fixation failure. Avascular necrosis of the femoral head occurs in 9%–18% of patients, between 2 and 8 years postfracture. Risk factors include the degree of fracture displacement, patient age, and delay in surgical treatment.

Treatment Modality and Diagnostic Clues of Complicated Hydatid Cyst of the Thorax: A Review of 65 Cases

Background: Complicated hydatid cyst of the thorax is important to the clinical approaches and treatment modalities in hytadid disease. The aim of this study was to evaluate the problems of complicated pulmonary hytatid cyst, including choice of surgical methods and diagnostic clues, and to discuss the inherent risks of medical therapy and the delay of surgical treatment in pulmonary hydatid disease.

Do Moderate Surgical Treatment Delays Influence Survival in Colon Cancer?

Studies examining treatment delay and survival after surgical treatment of colon cancer have varied in quality and outcome, with little evidence available regarding the safety of longer surgical treatment wait times. Our study examined the effect of surgical treatment wait times on survival for patients with stage I to III colon cancer. A subset cohort analysis was performed using data from a prospectively maintained database. The study was conducted at a tertiary referral center. Data on all of the patients undergoing elective surgery for stage I to III colon cancer from 2006 to 2015 were collected from a prospectively maintained clinical and administrative database. We examined the impact of prolonged wait time to surgery on disease-free and overall survival. Patients were divided into 2 groups based on a treatment wait time of ≤30 or >30 days and were compared using a Cox proportional hazards model. A subgroup analysis was performed using alternative treatment delay cutoffs of 60 and 90 days. There were 908 patients with stage I to III colon cancer treated over the study period, with a median treatment wait time of 38 days (interquartile range, 21-61 days); 368 patients were treated within 30 days, and 540 were treated beyond 30 days from diagnosis. In adjusted multivariate analysis, a treatment delay of >30 days was not associated with decreased disease-free survival (HR = 0.89 (95% CI, 0.61-1.3); p = 0.52) or overall survival (HR = 0.82 (95% CI, 0.63-1.1); p = 0.16). Likewise, subgroup analysis using alternative treatment delay cutoffs of 60 and 90 days did not demonstrate an adverse effect on survival. This study was limited by retrospective analysis. Despite longer median treatment wait times from diagnosis to surgery, with the majority of patients exceeding 30 days and many experiencing delays of 2 to 3 months, no adverse impact on survival was observed. Patients who require additional consultations or investigations preoperatively may safely have their surgery moderately delayed to minimize their perioperative risk without any evidence that this will compromise treatment outcomes. See Video Abstract at http://links.lww.com/DCR/A397.

Various outcomes of pinna abscess management in our experience

<p class="abstract"><strong>Background:</strong> Pinna perichondritis is a common secondary to trauma due to RTA or high ear piercings. Early intervention with antibiotics can lead to cure without sequelae. Delayed presentation, suboptimal treatment, abscess formation, delays in surgical intervention can cause cartilage loss and cosmetic deformity. This study is conducted to evaluate the various outcomes of surgical intervention of pinna abscess and its predisposing factors in our experience<span lang="EN-IN">. </span></p><p class="abstract"><strong>Methods:</strong> A retrospective review was conducted to identify the cause, microbiology, management and outcome of the pinna abscess. Over a period of 2 yrs from September 2014 to September 2016, patients presenting with pinna abscess to the department of ENT, SMVMCH, Pondicherry, who underwent incision and drainage at least once were included in this study. 21 patients were included in the study. Exclusion criteria were post auricular abscess, infected pre auricular sinus<span lang="EN-IN">. </span></p><p class="abstract"><strong>Results:</strong> Among 21 patients, 11 were males and 10 were females. Most common etiology was road traffic accident in 15 patients, followed by high ear piercing 3 patients, and post-surgical in 1 patient.8 patients responded well with initial incision and drainage and IV antibiotics, with no postoperative complications. 2 patients needed second incision and drainage. 11 patients required incision and drainage more than 2 times and change of IV antibiotics<span lang="EN-IN">. </span>Among 21 cases, 10 were culture positive. The commonest pathogen was <em>Pseudomonas aeruginosa</em> in 9 cases. <em>Staphylococcus</em> <em>aureus</em> in 1 case. 11 patients developed postoperative complications cauliflower deformity in 4 patients, recurrent abscess in 7 patients.</p><p class="abstract"><strong>Conclusions:</strong> <em>Pseudomonas aeruginosa</em> is the most common organism responsible for the pinna abscess caused by trauma (RTA), high ear piercings. Complications like cauliflower deformity and recurrent abscess were noted, which can be reduced by early initiation of antibiotics with surgical intervention<span lang="EN-IN">.</span></p>

Natural History of Anterior Shoulder Instability.

Background:The shoulder is the most complex joint in the body. The large freedom of motion in this joint is the main cause of instability. Instability varies in its degree, direction, etiology and volition and there is a large spectrum of conditions. Methods:Based on literature research and also in our own experience, we propose to elucidate the reader about the natural history of instability and its importance for the appropriate management of this pathology, by answering the following questions:What happens in the shoulder after the first dislocation? Which structures suffer damage? Who are the patients at higher risk of recurrence? How does the disease evolve without treatment? Will surgical treatment avoid future negative outcomes and prevent degenerative joint disease? Who should we treat and when?Results:80% of anterior-inferior dislocations occur in young patients. Recurrent instability is common and multiple dislocations are the rule. Instability is influenced by a large number of variables, including age of onset, activity profile, number of episodes,delay between first episode and surgical treatment.Conclusion:Understanding the disease and its natural evolution is determinant to decide the treatment in order to obtain the best outcome. It is crucial to identify the risk factors for recurrence. Delay in surgical treatment, when indicated, leads to worse results. Surgical technique should address the type and severity of both soft tissue and bone lesions, when present.

Editor's Choice – The National Norwegian Carotid Study: Time from Symptom Onset to Surgery is too Long, Resulting in Additional Neurological Events

The objective was to observe for 1 year all patients in Norway operated on for symptomatic carotid stenosis with respect to (i) the time from the index event to surgery and neurological events during this time; (ii) the level in the healthcare system causing delay of surgical treatment; and (iii) the possible relationship between peri-operative use of platelet inhibitors and neurological events while awaiting surgery. This was a prospective national multicentre study of a consecutive series of symptomatic patients. Patients were eligible for inclusion when referred for surgery. An index event was defined as the neurological event prompting contact with the healthcare system. All 15 departments in Norway performing carotid endarterectomy (CEA) participated. Three hundred and seventy one patients were eligible for inclusion between 1 April 2014 and 31 March 2015, and 368 patients (99.2%) were included. Fifty-four percent of the patients contacted their general practitioner on the day of the index event. Primary healthcare referred 84.2% of the patients to hospital on the same day as examined. In hospital median time from admission to referral for vascular surgery was 3 days. Median time between referral to the operating unit and actual CEA was 5 days. Overall, 61.7% of the patients were operated on within 2 weeks of the index event. Twelve patients (3.3%) suffered a new neurological event while awaiting surgery. The percentage of patients on dual antiplatelet therapy was lower (25.0%) in this group than among the other patients (62.6%) (p=.008). The combined 30day mortality and stroke rate was 3.8%. This national study with almost complete inclusion and follow-up shows that the delays occur mainly at patient level and in hospital. The delay is associated with new neurological events. Dual antiplatelet therapy is associated with reduced risk of having a new neurological event before surgery.

ЛУЧЕВАЯ ДИАГНОСТИКА ПРИ СТЕНОЗИРУЮЩИХ ПОРАЖЕНИЯХ ЖЕЛЧЕВЫВОДЯЩИХ ПУТЕЙ (ОБЗОР ЛИТЕРАТУРЫ)

Nowadays hospitals use a large number of methods of radiological diagnostics that are able not only to evaluate morphological changes of hepatobiliary zone, but also to assess functional state of the liver, and the state organ hemodynamics. Despite that, differential diagnostics of biliary tract occlusive lesions is still a challenge that requires a combination of various modern techniques. Misdiagnosis, delay in surgical treatment lead to serious complications, sometimes with fatal consequences. In this category of patients, each method of instrumental diagnostics has its advantages and disadvantages. To determine the nature of the pathological process in the majority of cases it is necessary to consistently use a wide range of diagnostic procedures. The issue of selection of optimal diagnostic algorithm for assessment of the state of hepatobiliary organs with application of new high-tech methods of radial diagnostics remains urgent. Early identification of biliary hypertension causes and the nature of the block helps to reduce the risk of serious complications, promotes the development of optimal management of patients, as well as allows to plan the type and volume of surgery.

Compartment syndrome and regional anaesthesia: Critical review

Acute compartment syndrome (ACS) is a potential orthopaedic/traumatology emergency. Without prompt, precise diagnosis and immediate treatment with surgical decompressive fasciotomy it can lead to neurological dysfunction and disability. The role of regional anaesthesia (RA) in patients at risk for ACS/ and in those with developed ACS is controversial. The aim of this critical review was to answer the question, whether regional anaesthesia can delay the diagnosis. The authors use an evidence-based approach to discuss these high risk patients in considering RA as a method of choice for effective analgesia. To the date of data collection, there was no single case report identified where RA alone led to delay in ACS diagnosis and surgical treatment. In four clinical cases, epidural analgesia can be associated with delayed ACS diagnosis. Frequent clinical evaluation and breakthrough pain despite a functional RA in combination with intracompartment pressure measurement remains the keystone of recommended management for patients at risk of ACS.

Predictors of Surgical Outcome of Abdominal Trauma in Tertiary Care Centres of Nepal

Introduction: The abdominal trauma is a surgical emergency most of which are preventable and many of them could have good outcome with timely management by dedicated trauma system. It is not only the rising health problem but also the social and economic burden. A study on abdominal trauma can guide to cost-effective quality management of the patients. This study is undertaken to study and evaluate the predictors of surgical outcome in abdominal trauma patients in tertiary care centers in Nepal.Methods: Seventy five patients with abdominal trauma who underwent surgical intervention were evaluated prospectively inside the inclusion criteria. Ethical approval was obtained. The data on demographic pattern, clinic-radiological findings, abdominal trauma index, injury severity scale, operative findings, infectious complications, and mortality were collected. Chi square test was used for statistical analysis. Results: Out of 75 patients male to female ratio was 4.6 : 1. Blunt trauma (49) was the common cause of abdominal injury. Accidental abdominal injury happened in 73% (55) and fall from height was common mode of abdominal organ injury 40% (30). The overall morbidity and mortality were 30.6% and 9.3% respectively. Age > 30 years, Shock at presentation, Operative Delay > 24 hours, and trauma score (ATI>15 and ISS>15) were all good predictors of surgical outcome of patients with abdominal trauma (p <0.05).Conclusion: The predictors of surgical outcome were patient’s age, clinical status at presentation and delay in surgical intervention. Trauma score (both ATI and ISS) are equally important in predicting outcome which are necessary for monitoring patients care and the quality of trauma systems.

Spontaneous resolution of large non-traumatic bilateral acute-on-chronic subdural hematoma

Abstract Background and importance: Chronic subdural hematomas are a frequently encountered neurosurgical pathology, especially in the elderly. They often require surgical evacuation, but recent studies have shown good results with conservative treatment in selected cases. Clinical presentation: We report the case of a 72-year old patient that developed large, non-traumatic, bilateral, acute-on-chronic subdural hematoma after repeated abdominal surgery for appendicular carcinoma. He presented an abdominal wound infection and good neurological status (GCS score of 14 points), factors that indicated the delay of surgical intervention. Subsequent clinical and radiological improvement forestalled the operation altogether and he presented complete spontaneous resolution of subdural hematomas at only 5 months after diagnosis. Conclusion: Although surgical treatment is performed in the majority of chronic subdural hematomas, in clinically and radiologically selected cases, the operation can be avoided. The hematoma can present resolution, either spontaneously or with the help of conservative treatment.

Diagnosing and Treatment of the Gallstone Intestinal Obstruction

Цель работы Анализ результатов диагностики и оперативного лечения больных с обтурационной желчнокаменной тон-кокишечной непроходимостью.Материал и методы Анализированы результаты лечения 15 пациенток в возрасте от 58 до 84 лет с обтурационной жел-тухой, которые были оперированы от 2 до 27 часов с момента поступления. Объем операции: лапаротомия, энтеротомия,удаление желчного камня из просвета кишки. Вмешательство на желчевыводящих путях не производилось.С целью диагностики использовались: эзофагогастроскопия, УЗИ, обзорная рентгенография брюшной полости.Результаты и их обсуждение Гладкое течение послеоперационного периода отмечено у 14 больных. Средняя длитель-ность послеоперационного периода составила 12 койко-дней. Осложнение в послеоперационном периоде развилось у однойпациентки. У 13 пациенток удаление камня из просвета кишки произведено дистально от места обтурации. У 2 больныхкамень удален из просвета кишки после смещения на 10-15 см проксимально, так как низвести его не удалось.Выводы Обтурационная тонкокишечная желчнокаменная непроходимость может протекать атипично, носить интер-миттирующий характер, что затрудняет диагностику и приводит к задержке оперативного лечения. При удалении камняиз просвета кишки предпочтительно его смещение в дистальном направлении, а при невозможности – смещение прокси-мально не менее чем на 30-40 см.Ключевые слова желчный камень, обтурационная кишечная непроходимость, хирургическое лечение

Feasibilty of early surgical intervention for acute appendicitis in gravid patients

Background: Acute appendicitis is the most common surgical non-obstetric pathology during pregnancy. Unnecessary hesitation and hence delay in surgical intervention for acute appendicitis in pregnancy is common. In this background, while attempting early suspicion and surgical intervention (appendectomy) in our patients, we encountered no mortality and no significant morbidity in the in immediate postoperative period. Materials and Methods: This prospective study was carried over a period of 3.5 years from June 2012 to November 2015, in the department of surgery, GMC (Government Medical College) Srinagar. Patients included were only those who had features of acute appendicitis on clinical grounds and/or imaging studies (ultrasound). Objective: Our aim was to study the feasibility of early suspicion and surgical intervention in patients with features of acute appendicitis in pregnancy. Results: The mean age of the patients was 28.84 years, ranging from 21 to 38 years. The mean gestational age of our patient cohort was 17.4 weeks (6-35 weeks). Majority of the patients presented in the 2nd trimester (55.9%) followed by 1st trimester (29.4%). The Alvarado score of the patients ranged from 5 to 9 (mean 6.76). WBC (white blood cell count) of our patients ranged from 5800 to 22400 (average 14150). Neutrophill count ranged from 64.4% to 92.2% (mean 79.20%). USG diagonosed 20 patients as acute appendicitis (58.82%) and 14 patients as negative for appendicitis (41.2%) with a sensitivity of 60.6% and specificity of 71.42 %. Intraoperatively 31 patients (22 inflamed and 9 perforated) had features of acute appendicitis, one had early lump formation, and two had grossly normal appendix. All patients were followed up strictly for 2 months postoperatively and no obstetrical complication was recorded. Conclusion: Diagnosis of acute appendicitis in pregnancy can be difficult; however, surgical intervention should be performed with any suspicion. Fetal morbidity and mortality are high in the presence of perforation and generalized peritonitis. For minimizing the unnecessary delay in diagnosis and surgery, high clinical suspicion can only be supplemented and not replaced by imaging studies. Ultrasound is not only safe in pregnancy but also easily available and affordable. The decision to perform laparotomy should be based on clinical findings and diagnostic imaging. Delays over 24 hours for intervention increase the risk of perforation. We noted no immediate fetal or other major complications in our patients, hence we recommend early surgical intervention in patients with suspicion of acute appendicitis in pregnancy. There is also need for some unequivocal diagnostic scoring system which should be highly predictive of acute appendicitis in pregnancy, early in the course of disease before giving way to complications.

Preoperative Deep Vein Thrombosis following Acute Anterior Cruciate Ligament Tear: Report of Three Cases

ABSTRACTCase reportWe report 3 cases of preoperative deep vein thrombosis (DVT) following anterior cruciate ligament (ACL) injury in a 20-year-old female volleyball player (C1), a 22-year-old female snowboarder (C2), and a 36-year-old male recreational basketball player (C3). In all three cases, the patients presented with hypersensitivity in the injured knee and guarded significantly on physical examination. The patients were all placed on anticoagulation prior to operative intervention. C1 underwent repair 45 days after her injury and C2 delayed repair until completion of a 6 month course of warfarin. C3 did not undergo repair of the ACL; he developed significant stiffness and had diagnostic arthroscopy with lysis of adhesions and synovectomy 5 months following his injury.ConclusionData is limited regarding the risk of DVT after nonmajor orthopaedic injury, such as ACL injury. Recognition and immediate treatment of the DVT is essential in minimizing the risk of additional complications. Duration of anticoagulation and delay in surgical intervention should be determined based on individual patient goals and risk factors.Baumgartner RE, Jones MD, Hame SL, McAllister DR. Preoperative Deep Vein Thrombosis following Acute Anterior Cruciate Ligament Tear: Report of Three Cases. The Duke Orthop J 2017;7(1):30-33.

Barriers responsible for delay in surgical correction of strabismus: A study among adults undergoing strabismus surgery at a tertiary care center in Kerala

Aim: The aim of this study is to analyze the factors responsible for delay in surgical treatment among adults with strabismus. Materials and Methods: A validated questionnaire-based study on fifty adult strabismic patients, enrolled through simple random sampling, who underwent surgical correction of strabismus at the strabismus clinic of a tertiary care eye hospital. Results: A total of fifty patients in the age group 18– 45 years, including 28 males (56%) and 22 females (44%) were studied. 24% were students, 22% were professionals, 18% were skilled laborers, and 18% were homemakers. Strabismus had significant psychological impact on the quality of life of the patient and 50% suffered from low self-esteem attributable to squint 32% reported peer pressure and bullying. Lack of awareness about surgery (32%), fear of surgery (24%), and nonaffordability were the most common reasons reported by patients for delayed the surgical correction. The reasons for seeking surgical treatment in adulthood were for improving self-esteem and quality of life (32%) and due to pressure from family and friends (24%). Conclusion: Social factors predominate as obstacles for timely correction of strabismus. Economic factors and lack of awareness among medical communities also contribute toward delay in treatment.