Akram Hussain Bijli

Isolated aglossia in a six year old child presenting with impaired speech: a case report

IntroductionThe most mobile organ of the body, the tongue is associated with various congenital anomalies; most of which are in association with many other systemic abnormalities. Rarely do they occur in isolation. Isolated aglossia, that we presented, is one of the more rare presentations.Case presentationOur patient is a 6-year-old male child of Asiatic origin from Kashmir (India), who was physically well built and mentally sound and presented with history of impaired speech. The patient had normal velopharangeal competence but absence of tongue which was replaced by a small mucus membrane projection near the floor of oropharangeal isthmus. The patient had no difficulty in feeding or taste sensation but he was unable to pronounce lingual consonants.ConclusionIsolated aglossia is very rare condition explained on the basis of growth failure of lateral lingual swellings and tubercular impar. Such patients do not usually need reconstruction of tongue; as feeding, swallowing and taste sensations are usually intact and speech cannot be improved by reconstruction. However, malocclusion of teeth needs to be taken care of.

Vascular injuries after bear attacks: Incidence, surgical challenges and outcome

Background: Bear mauling is rarely reported in medical literature due to its rare occurrence. Present study was undertaken to describe the pattern and management of bear maul vascular injuries in Kashmir. Patients and Methods: Study of patients with bear maul vascular injury from 1st Jan 2004 to 31st Dec. 2008. Fifteen patients with bear maul vascular injury were studied. All patients of bear maul without vascular injury were excluded from the study. Results: Most of the patients were treated by reverse saphenous vein graft or end to end anastomosis. Most common complication was wound infection (20%) followed by graft occlusion (13.33%). There was no operative death. Conclusion: Bear attacks are very common in Kashmir. Vascular injury due to bear maul needs prompt resuscitation and revascularization. Results are very good provided timely intervention for revascularization is done.

Epidemiology of burn patients in a tertiary care hospital in Kashmir: A prospective study

Background: Burns are a common injury in developing countries creating a major public health problem and are associated with significant morbidity and mortality. Our aim was to study the epidemiology of various demographic characteristics, their outcome and prevention. Materials and Methods: All acute burn cases admitted to the burn unit of Sheri-Kashmir Institute of Medical Sciences, ( tertiary care referral centre in Kashmir, India) over a period of 2 years (2010-2011) were investigated. The registration data regarding various demographic characteristics, mode of burn injury, time of presentation after burn and associated risk factors and illness. Assessment of burn wound was done regarding site, affected body surface area, degree, depth, severity of injury and complications. Data were collected and analyzed statistically. Results: Patient′s ages ranged from 1 to 65 years with a mean age of 24.2 ± 7.6 years. The most common class of the population burnt were school going children (32.70%) followed by housewives (19.10%). Eighty percentage of patients belonged to rural areas and 20% to urban areas. Flame burns were more common in females (52.1%), electric burns were more common in males (93.3%) and scalds were more common in children (64.3%). Most of the burns were accidental (96.4%). 64.5% of patients reported within 24 h to hospital. 56.3% of patients had mixed degrees of burns, and 22.7% had third degrees of burns. Mortality was 11.8% and most common causative agent responsible was flame. The outcome was significantly associated with mode of injury, degree, depth, extent, causative agent and gender. Conclusions: This study provides important aspects of burn injuries for medical and nonmedical healthcare workers. The majority of burns are accidental seen in school going children, housewives and linemen of Power Development Department as a result of scalds, flame and electric burns respectively. Measures should be taken regarding awareness and education programs about burn prevention to reduce morbidity and mortality associated with it.

Crohn's disease: A surgeon's perspective

Crohn’s disease (CD) is known for wide anatomic distribution, different presentations, life-threatening complications, and multiple modalities of management. Its multiple implications are still unaddressed. Since all the patients do not show a good response to medical modalities of treatment, a significant percentage of these patients are referred to the surgeon for the palliation of complications or for the ultimate curative treatment. Since most surgeons come across such patients only rarely, it is sometimes difficult for them to choose the appropriate procedure at the time of need. Moreover, the various surgical modalities available for the different presentations and complications of the disease have not been adequately discussed. The aim of this review is to offer insight and a detailed account of the management of CD from a surgical perspective. This review offers an overview of the various surgical options available, their utility in context, and an approach to various scenarios of complicated CD.

Evaluating a conservative approach to managing liver injuries in Kashmir, India

Aim: There has been a steep rise in incidence of liver injury in the past few years because of increase in incidence of road traffic accidents. The aim of this study was to evaluate the role of non-operative management of liver injury due to blunt abdominal trauma. Materials and Methods: All patients with liver injury from blunt trauma abdomen were studied between January 2000 and January 2010. A total of 152 patients with liver injury were put on conservative management. Hundred and three (67.77%) patients were males and 49 (32.23%) were females with an age range of 15-60 years (32.8 years). Most of the injuries were because of road traffic accidents (81.57%). Liver injuries were graded according to Moores classification using computed tomography. Patients with Grade V and VI were excluded from the study. Patients who were unstable hemodynamically on admission were also excluded from the study. Results: There was no mortality in our series. Eight patients needed exploration because they developed hemodynamic instability. Four of the patient developed post-operative liver abscess which was treated conservatively. Conclusion: Non-operative management of liver injury due to blunt trauma abdomen is a safe, effective and treatment modality of choice in hemodynamically stable Moores grade I to Grade IV injury.

Role of customised negative-pressure wound therapy in the integration of split-thickness skin grafts: A randomised control study

Background: Split-thickness skin grafting (STSG) is a time-tested technique in wound cover, but many factors lead to suboptimal graft take. Role of custom-made negative-pressure wound therapy (NPWT) is compared with conventional dress in the integration of STSG and its cost is compared with widely used commercially available NPWT. Materials and Methods: This is a parallel group randomised control study. Block randomisation of 100 patients into one of the two groups (NPWT vs. non-NPWT; 50 patients each) was done. Graft take/loss, length of hospital stay post-grafting, need for regrafting and cost of custom-made negative pressure wound therapy (NPWT) dressings as compared to widely used commercially available NPWT were assessed. Results: Mean graft take in the NPWT group was 99.74% ± 0.73% compared to 88.52% ± 9.47% in the non-NPWT group (P = 0.004). None of the patients in the NPWT group required second coverage procedure as opposed to six cases in the non-NPWT group (P = 0.035). All the patients in the NPWT group were discharged within 4–9 days from the day of grafting. No major complication was encountered with the use of custom-made NPWT. Custom-made NPWT dressings were found to be 22 times cheaper than the widely used commercially available NPWT. Conclusions: Custom-made NPWT is a safe, simple and effective technique in the integration of STSG as compared to the conventional dressings. We have been able to reduce the financial burden on the patients as well as the hospital significantly while achieving results at par with other studies which have used commercially available NPWT.

Microbiological and quantitative analysis of burn wounds in the burn unit at a tertiary care hospital in Kashmir

Background: The burn wound represents a susceptible site for opportunistic colonization by organisms of endogenous and exogenous origin. The present study was undertaken to analyze the microflora of burn wounds of the burn patients from a tertiary care hospital in Kashmir, India. Materials sand Methods: The study included all patients with acute burns admitted from January 2010 to December 2011 (2 years). The standard techniques, as practiced during collection of microbiological specimens, were used during wound swab/biopsy collection. Results: 74.19% of swab cultures yielded single isolates. On swab culture, Pseudomonas aeruginosa was the commonly isolated organism (46.86%). Staphylococcus aureus was the most common isolate isolated during 1st postburn week (30.86%). 258/288 (89.58%) blood cultures were sterile. 8/58 (13.79%) blood cultures were positive during the second postburn week. S. aureus was the most common organism grown on blood culture (44.44%). P. aeruginosa was mostly sensitive to polymyxin B (86.0%), amikacin (40.0%), and ciprofloxacin (37.3%), respectively. S. aureus was most commonly sensitive to linezolid (85.0%) and vancomycin (78.8%%) whereas Acinetobacter spp. was sensitive to polymyxin B (65.3%), piperacillin/tazobactam (44.9%), and amikacin (38.8%). Patients (27.27%) who showed local signs of burn wound infection and positive blood culture were subjected to burn wound biopsy. 93.33% of patients who had counts >105 colony-forming unit/g of tissue showed significant association with local signs of burn wound infection and positive blood culture for any organism. Conclusion: The microbiological surveillance of burn wounds needs to be continued for a rational antibiotic policy and prevention of emergence of resistant organisms. Burn wound biopsy culture is an effective tool for quantitative analysis of burn wounds; however, subjecting this biopsy to histological examination is more predictable of burn wound infection and its correlation with burn wound sepsis.

Amyand's hernia: A rare occurrence

Claudius Amyand, Surgeon to King George II, was the first to describe the presence of a perforated appendix within the hernial sac (in 1735) of an 11-year-old boy who had undergone successful appendicectomy. Amyand′s hernia is an inguinal hernia with an appendix involved. It is a rare condition. The chance finding of the vermiform appendix lying within an inguinal hernia occurs in approximately one percent of cases of inguinal hernia. Preoperative diagnosis is difficult. If additional pathologies exist, the diagnosis is more troublesome. We aimed to present a patient with Amyand′s hernia which is rare in the literature

Contralateral lumbo-umbilical flap: A versatile technique for volar finger coverage

Background: While contemplating any difficult soft tissue reconstruction, patient comfort and compliance is of paramount importance. Reconstruction of the volar aspect of fingers and hand by the ipsilateral pedicled flaps (groin flap, abdominal flaps) is demanding as the flap inset is difficult for the surgeon and very uncomfortable for the patient. This often leads to flap complications. For the comfort of the patient, better compliance and ease of complete inset, we planned to manage soft tissue defects of the volar aspect of fingers and hand by a new contralateral pedicled lumbo-umbilical flap. This flap is based on the paraumbilical perforators of deep inferior epigastric artery. Materials and Methods: The contralateral pedicled lumbo-umbilical flap was used in eight patients with high-tension electrical burn injuries involving the volar aspect of fingers and hand. The patients were closely observed for first 6 weeks for any flap or donor site complications and then followed monthly to assess donor and recipient site characteristics for 6 months to 2 years. Results and Conclusion: Large flaps up to 8 cm × 16 cm were raised. All but one flaps survived completely. All patients were mobilised within 48 h and five were discharged in less than a week after initial inset. The flap is reliable, easy to harvest and easy to inset on the volar aspect of fingers. The arm is positioned in a very comfortable position. The main disadvantage, however, is a conspicuous abdominal scar.

Footboards: Indigenous and novel method of screening for diabetes peripheral neuropathy – A pilot study

Background: To validate the effectiveness of indigenously designed “footboard (FB)” in early diagnosis of diabetic peripheral neuropathy (PNP) by comparing it with Semmes–Weinstein monofilament (SWM) and vibration perception (VP). Materials and Methods: Two hundred and forty-four patients with diabetes were examined for PNP using SWM and 128 Hz tuning fork. The findings were compared with indigenously designed FBs with 1, 2, and 3 mm elevations. Results: Out of 108 patients who did not have protective sensation as per SWM, only 10 (9.2%) felt 1 mm board bearings, and out of 72 patients who did not feel vibration, only 8 (11.1%) felt 1 mm board bearings. Out of 136 patients who had protective sensation, 128 (94.11%) felt 2 mm elevated board bearings, and out of 172 patients who had VP, only 152 patients (88.3%) felt 2 mm board bearings. With SWM as standard, the sensitivities and specificities, respectively, were 63% and 90% (1 mm board), and 94% and 60% (2 mm board). With VP, the sensitivities and specificities, respectively, were 59% and 90% (1 mm board), and 88% and 61% (2 mm board). Conclusions: FB, which simultaneously tests touch and pressure sensation, shows a high level of performance in detecting at-risk feet. FB may be simple, time-efficient, and inexpensive test for detection of neuropathy and needs further validation in a larger study.