ObjectiveThe aim of this study was to evaluate and compare the abilities of clinicians and clinical prediction models to accurately triage emergency department (ED) trauma patients. We compared the decisions made by clinicians with the Revised Trauma Score (RTS), the Glasgow Coma Scale, Age and Systolic Blood Pressure (GAP) score, the Kampala Trauma Score (KTS) and the Gerdin et al model.DesignProspective cohort study.SettingThree hospitals in urban India.ParticipantsIn total, 7697 adult patients who presented to participating hospitals with a history of trauma were approached for enrolment. The final study sample included 5155 patients. The majority (4023, 78.0%) were male.Main outcome measureThe patient outcome was mortality within 30 days of arrival at the participating hospital. A grid search was used to identify model cut-off values. Clinicians and categorised models were evaluated and compared using the area under the receiver operating characteristics curve (AUROCC) and net reclassification improvement in non-survivors (NRI+) and survivors (NRI−) separately.ResultsThe differences in AUROCC between each categorised model and the clinicians were 0.016 (95% CI −0.014 to 0.045) for RTS, 0.019 (95% CI −0.007 to 0.058) for GAP, 0.054 (95% CI 0.033 to 0.077) for KTS and −0.007 (95% CI −0.035 to 0.03) for Gerdin et al. The NRI+ for each model were −0.235 (−0.37 to −0.116), 0.17 (−0.042 to 0.405), 0.55 (0.47 to 0.65) and 0.22 (0.11 to 0.717), respectively. The NRI− were 0.385 (0.348 to 0.4), −0.059 (−0.476 to −0.005), −0.162 (−0.18 to −0.146) and 0.039 (−0.229 to 0.06), respectively.ConclusionThe findings of this study suggest that there are no substantial differences in discrimination and net reclassification improvement between clinicians and all four clinical prediction models when using 30-day mortality as the outcome of ED trauma triage in adult patients.Trial registration numberClinicalTrials.gov Registry (NCT02838459).

Context:Unfortunately, there is confusion among the medical community regarding the management of amoebic liver abscess (ALA). Therapeutic options range from simple pharmacotherapy to use of interventions like a needle or catheter aspiration under ultrasound guidance to surgical intervention. There is a plethora of thresholds for parameters such as the maximum diameter of the abscess and volume on ultrasound examination suggested by various authors to serve as a criterion to help to decide when to use which modality in these cases.Aims:To assess the outcome of patients with uncomplicated ALA treated using a conservative approach. Moreover, to identify factors associated with its failure.Settings and Design:A prospective, observational study was carried out at a large municipal urban health care center over a period of 3-year (2011–2014) in India.Materials and Methods:Patients with uncomplicated ALA were recruited. All patients were managed with pharmacotherapy initially for a period of 72 h. Response to treatment was assessed by resolution of symptoms within the given time frame. Failure to respond was considered an indication for intervention. Needle aspiration was offered to these patients and response assessed within 72 h. Failure to respond to aspiration was considered an indication for catheter drainage. Statistical Analysis Used: Data recorded were entered in a Microsoft Office Excel Sheet and analyzed using the SPSS version 16.0 (IBM).Results:Sixty patients with ALA were included in the study over its duration. Forty-nine (81.67%) patients were managed conservatively, while 11 (18.33%) patients needed an intervention for relief. Patients who required intervention had deranged liver function at presentation, a larger abscess diameter (10.09 ± 2.23 vs. 6.33 ± 1.69 cm P < 0.001) and volume (399.73 ± 244.46 vs. 138.34 ± 117.85 ml, P < 0.001) compared to those who did not need it. Patients that required intervention had a longer length of hospital stay (7.1 ± 2.4 vs. 4.8 ± 0.9 days, P < 0.001). On post hoc analysis, a maximum diameter of >7.7 cm was found to be the optimal criterion to predict the need of intervention in cases of ALA.Conclusions:A conservative approach is effective in the management of ALA for a majority of patients. Failure of conservative management was predicted by the size of the abscess (maximum diameter >7.7 cm). Even in the cases of failure, a gradual step-up with interventions was found to be safe and effective.

A rare case of a retroperitoneal rupture of the appendix is being reported here. A 53-year-old male presented to us with a right sided thigh abscess. There were not any abdominal complaints at presentation. There was continuous discharge after incision and drainage from the thigh. Isolation, in culture, of an enteric bacterium from the pus prompted an evaluation of the gastrointestinal tract as a possible source. An MRI scan revealed fluid tracking from the right paracolic gutter over the psoas sheath and paraspinal muscle into the thigh. A CT scan revealed the perforation at the base of the appendix into the retroperitoneum. At laparotomy the above findings were confirmed. A segmental ileocaecal resection was done. The patient made an uneventful recovery. The absence of abdominal symptoms at presentation leads to delay in diagnosis in such cases. Nonresolving thigh and groin abscesses should lead to the evaluation of the gastrointestinal tract as origin. Diagnostic clues may also be provided by culture reports what as happened in this case.

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Background: Appendicitis is one of the most common abdominal emergencies encountered in surgical patients and admissions due to acute appendicitis forms a major portion of hospital admissions in developed as well as developing countries. It is most commonly seen in young adolescent patients but no age is immune to this condition. Males are more commonly affected than females. Acute appendicitis is usually diagnosed clinically in patients presenting with typical history and clinical examination findings. The patients with lesser duration of symptoms usually have non perforated appendix while those having a longer duration of symptoms with signs of peritonitis are more likely to have perforated appendix. Appendicectomy is the treatment of choice. This study is conducted to study acute appendicitis with an emphasis on analyzing the difference in perforated and non perforated appendicitis in context with their presentation, intra-operative features, postoperative outcome and treatment options available for these cases. Aims and Objectives: (1)To study the clinical pattern of presentation and to analyze the difference in the anatomical , biochemical, microbiological and histological determinants in patients of perforated and non perforated acute appendicitis .(2) To evaluate the intraoperative features and postoperative outcome in patients with acute appendicitis presenting with or without perforation. (3) To evaluate the relative importance of these determinants, effect of preoperative delay, pre-hospital antibiotic therapy with postoperative morbidity of perforated acute appendicitis. Methods: This was a clinical prospective study comprising of 150 Patients presenting to a tertiary care centre with intra-operative findings of appendicitis conducted in the department of general surgery, in a postgraduate teaching institute and tertiary medical centre, in Mumbai over a period of 2 years. Results: The analysis of age distribution of the studied cases revealed that most of the patients were in their 2nd or 3rd decades of life. Maximum patients belonged to age group of 20-29 years (22.67%) and 30-39 years (18.67%). There was a male preponderance with the M:F ratio being 1: 0.57.Majority of the patients (64%) has symptoms less than that of 5 days duration. In patients presenting with perforated appendix 34/75 (45.33%) had duration of symptoms between 3-5 days and 20/75 (26.67%) had duration of symptoms between 6-7 days. The duration of symptoms less than 2 days was less commonly associated with perforation and was seen in 21.95% patients. Patients having perforated appendix most commonly presented with symptoms of abdominal pain (100 %), signs of localised peritonitis (85.33%), fever (49.33%), generalised peritonitis (48%) and vomiting (41.33%). In cases of Non-perforated appendix the patients most commonly presented with abdominal pain (100%), localised peritonitis (68%), fever (53.33%), vomiting (52%) and signs of generalized peritonitis (14.66%). Conclusion: Acute appendicites is a common surgical condition. T...