Blunt trauma to the abdomen can result in various injuries which are potentially fatal if not promptly recognized and treated. Mechanism of injury, anatomical location, patient demographics, and clinical profile play crucial roles in diagnosis and management. The article presents 2 cases illustrating the challenges, and successful management of isolated jejunal injuries, and highlight the significance of early recognition and surgical intervention. These injuries are rare and there needs to be a high index of suspicion, especially in cases with atypical presentation. The cases in this article underscore the critical role of early surgical intervention in achieving optimal recovery and reducing the morbidity and mortality associated with isolated jejunal injuries. Clinicians need to consider the possibility of small bowel perforation following apparently trivial injuries, and employ a comprehensive approach to managing abdominal trauma.

Blunt trauma to the abdomen can result in various injuries which are potentially fatal if not promptly recognized and treated. Mechanism of injury, anatomical location, patient demographics, and clinical profile play crucial roles in diagnosis and management. The article presents 2 cases illustrating the challenges, and successful management of isolated jejunal injuries, and highlight the significance of early recognition and surgical intervention. These injuries are rare and there needs to be a high index of suspicion, especially in cases with atypical presentation. The cases in this article underscore the critical role of early surgical intervention in achieving optimal recovery and reducing the morbidity and mortality associated with isolated jejunal injuries. Clinicians need to consider the possibility of small bowel perforation following apparently trivial injuries, and employ a comprehensive approach to managing abdominal trauma.

Blunt trauma to the abdomen can result in various injuries which are potentially fatal if not promptly recognized and treated. Mechanism of injury, anatomical location, patient demographics, and clinical profile play crucial roles in diagnosis and management. The article presents 2 cases illustrating the challenges, and successful management of isolated jejunal injuries, and highlight the significance of early recognition and surgical intervention. These injuries are rare and there needs to be a high index of suspicion, especially in cases with atypical presentation. The cases in this article underscore the critical role of early surgical intervention in achieving optimal recovery and reducing the morbidity and mortality associated with isolated jejunal injuries. Clinicians need to consider the possibility of small bowel perforation following apparently trivial injuries, and employ a comprehensive approach to managing abdominal trauma.

Approximately 20% of hepatocellular carcinomas (HCC) occur in noncirrhotic livers. Resection may be considered for patients with HCC, provided sufficient future liver remnant is available, regardless of the tumor size. Tumors located posteriorly near the right hepatic vein (RHV), or inferior vena cava can be managed through anterior or caudal approaches. RHV is typically conserved during right posterior sectionectomy. When a large posteriorly placed tumor causes chronic compression on RHV, the right anterior section drainage is redirected preferentially to the middle hepatic vein. The division of RHV in such instances does not cause congestion of segments 8 and 5. The technical complexity of laparoscopic right posterior sectionectomy arises from the large transection surface, positioned horizontally. We describe in this multimedia article, a case of large HCC in segments 6 and 7, which was successfully treated using laparoscopic anatomic right posterior sectionectomy.

Background: One of the symptoms annoying patients after total knee replacement (TKR) is numbness around the operative scar. Some studies have shown that altering the incision in terms of placement or length may decrease the incidence of numbness. It still remains unknown whether numbness affects patient-reported outcomes. Methods: We conducted a randomized study to compare a short-length incision (n = 50) and a lateral exit incision (n = 50) with a standard midline TKR incision (n = 50) in terms of the incidence of numbness and its progress over 1 year of follow-up. Our secondary objective was to look at the involved zone, area of numbness, and secondary symptoms. We also looked at patient-reported outcome in terms of satisfaction in all groups using a visual analog scale and Forgotten Joint Score. Results: At 3 months postoperatively, the incidence of numbness was least in the lateral exit group: 46.2% as compared to midline (62%) and short (58.3%), but the difference was not significant (p = 0.07). At 6 months, the short incision group had a significantly lower incidence (8%) of residual numbness as compared to 30% in the other two groups (p = 0.003). At 1 year, most patients recovered sensation loss and had similar function. Conclusions Placement or length of an incision did not significantly affect the incidence of numbness; however, the short incision led to early recovery of numbness. At 1 year of follow-up, most patients did not complain of loss of sensation and had similar functional outcome.

Background: With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies. Methods: This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA. Results: TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (p = 0.039). The commonest complication was pulmonary thromboembolic, 6 in each group. Blood transfusion rate was higher in the SP group (6%) than in the RM group (< 1%). Conclusions Screening and RM can reduce 90-day complications in patients undergoing TKA.

Background: With a quest to optimize outcomes, there have been significant advancements in modern designs of total knee implants, attempting to mimic the natural knee motion and feel. One such new design reproducing the medial and lateral knee pivot is a dual-pivot (DP) knee. In the present study, we endeavored to compare the performance of the DP knee vis-a-vis an ultracongruent (UC) Knee design. Methods: This prospective cohort study was performed in a joint replacement center of a tertiary care military hospital. We enrolled 50 patients each in the DP knee group and the UC knee group and assessed knee flexion, patient-reported outcome (new Knee Society Score [nKSS]), patient performance (Delaware Osteoarthritis Profile Score), and function Forgotten Joint Score [FJS]) at 2 years of follow-up. Results: The nKSS was similar in the two groups. In the DP group, patients had significantly better improvement in the stair climb test (p = 0.026). In the UC group, timed up and go test was significantly better (p = 0.004). The gain in knee flexion was similar in the two groups: 26.3° ± 23.3° in the DP group and 27.5° ± 27.5° in the UC group (p = 0.930). Return to activity as judged by 2-year FJS was similar in both groups (p = 0.687). Conclusions Our study showed that the DP knee design had similar knee function to the UC knee. The DP knee design had significantly better stair climbing ability, whereas getting up from chair was better in the UC knee design. With comparable patientreported outcome and possible differences in patient performance in terms of day-to-day activities, any future trial should focus on comparing patient performance.

Hospitals ; Humans ; Nursing Staff ; Perception ; Surveys and Questionnaires

Background: The indications for total knee arthroplasty (TKA) have been expanded to include younger, demanding patients. Some TKA patients expect a return to high-performance activities to restore optimum quality of life. The concept of the medial pivot (MP) TKA is that more natural knee kinematics can be achieved by altering the bearing design. In the present study, we compared the early outcomes of MP TKA with posterior-stabilized (PS) TKA in terms of patient-reported outcomes, function, and performance. Methods: This randomized study was performed in a high volume joint replacement facility of a tertiary care military hospital. We enrolled 40 patients each in the MP group and PS group and assessed knee flexion, patient-reported outcome (new Knee Society Score [new KSS]), patient performance (Delaware Osteoarthritis Profile Score [DOPS]), and function (Forgotten Joint Score [FJS]) at 2 years after surgery. Results: Compared to PS group patients, MP group patients had similar patient-reported outcomes assessed by new KSS (satisfaction, expectation, and activity scales) and FJS. MP knee patients had better performance in the timed up and go test (p < 0.026) and self-paced walk test (p < 0.002) of DOPS. The gain in knee flexion (9.3° ± 14°) compared to baseline was significantly greater in the PS group (p < 0.013). Conclusions When assessed by DOPS, getting up from chair and walking speed were significantly better in MP knee patients than in PS knee patients. However, considering the predictable rollback ensured by cam and post, the PS knee produced better knee flexion. Despite these results, patients were equally satisfied with the two designs.

Sleep disturbance is common in the elderly and is frequently undiagnosed. It has been estimated that 75 percent of adults >65 years of age has sleep disturbance and 30 percent of them has insomnia. The classification of insomnia has less significance in the older adults as the subtypes demonstrate significant overlap and usually treatment of the underlying disorder does not solve the problem or cure it. The elderly has multiple comorbidities and poly pharmacy with a myriad of cause for insomnia. A comprehensive medical and psychiatric history together with a complete physical examination and mental state examination should be done in the evaluation of the older patient. Behavioural therapy with sleep hygiene education should be the initial treatment together with the treatment of the contributing physical and psychiatric conditions. Referral to an expert for cognitive behavioural therapy or multicomponent therapy may be necessary if the initial therapy failed to produce any improvement. If medications are needed it can be combined with behavioural therapy. Medication used should be the lowest effective dose and prescribed for shortterm use of not more than four weeks. Medications used need to be discontinued gradually and one needs to be mindful of rebound insomnia upon withdrawal. Whenever possible, it will be ideal to avoid benzodiazepines and other sedative hypnotics as first choice for insomnia. Over the counter sleep aids which usually contain antihistamines may not be good choices as they carry significant risk of adverse events and drug interactions. Currently the safest medications for use in the elderly includes the Z-drugs (zolpidem, zopiclone), melatonin and low dose tricyclic antidepressant Doxepin.