Bikramjit Pal | Manipal Academy of Higher Education (original) (raw)

Papers by Bikramjit Pal

Introduction: The practice of high-fidelity simulation-based medical education has become a popul... more Introduction: The practice of high-fidelity simulation-based medical education has become a popular small-group teaching modality across all spheres of clinical medicine. High-fidelity simulation (HFS) is now being increasingly used in the context of undergraduate medical education, but its superiority over traditional teaching methods is still not established. The main objective of this study was to analyse the effectiveness of HFS-based teaching over video-assisted lecture (VAL)-based teaching in the enhancement of knowledge for the management of tension pneumothorax among undergraduate medical students. Methods: A cohort of 111 final-year undergraduate medical students were randomised for this study. The efficacy of HFS-based teaching (intervention group) and VAL-based teaching (control group), on the acquisition of knowledge, was assessed by singlebest answer multiple choice questions (MCQ) tests in the first and eighth week of their surgery posting. Mean and standard deviation (SD) for the total score of MCQ assessments were used as outcome measures. ANCOVA was used to determine the difference in post-test MCQ marks between groups. The intragroup comparison of the pre-test and post-test MCQ scores was done by using paired t-test. The P-value was set at 0.05. Results: The mean of post-test MCQ scores were significantly higher than the mean of pre-test MCQ scores in both groups. The mean pre-test and post-test MCQ scores in the intervention group were slightly more than those of the control group but not statistically significant. Conclusion: There was a statistically significant enhancement of knowledge in both groups but the difference in knowledge enhancement between the groups was insignificant.

Introduction: Simulation is the imitation of the operation of a real-world process or system over... more Introduction: Simulation is the imitation of the operation of a real-world process or system over time. Innovative simulation training solutions are now being used to train medical professionals in an attempt to reduce the number of safety concerns that have adverse effects on the patients. Objectives: (a) To determine its usefulness as a teaching or learning tool for management of surgical emergencies, both in the short term and medium term by students' perception. (b) To plan future teaching methodology regarding hi-fidelity simulation based on the study outcomes and re-assessment of the current training modules. Methods: Quasi-experimental time series design with pretest-posttest interventional study. Quantitative data was analysed in terms of Mean, Standard Deviation and standard error of Mean. Statistical tests of significance like Repeated Measure of Analysis of Variance (ANOVA) were used for comparisons. P value < 0.001 was considered to be statistically significant. Results: The students opined that the simulated sessions on high fidelity simulators had encouraged their active participation which was appropriate to their current level of learning. It helped them to think fast and the training sessions resembled a real life situation. The study showed that learning had progressively improved with each session of simulation with corresponding decrease in stress. Conclusion: Implementation of high fidelity simulation based learning in our Institute had been perceived favourably by a large number of students in enhancing their knowledge over time in management of trauma and surgical emergencies.

Background: The study is to determine the relation between the high HbA1c and ESR as prognostic f... more Background: The study is to determine the relation between the high HbA1c and ESR as prognostic factors with the severity of the diabetic foot ulcer disease, particularly, in predicting the final outcome in the form of higher incidence of lower extremity amputation (LEA) and/or prolonged hospital stay. The study explored the importance of increased level of serum HbA1c and erythrocyte sedimentation rate (ESR) in determining the final outcome of the disease. It revealed that the severity of diabetic foot ulcer disease is more in patients who had concomitant high levels of baseline HbA1c and ESR on admission. Methods: This observational study was done in 89 patients who were admitted in the surgical wards of the two teaching hospitals in India. The cohort consisted of patients from the age of 26 to 83 years of age who presented with clinically infected foot ulcers. Routine blood tests were done which include HbA1C on the day of admission and fasting ESR (1st hour) on the next day morning. The standard X-ray plates were routinely taken on the first day for determination of the involvement of underlying bones and soft tissues. The outcome of the diabetic foot ulcer was assessed from the severity of the disease according to Meggit-Wagner classification, the incidence of lower extremity amputation and the duration of hospital stay. Results: The high levels of baseline HbA1C (more than 7.0%) in blood on the first day of admission was found in all of the 89 patients who were included in this study but the criteria for consideration of high risk was more than 9% which was found in 41 patients. The criteria for consideration of high ESR in this study was set to be 50 mm/h. High ESR of more than 50 mm was found in 63 patients. We had subdivided 31 patients into a High Risk Group whose baseline levels of HbA1C > 9% and ESR > 50 mm/h. The incidence of amputation was 79.31% and 44.44% with HbA1c of more than 9.0% and ESR of more than 50 mm respectively and was considerably increased (83.87%) when both HbA1c and ESR were more than the critical value as set in the study. Similarly, the incidence of prolonged hospital stay of more than 14 days was 58.54% in patients with HbA1C level of greater than 9 %, 51.85% in patients with baseline ESR > 50 mm/h and 93.55% in presence of high levels of both HbA1C (>9%) and ESR (>50 mm/h).. Conclusions: The study observed that the patients who presented with baseline high levels of HbA1C, ESR or both on admission had unfavourable prognosis with increased incidence of lower extremity amputation and prolonged hospital stay than the other patients in the cohort. .

Biliary strictures both benign and malignant, remain one of the most difficult problem encountere... more Biliary strictures both benign and malignant, remain one of the most difficult problem encountered by the surgeons. The vast majority of bile duct strictures are iatrogenic and occur mainly as a complication of cholecystectomy, despite greater awareness of the problem and safer techniques of dissection during biliary surgery. Malignant strictures involving the bile ducts remain a major challenge in biliary surgery and may result either from cancers afflicting the ducts, primarily or involving them by extension from the liver, the gallbladder, the pancreas, the papilla of Vater or the duodenum or from adjacent lymph nodes. In our study, this procedure was done in 10 patients (41.7%) where high biliary strictures were found. The surgical management of biliary stricture has reached a level of 66.7% successful outcome in this series due to the selection of an optimum operative procedure and its conduct by following well established principles. Our experience also suggests that an improv...

Primary Carcinoma of the Jejunum is very rare and very difficult to diagnose before surgery. No d... more Primary Carcinoma of the Jejunum is very rare and very difficult to diagnose before surgery. No definite investigations are available to come into a pre-operative diagnosis though barium meal studies and capsule endoscopy may help in some cases to arrive at a proper diagnosis. It is characterized by hidden and non-specific symptomatology. Our patient presented with sub-acute intestinal obstruction with dyselectrolytemia due to persistent vomiting. The patient was subjected to a battery of tests and most of them were inconclusive. Ultimately an exploratory laparotomy with resection of diseased segment of jejunum and histopathological examination confirmed the diagnosis of primary carcinoma of jejunum. KEY WORDS: Primary carcinoma of jejunum; Adenocarcinoma of jejunum; Small intestinal malignancy. CASE REPORT: A 48 years female patient was admitted in this hospital in March, 2012 with complaints of acute upper abdominal pain with projectile vomiting and abdominal distension. She gave a history of intermittent acute pain in the upper abdomen with fullness of abdomen which started 3 months prior to admission. The pain and fullness were relieved after 2 to 3 bouts of vomiting and the patient refrained from taking solid food at night and preferred liquid diet. There was no history of fever, hematemesis, melena or past abdominal surgery. There was mild weight loss about 3 kg in last 3 months. Routine blood tests were normal except mild anaemia. Stool for occult blood test was negative. USG abdomen revealed mild hepatomegaly. UGI Endoscopy showed minute superficial ulcers in the duodenum. Colonoscopy revealed erythematous patches in caecum and ascending colon; biopsy from it came out to be chronic non-specific colitis. Small bowel enema was tried but failed. Barium meal X-ray revealed grossly dilated jejunal loops with abrupt cut off suggestive of intussusception. CECT abdomen could not be done due to residual barium in the intestines. Exploratory laparotomy was done as medical management failed and no definite diagnosis could be made. A stricture was found about 150 cm from duodeno-jejunal flexure. Wide resection of the stricture with adequate normal margin followed by end to end anastomosis was done. The post operative period was uneventful and the patient was discharged after 12 days. The biopsy revealed well differentiated adenocarcinoma; no lymphovascular or perineural invasion; resection margins were free of tumour; TNM –stage-pT3NxMx. The patient was subjected to adjuvant oral chemotherapy. CECT abdomen and thorax were done after 1 month revealed no abnormality except mild thickening in distal jejunal wall with mild hepatomegaly. The patient was subjected to full course of adjuvant oral chemotherapy. Regular follow up were done and the patient is fine till date.

Littre's Hernia is an abnormal protrusion of Meckel's Diverticulum through an abdominal opening. ... more Littre's Hernia is an abnormal protrusion of Meckel's Diverticulum through an abdominal opening. Alexis Littre first described the condition in relation to a femoral hernia in 1770 (1). It is a very rare condition and very few cases are reported till date. Meckel's diverticulum is the most common congenital abnormality of the gastrointestinal tract. It is a true diverticulum found in the anti-mesentric border. It is the remnant of the persistent intestinal part of the vitello-intestinal or omphalo-enteric duct and comprises of all intestinal layers (2, 3, 4). It is found in 2% of total population, 2 feet from ileo-caecal junction and 2 inches in length, 2 types of common ectopic tissue (gastric and pancreatic). Meckel's diverticulum may be accompanied in the sac by the ileal loop to which it is attached; rarely, it may undergo incarceration or strangulation, necrosis, and perforation. In children, it is mostly found in umbilical hernias in which case it is more prone to adhere to the sac. Intestinal obstruction may occur due to volvulus, intussusception or very rarely as a complication of Littre's hernia (2, 3, 5). Its diagnosis is usually difficult despite the availability of modern investigative tools. A high index of suspicion is mandatory. In most cases it is an incidental finding. Hernial obstruction and strangulation of Meckel's diverticulum (Littre's Hernia) is a rare phenomenon and representing 10% of all complications of Meckel's diverticulum (6, 7). Surgery is the mainstay of treatment. We herein present an extremely rare case of strangulated Meckel's diverticulum in a Ventral Hernia (Littre's Hernia) which only became evident during surgery. The ventral hernia developed following emergency appendicectomy operation done for acute appendicitis 5 months back. CASE REPORT: A 47 years old male patient was admitted through Emergency with complaints of diffuse abdominal pain with distension, intermittent vomiting, dyspepsia and anorexia for last 2 days. There was no history of loose motion, fever or bleeding per rectum. The patient had undergone emergency appendicectomy five months back. On clinical examination, tachycardia (110 / minute) was noted, blood pressure was 146/90 mm. of Hg and slightly dehydrated; a very tender irreducible lump was found at the region of scar (right lower paramedian incision) of previous appendicectomy operation; absent peristaltic sounds. The cough impulse was absent. Examination of other systems was unremarkable. Straight X-ray abdomen showed multiple distended bowel loops with fluid levels; Ultrasound scan suggested an obstructed loop of intestine at the hernia site. The diagnosis of strangulated ventral hernia was made and emergency surgery was planned after resuscitation with IV fluids and antibiotics. Abdomen was opened through the scar of the previous appendicectomy operation; careful and meticulous dissection revealed the hernia sac which was opened; foul smelling dirty fluid was mopped up and the constricting ring-like formation in the anterior sheath was cut. The sac contained the inflamed Meckel's diverticulum with a part (about 5 cm) of ileum. The whole of

The study is to determine the common risk factors affecting the diabetic foot ulcer disease with ... more The study is to determine the common risk factors affecting the diabetic foot ulcer disease with its implications and the severity of the disease in relation to the socioeconomic status, level of education, concomitant hypertension anddyslipidemiawith particular correlation to the incidence of amputation.The study was done in 53 patients admitted in the surgical ward of a large private medical college hospital in Kolkata, India over a period of one year. The selected patients were randomly selected as per criteria of modified Kuppuswamy's socioeconomic scale 2007 for the urban population in India, with education level from primary school (up to Class VIII) to post-graduation. The severity of the ulcers were determined by Wagner classification and the patients were managed either conservatively or surgically (wound debridement or amputation).It has been found from this study that the incidence and severity of diabetic foot ulcer is more in patients with lower socioeconomic status and low education level, especially in females. 86.79% of the patients developed the foot ulcer after a minor trauma, friction or injury due to a foreign body, apparently may be due to the habit of walking bare foot and ignorant about optimum foot care. A strong correlation is found in patients suffering from hypertension (58.49% of the total patients) and the severity of the foot ulcer disease. Dyslipidemia as determined by serum LDL level in our study, was found to be abnormal in 86.79% of patients which may be a significant prognostic indicator for the development and severity of diabetic foot ulcer disease. Surgical intervention had to be done in 62.26% of patients and ultimately 28.30% of them undergone amputation, mostly in Wagner Stage IV foot ulcers. The incidence of amputation was highest in female patients with low education level and socioeconomic status. ulcer, , education level and diabetic foot disease, hypertension and diabetic foot disease, serum LDL and diabetic foot disease, socioeconomic status and diabetic foot ulcer disease.

ABSTRACT Background: The study is to determine the relation between severity of the diabetic foot... more ABSTRACT
Background: The study is to determine the relation between severity of the diabetic foot ulcers and the organisms
isolated from the wounds; its implications and prognosis with particular reference to the differences in the final
outcome depending upon the type of organism infecting the wound. The study try to correlate the severity of the
diabetic foot infection according to Meggit-Wagner classification, the incidence of amputation and the impact on the
hospital stay with the difference of bacterial flora isolated from the wounds. This is an observational study done in 53
patients who were admitted in the surgical ward of a large private medical college in Jadavpur, India. It has been
found from this study that the incidence and severity of diabetic foot ulcer is more in patients with some particular
type of bacteria found in their wounds. A strong correlation is found in patients whose wounds were infected with
some particular bacteria had resulted in more severe type of foot ulcers with higher incidence of amputation and
concomitant longer hospital stay.
Methods: An observational study was done in 53 patients who were admitted in the surgical ward of a teaching
hospital in Kolkata, India. The youngest patient was aged 28 years and the oldest patient was 83 years of age. All of
them presented with clinically infected foot ulcers. The patients were explained about the study methods in their own
language and due consent was taken. A standardized proforma in English, Hindi and the vernacular languages was
made for recording the necessary data. The standard X-ray plates were taken into consideration for determination of
the involvement of underlying bones. The microbiological studies were done in all patients from the wound swabs of
the foot ulcers. The outcome of the diabetic foot ulcer was assessed from the severity of the disease, the presence of
the different bacterial flora in their wounds, the incidence of amputation and the duration of hospital stay.
Results: The positive wound culture was found in 67.92 of patients, Methicillin resistant Staph. aureus (MRSA) was
the commonest isolated organism (44.44%) followed by mixed bacterial flora (Staph. aureus, Streptococcus
epidermidis, Peptococcus, and Bacteroides fragilis) in 16.98% of patients. ESBL Klebsiella was found in 13.89% of
patients, Pseudomonas aeruginosa and Enterococcus feacalis were isolated in 8.33% of patients. 80% of ESBL
infected wounds presented with Grade IV ulcers. The incidence of amputation was highest in patients whose wounds
were colonized by MRSA and 60% of patients with ESBL Klebsiella infected wounds had hospital stay of more than
three weeks.
Conclusions: The study observed that the prognosis and outcome of a diabetic foot ulcer vary considerably with the
specific type of bacteria colonizing the wound.
Keywords: Diabetic foot ulcer, Wagner classification of diabetic foot ulcers, Bacterial flora and diabetic wounds,
Amputation and diabetic foot ulcer disease, Hospital stay and diabetic foot ulcer disease.

ABSTRACT Background: This is an observational study to determine the relation between the life st... more ABSTRACT
Background: This is an observational study to determine the relation between the life style factors like smoking and chronic alcoholism with the severity of the diabetic foot ulcer disease; its implications and prognosis and outcome with particular reference to the incidence of amputation and the duration of the hospital stay. This study was done in 89 patients who were admitted in the surgical wards of two large private medical colleges in India: KPC Medical College and Hospital, Kolkata, West Bengal and Bhaskar Medical College and Hospital, Yenkepally Village, Ranga Reddy District, Telengana. In our study, we explored the relationship between two determinant factors - smoking and chronic alcoholism with the increased incidence of amputation and prolonged hospital stay in a diabetic cohort. It has been found from this study that the severity of diabetic foot ulcer disease is more in patients who were addicted to either smoking, alcohol or both.
Methods: The study was done on 89 patients who were admitted in the surgical wards of the following teaching hospitals in India - KPC Medical College and Hospital which deals mostly with middle income group of urban population (Rs.7594 to 15188) and Bhaskar Medical College and Hospital which deals mostly with low income group of semi-urban population (Rs.4556 to 11361) as per Kuppuswamy’s socio-economic status scale (updating for 2012). The youngest patient was from semi-urban area aged 26 years and the oldest patient was from urban area aged 83 years. The outcome and prognosis of the diabetic foot ulcer disease were assessed with the incidence of amputation and duration of hospital stay in relation to the two determinant factors of smoking and alcoholism.
Results: The diabetic patients who were smokers and/or chronic alcoholic underwent more amputations with concomitant longer hospital stay than the patients who had no addiction to these substances. The prognosis was worse in the subgroup of patients who were both smoker and chronic alcoholic.
Conclusions: The study observed that the prognosis and outcome of a diabetic foot ulcer disease changes significantly in patients who are addicted to smoking and alcoholism with higher incidence of amputation and longer hospital stay.
Keywords: Diabetic foot ulcer disease, Wagner classification of diabetic foot ulcer disease, Smoking and diabetic foot ulcer, Alcoholism and diabetic foot ulcer, Amputation and diabetic foot ulcer disease, Hospital stay and diabetic foot ulcer disease.