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SYNOPSIS
COMPLICATIONS AND
MANAGEMENT OF HAND
INFECTIONS
SYNOPSIS SUBMITTED FOR APPROVAL BY ETHICAL
COMMITTEE BY
DR. AJIT MISHRA
FOR BRANCH MS (GENERAL SURGERY)
DOCUMENTS FOR DISSERTATION
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CHECK-LIST ENCLOSURES (DISSERTATIONS)
For submission of Research proposal to
Ethics Committee of B.J.M.C. and S.G.H. Pune
1] Cover Page (Appendix 1)
2] Check-List Enclosures (Dissertations)
1. Research Proposal (Appendix 2)
1. a Part IGeneral Information
1. b Part IIOne page executive summary sheet
1.c Part III - Details of Research Proposal2. Inform Consent (Appendix 3)
2. a English
2. b Marathi
2. c Hindi
3. Application for Permission for Animal Experiments
(Appendix 4)
4. PI undertaking (Appendix 5)5. Certificate from HOD (Appendix 6)
------------------------------------------------------------------------------
Research proposal should be submitted inA) Hard copy: i. e. PrintoutsOne Copy only
B) Soft Copy: On C D /DVD;Preferably in *.pdf format
OR in Word document format
Appendix 1:
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Cover Page (for Dissertations)
For submission of Research proposal to
Ethics Committee of B.J.M.C. and S.G.H. Pune
1.Full Name of PG Student:
Dr. MISHRA AJIT MATAPRASAD
2.Department: SURGERY
3.Candidate admitted in the year: 2011
4.Course and subject: SURGERY
5.College Name & Address:
B.J.MEDICAL COLLEGE, PUNE.
6 Title of Research Project topic:COMPLICATIONS AND MANAGEMENT OF
HAND INFECTIONS
7. Full name of P.G. Guide :Dr. SHAILAJA P.
JADHAV
8. Contact phone number of PG Student: 9324381753
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Appendix 2:
Research Proposal
For submission of Research proposal toEthics Committee of B.J.M.C. and S.G.H. Pune
PART I : GENERAL INFORMATION
1. TITLE OF THE PROJECT :COMPLICATIONS AND MANAGEMENT OF
HAND INFECTIONS
2. NAME AND DESIGNATION OF :
a) Postgraduate Guide:DR.SHAILAJA P. JADHAVPROFESSORDEPT OF SURGERY
B.J.MEDICAL COLLEGE, PUNE.
b) Postgraduate Student:
Dr. MISHRA AJIT MATAPRASADRESIDENT
DEPT OF SURGERY
B.J.MEDICAL COLLEGE, PUNE.
3. DURATION OF THE PROJECT :
a) Period that may be required for data collection : 2 YEARb) Deadline for collecting data : JUNE2013
c) Period that may be required for analysis of data : 6 MONTHSd) Deadline for analysis of data : DEC 2013
4. DEADLINE FOR SUBMISSION OF THE
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DISSERTATION TO THE UNIVERSITY : DEC 2013
5. REVIEW OF PROGRESS :
Reviews 1st
quarter 2nd
quarter 3rd
quarter
Review of progress of
project
Review of collection of
data
Review of analyzed data
6. SIGNATURES :
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a) Postgraduate student :
b) Postgraduate guide :
c) Head of dept,Dept of surgery,B.J.Medical college, pune.
d) Head of dept,Dept of Radiodiagnosis,,
B.J.Medical college, pune
e) Head of dept ,
Dept of surgery,B.J.Medical college, pune
7. a) Date of submission to ethical committee :
b) Date of clearance of the committee:
c) Remarks of the secretary:
PART II :ONE PAGE EXECUTIVE SUMMARY SHEET
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1) Title of the Project:- COMPLICATIONS AND MANAGEMENT OF
HAND INFECTIONS
2) Name of the PG guide:- DR. SHAILAJA P. JADHAV
3) Name of the PG Student:- DR. MISHRA AJIT MATAPRASAD
4) Name of the Department:- SURGERY
5) Name of the Institute:- B.J.MEDICAL , PUNE.
6) Aims & Objectives:-
Early diagnosis and management of various hand infections
Early detection of complications of hand infections andtheir management
Preserve optimal function of hand following infection
7) Introduction:.
Few structures of the body are as complex or as unique as
the human hand with the functions of sensation, mobility,and strength in one small area. The hand consists of multiple
compartments and planes, the knowledge of which allows
one to understand the pathophysiology, diagnosis, and
treatment of hand infections The hands compartmentalized
anatomy is one of the reasons why the hand is more prone to
infections.
Seemingly simple infections of the hand can more often
result in debilitating conditions and significant morbidity.
The hand being one of the more important functional organs
required in day to day physical activities, it becomes
important that such morbid conditions should be diagnosed
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and treated effectively at an early stage so that the function of the
hand can be well preserved. If an infection is not appropriately
diagnosed and treated, significant morbidity can result.
8) Material & Methods:-
Sample size- All cases admitted between period June 2011June 2014
Number of cases- 25
Type of study- Prospective
Duration of study:- 2 years
9) Risks Involved:- This is not an interventional study so complications related toprocedure and anesthetic complications are the only risk involved in this study.
PART III : DETAILS OF RESEARCH PROPOSAL
1. TITLE OF THE PROJECT : COMPLICATIONS AND
MANAGEMENT OF HAND INFECTIONS
2. AIMS AND OBJECTIVES
Early diagnosis and management of various hand infections
Early detection of complications of hand infections and
their management
Preserve optimal function of hand following infection
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3. INTRODUCTION (Background information)
Few structures of the body are as complex or as unique as the human
hand with the functions of sensation, mobility, and strength in one
small area. The hand consists of multiple compartments and planes,the knowledge of which allows one to understand the
pathophysiology, diagnosis, and treatment of hand infections The
hands compartmentalized anatomy is one of the reasons why the
hand is more prone to infections.
Seemingly simple infections of the hand can more often result in
debilitating conditions and significant morbidity. The hand being one
of the more important functional organs required in day to day
physical activities, it becomes important that such morbid conditionsshould be diagnosed and treated effectively at an early stage so that
the function of the hand can be well preserved. If an infection is not
appropriately diagnosed and treated, significant morbidity can result.
A thorough understanding of hand and finger anatomy and
knowledge of the bacteria commonly involved in infections of the
upper extremity are required of the surgeon who will be caring for
these patients. An understanding of the fascial boundaries of thehand will help to identify the extent of the infection and plan surgical
incisions.
Host factors, location, and circumstances of the infection are
important guides to initial treatment strategies. Many hand infections
improve with early splinting, elevation, appropriate antibiotics and, if
an abscess is present, incision and drainage..
4. MATERIAL & METHODS
Sample size-All cases admitted between period June 2011 June
2013
Number of cases -25
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Type of study- Prospective
Duration of study:-2 years
5.
DETAILED RESEARCH PLAN
(Groups / Procedures etc)
Patients will be selected according to the selection criterion i.e- All patients belonging to all age groups having hand infections will be
included in the study.
Selected patients will be evaluated by- Proper history
- clinical examination
- Investigations
Plan of the study-
All patients coming to the casualty and outdoor patient department with
non specific complaints associated with hand infections such as pain,
swelling, redness, pus and discharge will be evaluated. One important
aspect of this study will be follow up of these patients.
Various conditions that will be considered in this study are:
1)Paronychia
2)Herpetic whitlow
3)Felon
4)Tenosynovitis
5)Secondary infections of post traumatic crush injuries.
6)Cellulitis
7)Infections of the joint spaces, web spaces and palmar spaces
The aim of this study will be early diagnosis and treatment of hand
infections. This is important as more often than not hand infections
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go undiagnosed and are associated with significant morbidity and
devastating complications such as stiffness, contractures and
amputation.
One important life threatening condition is necrotizing fasciitiswhich because of its spreading nature requires early diagnosis and
early surgical management.
A detailed understanding of the anatomy of the hand is essential
for the appropriate surgical management of hand infections. This
includes the following:
1)bones and joints2)skin
3)palmar spaces
4)muscles and tendons
One of the most common causes of hand infections is penetrating
trauma which introduces various organisms most common ones
being staphylococci and streptococci. In immunocompromisedconditions and diabetes mellitus gram negative and anaerobic
organisms have also been implicated.
Patients will be evaluated under the following criteria:
1)history2)clinical findings- local and systemic findings3)laboratory investigations blood culture, blood sugar levels,
blood counts
4)gram staining, anaerobic cultures to identify the causativeorganisms.
5)Radiological investigations such as x-rays to rule outinvolvement of bones and joints and to exclude fractures and
foreign body.
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Management:
Goal of treatment of hand infections is rapid and full recovery of
function as well as prevention of complicationsManagement includes:
1)Conservative management2)Active surgical mangement
Conservative line of management is usually adopted in the early
stages of the disease when the infection has been diagnosed 24-48
hours after the onset.
It includes:
1)Splinting2)Elevation of limb3)Moist heat to the affected part4)Systemic antibioticsoral or intravenous
Following conservative treatment, follow up of the patient will be
done. Decrease in presenting symptoms will be indicative of
effectiveness of conservative treatment while increase in
symptoms and local skin changes(increased swelling, redness,tenderness, pus discharge)will be indicative of failure of
conservative treatment thus compelling the need for active surgical
treatment.
Surgical treatment is considered when conservative means fail to
control the infection.
1)Open drainage
2)Debridement
Thus in conclusion, my study aims at treating hand infections at an
early stage so that the optimal function of the hand can be
preserved. Complications include septicemia, gangrene,
contractures, amputation of the involved limb.
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6. SELECTION OF CASES (Inclusion & Exclusion Criteria)
Case selection (Inclusion criterion)
All patients having hand infections.
7. CASE RECOD FORMS :-
1. Name2. Age3. Sex4. Address5. Occupation6. Religion7. Chief complaints8. History
9. Past history
10.Any trauma related history
11.Any other relevant past surgical procedure performed
General examination
Temperature
Pulse
Respiration
Blood pressure
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Respiratory rate
Weight
Pallor\ icterus\ cyanosis\clubbing
Lynphadenopathy \edema
C.V S examination
Respiratory system examination
C.N S examination
Examination for cervical spine and thoracic outlet syndrome
Examination of distal circulation(radial and ulnar pulsation)
9. PARAMETERS :
Routine lab Investigations
- Hb
- BT/CT
- Urine examination
- Blood sugar
- Renal profile
- Liver profile
- HIV and HbSAg testing
Radiological investigations
- X-ray
- Ultrasound
- MRI
10 FACILITIESAVAILABLE:
- O.T for surgery
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- Basic surgical instruments
12. REQUIREMENTS :
- O.T for surgery
- Basic surgical instruments
13.REFERENCES :
1. Hausman MR, Lisser SP. Hand infections. Orthop Clin North Am. 1992;23:17185.
2. Nathan R, Taras JS. Common infections in the hand. In: Hunter JM, Mackin E, Callahan AD, eds. Rehabilitation of
the hand: surgery and therapy. 4th ed. St. Louis: Mosby, 1995:25160.
3. Moran GJ, Talan DA. Hand infections. Emerg Med Clin North Am. 1993;11:60119.
4. Brown DM, Young VL. Hand infections. South Med J. 1993;86:5666.
5. Krieger LE, Schnall SB, Holtom PD, Costigan W. Acute gonococcal flexor
tenosynovitis. Orthopedics. 1997;20:64950.
6. Schaefer RA, Enzenauer RJ, Pruitt A, Corpe RS. Acute gonococcal flexor tenosynovitis in an adolescent male
with pharyngitis. A case report and literature review. Clin Orthop. 1992;281:2125.
7. Townsend DJ, Singer DI, Doyle JR. Candida tenosynovitis in an AIDS patient: a case report. J Hand Surg
[Am]. 1994;19:2934.
8. Gunther SF, Gunther SB. Diabetic hand infections. Hand Clin. 1998;14:64756.
9. Bhatty MA, Turner DP, Chamberlain ST. Mycobacterium marinumhand infection: case reports and review of
literature. Br J Plast Surg. 2000;53:1615.
10. Gomperts BN, White LK. Gonococcal hand abscess. Pediatr Infect Dis J. 2000;19:6712.
11. Rockwell PG. Acute and chronic paronychia. Am Fam Physician. 2001;63:11136.
12. Jebson PJ. Infections of the fingertip. Paronychias and felons. Hand Clin. 1998;14:54755.
13. Roberge RJ, Weinstein D, Thimons MM. Perionychial infections associated with sculptured nails. Am J Emerg
Med. 1999;17:5812.
14. Harrison BP, Hilliard MW. Emergency department evaluation and treatment of hand injuries. Emerg Med Clin
North Am. 1999;17:793822.
15. Stern PJ. Selected acute infections. Instr Course Lect. 1990;39:53946.
16. Watson PA, Jebson PJ. The natural history of the neglected felon. Iowa Orthop J. 1996;16:1646.
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17. Connolly B, Johnstone F, Gerlinger T, Puttler E. Methicillin-resistant Staphylococcus aureusin a finger
felon. J Hand Surg. 2000;25:1735.
18. Karanas YL, Bogdan MA, Chang J. Community acquired methicillin-resistant Staphylococcus aureushand
infections: case reports and clinical implications. J Hand Surg. 2000;25:7603.
19. Mohler A. Herpetic whitlow of the toe. J Am Board Fam Pract. 2000;13:2135.
20. Crumpacker CS. Herpes simplex. In: Freedberg IM, Fitzpatrick TB, eds. Fitzpatrick s Dermatology in general
medicine. 5th ed. New York: McGraw-Hill, 1999:2414
26.
21. Schwandt NW, Mjos DP, Lubow RM. Acyclovir and the treatment of herpetic whitlow. Oral Surg Oral Med Oral
Pathol. 1987;64:2558.
22. Gill MJ, Arlette J, Buchan K, Tyrrell DL. Therapy for recurrent herpetic whitlow. Ann Intern
Med. 1986;105:631.
23. Laskin OL. Acyclovir and suppression of frequently recurring herpetic whitlow. Ann Intern Med. 1985;102:494
5.
24. Boles SD, Schmidt CC. Pyogenic flexor tenosynovitis. Hand Clin. 1998;14:56778.
25. Kanavel AB. Infections of the hand. Aguide to the surgical treatment of acute and chronic suppurative processes
in the fingers, hand, and forearm.7th ed. Philadelphia: Lea & Febiger, 1939.
26. Neviaser RJ. Tenosynovitis. Hand Clin. 1989;5:52531.
27. Schnall SB, Vu-Rose T, Holtom PD, Doyle B, Stevanovic M. Tissue pressures in pyogenic flexor
tenosynovitis of the finger: compartment syndrome and its management. J Bone Joint Surg [Br]. 1996;78:793
5.
28. Cardinal E, Bureau NJ, Aubin B, Chhem RK. Role of ultrasound in musculoskeletal infections. Radiol Clin
North Am. 2001;39:191201.
29. Lille S, Hayakawa T, Neumeister MW, Brown RE, Zook EG, Murray K. Continuous postoperative catheter
irrigation is not necessary for the treatment of suppurative flexor tenosynovitis. J Hand Surg. 2000;25B:3047.
30. Griego RD, Rosen T, Orengo IF, Wolf JE. Dog, cat, and human bites: a review. J Am Acad
Dermatol. 1995;33:101929.
31. Kelleher AT, Gordon SM. Management of bite wounds and infection in primary care. Cleve Clin J
Med. 1997;64:13741.
32. Perron AD, Miller MD, Brady W J. Orthopedic pitfalls in the ED: fight bite. Am J Emerg Med. 2002;20:1147.
33. Patzakis MJ, Wilkins J, Bassett RL. Surgical findings in clenched-fist injuries. Clin Orthop. 1987;220:23740.
34. Dellinger EP, Wertz MJ, Miller SD, Coyle MB. Hand infections. Bacteriology and treatment: a prospective
study. Arch Surg. 1988;123:745
50.
35. Zubowicz VN, Gravier M. Management of early human bites of the hand: a prospective randomized
study. Plast Reconstr Surg. 1991;88:1114.
36. Medeiros I, Saconato H. Antibiotic prophylaxis for mammalian bites (Cochrane Review). Cochrane Database
Syst Rev. 2003;2:CD001738.
37. Louis DS, Jebson PJ. Mimickers of hand infections. Hand Clin. 1998;14:51929.
38. Matsui T. Acute nonspecific flexor tenosynovitis in the digits. J Orthop Sci. 2001;6:2347.
NAME AND SIGNATURE OF POSTGRADUATE STUDENT
(DR MISHRA AJIT MATAPRASAD):
NAME AND SIGNATURE OF POSTGRADUATE GUIDE
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(DR SHAILAJA P JADHAV):
PROFESSOR AND HEAD,
DEPARTMENT OF SURGERY
B. J. MEDICAL COLLEGE, PUNE.
Appendix 3:
INFORMED CONSENT FORM
For submission of Research proposal toEthics Committee of B.J.M.C. and S.G.H. Pune
1. I, Mr./ Mrs. ____________________________________, age ______ yearsresiding at
_________________________________________________________________
hereby give my informed consent to participate in COMPLICATION AND
MANAGEMENT OF HAND INFECTIONS project..
2. There is no compulsion on me to participate in this project and I am giving my
free consent for it.
3. I am ready and willing to undergo all tests and treatments in the present project.
4. I have read and I have been explained the general information and purpose of thepresent project.
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5. I have been informed / I have read the probable complications while participating
in the present project.
6. I know that I can withdraw from the present project at any time.
7. Any data or analysis of this project will be purely used for scientific purpose andmy name will be kept confidential except when required for any legal purpose.
8. I can read English / I can understand data read out to me in English.
Signature 0f VolunteerSignature of parent/Guardian in caseOf minor person.
Witnesses:
1.
2.
Signature of Principal Investigator.
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APPENDIX 5:
UNDERTAKING BY THE INVESTIGATOR
For submission of Research proposal to
Ethics Committee of B.J.M.C. and S.G.H. Pune
1] Full name, address and title of the Principal Investigator
Dr. SHAILAJA P JADHAVPROFESSORDEPT OF SURGERY
B.J.MEDICAL COLLEGE, PUNE
2] Name and address of the medical college, hospital or other facility where the
clinical trial will be conducted: Education, training & experience that qualify
the Investigator for he clinical trial (Attach details including Medical
Council registration number, and /or any other statement(s) of
qualification(s)
Dr. MISHRA AJIT MATAPRASADRESIDENTDEPT OF SURGERY
B.J.MEDICAL COLLEGE, PUNE.
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3] Name and address of all clinical laboratory facilities to be used in the study.
4] Name and address of the Ethics Committee that is responsible for approval
and continuing review of the study.
B.J.M.C. SGH, Pune
5] Names of the other members of the research team (Co-or sub-
Investigators) who will be assisting the Investigator in the conduct of the
investigation(s).
6] Protocol Title and study number (if any) of the clinical trial to be conductedby the Investigator.
7] Commitments
i. I have reviewed the clinical protocol and agree that it contains all the
necessary information to conduct the study. I will not begin the
study until all necessary Ethics Committee and regulatory approvals
have been obtained.
ii. I agree to conduct the study in accordance with the current protocol.
I will not implement any deviation from or changes of the protocol
without agreement by the Sponsor and prior review and documented
approval/favorable opinion from the Ethics Committee of the
amendment, except where necessary to eliminate an immediate
hazard(s) to the trial Subjects or when the change(s) involved are
only logistical or administrative in nature.
iii. I agree to personally conduct and/or supervise the clinical trial at my
site.
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iv. I agree to inform all Subjects that the drugs are being used for
investigational purposes and I will ensure that the requirements
relating to obtaining informed consent and ethics committee review
and approval specified in the GCP guidelines are met.
v. I agree to report to the Sponsor all adverse experiences that occur in
the course of the investigation(s) in accordance with the regulatory
and GCP guidelines.
vi. I have read and understood the information in the Investigators
broacher, including the potential risks and side effects of the drug.
vii. I agree to ensure that all associates, colleagues and employees
assisting in the conduct of the study are suitably qualified and
experienced and they have been informed about their obligations in
meeting their commitments in the trial.
viii. I agree to maintain adequate and accurate records and to make
those records available for audit/inspection by the Sponsor, Ethics
Committee, Licensing Authority or their authorized representatives,
in accordance with regulatory and GCP provisions; I will fully
cooperate with any study related audit conducted by regulatory
officials or authorized representatives of the Sponsor.
ix. I agree to promptly report to the Ethics Committee all changes in the
clinical trial activities and all unanticipated problems involving risks
to human subjects or others.
x. I agree to inform all unexpected serious adverse events to the
Sponsor as well as the Ethics Committee within seven days of their
occurrence.
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xi. I will maintain confidentiality of the identification of all participating
study patients and assure security and confidentiality of study data.
xii. I agree to comply with all other requirements, guidelines and
statutory obligations as applicable to clinical investigators
participating in clinical trails.
8] Signature of Investigators with Name and Date.
Investigators Name Signature Date
Principal Investigator
Co-Investigator 1
Co-Investigator 2
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Appendix 6:
CERTIFICATE from HOD
For submission of Research proposal to
Ethics Committee of B.J.M.C. and S.G.H. Pune
Date:
This is to certify that Research Protocol entitled
COMPLICATION AND MANAGEMENT OF
HAND INFECTIONS
Has been presented, discussed and modified accordingly.
Further it is stated that to the best of my knowledge there is no
ethical dispute in this research protocol and therefore may be
approved by the Ethics Committee, B. J. Medical College &
Sassoon General Hospitals, and Pune.
Signature
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