INFLUENCE OF THE DURATION OF DIABETES AND VIBRATION PERCEPTION THRESHOLD ON THE SEVERITY OF ERECTILE DYSFUNCTION IN PATIENTS WITH TYPE 2 DIABETES MELLITUS

BACKGROUND

Erectile dysfunction(ED) in men is a frequent under-reported complication of diabetes mellitus, which is becoming significant health problem worldwide.

AIMS

The study aims to determine the prevalence and risk factors for development of ED in North Indian patients with type 2 diabetes mellitus.

METHODS

We used international index of erectile function (IIEF-5) for the assessment of ED in 796 patients with type 2 diabetes mellitus. We recorded the age, duration of diabetes, glycemic status, body mass index, diabetes medications, microvascular and macrovascular complications.

RESULTS

The mean age of patients in the study was 49.38 ± 9.52 years. The prevalence of ED in patients with type 2 diabetes mellitus was 79.4%. Logistic regression analysis revealed that age, body mass index, glycemic control, insulin therapy, retinopathy and nephropathy was not significantly associated with erectile dysfunction in patients with type 2 diabetes mellitus. Duration of diabetes (OR = 1.054, 95% CI 1.007 to 1.102, P=0.023) and vibration perception threshold (OR = 1.071, 95% CI 1.042 to 1.102, P=0.000) were identified as key risk factors for development of ED.

CONCLUSION

Duration of diabetes and peripheral neuropathy emerged as significant risk factors for development of severe erectile dysfunction.

133 A Quality Improvement Project to Improve the Appropriateness of Acute Clinic Referrals to a Local ENT Department Using an Electronic Booking System

Aim

Assess and improve the proportion of inappropriate acute clinic referrals being made to our local ENT department via a telephone referral system with regards to nature and suitability for a junior grade doctor run clinic with senior supervision. Additionally, to make a more efficient, timely and failproof booking system with an auditable trail by transitioning to an electronic referral system.

Method

A guideline was created using based on common protocols from major Trusts within the UK which was then used to assess 101 acute clinic referrals taken from February 2021 to our local service. An electronic referral system was created, and guidelines disseminated to departments commonly making referrals to the acute clinic in anticipation for re-audit in September 2021 alongside introduction of the guideline to new doctors rotating to the specialty at induction in August.

Results

Initial audit revealed 29% of referrals were inappropriate, 50% of which were too complex, 45% were not acute and 5% were due to accidental double-bookings. Additionally, nasal fracture reviews were seen within 10 days only one third of the time, 37% of patients referred did not have a recorded contact number and 13.8% of all referrals were made with incorrect or unclear clinical information.

Conclusions

The lack of clear clinical guidance on referrals to an acute ENT service at our local centre with an outdated telephone referral system is associated with a large proportion of inappropriate referrals, delays to timely care and transcription errors potentially putting patients at risk of harm.

106 Laparoscopic Cholecystectomy Following an Episode of Cholecystitis: Are We Meeting the NICE Guidance?

Aim

On average, acute cholecystitis is responsible for 3% of admissions to emergency general surgery wards. NICE Guideline [QS104] states that adult patients admitted with acute cholecystitis should be offered a laparoscopic cholecystectomy within one week of diagnosis. This study aims to assess adherence to this guideline in a medium size district general hospital.

Method

Data was gathered retrospectively from contemporaneous electronic-based patient record system. Patients with a first case of cholecystitis within a 486-days’ time period were included; incorrect coding or repeat admissions within our time period were excluded. Data was gathered on admission length, aetiology, investigations undergone and procedure type (open vs laparoscopic). Additionally, for those that underwent a cholecystectomy, the length of time between diagnosis and operation was calculated.

Results

72 adults were admitted with acute cholecystitis in the 486-day study period. The median length of stay was 3 days. The commonest aetiology was either gallstones or unknown (47.2% of cases each), followed by bacterial infection (5.6%). 9 patients (12.5%) underwent laparoscopic cholecystectomy, and 10 (13.9%) were placed on a waiting list. The remaining 53 (73.6%) had no mention of being listed for surgery in their notes. Of those undergoing laparoscopic cholecystectomy (n = 9), none were within the recommended one-week period from time of diagnosis.

Conclusions

Over 486 days, no patients diagnosed with acute cholecystitis in our unit were being treated according to NICE guidance. We therefore recommend reinstating the hot gallbladder list at this hospital, which will enable surgeons to deliver the biliary emergency service advocated by the national guidelines.

107 Retrospective Pilot Study in Preparation for Setting Up an Acute Pancreatitis MDT in a Medium Sized NHS Acute Trust in the UK

Aim

Within the spectrum of pancreatitis, patients with severe disease require specialist multidisciplinary care including dietician and radiology input. Therefore, certain patients would benefit from an MDT approach to coordinate their management. This retrospective study analyses data on pancreatitis admissions within our Trust, to inform the set-up of a new specialist MDT.

Method

Patients were identified using admission coding data. Relevant patient data was extracted, including demographics, disease severity (using the Atlanta classification) and relevant outcomes. Both first-time and repeat admissions were included. Incorrectly coded patients were excluded. Statistical analysis was performed using SPSS (Version 23.0).

Results

Over a study period of 489 days, 246 patients were coded as having pancreatitis.186 patients were first time admissions, and 27 patients were repeat admissions. 33 patients were incorrectly coded and excluded.

Hence, the annual acute pancreatitis admission rate was 139 patients/year, with an additional 20 readmissions. 149 (80%) admissions were mild cases, with the remaining 14 (8%) and 23 (12%) being moderate and severe respectively. 149 (80%) were acute cases, compared to 20 (11%) chronic and 17 (9%) acute-on-chronic. 52/186 cases had no cause of pancreatitis recorded; where cause was identified, gallstones were the most common aetiology.

Conclusions

Pancreatitis is a common reason for admission during a general surgery on-call in our Trust; while the majority of cases are mild, the remaining 20% of moderate–severe cases qualify for discussion at an Acute Pancreatitis MDT. This pilot has facilitated the allocation of resources in our Trust and the MDT goes live in September 2021.

Utility of sonographic transcerebellar diameter in the assessment of gestational age in normal and intrauterine growth-retarded fetuses

Background

The fetal cerebellum has been shown to be least affected by external pressures and molding during pregnancy and therefore might provide more accurate estimation of GA.

Aims

To study the utility of transcerebellar diameter (TCD) measured by ultrasound for the detection of GA in normal and intrauterine growth-retarded (IUGR) fetuses.

Subjects and Methods

This cross-sectional study comprised 500 antenatal patients with a GA between 14 and 39 weeks and who were certain of their last menstrual periods. The TCD was measured ultrasonographically and the corresponding GA was determined. The GA was also determined with other customarily used sonographic parameters such as biparietal diameter (BPD), head circumference (HC), abdominal circumference (AC), and femur length (FL) and compared with TCD. Data of normal pregnancy patients was used to formulate nomograms by taking the 5^th, 50^th, and 95^th percentile measurements. TCD to AC ratio was also calculated in both normal (n = 424) and IUGR pregnancies (n = 76).

Results

TCD showed significant correlation with gestational age (GA) measured by last menstrual period (LMP) as well as with GA calculated with other biometric fetal parameters. TCD also showed significant correlation with GA in normal (R² = 0.979) as well as with IUGR pregnancies (R² = 0.942). TCD to AC ratio remained fairly constant in normal pregnancies while it was increased in IUGR pregnancies.

Conclusions

TCD and TCD/AC ratio can be employed as an objective parameter to establish the GA in normal as well as IUGR pregnancy cases.

Intrauterine proteolytic enzymes therapy hastens expulsion of fetal membranes in dystocia affected buffaloes

Background

Difficult calving (dystocia) in buffalo cows is a major obstetrical problem which further leads to metritis complex, encompassing the retention of fetal membranes (RFM), puerperal metritis, endometritis and pyometra with impaired future fertility.

Aims

The current study aimed to evaluate the effect of the administration of intrauterine proteolytic enzymes on the expulsion of fetal membranes and postpartum fertility in dystociac buffaloes.

Methods

Proteolytic enzymes consisting of Trypsin (16 mg), Chymotrypsin (16 mg), and Papain (8 mg) were dissolved in 500 ml normal saline were administered after 1 h of assisted delivery in dystociac buffaloes along with the conventional therapy.

Results

The treated animals (n=15) expelled fetal membranes within a shorter period of time (P=0.043) compared to the control group (n=15) with none in the treatment group retaining it for more than 24 hours. Fewer (26.67 vs 73.33%; P=0.027) postpartum uterine infections developed in the treated animals compared to the control group. The interval between first postpartum estrus (P=0.067), service period (P=0.554), and open days (P=0.557) was shorter in the treatment group compared to the control group where postpartum anestrus developed less frequently (26.67 vs 66.67%; P=0.066) in the animals treated with enzymatic therapy. Systemic illness (neutrophillia) was reduced in the treatment group compared to the control on day 20 (64.55 ± 1.14% vs 70.23 ± 0.99%; P=0.001) and 45 (55.05 ± 1.63% vs 64.92 ± 1.45%; P<0.001) postpartum.

Conclusion

It is concluded that proteolytic enzymes therapy after assisted delivery in dystociac buffalo cows could help in the early expulsion of fetal membranes and reduce uterine infections with decreased neutrophils count.

Changes in surface morphology, lectin staining, and gene expression of caprine endometrium exposed to estradiol, progesterone, and mifepristone in vitro

BACKGROUND

In mammalian females, the uterine tissue is highly responsive to steroid hormones and their antagonists.

AIMS

In the present study, topographical, histoarchitectural, and gene expression changes in goat endometrium treated with estradiol, progesterone, and mifepristone for 24 h were investigated, in vitro.

METHODS

Scanning electron microscopy (SEM) was used for surface topographical analysis; WGA and DBA lectins were used for histochemical analysis; and qRT-PCR was done for the quantification of mRNA levels of MKI67 (marker of proliferation Ki67), ESR1 (estrogen receptor), PGR (progesterone receptor), CASP3 (caspase 3), and PDGFR-β (platelet derived growth factor receptor-β).

RESULTS

Few topographical alterations were observed in endometrial glands and the presence of scattered mucoid granules. A significant decline in WGA staining was reported only in the progesterone group. However, DBA binding was highest in the progesterone group and lowest in the mifepristone group. The expression of MKI67 gene declined to 79% in the mifepristone group, while in the estradiol and progesterone groups it elevated to 153% and 41%, respectively, than control; a similar trend was observed for PDGFR-β. The mRNA abundance for ESR1 declined to 59% in the progesterone group and 10% in the mifepristone group. However, a 100% increase occurred in the estradiol group. PGR expression followed the same trend as that of ESR1. CASP3 declined in the estradiol (50%) and progesterone (37%) group, but it showed a 67% increase in the mifepristone group.

CONCLUSION

We concluded that the caprine uterus undergoes dramatic alteration in structure and functions in response to different kinds of steroidal environments.

TB free India: Reaching the unreached tribal population under National Tuberculosis Elimination Programme

India is the highest TB burden country in the world. The burden however is not uniform in different strata including tribal population - one of the key affected populations in the country. As the evidences from tribal population are hardly available, most of the policies and strategies implemented under National Tuberculosis Elimination Programme (NTEP) are usually based on the evidences from general populations. NTEP is continuously taking steps to strengthen TB services in tribal areas. The Social Action Plan including Tribal Action Plan is in place and the appropriate strategies are incorporated in the National Strategic Plan (NSP) to ensure universal access to quality TB services to vulnerable population groups. However, its implementation becomes challenging especially in tribal areas as different tribal groups have their own unique ways of dealing with health issues. These issues are therefore required to be addressed holistically involving all the stakeholders. In view of this a symposium was jointly organized by the Central TB Division (CTD), Govt. of India and ICMR - National Institute of Research in Tribal Health (NIRTH), Jabalpur on 17th and 18th December, 2019 at ICMR - NIRTH, Jabalpur. It provided an excellent platform for all the stakeholders from different parts of the country to share their experiences in tuberculosis particularly among marginalized populations. The recommendations emerged out of this interactive symposium highlight the sincere effort of NTEP to tackle TB situation in tribal population and show the way forward towards India's TB elimination goal by 2025 especially in hard to reach tribal areas.

Photophobia as a Presenting Feature in Adie's Tonic Pupil

A 34 years old female presented with complains of photophobia since 6-7 months. On examination, she had anisocoria of 4 mm in room light which increased in bright light. The left pupil was dilated and unresponsive to direct and indirect light stimuli. It did however, constrict slowly on near fixation followed by slow redilatation on distance fixation. A diagnosis of Adie's tonic pupil was made since left pupil constricted with instillation of dilute pilocarpine 0.1%. Her symptoms of photophobia and blurred vision immediately resolved. Photochromatic glasses and dilute pilocarpine 0.1% three times a day were prescribed. Prompt symptomatic relief of photophobia and blurred vision was observed.

Performance of prognostic scores in prediction of 30-day postoperative mortality in COVID-19 patients after emergency surgery: A retrospective cohort study

Background

: Risk assessment with prognostic scoring, though important, is scarcely studied in emergency surgical patients with COVID-19 infection.

Methods and Material

We conducted a retrospective cohort study on adult emergency surgical patients with COVID-19 infection in our institute from 1 May 2020 to 31 October 2021 to find the 30-day postoperative mortality and predictive accuracy of prognostic scores. We assessed the demographic data, prognostic risk scores (American Society of Anesthesiologists-Physical Classification (ASA-PS), Sequential Organ Failure Assessment (SOFA), Quick SOFA (qSOFA), Physiologic and Operative Severity Score for the enUmeration of Mortality and Morbidity (POSSUM) and Portsmouth-POSSUM (P-POSSUM) scores), surgical and anesthetic factors. We assessed the postoperative morbidity using the Clavien-Dindo scale and recorded the 30-day mortality. Correlation of prognostic scores and mortality was evaluated using Univariate Cox proportional hazards regression, receiver operating characteristic curve (ROC), Youden's index and Hosmer- Lemeshow goodness of fit model.

Results

Emergency surgery was performed in 67 COVID-19 patients with postoperative complication and 30-day mortality rate of 33% and 19%, respectively. A positive qSOFA and ASAPS IIIE/IVE had a 9.03- and 12.7-times higher risk of mortality compared to a negative qSOFA and ASA-PS IE/IIE (P &lt; 0.001), respectively. Every unit increase of SOFA, POSSUM and P-POSSUM scores was associated with a 50%, 18% and 17% higher risk of mortality, respectively. SOFA, POSSUM and P-POSSUM AUCROC curves showed good discrimination between survivors and non-survivors (AUC 0.8829, 0.85 and 0.86, respectively).

Conclusions

SOFA score has a higher sensitivity to predict 30-day postoperative mortality as compared to POSSUM and P-POSSUM. However, in absence of a control group of non-COVID-19 patients, actual risk attributable to COVID-19 infection could not be determined.

Metachronous isolated inferior vena cava tumour thrombus in renal cell cancer: a rare aftermath

Renal cell cancer (RCC) accounts for 3% of all solid malignancies. Synchronous tumour thrombus in the renal vein or inferior vena cava is reported in 4-10% cases and is a surgical challenge. Contemporary imaging modalities that are used to define the presence and extent of venous thrombus include colour Doppler, contrast-enhanced computed tomography and magnetic resonance venography. Surgical management depends upon the degree of tumour thrombus. We report isolated recurrence of RCC in the inferior vena cava 2 years after radical nephrectomy, and discuss its pathophysiology and management.

Benefits and pathologies associated with the inflammatory response

Adult skeletal muscle regenerates completely after a damage, thanks to the satellite cells, or muscle stem cells (MuSCs), that implement the adult myogenic program. This program is sustained by both robust intrinsic mechanisms and extrinsic cues coming from the close neighborhood of MuSCs during muscle regeneration. Among the various cell types present in the regenerating muscle, immune cells, and particularly macrophages, exert numerous functions and provide sequential transient niches to support the myogenic program. The adequate orchestration of the delivery of these cues ensures efficient muscle regeneration and full functional recovery. The situation is very different in muscular dystrophies where asynchronous and permanent microinjuries occur, triggering contradictory regenerating cues at the same time in a specific area, that lead to chronic inflammation and fibrogenesis. Here we review the beneficial effects that leukocytes, and particularly macrophages, exert on their neighboring cells during skeletal muscle regeneration after an acute injury. Then, the more complicated (and less beneficial) roles of leukocytes during muscular dystrophies are presented. Finally, we discuss how the inflammatory compartment may be a target to improve muscle regeneration in both acute muscle injury and muscle diseases.

IgG4-related retroperitoneal fibrosis: a rare cause of obstructive uropathy

Immunoglobulin G4 (IgG4)-related disease was described in 2003 and is known to affect almost all organ systems. Rarely, this disease can manifest in the retroperitoneum, which can lead to sequalae such as obstructive uropathy. Here we describe a case of IgG4-related retroperitoneal fibrosis leading to obstructive uropathy. The patient was managed with bilateral Double J (DJ) stenting and oral steroids. Following remission of the disease, the DJ stents were removed and the patient remained asymptomatic over the follow-up period. A high index of suspicion is required for diagnosis of this rare disease and timely management can lead to a positive outcome.

Search for Active-Sterile Antineutrino Mixing Using Neutral-Current Interactions with the NOvA Experiment

This Letter reports results from the first long-baseline search for sterile antineutrinos mixing in an accelerator-based antineutrino-dominated beam. The rate of neutral-current interactions in the two NOvA detectors, at distances of 1 and 810 km from the beam source, is analyzed using an exposure of 12.51×10^{20} protons-on-target from the NuMI beam at Fermilab running in antineutrino mode. A total of 121 of neutral-current candidates are observed at the far detector, compared to a prediction of 122±11(stat.)±15(syst.) assuming mixing only between three active flavors. No evidence for ν[over ¯]_{μ}→ν[over ¯]_{s} oscillation is observed. Interpreting this result within a 3+1 model, constraints are placed on the mixing angles θ_{24}<25° and θ_{34}<32° at the 90% C.L. for 0.05  eV^{2}≤Δm_{41}^{2}≤0.5  eV^{2}, the range of mass splittings that produces no significant oscillations at the near detector. These are the first 3+1 confidence limits set using long-baseline accelerator antineutrinos.

Postoperative outcomes in oesophagectomy with trainee involvement

BACKGROUND

The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting.

METHODS

Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups.

RESULTS

Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005).

CONCLUSION

Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

Martensitic Transformation in Fe_{x}Mn_{80-x}Co_{10}Cr_{10} High-Entropy Alloy

High-entropy alloys and even medium-entropy alloys are an intriguing class of materials in that structure and property relations can be controlled via alloying and chemical disorder over wide ranges in the composition space. Employing density-functional theory combined with the coherent-potential approximation to average over all chemical configurations, we tune free energies between face-centered-cubic and hexagonal-close-packed phases in Fe_{x}Mn_{80-x}Co_{10}Cr_{10} systems. Within Fe-Mn-based alloys, we show that the martensitic transformation and chemical short-range order directly correlate with the face-centered-cubic and hexagonal-close-packed energy difference and stacking-fault energies, which are in quantitative agreement with recent observation of two phase region (face-centered cubic and hexagonal closed pack) in a polycrystalline high-entropy alloy sample at x=40 at.%. Our predictions are further confirmed by single-crystal measurements on a x=40 at.% using transmission-electron microscopy, selective-area diffraction, and electron-backscattered-diffraction mapping. The results herein offer an understanding of transformation-induced or twinning-induced plasticity in this class of high-entropy alloys and a design guide for controlling the physics at the electronic level.

Systematic review on reporting of components and outcomes in randomized clinical trials of paraoesophageal hernia mesh repair

BACKGROUND

Surgical interventions, such as paraoesophageal hernia (POH) repair, are complex with multiple components that require consideration in the reporting of clinical trials. Many aspects of POH repair, including mesh hiatal reinforcement and fundoplication type, are contentious. This review summarizes the reporting of components and outcomes in RCTs of POH repair.

METHODS

Systematic searches identified RCTs of POH repair published from 1995 to 2020. The patient selection criteria for RCT involvement were noted. The components of the surgical interventions in these RCTs were recorded using the CONSORT guidelines for non-pharmacological treatments, Template for Intervention Description and Replication (TIDieR) and Blencowe frameworks. The outcomes were summarized and definitions sought for critical variables, including recurrence.

RESULTS

Of 1918 abstracts and 21 screened full-text articles, 12 full papers reporting on six RCTs were included in the review. The patient selection criteria and definitions of POH between trials varied considerably. Although some description of trial interventions was provided in all RCTs, this varied in depth and detail. Four RCTs described efforts to standardize the trial intervention. Outcomes were reported inconsistently, were rarely defined fully, and overall trial conclusions varied during follow-up.

CONCLUSION

This lack of detail on the surgical intervention in POH repair RCTs prevents full understanding of what exact procedure was evaluated and how it should be delivered in clinical practice to gain the desired treatment effects. Improved focus on the definitions, descriptions and reporting of surgical interventions in POH repair is required for better future RCTs.

Novel major QTLs associated with low soil phosphorus tolerance identified from the Indian rice landrace, Wazuhophek

With an objective of mapping novel low soil P (Phosphorus) tolerance loci in the non-Pup1 type donor rice line, Wazuhophek, we screened a recombinant inbred line (RIL) mapping population consisting of 330 lines derived from the cross Wazuhophek x Improved Samba Mahsuri (which is highly sensitive to low soil P) in a plot with low soil P for tolerance associated traits. Molecular mapping with SSR markers revealed a total of 16 QTLs (seven major and nine minor QTLs), which are associated with low soil P tolerance related traits. Interestingly, a QTL hotspot, harbouring 10 out of 16 QTLs were identified on the short arm of chromosome 8 (flanked by the makers RM22554 and RM80005). Five major QTLs explaining phenotypic variance to an extent of 15.28%, 17.25%, 21.84%, 20.23%, and 18.50%, associated with the traits, plant height, shoot length, the number of productive tillers, panicle length and yield, respectively, were located in the hotspot. Two major QTLs located on chromosome 1, associated with the traits, total biomass and root to shoot ratio, explaining 15.44% and 15.44% phenotypic variance, respectively were also identified. Complex epistatic interactions were observed among the traits, grain yield per plant, days to 50% flowering, dry shoot weight, and P content of the seed. In-silico analysis of genomic regions flanking the major QTLs revealed the presence of key putative candidate genes, possibly associated with tolerance.

Proteomics: A prospective new tool in forensic investigations

Over the last few decades, DNA evidence has become a very powerful tool in forensics, but it also has its limitations. DNA, being a very fragile molecule, can be easily damaged and contaminated. It can be very challenging to find enough DNA in an investigation to really make a breakthrough in certain types of evidence samples. For instance, about half of all rape kits do not yield sufficient genetic information to determine the perpetrator's DNA profile. This is where proteomics, the modern concept of protein analysis, steps in. By observing the amino acid sequence of protein fragments, researchers can work backward to conclude the DNA sequence used to make proteins. Proteomics methods can be used to classify and explain the circumstances that produced the biological samples. This article provides a conceptual overview on the different proteomics applications in forensics, including human identification using hair samples and fingermarks, species determination utilizing teeth and bones, and the determination of postmortem intervals.

Evaluation of analgesic interaction between morphine, maropitant and dexmedetomidine in dogs undergoing ovariohysterectomy

ABSTRACTAims: To compare the analgesic effect of morphine combined with maropitant and/or dexmedetomidine to morphine alone but at a higher dose, and to evaluate the pharmacokinetics of the drug combinations, in dogs undergoing ovariohysterectomy (OHE).Methods: Forty client-owned dogs were randomised into four treatment groups (n = 10 per group) each to receive a different analgesic protocol. After premedication with I/M acepromazine, anaesthesia was induced with propofol to effect and maintained with isoflurane in 100% oxygen delivered via a circle system. The heart rate, respiratory rate, blood pressure, haemoglobin oxygen saturation, end-tidal partial pressure of carbon dioxide, electrocardiogram and rectal temperature were monitored during anaesthesia. The test drugs (Mor: 0.6 mg/kg morphine; Maro + Mor: 0.3 mg/kg morphine and 1 mg/kg maropitant; Dex + Mor: 0.3 mg/kg morphine and 10 μg/kg dexmedetomidine; Dex + Maro + Mor: 0.2 mg/kg morphine, 7 μg/kg dexmedetomidine and 0.7 mg/kg maropitant) were administered I/M after induction of anaesthesia and 30 minutes before the expected start time of ovariohysterectomy, which was carried out by veterinary students under veterinary supervision. The short form of the Glasgow composite measure pain scale (CMPS-SF) and visual analogue scale (VAS) were used for pain assessment at 15 and 30 minutes and 1, 2, 3, 6, 9 and 24 hours after extubation. Dogs with CMPS-SF pain score ≥ 6 received rescue analgesia with S/C buprenorphine (0.02 mg/kg). Blood samples were collected before, 15, 30, 60 and 120 minutes after injection of the test drugs and concentration of the test drugs in plasma was determined by liquid chromatography-mass spectrometry.Results: Dogs that received Dex + Mor had significantly lower CMPS-SF (estimate of difference = -1.53 (SE 0.58); p = 0.010) and VAS (estimate of difference = -0.67 (SE 0.25); p = 0.007) scores compared to the dogs that received morphine alone. There was no evidence of a difference in the number of dogs requiring rescue between groups. All dogs that received dexmedetomidine showed cardiac arrhythmia and second-degree heart block. Mean (SD) maximum concentrations (C_max,) of morphine in plasma were 6.8 (4.56), 9.56 (8.29), 9.30 (3.35) and 18.99 (9.41) ng/mL for the groups Dex + Mor, Dex + Maro + Mor, Maro + Mor and Mor respectively. The C_max of morphine was significantly lower in the Dex + Mor (p = 0.004), Dex + Maro + Mor (p = 0.034) and Maro + Mor (p = 0.018) groups compared to the Mor group.Conclusions For dogs undergoing ovariohysterectomy, lower doses of morphine (0.2 and 0.3 mg/kg) combined with dexmedetomidine or maropitant may provide analgesia equivalent to or better than morphine when given alone at a higher dose (0.6 mg/kg).Abbreviations: AUC: Area under curve; C_max: Maximum concentration in plasma; CMPS-SF: Glasgow composite measure pain scale - short form; NK1: Neurokinin-1; OHE: Ovariohysterectomy; T_max: Time to C_max; T_1/2: Half-life of terminal elimination phase; VAS: Visual analogue scale.

Association of Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium and Ureaplasma species infection and organism load with cervicitis in north Indian population

Cervicitis is predominantly caused by Neisseria gonorrhoeae and Chlamydia trachomatis, which accounts for almost half of all the cases of cervicitis. The role of newer organisms like Mycoplasma genitalium and Ureaplasma sp. and association of bacterial load with cervicitis are also not well established. So the study aimed to determine the relative frequency of these organisms and their load in association with cervicitis cases from north India. A case-control study involving 300 women was conducted using quantitative real-time PCR from endocervical swabs for identification of organisms and quantification of bacterial load. Among 150 cervicitis cases, C. trachomatis, N. gonorrhoeae, M. genitalium and Ureaplasma parvum were detected in 5 (3·3%), 10 (6·6%), 37(24·6%) and 47 (31·3%) respectively. Old age (<0·001, chi-squared test) and irregular menstrual cycles (<0·001, chi-squared test) were significantly associated with cervicitis. M genitalium was the only organism to be associated significantly with cervicitis with regard to age (<0·031) and symptoms like discharge (P < 0·033, chi-squared test) and dysuria (P < 0·044, chi-squared test) in multivariate analysis. Our finding suggests that the bacterial load of these organisms is not significantly associated with cervicitis. However, we found significant association of M. genitalium infection with clinical characteristics of cervicitis cases.

Mortality from esophagectomy for esophageal cancer across low, middle, and high-income countries: An international cohort study

BACKGROUND

No evidence currently exists characterising global outcomes following major cancer surgery, including esophageal cancer. Therefore, this study aimed to characterise impact of high income countries (HIC) versus low and middle income countries (LMIC) on the outcomes following esophagectomy for esophageal cancer.

METHOD

This international multi-center prospective study across 137 hospitals in 41 countries included patients who underwent an esophagectomy for esophageal cancer, with 90-day follow-up. The main explanatory variable was country income, defined according to the World Bank Data classification. The primary outcome was 90-day postoperative mortality, and secondary outcomes were composite leaks (anastomotic leak or conduit necrosis) and major complications (Clavien-Dindo Grade III - V). Multivariable generalized estimating equation models were used to produce adjusted odds ratios (ORs) and 95% confidence intervals (CI95%).

RESULTS

Between April 2018 to December 2018, 2247 patients were included. Patients from HIC were more significantly older, with higher ASA grade, and more advanced tumors. Patients from LMIC had almost three-fold increase in 90-day mortality, compared to HIC (9.4% vs 3.7%, p < 0.001). On adjusted analysis, LMIC were independently associated with higher 90-day mortality (OR: 2.31, CI95%: 1.17-4.55, p = 0.015). However, LMIC were not independently associated with higher rates of anastomotic leaks (OR: 1.06, CI95%: 0.57-1.99, p = 0.9) or major complications (OR: 0.85, CI95%: 0.54-1.32, p = 0.5), compared to HIC.

CONCLUSION

Resections in LMIC were independently associated with higher 90-day postoperative mortality, likely reflecting a failure to rescue of these patients following esophagectomy, despite similar composite anastomotic leaks and major complication rates to HIC. These findings warrant further research, to identify potential issues and solutions to improve global outcomes following esophagectomy for cancer.

Comparison of short-term outcomes from the International Oesophago-Gastric Anastomosis Audit (OGAA), the Esophagectomy Complications Consensus Group (ECCG), and the Dutch Upper Gastrointestinal Cancer Audit (DUCA)

BACKGROUND

The Esophagectomy Complications Consensus Group (ECCG) and the Dutch Upper Gastrointestinal Cancer Audit (DUCA) have set standards in reporting outcomes after oesophagectomy. Reporting outcomes from selected high-volume centres or centralized national cancer programmes may not, however, be reflective of the true global prevalence of complications. This study aimed to compare complication rates after oesophagectomy from these existing sources with those of an unselected international cohort from the Oesophago-Gastric Anastomosis Audit (OGAA).

METHODS

The OGAA was a prospective multicentre cohort study coordinated by the West Midlands Research Collaborative, and included patients undergoing oesophagectomy for oesophageal cancer between April and December 2018, with 90 days of follow-up.

RESULTS

The OGAA study included 2247 oesophagectomies across 137 hospitals in 41 countries. Comparisons with the ECCG and DUCA found differences in baseline demographics between the three cohorts, including age, ASA grade, and rates of chronic pulmonary disease. The OGAA had the lowest rates of neoadjuvant treatment (OGAA 75.1 per cent, ECCG 78.9 per cent, DUCA 93.5 per cent; P < 0.001). DUCA exhibited the highest rates of minimally invasive surgery (OGAA 57.2 per cent, ECCG 47.9 per cent, DUCA 85.8 per cent; P < 0.001). Overall complication rates were similar in the three cohorts (OGAA 63.6 per cent, ECCG 59.0 per cent, DUCA 62.2 per cent), with no statistically significant difference in Clavien-Dindo grades (P = 0.752). However, a significant difference in 30-day mortality was observed, with DUCA reporting the lowest rate (OGAA 3.2 per cent, ECCG 2.4 per cent, DUCA 1.7 per cent; P = 0.013).

CONCLUSION

Despite differences in rates of co-morbidities, oncological treatment strategies, and access to minimal-access surgery, overall complication rates were similar in the three cohorts.

Status of Beta Defensin-1 and its Effect on Post-thaw Semen Fertility Gene Expression in Indian Goat Breed

BACKGROUND

Defensins are antimicrobial peptides and uniformly spans the entire sperm surface and is not exclusive to a specific domain. Goat β-defensin-1 helps in initiation of motility and capacitation of sperm.

OBJECTIVE

To know the status of β-defensin-1 in blood, semen and its effect on post thaw fertility gene expression in Indian goat breeds.

MATERIALS AND METHODS

Semen was extended and divided for estimation of β-defensin-1 and cryopreserved having different concentrations of β-defensin-1.

RESULTS

Bet defensin-1 concentration (pg/mL) in neat semen, sperm pellet and seminal plasma was significantly higher (P< 0.05) in goat breed Barbari followed by Jamunapari and Jakhrana. β-defensing-1 was also high in Jakhrana blood followed by Barbari and Jamunapari. The post thaw motility, live sperm, acrosome intactness and hypo osmotic swelled sperms were significantly higher (P< 0.05) with 10 ng/mL β-defensin in the semen dilutor.

CONCLUSION

Beta defensin (10 ng/mL) in semen dilutor may be used as immuno-modulator to get better post thaw quality suitable for artificial insemination.

New TB drugs for the treatment of children and adolescents with rifampicin-resistant TB in Mumbai, India

SETTING: Médecins Sans Frontières (MSF) clinic in Mumbai, India.OBJECTIVE: To determine the final treatment outcomes, culture conversion and adverse events (AEs) during treatment among children and adolescents (0-19 years) with rifampicin-resistant tuberculosis (RR-TB) who received ambulatory injectable-free treatment, including bedaquiline (BDQ) and/or delamanid (DLM) during September 2014-January 2020.DESIGN: This was a retrospective cohort study based on review of routinely collected programme data.RESULTS: Twenty-four patients were included; the median age was 15.5 years (min-max 3-19) and 15 (63%) were females. None were HIV-coinfected. All had fluoroquinolone resistance. Twelve received treatment, including BDQ and DLM, 11 received DLM and one BDQ. The median exposure to BDQ (n = 13) and DLM (n = 23) was 82 (IQR 80-93) and 82 (IQR 77-96) weeks, respectively. Seventeen (94%) patients with positive culture at baseline (n = 18) had negative culture during treatment; median time for culture-conversion was 7 weeks (IQR 5-11). Twenty-three (96%) had successful treatment outcomes: cured (n = 16) or completed treatment (n = 7); one died. Eleven (46%) had 17 episodes of AEs. Two of 12 serious AEs were associated with new drugs (QTcF >500 ms).CONCLUSION: Based on one of the largest global cohorts of children and adolescents to receive new TB drugs, this study has shown that injectable-free regimens containing BDQ and/or DLM on ambulatory basis were effective and well-tolerated among children and adolescents and should be made routinely accessible to these vulnerable groups.

Keratoconus in Asian eyes at a tertiary eye care facility

BACKGROUND

The purpose of this study was to assess the demographic variables, age at diagnosis, keratometry and slitlamp signs in keratoconus.

METHODS

Thirty-one patients with 61 keratoconic eyes were selected provided they met one of two criteria: 1. They had an irregular corneal surface, Vogt's striae, Fleischer's ring or apical sub-epithelial corneal scarring characteristic of keratoconus; 2. Corneal topography revealed an average simulated keratometry of more than 45.2 D, central corneal power higher than 47.2 D or infero-superior asymmetry greater than 1.4 D. The main outcome measures were demographic variables, age at diagnosis, disease severity on keratometry and biomicroscopic signs.

RESULTS

The patients' mean age at presentation was 20.2 +/- 6.4 years. Based on average keratometry values, 67.2 per cent of eyes had severe and 32.8 per cent had moderate keratoconus. Eyes with severe keratoconus presented at a younger average age (18.8 +/- 5.35 years) than moderate keratoconus (23.69 +/- 8.07 years). Thirty-eight eyes (92.5 per cent) with severe and 13 eyes (65 per cent) with moderate keratoconus demonstrated biomicroscopic signs of keratoconus. Twenty eyes (32.7 per cent) demonstrated apical sub-epithelial cornea scarring and 95 per cent of these eyes had severe keratoconus.

CONCLUSIONS

The majority of keratoconic eyes in Asian-Indian patients demonstrate the severe stage of the disease by the second decade.

Integrative analysis of cell state changes in lung fibrosis with peripheral protein biomarkers

The correspondence of cell state changes in diseased organs to peripheral protein signatures is currently unknown. Here, we generated and integrated single-cell transcriptomic and proteomic data from multiple large pulmonary fibrosis patient cohorts. Integration of 233,638 single-cell transcriptomes (n = 61) across three independent cohorts enabled us to derive shifts in cell type proportions and a robust core set of genes altered in lung fibrosis for 45 cell types. Mass spectrometry analysis of lung lavage fluid (n = 124) and plasma (n = 141) proteomes identified distinct protein signatures correlated with diagnosis, lung function, and injury status. A novel SSTR2+ pericyte state correlated with disease severity and was reflected in lavage fluid by increased levels of the complement regulatory factor CFHR1. We further discovered CRTAC1 as a biomarker of alveolar type-2 epithelial cell health status in lavage fluid and plasma. Using cross-modal analysis and machine learning, we identified the cellular source of biomarkers and demonstrated that information transfer between modalities correctly predicts disease status, suggesting feasibility of clinical cell state monitoring through longitudinal sampling of body fluid proteomes.

Reference Charts of Fetal Biometric Parameters at Different Gestational Age Groups in Indian Population

To develop, a reference charts of fetal abdominal circumference and femur length in normal pregnant women by using ultrasonography for Indian population. Further comparison of our findings with data derived from different population. This retrospective cross-sectional study included 300 normal singleton pregnancies and was carried out in the department of Anatomy, All India Institute of Medical Sciences, Jodhpur (Rajasthan), India from September 2017 to April 2019. Ultrasonography measurements included Abdominal circumference (AC) and Femur length (FL). Reference charts with mean AC and FL for corresponding Gestational age (GA) in weeks were developed. Also reference centiles (10th, 50th, 90th and 95th) were derived from this model and compared with similar studies done on different population. There was no statistically significant difference in age distribution of pregnant women (p=0.87). Both AC and FL were found to have statistically significant linear relationship with advancing gestational age (p=0.0005 & p=0.0003 respectively). There is significant difference observed between the values obtained in present study with studies concluded on Chinese and European population. Measurement of AC and FL are used to predict gestational age of fetus by using various regression formulae, also AC is known to be good predictor of nutritional status of fetus in utero. A separate chart is required for every different population because ethnicity, nutrition and environmental factor can have impact on normal values. Therefore, a reference chart for these parameters according to Indian population standards is essential to avoid misinterpretation of data. This would help to avoid misdiagnosis of intrauterine growth retardation or macrosomia during prenatal and perinatal period.

Anesthetic challenges while performing emergency laparotomy in a patient having COVID-19 infection

An elderly hypertensive lady presented with fever, respiratory symptoms, and mild abdominal discomfort and was diagnosed to have COVID-19 pneumonia. Respiratory symptoms improved with steroids, awake proning, high flow nasal cannula oxygen therapy and antibiotics. After 4 days, she developed non-occlusive superior mesenteric artery thrombosis, which initially responded to anticoagulants but was complicated on tenth day by intestinal obstruction necessitating emergency surgery. Challenges encountered perioperatively were multi systemic involvement, pneumonia, ventilation- perfusion mismatch, sepsis along with technical difficulties like fogging of goggles, stuck expiratory valve on anesthesia machine, inaudibility through stethoscope and discomfort due to personal protective equipment. Perioperative focus should be on infection prevention, maintenance of hemodynamics, and optimization of oxygenation with preoperative high flow nasal cannula oxygen therapy. Ultrasound lung helps in correct placement of endotracheal tube. We recommend daily machine check, taping of N95 mask to face and ambient operation theatre temperatures of 20-22°C to reduce technical problems.

Safe surgical tracheostomy in patients with COVID-19: key clinical considerations

Surgical tracheostomy is a high aerosol-generating procedure that is an essential aid to the recovery of patients who are critically ill with COVID-19 pneumonia. We present a single-centre case series of 16 patients with COVID-19 pneumonia who underwent tracheostomy. We recommend that the patient selection criteria for achieving a favourable outcome should be based on fraction of inspired oxygen together with prone-position ventilation. As with any challenging situation, the importance of effective communication is paramount. The critical modifications in the surgical steps are clearly explained. Timely tracheostomy also leads to an earlier freeing up of ventilator space during a period of a rapidly escalating pandemic. The outcomes in terms of swallow and speech function were also assessed. The study has also helped to remove the anxiety around open a tracheostomy in patients who are COVID-19 positive.

Histomorphometric analysis of goat uterine tissue on in vitro exposure with ovarian hormones and mifepristone

Uterus, the largest reproductive tract organ in female mammals, is the site of implantation of fertilised egg and foetus development. Uterus is a dynamic reproductive organ; its morphology alters with reproductive phase and steroidal cues. The aim of the present study was to assess the effects of progesterone (P4), estrogen (E2) and antiprogestogen i.e., mifepristone on goat’s uterine histoarchitecture in in vitro short term culture. Uterine tissue slices were cultured in the presence of E2, P4 and mifepristone at the dose of 10–9 M, 10–7 M and 10–6 M respectively for 24 hours. Uter-ine morphology of E2- and P4-treated groups did not reveal marked changes from that of control group. Mifepristone treatment caused conspicuous changes in uterine histoarchitecture, led to congested endometrium, regressed uterine glands and constricted blood vessels. The changes ob-served in morphometry after E2 and P4 exposure included increased uterine gland diameter (47.00 and 45.95 µm respectively) and glandular epithelial cell height (18.37 and 17.43 µm respectively) while the mifepristone treatment resulted in significant reduction of gland diameter (34.95 µm) as well as epithelium height (14.25 µm) as compared to those in control group (39.9 and 15.56 µm respectively). These morphometrical changes revealed prominent regressive changes in anti-progestin treated group while E2 and P4 showed prolific effects in in vitro culture. Thus it is envis-aged that E2 and P4 induced characteristic progressive changes in the histologic structure especially in endometrial glands of the goat uterus while anti-steroidogenic formulation i.e. mifepristone severely reduced the normal histoarchitecture of the uterus which is a prerequisite for implanta-tion.