Effect of informed consent on patients undergoing gastrointestinal surgery and living donor liver transplantation and on their relatives in a developing country

Background

Informed consent is a systematic process for obtaining permission before conducting a healthcare intervention. In a developing country, gaining informed consent is generally perceived to be a ritual only to comply with legal requirements. The present study examined this by assessing the process of informed consent in patients undergoing gastrointestinal surgery or living donor liver transplantation (LDLT) and their relatives, based on their comprehension and overall satisfaction, in India.

Methods

All patients undergoing any gastrointestinal surgery or LDLT procedure between August 2015 and July 2016 and their relatives were included, and were administered a structured questionnaire 5 days after the procedure.

Results

The majority of patients (94·2 per cent) could recall the nature of their disease, the surgery performed (81·6 per cent) and anticipated complications (55·6 per cent). Among their relatives, these proportions were 97·8, 87·3 and 58·5 per cent respectively. Recall was associated with age, occupation and education among both patients and relatives. Patients undergoing LDLT, their donors and their relatives had better recall than those who had other gastrointestinal procedures (P < 0·001). Many patients found the process of informed consent useful and reassuring.

Conclusion

The details and risks of an operation were understood by most of the patients, especially those undergoing liver transplantation. Patients from developing countries can generally understand ‘informed consent’, and value it.

A Role for Nrf2 Expression in Defining the Aging of Hippocampal Neural Stem Cells

Redox mechanisms are emerging as essential to stem cell function given their capacity to influence a number of important signaling pathways governing stem cell survival and regenerative activity. In this context, our recent work identified the reduced expression of nuclear factor (erythroid-derived 2)-like 2, or Nrf2, in mediating the decline in subventricular zone neural stem progenitor cell (NSPC) regeneration during aging. Since Nrf2 is a major transcription factor at the heart of cellular redox regulation and homeostasis, the current study investigates the role that it may play in the aging of NSPCs that reside within the other major mammalian germinal niche located in the subgranular zone (SGZ) of the dentate gyrus (DG) of the hippocampus. Using rats from multiple aging stages ranging from newborn to old age, and aging Nrf2 knockout mice, we first determined that, in contrast with subventricular zone (SVZ) NSPCs, Nrf2 expression does not significantly affect overall DG NSPC viability with age. However, DG NSPCs resembled SVZ stem cells, in that Nrf2 expression controlled their proliferation and the balance of neuronal versus glial differentiation particularly in relation to a specific critical period during middle age. Also, importantly, this Nrf2-based control of NSPC regeneration was found to impact functional neurogenesis-related hippocampal behaviors, particularly in the Morris water maze and in pattern separation tasks. Furthermore, the enrichment of the hippocampal environment via the transplantation of Nrf2-overexpressing NSPCs was able to mitigate the age-related decline in DG stem cell regeneration during the critical middle-age period, and significantly improved pattern separation abilities. In summary, these results emphasize the importance of Nrf2 in DG NSPC regeneration, and support Nrf2 upregulation as a potential approach to advantageously modulate DG NSPC activity with age.

Drive-induced delocalization in the Aubry-André model

Motivated by the recent experiment by Bordia et al. [Nat. Phys. 13, 460 (2017)NPAHAX1745-247310.1038/nphys4020], we study the single particle delocalization phenomena of the Aubry-André (AA) model subjected to periodic drives. In two distinct cases we construct an equivalent classical description to illustrate that the drive-induced delocalization phenomena stems from an instability and the onset of chaos in the underlying dynamics. In the first case we analyze the delocalization and the thermalization in a time modulated AA potential with respect to driving frequency and demonstrate that there exists a threshold value of the amplitude of the drive. In the next example, we show that the periodic modulation of the phase of the hopping amplitude induced by a gauge field leads to an unusual effect on delocalization with a nonmonotonic dependence on the driving frequency. Within a window of such a driving frequency a delocalized Floquet band with a mobility edge appears, exhibiting multifractality in the spectrum as well as in the Floquet eigenfunctions. Finally, we explore the effect of interaction and discuss how the results of the present analysis can be tested experimentally.

Management protocols for chronic heart failure in India

Heart failure is a common clinical syndrome and a global health priority. The burden of heart failure is increasing at an alarming rate worldwide as well as in India. Heart failure not only increases the risk of mortality, morbidity and worsens the patient's quality of life, but also puts a huge burden on the overall healthcare system. The management of heart failure has evolved over the years with the advent of new drugs and devices. This document has been developed with an objective to provide standard management guidance and simple heart failure algorithms to aid Indian clinicians in their daily practice. It would also inform the clinicians on the latest evidence in heart failure and provide guidance to recognize and diagnose chronic heart failure early and optimize management.

Profile of chronic kidney disease related-mineral bone disorders in newly diagnosed advanced predialysis diabetic kidney disease patients: A hospital based cross-sectional study

AIM

Chronic kidney disease related-mineral bone disorder (CKD-MBD) has been poorly studied in pre-dialysis Indian CKD population. There are limited data on the pattern of these disturbances in diabetic CKD patients. Therefore, a study was conducted to find out the profile of mineral bone disorders in T2DM patients with pre-dialysis CKD.

METHODS

In this cross-sectional design, diabetic patients with newly-diagnosed stage 4 and 5 CKD were evaluated. Serum levels of calcium, phosphorus, intact parathyroid hormone (iPTH), 25 hydroxy vitamin D and total alkaline phosphatase (ALP) were measured in all patients. Bone mineral density (BMD) was measured using dual-energy X-ray absorptiometry (DXA).

RESULTS

A total of 72 eligible patients participated (44 males, 28 females; age 54.2±11.7). Patients with CKD Stage 5 had a lower level of corrected serum calcium and significantly higher level of inorganic phosphorus, total ALP and iPTH as compared to stage 4 patients. Overall, 38.5% were hypocalcemic, 31.43% were hyperphosphatemic. 24.2% of CKD subjects were vitamin D deficient (<10ng/ml) and 41.4% having vitamin D insufficiency (10-20ng/ml). In stage 4, hyperparathyroidism (iPTH>110pg/ml) was detected in nearly 43% of patients. In stage 5, only 32% patients was found to have hyperparathyroidism (iPTH>300pg/ml). There was a good correlation between iPTH and total ALP (r=0.5, p=0.0001) in this cohort. 25 (OH) vitamin D was inversely correlated with ALP (r=-0.39, P=0.001) and showed negative correlation with urine ACR (r=-0.37, P=0.002). As a group, the osteoporotic CKD subjects exhibited higher iPTH (220.1±153.8 vs. 119±108pg/ml, p<0.05) as compared to those who were osteopenic or had normal bone density. There was significant correlation between BMD and iPTH (adjusted r=-0.436; P=0.001). In the multivariate regression model, we found intact PTH to predict BMD even after adjustment of all the confounders.

CONCLUSION

The current study showed that adynamic bone disease is prevalent even in pre-dialysis CKD population. High bone turnover disease may not be the most prevalent type in diabetic CKD. However, it could contribute to the development of osteoporosis in CKD subjects. Serum total ALP can serve as a biochemical marker to identify pattern of bone turnover where intact PTH is not available.

Robert Mathys Finger prosthesis of the proximal interphalangeal joint: a retrospective case series of 19 joints in 17 patients

INTRODUCTION

The Robert Mathys (RM) Finger is a hinged type of arthroplasty for the metacarpophalangeal and proximal interphalangeal (PIP) joint that compensates ligament instability. The aim of this study is to evaluate the outcomes and complications of RM Finger arthroplasty of the PIP joint.

MATERIALS AND METHODS

A retrospective case series of 19 RM Finger arthroplasties of the PIP joint in 17 patients was performed with a median follow-up of 36 months. The active range of motion (AROM) was measured pre-operatively, at the 6-week follow-up, at the termination of hand therapy, and at the final follow-up. Complications were recorded, as well as pain on a visual analog scale (VAS), stability, deformity, pinch strength, the Michigan Hand Outcomes Questionnaire (MHQ), and the Patient Global Index of Improvement Questionnaire.

RESULTS

One implant fracture occurred. Another patient had an amputation due to stiffness. For the remaining joints, AROM was 61°. One joint mobilization under local anesthesia, one arthrolysis and two extensor tendon reconstructions were also necessary. Pain at the follow-up was 1.2 on the VAS. Relative pinch strength was 69%. Joint stability was restored in all fingers, although one joint had an ulnar deviation of 15°. Eight fingers developed a snapping phenomenon, of which five had a swan neck deformity. One finger had an extension lag with a Boutonnière deformity. MHQ scores were less compared to the unaffected hand. Fifteen patients rated their outcome as improved compared to their pre-operative condition.

CONCLUSIONS

RM Finger arthroplasty of the PIP joint restores joint stability with AROM improvement, and with low pain, although it has a high rate of complications.

LEVEL OF EVIDENCE

IV.

The impact of immunoglobulin in acute HIV infection on the HIV reservoir: a randomized controlled trial

OBJECTIVES

Antiretroviral therapy (ART) during acute HIV infection (AHI) restricts the HIV reservoir, but additional interventions are necessary to induce a cure. Intravenous immunoglobulin (IVIG) is not HIV-specific but is safe and temporarily reduces the HIV reservoir in chronic HIV infection. We present a randomized controlled trial to investigate whether IVIG plus ART in AHI reduces the HIV reservoir and immune activation compared with ART alone.

METHODS

Ten men with AHI (Fiebig II-IV) initiated ART (tenofovir, entricitabine, ritonavir boosted darunavir and raltegravir) at HIV-1 diagnosis and were randomized to ART alone or ART plus 5 days of IVIG, once virally suppressed (week 19). Blood samples were evaluated for viral reservoir, immune activation, immune exhaustion and microbial translocation. Flexible sigmoidoscopy was performed at weeks 19, 24 and 48, and gut proviral DNA and cell numbers determined.

RESULTS

IVIG was well tolerated and no viral blips (> 50 HIV-1 RNA copies/mL) occurred during IVIG therapy. From baseline to week 48, total HIV DNA in peripheral blood mononuclear cells (PBMCs) (cases: -3.7 log₁₀ copies/10⁶ CD4 cells; controls: -3.87 log₁₀ copies/10⁶ CD4 cells) declined with no differences observed between the groups (P = 0.49). Declines were observed in both groups from week 19 to week 48 in total HIV DNA in PBMCs (P = 0.38), serum low copy RNA (P = 0.57) and gut total HIV DNA (P = 0.55), but again there were no significant differences between arms. Biomarkers of immune activation, immune exhaustion and microbial translocation and the CD4:CD8 ratio were similar between arms for all comparisons.

CONCLUSIONS

Although safe, IVIG in AHI did not impact total HIV DNA, immune function or microbial translocation in peripheral blood or gut tissue.

Characterisation of Activated Carbons Obtained from Rice Husk

Rice husk derived activated carbons doped with nitrogen have been studied using low temperature nitrogen adsorption, scanning electron microscopy, mercury porosimetry, thermogravimetric analysis combined with mass-spectrometry, differential scanning calorimetry and X-ray photoelectron spectroscopy. It has been shown that N-doped activated carbon produced by high temperature treatment of the starting material soaked with urea, has a significantly higher anion exchange capacity than the other samples studied, which correlates with its higher adsorption capacity towards nitrate ion removal from aqueous solutions with the initial concentration of 5 and 15 ppm.

Hydration education: developing, piloting and evaluating a hydration education package for general practitioners

OBJECTIVES

To (1) assess the hydration knowledge, attitudes and practices (KAP) of doctors; (2) develop an evidence-based training package; and (3) evaluate the impact of the training package.

DESIGN

Educational intervention with impact evaluation.

SETTING

Cambridgeshire, UK.

PARTICIPANTS

General practitioners (GPs (primary care physicians)).

INTERVENTIONS

Hydration and healthcare training.

MAIN OUTCOME MEASURES

Hydration KAP score before and immediately after the training session.

RESULTS

Knowledge gaps of doctors identified before the teaching were the definition of dehydration, European Food Safety Authority water intake recommendations, water content of the human body and proportion of water from food and drink. A face-to-face teaching package was developed on findings from the KAP survey and literature search. 54 questionnaires were completed before and immediately after two training sessions with GPs. Following the training, total hydration KAP scores increased significantly (p<0.001; median (25th, 75th centiles); 32 (29, 34)). Attendees rated the session as excellent or good (90%) and reported the training was likely to influence their professional practice (100%).

CONCLUSIONS

The training package will continue to be developed and adapted, with increased focus on follow-up strategies as well as integration into medical curricula and standards of practice. However, further research is required in the area of hydration care to allow policymakers to incorporate hydration awareness and care with greater precision in local and national policies.

Proceedings of the inaugural International Summit for Medical Nutrition Education and Research

Medical Nutrition Education (MNE) has been identified as an area with potential public health impact. Despite countries having distinctive education systems, barriers and facilitators to effective MNE are consistent across borders, demanding a common platform to initiate global programmes. A shared approach to supporting greater MNE is ideal to support countries to work together. In an effort to initiate this process, the Need for Nutrition Education/Innovation Programme group, in association with their strategic partners, hosted the inaugural International Summit on Medical Nutrition Education and Research on August 8, 2015 in Cambridge, UK. Speakers from the UK, the USA, Canada, Australia, New Zealand, Italy, and India provided insights into their respective countries including their education systems, inherent challenges, and potential solutions across two main themes: (1) Medical Nutrition Education, focused on best practice examples in competencies and assessment; and (2) Medical Nutrition Research, discussing how to translate nutrition research into education opportunities. The Summit identified shared needs across regions, showcased examples of transferrable strategies and identified opportunities for collaboration in nutrition education for healthcare (including medical) professionals. These proceedings highlight the key messages presented at the Summit and showcase opportunities for working together towards a common goal of improvement in MNE to improve public health at large.

Quantum signature of chaos and thermalization in the kicked Dicke model

We study the quantum dynamics of the kicked Dicke model (KDM) in terms of the Floquet operator, and we analyze the connection between chaos and thermalization in this context. The Hamiltonian map is constructed by suitably taking the classical limit of the Heisenberg equation of motion to study the corresponding phase-space dynamics, which shows a crossover from regular to chaotic motion by tuning the kicking strength. The fixed-point analysis and calculation of the Lyapunov exponent (LE) provide us with a complete picture of the onset of chaos in phase-space dynamics. We carry out a spectral analysis of the Floquet operator, which includes a calculation of the quasienergy spacing distribution and structural entropy to show the correspondence to the random matrix theory in the chaotic regime. Finally, we analyze the thermodynamics and statistical properties of the bosonic sector as well as the spin sector, and we discuss how such a periodically kicked system relaxes to a thermalized state in accordance with the laws of statistical mechanics.

Increasing resistance to ciprofloxacin and other antibiotics in Neisseria gonorrhoeae from East Java and Papua, Indonesia, in 2004 – implications for treatment

We examined gonococci isolated in 2004, in East Java and Papua, Indonesia, to review the suitability of ciprofloxacin-based and other treatment regimens. Gonococci from the two provinces were tested in Sydney for susceptibility to penicillin, tetracycline, spectinomycin, ceftriaxone, ciprofloxacin, gentamicin, azithromycin and rifampicin. Of 163 gonococcal isolates from East Java (91) and Papua (72), 120 (74%) of gonococci, 62 (68%) and 58 (80%) from East Java and Papua, respectively, were penicillinase-producing gonococci and 162 displayed high-level tetracycline resistance. Eighty-seven isolates (53%) were ciprofloxacin resistant, 44 (48%) from East Java and 43 (60%) from Papua. All isolates were sensitive to cefixime/ceftriaxone, spectinomycin and azithromycin. Minimum inhibitory concentrations of gentamicin were in the range 0.05–8 mg/L. Sixty-nine gonococci (42%) showed combined resistance, to penicillin, tetracycline and quinolones. Quinolone resistance has now reached unacceptable levels, and their use for the treatment of gonorrhoea in Indonesia should be reconsidered.

Acquired torticollis due to primary pyomyositis of the paraspinal muscles in an 11-year-old boy

Torticollis is characterised by tilting and rotation of the cervical spine in opposite directions. Causes can be congenital or acquired. Primary pyomyositis is a rare subacute deep bacterial infection of skeletal muscles that typically affects individuals under 20 years of age from tropical countries. Infrequently, pyomyositis occurs in individuals from temperate regions, usually in immunocompromised adults, and this is defined as secondary pyomyositis. We report a case of acquired torticollis due to primary pyomyositis of the paraspinal muscles in a previously healthy boy from the UK. A prolonged course of antibiotics and physiotherapy led to a complete resolution of his illness. We review how to differentiate pyomyositis from focal myositis, a more common inflammatory muscular cause of acquired torticollis.