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.

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.

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.