Residents' working hours and patient safety: Have we finally laid the issue to rest.

Bilimoria KY, Chung JW, Hedges LV, Dahlke RD, Love R, Cohen ME, Hoyt DB, Yang AD, Tarpley JL, Mellinger JD, Mahvi DM, Kelz RR, Ko CY, Odell DD, Stulberg JJ, Lewis FR. (Surgical Outcomes and Quality Improvement Center [SOQIC], Department of Surgery and Center for Healthcare Studies, Feinberg School of Medicine and Northwestern Medicine, Northwestern University, Evanston; the American College of Surgeons, Chicago; Department of Statistics, Northwestern University, Evanston; Department of Surgery, Southern Illinois University, Springfield; Department of Surgery, Vanderbilt University, Nashville; Department of Surgery and the Center for Surgery and Health Economics, Perelman School of Medicine, University of Pennsylvania; the American Board of Surgery, Philadelphia; Department of Surgery, University of California, Los Angeles, School of Medicine, Los Angeles, USA.) National cluster randomized trial of duty-hour flexibility in surgical training. N Engl J Med 2016;374:713–27.

A hospital-based epidemiological study of corrosive alimentary injuries with particular reference to the Indian experience.

Corrosive alimentary tract injuries are a source of considerable morbidity all over the world. Despite this, actual data on the epidemiology of this problem are scarce mainly due to the lack of a well-established reporting system for poisoning in most countries. The burden of the disease is naturally more in countries such as India where the condition is common because of poor regulation of sale of corrosive substances. We analyse the available data on epidemiology of corrosive injuries, as well as patterns of involvement of the alimentary tract, with special reference to Indian data, and also provide an overview of the management options and long-term sequelae of this condition.

ICMR’s Ethical guidelines for biomedical research on human participants: need for clarification.

The “Ethical guidelines for biomedical research on human participants” prepared by the Indian Council of Medical Research in 2006 came as a welcome step in the process of regulation of research on human subjects, since clear cut Indian guidelines were absent earlier. The guidelines have been accepted as the standard operating manual by Institutional Ethics Committees (IEC) in India. However, over a period of time, it has become obvious that the guidelines lack clarity in certain areas and require to be revised in the light of experiences of members in the IECs. Some of these problems with the ICMR guidelines have been highlighted in this paper to press for revision of the manual in the light of these experiences.

Is there need for a transformational change to overcome the current problems with postgraduate medical education in India.

In spite of the existence of a dual system of postgraduation, one under the Medical Council of India (MCI) and the other on a parallel track under the National Board of Examinations, postgraduate medical education in India is beset with several problems. For example, the curriculum has not been revised comprehensively for several decades. The diploma course under the MCI has become unpopular and is largely a temporary refuge for those who do not get admission to degree courses. The level of skills of the outgoing graduate is falling and the increase in the number of seats is taking place in a haphazard manner, without reference to the needs. In spite of increase in seats, there is a shortage of specialists at the secondary and tertiary care levels, especially in medical colleges, to share teaching responsibilities. Further, the distribution of specialists is skewed, with some states having far more than others. To remedy these ills and fulfil the requirements of the country over the next two decades, a working group appointed by the erstwhile governors of the MCI was asked to suggest suitable modifications to the existing postgraduate system. After an extensive review of the lacunae in the present system, the needs at various levels and the pattern of postgraduate education in other countries, it was felt that a competency-based model of a 2-year postgraduate course across all specialties, the use of offsite facilities for training and a criterion-based evaluation system entailing continuous monitoring would go a long way to correct some of the deficiencies of the existing system. The details of the proposal and its merits are outlined for wider discussion and to serve as a feedback to the regulatory agencies engaged in the task of improving the medical education system in India. We feel that the adoption of the proposed system would go a long way in improving career options, increasing the availability of teachers and dissemination of specialists to the secondary and primary levels, and improving the quality of outgoing postgraduates.

Attempts at regulation of medical education by the MCI: issues of unethical and dubious practices for compliance by medical colleges and some possible solutions.

There are, at present, over 335 medical colleges in the country conducting the MBBS course. Of these, well over 50 per cent are run by private organisations. Further, an overwhelming majority of institutions set up within the last two decades are privately run and not state sponsored.

Diagnostic value of C-reactive protein in suspected acute appendicitis - A prospective case control study.

Aim: To find out the Sensitivity, Specificity and Predictive value of C-reactive protein in the diagnosis of acute appendicitis. Materials and Methods: Hundred patients undergoing emergency appendicectomy were cases and thirty patients undergoing interval appendicectomy during the same period were controls. Creactive protein was measured pre-operatively. Results: CRP was reactive in 89% of cases and 3 of 30 controls (P = 0). Among the thirteen complicated cases, two had a CRP reactivity of 1.2 mg/dl, eight had 2.4 mg/dl and three had 3.6 mg/dl. In the uncomplicated cases, forty nine were reactive at 1.2 mg/dl, twenty six at 2.4 mg/dl and one at 3.6 mg/dl ( P = 0.0009). In histopathologically inflamed appendix, reactivity was 94.4% and in normal appendix reactivity was 40% ( P = 0.00007). CRP positivity had a sensitivity of 94.4% (CI 89.9-98.9) and a positive predictive value of 95.5% (CI 91.4-99.6). CRP reactivity and leucocytosis if combined, the sensitivity, specificity, PPV and NPV were 85%, 100%, 100% and 81% respectively. Threshold for CRP reactivity if raised to 2.4 mg/dl, the sensitivity, specificity, PPV and NPV are 42%, 100%, 100% and 16% respectively. Conclusion: CRP estimation is a good 'rule-in' test and not-so-good 'rule-out' test to diagnose acute appendicitis.

Assessment of vagotomy status with postprandial urinary alkaline tide.

Aim: This study was carried out to assess whether the postprandial urinary alkaline tide, as a marker for the completeness of vagotomy, is dependent on the nature of the test meal, whether it is affected by proton pump inhibitor therapy, and whether it is reliable. Methods: The postprandial urinary alkaline tide (PUAT) pattern was prospectively assessed in three different study groups and one control group of healthy volunteers. The three study groups were as follows; A (n = 20) i.e. the Proton Pump Inhibitor (PPI) Group; B (n = 25) i.e. the Truncal Vagotomy (TV) Group; and C (n = 5) i.e. the Recurrent Ulcer (RU) Group. Urinary pH was measured by a pocket digital pH meter. Results: Postprandial urinary alkaline tide in the control group was significantly higher compared to the fasting levels. Liquid diet did not elicit a significant urinary alkaline tide response. There was a statistically significant fall in both fasting urinary pH (5.34 ± 0.70 vs. 4.80 ± 0.61, p = 0.031) and the postprandial alkaline tide (6.99 ± 0.79 vs. 4.94 ± 0.63, p = 0.0001) after taking proton pump inhibitors. In the truncal vagotomy and gastrojejunostomy group it was found that there was a significant fall in both the mean fasting (5.28 ± 0.58, vs. 4.92 ± 0.66, p = 0.032) and the postprandial urinary pH (6.29 ± 0.92 vs. 5.09 ± 0.73, p = 0.0001) following surgery. Conclusion: This study establishes that simple measurement of the urinary pH before and after a standard test meal can be used as an accurate routine test for the completion of vagotomy. It also showed that proton pump inhibitors abolish the alkaline tide and therefore must be discontinued before measuring the alkaline tide. Liquid test meal was not effective in eliciting an alkaline tide as compared to a solid meal.

Does elective re-siting of intravenous cannulae decrease peripheral thrombophlebitis? A randomized controlled study.

Background. Peripheral venous thrombophlebitis (PVT) is a common complication of intravenous cannulation, occurring in about 30% of patients. We evaluated the effect of elective re-siting of intravenous cannulae every 48 hours on the incidence and severity of PVT in patients receiving intravenous fluids/drugs. Methods. We randomized 42 patients who were admitted for major abdominal surgery to either the control or study group (n=21 in either group). Informed consent was obtained from all of them. Cannulae in the control group were removed only if the site became painful, the cannula got dislodged or there were signs and symptoms suggestive of PVT, namely pain, erythema, swelling, excessive warmth or a palpable venous cord. Cannulae in the study group were changed and re-sited electively every 48 hours. All the patients were examined every 24 hours for signs and symptoms of PVT at the current and previous sites of infusion. Results. The incidence of PVT was 100% (21/21) in the control group and only 9.5% (2/21) in the study group (p<0.0001). The severity of PVT was also less in the study group compared with that in the control group. Day-wise correlation of the incidence of PVT showed that 82.6% of the episodes of PVT occurred on day 3. Conclusion. Elective re-siting of intravenous cannulae every 48 hours results in a significant reduction in the incidence and severity of PVT. We recommend that this should be adopted as standard practice in managing all patients who require prolonged intravenous therapy.

Isolated mesenteric fibromatosis.

Fibromatosis is a rare, locally aggressive but non-metastasising fibrous mass often associated with familial adenomatous polyposis in Gardner's Syndrome (GS). Although sporadic cases occur, unlike in GS, they are predominantly extra-abdominal. We report the case of a 40-year-old lady who underwent laparotomy for a large isolated abdominal mass three years after a Whipple's procedure for adenocarcinoma of the distal common bile duct. A spherical, football sized tumour was found in the jejunal mesentery. Resection of the tumour with jejunum was carried out. No metastasis was detected. This case is peculiar in that mesenteric fibromatosis occurred in a patient with prior history of periampullary carcinoma and without history of familial adenomatous polyposis.

Serum pepsinogen I and II levels in various gastric disorders with special reference to their use as a screening test for carcinoma stomach.

INTRODUCTION: The role of serum pepsinogen in the diagnosis of gastric carcinoma is well established. Its role in other common upper alimentary disorders has not been widely studied. The aim of this study was to describe the effect of various gastric disorders on the levels of pepsinogen I, pepsinogen II and pepsinogen I/II ratio, with an emphasis on the diagnosis of carcinoma stomach in the South Indian population. METHODS: A total of 210 patients in seven groups, including one control group, were studied. The groups included patients with carcinoma stomach, Helicobacter pylori gastritis, peptic ulcer, portal hypertensive gastropathy, non-ulcer dyspepsia and erosive gastritis. Serum pepsinogen I, pepsinogen II and pepsinogen I/II ratio were estimated using an enzyme-linked immunosorbent assay technique. RESULTS: Patients with carcinoma of the stomach, when compared with controls, had a significantly lower pepsinogen I level (87.2 microg/L vs. 158.1 microg/L, p=0.0002) and pepsinogen I/II ratio (4.3 vs. 7.2, p = 0.0001). No significant change in pepsinogen levels occurred in the other groups. The cut-off levels of pepsinogen I (115.3 microg/L) and pepsinogen I/II ratio (6.2), determined by THE ROC curve, when applied in parallel provided a sensitivity of 97% and a negative predictive value of 91.4% for the diagnosis of carcinoma stomach. When the tests were applied in parallel, the likelihood ratio of a negative test was 0.06, indicating that individuals without carcinoma stomach were 16 times more likely to have a negative test than those with carcinoma. This fulfilled the essential prerequisites of an ideal screening test. CONCLUSION: Serum pepsinogen estimation is a useful diagnostic tool in the diagnosis of carcinoma stomach. The significance of serum pepsinogen level in portal hypertensive gastropathy, non-ulcer dyspepsia, peptic ulcer, Helicobacter pylori gastritis and erosive gastritis was not established.

Is Helicobacter pylori eradication indicated in cirrhotic patients with peptic ulcer disease?

INTRODUCTION: The association between H. pylori infection and peptic ulcer disease (PUD) and the efficacy of eradication of H. pylori in treating ulcer disease in cirrhotic patients remains controversial. This study was carried out to ascertain the prevalence and significance of H. pylori in cirrhotic patients with PUD and to assess the need for anti H. pylori thrapy METHODS: Three groups of patients were studied . These were patients with (A) cirrhosis and PUD, (B) uncomplicated PUD and (C) cirrhosis without PUD. H. pylori status was determined by endoscopic urease test . Eradication therapy was given with a four drug regimen and repeat endoscopy was done three months later to detect ulcer healing as well as H. pylori status with PUD in groups A and B. RESULTS: Cirrhotic patients with PUD had a significantly lesser prevalence of H. pylori compared to uncomplicated ulcer patients (46.9 % vs 80 %; p = 0.04). While H. pylori eradication rates were similar between cirrhotic and non cirrhotic patients, ulcer healing rate was significantly lesser in cirrhotic patients ( 48 % vs 80.9 %) . Majority of residual ulcers in cirrhotic patients were negative for H. pylori. CONCLUSION: Eradication of H. pylori does not reduce the residual ulcer rate indicating that H. pylori infection might not be a significant risk factor for PUD in cirrhotic patients. Hence, routine H. pylori eradication might not be warranted in patients with cirrhosis and peptic ulcer disease.

Improvement in dysphagia and quality of life with self-expanding metallic stents in malignant esophageal strictures.

BACKGROUND: Carcinoma of the esophagus often presents at an advanced stage, with absolute dysphagia or aspiration. Palliative procedures have an important role in improving the quality of life (QOL) of patients who are not candidates for curative therapy. We report on the efficacy and complications of self-expanding metallic stents (SEMS) in such patients. METHODS: Ultraflex nitinol SEMS were placed under endoscopic guidance in patients with malignant esophageal strictures. Dysphagia, pain and QOL were assessed before and after SEMS placement. RESULTS: Thirty patients were treated with SEMS. QOL score improved significantly from 62-94 before stenting to 80-133 after the procedure. There was improvement in dysphagia grades. Pain was the most common complaint noted on follow up. There was no major morbidity or mortality related to the procedure. CONCLUSIONS: SEMS placement is a safe and effective treatment modality for palliation of dysphagia due to malignant esophageal strictures. It provides lasting relief in dysphagia and improvement in QOL, without major complications.

Role of eradication of Cag A Helicobacter pylori in non ulcer dyspepsia.

The role of Helicobacter pylori (H.pylori) in patients with non ulcer dyspepsia (NUD), the relationship of the virulence of the organism to the occurrence and severity of NUD and the need for eradication of H. pylori in alleviating symptoms of NUD remain controversial. This study was carried out for the purpose of determining the interaction between virulent H.pylori and symptoms of NUD and to clarify whether H. pylori eradication is beneficial in-patients with NUD. Sixty consecutive patients who fulfilled standard criteria for the diagnosis of NUD and who were positive H. pylori status by the urease test were studied. NUD was classified into ulcer-like and dysmotility-like as per standard criteria. All patients were treated with a triple drug regimen for H. pylori for 10 days, which consisted of Clarithromycin, Amoxicillin and Omeprazole. Blood was drawn for IgG antibodies against Cag A strains and H. pylori by ELISA. All patients were evaluated at 6 months for symptomatic improvement, which was, correlated with Cag A H. pylori positive status. No significant difference was seen in the H. pylori Cag A prevalence between ulcer-like and dysmotility-like dyspepsia. While there was a trend towards a better symptomatic improvement with H.pylori eradication in patients with ulcer-like NUD as opposed to dysmotility-like NUD, this did not reach significance (73% vs. 57%, p= 0.18). However "there was a statistically significant benefit of eradication of H. pylori in-patients with ulcer-like NUD who were positive for Cag A H.pylori status (p=0.02). No such benefit was seen in-patients with dysmotility-like NUD. H. pylori eradication seems to confer significant benefit as regards symptomatic relief inpatients with ulcer like NUD who are positive for Cag A strain for H. pylori.