Assessment of Epidemiological Implications Due to Serial Tropical Cyclones in India: Introspecting the Recent Sanitation Interventions.

OBJECTIVES: The Indian subcontinent is prone to tropical cyclones that used to originate in the North Indian Ocean. Through this study, an inventory of disease outbreaks for the tropical cyclone-affected regions from 2010 to 2018 has been compiled. This inventory is used to assess the success of recent sanitation intervention, Swachh Bharat Mission, also known as the Clean India Mission. METHODS: Meteorological parameters from the Indian satellites were used to demarcate the cyclone-affected area. Disease outbreaks and epidemics during the tropical cyclones were compiled from the Integrated Disease Surveillance Program and other relevant sources. The inventory has been used to track the effect of recent sanitation interventions on disease outbreaks. RESULTS: Districts in the eastern coast of India are frequently affected due to tropical cyclones that have originated from the North Indian Ocean. Infectious diseases like the acute diarrheal diseases, vector-borne diseases, viral fevers, enteric fevers, and food poisoning have recursively occurred during the cyclonic events and persisted up to 2 weeks from the cyclonic episode. The effectiveness of the Clean India Mission is evident during the recent cyclones, Ockhi, Titli, and Gaja, where a significantly lower number of infectious disease outbreaks were recorded. CONCLUSIONS: The Clean India Mission has exhibited positive results on the public health consequences associated with tropical cyclones.

Utilization of absolute monocyte counts to predict cardiovascular events in people living with HIV.

OBJECTIVES: Cardiovascular risk is increased in people living with HIV (PLWH). In HIV-uninfected populations, total absolute monocyte count (AMC) has been shown to be predictive of future cardiovascular events (CVEs). We sought to determine whether AMC predicts CVEs in PLWH independent of established and HIV-related cardiovascular risk factors. METHODS: We identified all PLWH within the Partners HIV Cohort without factors that could confound the monocyte count. CVE was defined as fatal or non-fatal acute myocardial infarction or ischaemic stroke. Baseline-measured AMC was defined as the average of all outpatient AMC counts a year before and after the baseline date. Multivariable Cox proportional hazards models were used to assess the association of baseline AMC with CVEs. RESULTS: Our cohort consisted of 1980 patients, with median follow-up of 10.9 years and 182 CVEs. Mean (± SD) age was 41.9 ± 9.3 years; 73.0% were male. Mean CD4 count was 506.3 ± 307.1 cells/µL, 48% had HIV viral load (VL) < 400 copies/mL, and 87% were on antiretroviral therapy. Mean AMC was 0.38 × 103  ± 0.13 cells/µL. In multivariable modelling adjusted for traditional CV risk factors, CD4 cell count, and HIV VL, AMC quartile 2 (Q2) (HR = 1.01, P = 0.98), Q3 (HR = 1.07, P = 0.76), and Q4 (HR = 0.97, P = 0.89) were not significantly predictive of CVE compared with Q1. DISCUSSION: Baseline AMC was not associated with long-term CVEs in PLWH. AMC obtained in routine clinical encounters does not appear to enhance CV risk stratification in PLWH.

Impact assessment of India's Swachh Bharat Mission - Clean India Campaign on acute diarrheal disease outbreaks: Yes, there is a positive change.

BACKGROUND: Enough evidence exists to attribute the occurrence of diarrheal disease outbreaks due to open defecation practice and unsafe sanitation methods. Open defecation enables pathogens such as virus, bacteria, and protozoa to infect humans by means of fecal-oral transmission methods through contaminated fluids, water, and fomites. To curb the malefic effects of open defecation, the Indian government had initiated pro sanitation program namely Swachh Bharat Mission (SBM) in 2014. SBM became the world's largest toilet-building initiative. More than 95 million toilets have been built across rural and urban India since the launch of this mission. This articulation summarizes the trend analysis of acute diarrheal disease (ADD) outbreaks over a 9-year period with emphasis on changes due to the building of toilets under the clean India campaign. METHODS: Weekly ADD outbreaks data from national-level Integrated Disease Surveillance Program between 2010 and 2018 were used for trend analysis along with the number of toilets constructed in rural areas under SBM from the year 2014. RESULTS: ADD outbreaks were analyzed from 2010 to 2018. The number of ADD outbreaks per year during the past 2 years (i.e., 2017 and 2018) of SBM regime was lesser than in any year during the investigation period. Seasonal variations during the months of May, June, July, and August account for 55%-60% of ADD outbreaks in any of the years; but for 2018, the total outbreaks were 46%, which is significantly lower than that of regular range of outbreaks in the peak season. CONCLUSION: The recent pattern of ADD outbreaks exhibits a declining rate.

Beneficial Role of Hydro-alcoholic Seed Extract of Trigonella foenum graecum on Bone Structure and Strength in Menopause Induced Osteopenia.

BACKGROUND: The current strategies to prevent and treat menopausal osteoporosis are hormone replacement therapy (HRT). However, the long-term use of hormone replacement therapy is limited due to its side-effects. Alternately, use of phytoestrogens has been implicated. Trigonella foenum graecum (TFG) seeds are rich in phytoestrogen and known traditional medicine to treat menopause induced hyperlipidemia. Therefore, in this study, we evaluated the role of dietary TFG seed extract on bone structure and mechanical properties in ovariectomized rats. METHODS: Twenty four female Wistar rats were randomly allocated into four groups; 1) control, 2) ovariectomized, 3) ovariectomized + TFG seed extract and 4) ovariectomized + 17ß-estradiol. TFG seed extract/17ß-estradiol was administered for 30 days, 14 days after ovariectomy. After the treatment, right femora were collected to measure the length and biomechanical properties, and left femora were gathered to study the micro architectural changes while tibia were collected to measure the dry weight. RESULTS: Maximum flexor load to break femur bone was significantly low in ovariectomized rats in comparison with control rats (P<0.05). Supplementation with TFG significantly improved the maximum flexor load (P<0.05) and tibia dry weight (P<0.01) compared to ovariectomized untreated rats. TFG administration also significantly preserved the trabecular (P<0.01) and cortical bone (P<0.05) thickness compared to ovariectomized rats. CONCLUSION: This study found that dietary intake of TFG seeds can improve the bone structure and biomechanical properties in ovariectomized rats indicating that TFG may be an alternative treatment strategy to prevent the menopause induced osteopenia.

A Family Study of Consanguinity in Children with Intellectual Disabilities in Barwani, India.

BACKGROUND: Intellectual disability (ID) can be inherited in families through consanguineous marriage. The ID in an individual can be associated with the ID, epilepsy, and mental illness in their parents. Such connections can be seen more closely among consanguineous marriages in tribal and nontribal population in India. OBJECTIVE: This study shows a few common patterns of the consanguineous relationship in the parents of children with ID in India. MATERIALS AND METHODS: This is a case series research design. Extreme or deviant case sampling was applied. Data were collected in homes, camps, and clinical settings in the Barwani district of Madhya Pradesh, India. The patterns of consanguineous marriages and the relationship between children with ID and their relatives with ID, epilepsy, and mental illness were analyzed and reported with pedigree charts. RESULTS: Multiple patterns of consanguineous marriages in tribal and nontribal populations were observed. ID was found to be associated in children with their relatives of the first, second, and third generations. CONCLUSION: ID may inherit in individuals from their relatives of the first, second, and third generations who have ID, epilepsy, or mental illness and married in the relationship. Appropriate knowledge, guidance, and counseling may be provided to potential couples before planning a consanguineous marriage.

Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery.

BACKGROUND: Several recent studies have investigated the role of C-reactive protein (CRP) as an early marker of anastomotic leakage following colorectal surgery. The aim of this systematic review and meta-analysis was to evaluate the predictive value of CRP in this setting. METHODS: A systematic literature search was performed using MEDLINE, Embase and PubMed to identify studies evaluating the diagnostic accuracy of postoperative CRP for anastomotic leakage following colorectal surgery. A meta-analysis was carried out using a random-effects model and pooled predictive parameters were determined along with a CRP cut-off value at each postoperative day (POD). RESULTS: Seven studies, with a total of 2483 patients, were included. The pooled prevalence of leakage was 9·6 per cent and the median day on which leakage was diagnosed ranged from POD 6 to 9. The serum CRP level on POD 3, 4 and 5 had comparable diagnostic accuracy for the development of an anastomotic leak with a pooled area under the curve of 0·81 (95 per cent confidence interval 0·75 to 0·86), 0·80 (0·74 to 0·86) and 0·80 (0·73 to 0·87) respectively. The derived CRP cut-off values were 172 mg/l on POD 3, 124 mg/l on POD 4 and 144 mg/l on POD 5; these corresponded to a negative predictive value of 97 per cent and a negative likelihood ratio of 0·26-0·33. All three time points had a low positive predictive value for leakage, ranging between 21 and 23 per cent. CONCLUSION: CRP is a useful negative predictive test for the development of anastomotic leakage following colorectal surgery.

Systematic review and meta-analysis of oesophageal Doppler-guided fluid management in colorectal surgery.

BACKGROUND: Oesophageal Doppler monitor (ODM)-guided fluid therapy has been recommended for routine use in patients undergoing colorectal surgery. However, recent trials have suggested either equivalent or inferior results for patients randomized to ODM-guided fluid management, especially when compared with fluid restriction or within the context of optimized perioperative care. Hence, an updated systematic review and meta-analysis was conducted. METHODS: A systematic review and meta-analysis was conducted of all randomized trials exploring ODM-guided fluid management in major colorectal surgery with the endpoints total complications and length of hospital stay (LOS). Subset analyses were planned a priori specifically to investigate the role of the ODM in the context of fluid restriction or optimized perioperative care. RESULTS: Six high-quality trials comprising a total of 691 patients were included in the final analysis. ODM-guided fluid therapy did not influence the incidence of complications (odds ratio 0·74, 95 per cent confidence interval (c.i.) 0·50 to 1·11; P = 0·15), with moderate heterogeneity in the results (I(2) = 33 per cent; P = 0·19). There was no difference in mean LOS between patients receiving ODM-guided fluid therapy and controls: mean difference -0·88 (95 per cent c.i. -2·89 to 1·13) days (P = 0·39). There was no difference in complications or LOS when ODM-guided fluid therapy was compared with fluid restriction or used within an otherwise optimized perioperative environment. CONCLUSION: ODM-guided fluid therapy did not influence LOS or complications in patients undergoing colorectal surgery. Results favouring the ODM were seen only in early studies, whereas newer trials did not show any benefit from such monitoring.

A peculiar liver with surgically and radiologically important variations: a case report.

A peculiar liver was found in an adult male cadaver during a dissection class for undergraduate medical students. The quadrate lobe and fissure for the ligamentum teres were totally absent. Thus, the cystic notch on the inferior border was very broad and deep, and the fundus and body of the gall bladder popped out through this notch. The cystic duct terminated into the right hepatic duct at the porta hepatis instead of terminating into the common hepatic duct. Awareness of variations of the lobes and fissures may minimize a misdiagnosis of liver problems. The aim of the current study was to alert radiologists and surgeons about possible variations in the external appearance and anomalies of the lobes and fissures of the liver.

Randomized clinical trial of goal-directed fluid therapy within an enhanced recovery protocol for elective colectomy.

BACKGROUND: Goal-directed fluid therapy (GDFT) has been compared with liberal fluid administration in non-optimized perioperative settings. It is not known whether GDFT is of value within an enhanced recovery protocol incorporating fluid restriction. This study evaluated GDFT under these circumstances in patients undergoing elective colectomy. METHODS: Patients undergoing elective laparoscopic or open colectomy within an established enhanced recovery protocol (including fluid restriction) were randomized to GDFT or no GDFT. Bowel preparation was permitted for left colonic operations at the surgeon's discretion. Exclusion criteria included rectal tumours and stoma formation. The primary outcome was a patient-reported surgical recovery score (SRS). Secondary endpoints included clinical outcomes and physiological measures of recovery. RESULTS: Eighty-five patients were randomized, and there were 37 patients in each group for analysis. Nine patients in the GDFT and four in the fluid restriction group received oral bowel preparation for either anterior resection (12) or subtotal colectomy (1). Patients in the GDFT group received more colloid during surgery (mean 591 versus 297 ml; P = 0·012) and had superior cardiac indices (mean corrected flow time 374 versus 355 ms; P = 0·018). However, no differences were observed between the GDFT and fluid restriction groups with regard to surgical recovery (mean SRS after 7 days 47 versus 46 respectively; P = 0·853), other secondary outcomes (mean aldosterone/renin ratio 9 versus 8; P = 0·898), total postoperative fluid (median 3750 versus 2400 ml; P = 0·604), length of hospital stay (median 6 versus 5 days; P = 0·570) or number of patients with complications (26 versus 27; P = 1·000). CONCLUSION: GDFT did not provide clinical benefit in patients undergoing elective colectomy within a protocol incorporating fluid restriction. REGISTRATION NUMBER: NCT00911391 (http://www.clinicaltrials.gov).

A peculiar liver with surgically and radiologically important variations: a case report / 대한해부학회지

A peculiar liver was found in an adult male cadaver during a dissection class for undergraduate medical students. The quadrate lobe and fissure for the ligamentum teres were totally absent. Thus, the cystic notch on the inferior border was very broad and deep, and the fundus and body of the gall bladder popped out through this notch. The cystic duct terminated into the right hepatic duct at the porta hepatis instead of terminating into the common hepatic duct. Awareness of variations of the lobes and fissures may minimize a misdiagnosis of liver problems. The aim of the current study was to alert radiologists and surgeons about possible variations in the external appearance and anomalies of the lobes and fissures of the liver.

A comparison of the colorectal surgical research across Europe, USA and Australasia.

AIM: The annual scientific meetings of the Association of Coloproctology of Great Britain and Ireland (ACPGBI), the American Society of Colon and Rectal Surgeons (ASCRS), the European Society of Coloproctology (ESCP) and the Royal Australasian College of Surgeons (RACS) are the major fora for presentation of colorectal surgical research. Thus, their content could be a proxy of the content and quality of colorectal surgical research worldwide. We aimed to critically appraise the quantity, quality and topics of colorectal surgical research over the previous 5 years for the above meetings. METHOD: All published abstracts from the ACPGBI, ASCRS, ESCP and the colorectal-specific component of the RACS from 2006 to 2010 were appraised. Abstracts were coded by predefined categories pertaining to study type and topic. RESULTS: Level 1 evidence (systematic reviews/meta-analyses) and level 2 evidence (randomized controlled trials) comprised 3% (95% CI 1-9%) and 5% (95% CI 2-11%), respectively, of research presented at the meetings. There was a predominance of level 4 evidence (retrospective studies) across all years (mean 54%, 95% CI 44-68%). Operative management was most commonly studied (mean 43%, 95% CI 36-49%). There was minimal research in perioperative care (mean 6%, 95% CI 2-13%) and basic surgical science (mean 6%, 95% CI 2-11%). Research related to perioperative care was significantly higher at the ACPGBI and RACS meetings than the ASCRS and ESCP meetings (P<0.01). CONCLUSION: The research at these meetings consists largely of retrospective reviews exploring operative management with minimal high quality scientific content. Active steps need to be taken to increase the quantity of high level evidence especially in topics other than operative management.

Systematic review and meta-analysis of intraperitoneal local anaesthetic for pain reduction after laparoscopic gastric procedures.

BACKGROUND: With the advent of minimally invasive gastric surgery, visceral nociception has become an important area of investigation as a potential cause of postoperative pain. A systematic review and meta-analysis was carried out to investigate the clinical effects of intraperitoneal local anaesthetic (IPLA) in laparoscopic gastric procedures. METHODS: Comprehensive searches were conducted independently without language restriction. Studies were identified from the following databases from inception to February 2010: Cochrane Central Register of Controlled Trials, the Cochrane Library, MEDLINE, PubMed, Embase and CINAHL. Relevant meeting abstracts and reference lists were searched manually. Appropriate methodology according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was adhered to. RESULTS: Five randomized controlled trials in laparoscopic gastric procedures were identified for review. There was no significant heterogeneity between the trials (χ(2) = 10·27, 10 d.f., P = 0·42, I(2) = 3 per cent). Based on meta-analysis of trials, there appeared to be reduced abdominal pain intensity (overall mean difference in pain score -1·64, 95 per cent confidence interval (c.i.) -2·09 to -1·19; P < 0·001), incidence of shoulder tip pain (overall odds ratio 0·15, 95 per cent c.i. 0·05 to 0·44; P < 0·001) and opioid use (overall mean difference -3·23, -4·81 to -1·66; P < 0·001). CONCLUSION: There is evidence in favour of IPLA in laparoscopic gastric procedures for reduction of abdominal pain intensity, incidence of shoulder pain and postoperative opioid consumption.

Oesophageal Doppler-guided fluid administration in colorectal surgery: critical appraisal of published clinical trials.

The evidence underpinning oesophageal Doppler monitoring (ODM)-guided fluid administration in colorectal surgery has not been critically appraised despite quantitative meta-analyses. A qualitative systematic review of the methodology and findings of all published randomised-controlled trials (RCTs) exploring ODM-guided fluid administration in major abdominal surgery was conducted. Four, well-designed single-centre trials inclusive of 393 patients in total have primarily demonstrated that ODM-guided intraoperative fluid administration decreases hospital length of stay (LOS) and complications by optimising intraoperative cardiac parameters. One subsequently published RCT shows that ODM-guided fluid administration predisposes to a greater LOS and significantly increased complications. However, all the trials have been hampered by imprecise definitions with heterogeneity in patient selection, intraoperative fluid administration strategies and methods of outcome assessment. ODM-guided fluid administration has only been investigated in the setting of laparoscopic colonic surgery and within an optimised perioperative care protocol in one trial, where it was not shown to be beneficial. Nevertheless, it was recommended for use in this context before the trial was even published. ODM-guided fluid administration has not been compared with intraoperative fluid restriction. Current evidence regarding the use of Doppler-guided fluid administration is limited by heterogeneity in the trial design, and the initial clinical benefits observed may be largely offset by recent advances in surgical techniques and perioperative care.

Elasticity measurements in scarred rabbit vocal folds using air pulse stimulation.

This study aimed to compare vocal fold elasticity data from a new method for non-invasive analysis by stimulations of the mucosa with short air pulses. The depth of the mucosal deflections is measured with laser pulses by means of a special algorithm. Ten scarred New Zealand rabbit vocal folds and four normal rabbit folds were measured directly after sacrifice. The elastic data were compared to histological sections from the scarred vocal folds analysed by a pathologist. The results showed significantly lower elasticity (higher stiffness) values for the more scarred vocal folds as compared to samples with minor damage (P=0.03). It is concluded that the air pulse stimulation method is a promising tool for non-invasive quantification of vocal fold scarring.