Patient and operative factors influence delayed discharge following bariatric surgery in an enhanced recovery setting

BACKGROUND

Enhanced Recovery After Surgery (ERAS) programs have been widely adopted in bariatric surgery. However, not all patients are successfully managed in the ERAS setting and there is currently little way of predicting the patients who will deviate from the program. Early identification of these patients could allow for more tailored protocols to be implemented preoperatively to address the issues, thereby improving patient outcomes.

OBJECTIVES

The aim of this study was to elucidate the factors which preclude discharge by comparing patients who were successfully discharged by the end of the first postoperative day (POD 0/1) to those who stayed longer, including revisional surgery in this analysis.

SETTING

A tertiary, high-volume Bariatric Centre, United Kingdom.

METHODS

A retrospective analysis was performed of all patients undergoing bariatric surgery in a single centre in 1 year. Multivariate analyses compared patient and operative variables between patients who were discharged on POD 0/1 and those who stayed longer.

RESULTS

A total of 288 bariatric operations were performed: 78% of operations performed were laparoscopic Roux-en-Y gastric bypass; 22% laparoscopic sleeve gastrectomy. Of these cases, 13% were revisional operations. Four patients returned to theatre on the index admission. 81% of patients were discharged by POD 0/1. A re-presentation within 30 days was seen in 6% of patients. There was no significant difference in length of stay for the type of operation performed (P = .86). Patients who had a revisional procedure were not more likely to stay longer. Length of stay was also independent of age, BMI, and comorbidities. Caucasian patients were more likely to be discharged on POD 0/1 than those of other ethnicities (90% versus 78%; P = .02). Operations performed by trainee surgeons, under consultant supervision, were significantly more likely to be discharged on POD 0/1 (P = .03). However, a logistic regression analysis was unable to predict patients who had a prolonged stay.

CONCLUSIONS

Patient length of stay is independent of BMI, operation, and comorbidities and these factors do not need special consideration in ERAS pathways. Patients undergoing revisional procedures can be managed in the same way as those having primary procedures, with a routine POD 0/1 discharge. However, the impact of individual patient factors, and their interaction, is complex and cannot predict overstay.

Impact of Gastrojejunostomy Anastomosis Diameter on Weight Loss Following Laparoscopic Gastric Bypass: A Systematic Review

Laparoscopic Roux-en-Y gastric bypass (RYGB) is crucial for significant weight reduction and treating obesity-related issues. However, the impact of gastrojejunostomy (GJ) anastomosis diameter on weight loss remains unclear. We investigate this influence on post-RYGB weight loss outcomes. A systematic search was conducted. Six studies met the inclusion criteria, showing varied GJ diameters and follow-up durations (1-5 years). Smaller GJ diameters generally correlated with greater short-to-medium-term weight loss, with a threshold beyond which complications like stenosis increased. Studies had moderate-to-low bias risk, emphasizing the need for precise GJ area quantification post-operation. This review highlights a negative association between smaller GJ diameters and post-RYGB weight loss, advocating for standardized measurement techniques. Future research should explore intra-operative and AI-driven methods for optimizing GJ diameter determination.

Characterizing barriers and facilitators of metabolic bariatric surgery tourism: a systematic review

BACKGROUND

Metabolic bariatric surgery tourism continues to rise and has become a growing concern for bariatric surgeons globally. With varying degrees of regulation, counselling and success, those that develop complications may have to deal with a multitude of challenges often distant from their country of operation. The aim of this study was to characterize the barriers and facilitators influencing individuals to undergo metabolic bariatric surgery tourism, in order to better understand the implications to the National Health Service and other healthcare systems.

METHODS

A systematic literature search, restricted to the English language, was performed to identify relevant studies. All studies were included until December 2022, the last search date. Study quality was assessed with the validated mixed-methods appraisal tool. A Braun and Clarke thematic analysis was undertaken to identify themes and subthemes.

RESULTS

A total of five studies met the inclusion criteria. Identified themes included: availability, accessibility, cost, eligibility, reputation, and stigma; the available evidence was of varying quality.

CONCLUSION

This work identifies a series of subthemes influencing the decision to undertake metabolic bariatric surgery tourism. The results highlight the limited literature available in understanding the complex motivational insights; the scale of the problem in the current healthcare system; cost and long-term outcomes. A National Emergency Bariatric Surgery audit would allow generation of more robust data to explore further the issues of clinical relationships and networks and to guide policy making.

Systematic Review and Meta-analysis of the Effects of Laparoscopic Roux-en-Y Gastric Bypass and Laparoscopic Sleeve Gastrectomy on Dyslipidemia

The aim of this meta-analysis was to compare the effects of LRYGB and LSG on dyslipidemia. Studies comparing the effects of LRYGB and LSG on dyslipidemia with follow-up of 12 months or more were included. Twenty-four studies comprising seven RCTs and 17 comparative observational studies were included. Meta-analysis of RCTs (n=487) showed that improvement/resolution of dyslipidemia was better after LRYGB (68.5%, n=161/235) compared to LSG (48.4%, n=122/252). Patients undergoing LRYGB were more than twice as likely to experience improvement/resolution in dyslipidemia compared to those undergoing LSG (OR 2.28, 95% CI 1.21-4.29, p=0.010). Both LRGYB and LSG appears effective in improving dyslipidemia at >12 months after surgery; however, this improvement is more than twice higher after LRYGB compared to LSG.

The surgical management of obesity

Obesity has reached pandemic levels globally. Surgical management of obesity aims to establish metabolic control, weight loss and resolution of multiple health conditions and to improve quality of life. Here, we examine the role of surgery in the management of obesity within the context of a multidisciplinary team involving a variety of healthcare professionals. We highlight the importance of patient selection, perioperative care, the various types of bariatric surgery currently available as well as emerging procedures. In addition to clarifying the different types of procedure, we also examine the potential complications and issues of weight regain and failure to lose weight. Ultimately, bariatric surgery remains comparatively safe and with generally excellent results in terms of control of existing obesity-related conditions; with the ever-increasing number of patients living with obesity, the scope of bariatric surgery is thus likely to increase.

BS O06 The burden of bariatric-related emergency interventions at a tertiary bariatric centre: The Luton and Anglian Experience

Background

Bariatric surgery is becoming more prevalent worldwide due to increasing rates of obesity. British patients can access bariatric surgical services through established NHS services, or privately via British hospitals or abroad. Post-operatively, patients might require urgent surgical admission for analgesia, nutritional evaluation and even emergency surgery. Few publications have addressed the rates of late endoscopic or surgical re-intervention in British bariatric patients. This study investigated the burden of emergency bariatric-related surgery at an established high volume bariatric centre.

Methods

All bariatric-related procedures were selected from a prospectively maintained emergency surgery database. Patients who underwent unplanned, endoscopic or surgical procedures between September 2018 and September 2021 were included. Patients who had bariatric surgery at our institution and returned to theatre within their inpatient stay were excluded.

Primary outcomes were the location of the index procedure (local, other institutions within the UK, or abroad), type of the index bariatric procedure, length of stay (LOS), admission to intensive care, and mortality.

Results

During the study period, 87 patients underwent 102procedures. Index procedures were roux-en-Y gastric bypass 32 (37%), gastric banding 28 (32%), balloon insertion 12 (14%), sleeve gastrectomy 7 (8%), one-anastomosis gastric bypass 4 (5%) and band-to-sleeve gastrectomy revision 3 (3%). 34 (39%) patients had their initial procedure at our unit, 36 (41%) at another British centre and 17 (20%) abroad. The commonest index procedure to require emergency reintervention of those who had surgery at our hospital was the roux-en-Ygastric bypass (26%). Amongst those who had surgery at another UK hospital, it was the gastric band (28%), and intragastric balloons (6%) in the abroad group.

The most common emergency procedures performed for patients from our centre were OGD 11 (11%) and redo jejuno-jejunostomy 7 (7%). Patients from other UK centres required removal of gastric bands 25 (25%) and removal of intragastric balloons 4 (4%). Patients who underwent surgery abroad required OGD 5 (5%), removal of gastric balloons 5 (5%) or gastric bandremoval 4 (4%).

Median length of stay was 4 days (IQR 3.9–12.7). There were 9 (9%) admissions to ITU. There were two mortalities (2%), one patient from our hospital and onepatient from another British centre.

Conclusions

Our centre experiences a high volume of bariatric surgical emergencies that are promptly managed surgically and endoscopically with increased demand from patients who underwent bariatric surgery abroad. More than a third of patients are from other British centres reflecting the importance of established regional networks for the specialised care of these patients, while a fifth underwent surgery abroad. Further work should involve exploring factors affecting patients decision to seek private bariatric surgery, within the UK or abroad, and a consideration of the cost-burden to the NHS.

BS P02 Sleeve gastrectomy and gastric bypass day surgery: outcomes and experience from a single centre

Background

Internationally, day case Bariatric surgery has been shown to be safe, feasible and economically beneficial. However, it has not been widely adopted in the UK. It requires careful patient selection and a mature enhanced recovery programme. We report on the outcomes and lessons learned during our 2.5-year experience of day case laparoscopic sleeve gastrectomies (LSG) and Roux-en-y gastric bypass (RYGB) operations.

Methods

A retrospective analysis was performed of all patients who were selected as candidates for day case Bariatric surgery in a single-centre since October 2019. Patients were considered eligible if they had a BMI <60, lived within 30 minutes of the hospital, were having primary surgery with no additional procedure and were not on CPAP. All patients received a nurse-led telephone assessment on day 1. Rates of successful discharge, patient demographics, readmission and outcomes were analysed.

Results

Thirty-nine patients were identified as suitable candidates for day case operations: 24 (62%) RYGB, 15 (38%) LSG. The mean BMI was 46.5; 85% female. The main reason for not being considered was the patient living >30 minutes away. Overall, 18 (13 RYGB, 5 LSG; 46.2%) were successfully discharged on the day of surgery. Fifteen (38.5%) were discharged on the first post-operative day and 6 (15.4%) stayed two or more days. The commonest reasons for failed discharge were nausea/vomiting 6 (15.4%) and logistical issues e.g. operation in the afternoon 6 (15.4%). There was one readmission within 30 days (sealed leak from the gastro-jejunal anastomosis) but no returns to theatre.

Conclusions

We have successfully performed day case Bariatric surgery in our centre. However, it is a logistical challenge and to date has only been carried out successfully on a small number of patients. The main challenge being the vast catchment area for our tertiary centre. Further work is needed to better define the parameters for patient eligibility in order to safely offer this to more patients.

The influence of anastomotic techniques on postoperative anastomotic complications: Results of the Oesophago-Gastric Anastomosis Audit

BACKGROUND

The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage and conduit necrosis are not known. The aim of this study was to assess whether the anastomotic technique was associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit cohort.

METHODS

This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over 9 months during 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled, or circular stapled. The primary outcome was anastomotic failure, namely a composite of anastomotic leakage and conduit necrosis, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modeling was used to identify the association between anastomotic techniques and anastomotic failure, after adjustment for confounders.

RESULTS

Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0%, and circular stapled in 51.9%. Anastomotic techniques differed significantly by the anastomosis sites (P < .001), with the majority of neck anastomoses being handsewn (69.9%), whereas most chest anastomoses were stapled (66.3% circular stapled and 19.3% linear stapled). Rates of anastomotic failure differed significantly among the anastomotic techniques (P < .001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled anastomoses, and 12.1% in circular stapled anastomoses. This effect remained significant after adjustment for confounding factors on multivariable analysis, with an odds ratio of 0.63 (95% CI, 0.46-0.86; P = .004) for circular stapled versus handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with anastomotic failure rates of 23.2% versus 14.6% versus 5.9% for handsewn versus linear stapled anastomoses versus circular stapled neck anastomoses, compared with 13.7% versus 13.8% versus 12.2% for chest anastomoses.

CONCLUSIONS

Handsewn anastomoses appear to be independently associated with higher rates of anastomotic failure compared with stapled anastomoses. However, this effect seems to be largely confined to neck anastomoses, with minimal differences between techniques observed for chest anastomoses. Further research into standardization of anastomotic approach and techniques may further improve outcomes.

Field evaluation of biosurfactants, surfactin and di-rhamnolipid produced by Bacillus subtilis subsp. subtilis (VCRC B471) and Pseudomonas fluorescens (VCRC B426) against immature stages of the urban malaria vector Anopheles stephensi

BACKGROUND & OBJECTIVES

Bacillus subtilis subsp. subtilis (VCRC B471) and Pseudomonas fluorescens (B426) produce mosquitocidal biosurfactant, surfactin and di-rhamnolipid. The objective of the study was to carry out a small-scale field evaluation of the two biosurfactants to determine the efficacy, application dosage, residual activity and frequency of application against Anopheles stephensi immatures in selected sites in Goa, India.

METHODS

Surfactin (VCRC B471) and di-rhamnolipid (VCRC B426) were formulated as aqueous suspensions (5% AS), and were applied at the dosages of 34, 51 and 68 mL/m² and 27, 41 and 54 mL/m² respectively. Two experiments were carried out with the two formulations.

RESULTS

Surfactin (VCRC B471) formulation was effective at all the dosages and there was sustained reduction (>80%) in immature density in the treated sites up to 18 days in experiment 1 and up to 15 days in experiment 2. No pupae were found in the treated sites throughout the study. Di-rhamnolipid (VCRC B426) formulation was also found to reduce the immature density in the treated sites up to 14 days in experiment 1 and up to 15 days in experiment 2.

INTERPRETATION & CONCLUSION

For VCRC B471, the optimum application dosage determined was 51 mL/m² and for VCRC B426, 27mL/m². The formulations are to be applied fortnightly for effective control of Anopheles. The application dosage determined in the present study can be used for large scale field evaluation to assess their suitability for use in public health programmes for the control of Anopheles mosquitoes vectoring malaria.

Textbook outcome following oesophagectomy for cancer: international cohort study

Background

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

Methods

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

Results

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter ‘no major postoperative complication’ had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P &lt; 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P &lt; 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

Conclusion

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

Textbook outcome following oesophagectomy for cancer: international cohort study

BACKGROUND

Textbook outcome has been proposed as a tool for the assessment of oncological surgical care. However, an international assessment in patients undergoing oesophagectomy for oesophageal cancer has not been reported. This study aimed to assess textbook outcome in an international setting.

METHODS

Patients undergoing curative resection for oesophageal cancer were identified from the international Oesophagogastric Anastomosis Audit (OGAA) from April 2018 to December 2018. Textbook outcome was defined as the percentage of patients who underwent a complete tumour resection with at least 15 lymph nodes in the resected specimen and an uneventful postoperative course, without hospital readmission. A multivariable binary logistic regression model was used to identify factors independently associated with textbook outcome, and results are presented as odds ratio (OR) and 95 per cent confidence intervals (95 per cent c.i.).

RESULTS

Of 2159 patients with oesophageal cancer, 39.7 per cent achieved a textbook outcome. The outcome parameter 'no major postoperative complication' had the greatest negative impact on a textbook outcome for patients with oesophageal cancer, compared to other textbook outcome parameters. Multivariable analysis identified male gender and increasing Charlson comorbidity index with a significantly lower likelihood of textbook outcome. Presence of 24-hour on-call rota for oesophageal surgeons (OR 2.05, 95 per cent c.i. 1.30 to 3.22; P = 0.002) and radiology (OR 1.54, 95 per cent c.i. 1.05 to 2.24; P = 0.027), total minimally invasive oesophagectomies (OR 1.63, 95 per cent c.i. 1.27 to 2.08; P < 0.001), and chest anastomosis above azygous (OR 2.17, 95 per cent c.i. 1.58 to 2.98; P < 0.001) were independently associated with a significantly increased likelihood of textbook outcome.

CONCLUSION

Textbook outcome is achieved in less than 40 per cent of patients having oesophagectomy for cancer. Improvements in centralization, hospital resources, access to minimal access surgery, and adoption of newer techniques for improving lymph node yield could improve textbook outcome.

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.

614 Elective Bariatric and Metabolic Surgery in United Kingdom During the Coronavirus Pandemic

Aim

Elective Bariatric and Metabolic Surgery (BMS) was halted in the UK during the first wave of the Coronavirus (COVID-19) pandemic. Obesity is a predictor of poor outcome in those infected with this virus. This study reports our experience resuming elective weight loss surgery safely amidst the pandemic.

Method

Guidance from national bodies (BOMSS/NICE) were reviewed and a Standard Operating Procedure (SOP) was drafted to accommodate local considerations. Data were prospectively collected on patients undergoing BMS following commencement of elective surgery after the first national lockdown.

Results

A total of 50 patients underwent BMS at our institution within six weeks of resuming the services. The median age was 41 years old and BMI was 43.8(IQR 40.0-48.8 kg/m2). Equal number of patients underwent laparoscopic Sleeve Gastrectomy (SG) and Roux en-Y Gastric Bypass (RYGB). Of these, 9 patients (18%) had revisional surgery and 48 patients (96%) were discharged within 24 hours of their surgery. The rate of readmission within thirty days of surgery was 6% (n = 3) and 1 patient returned to theatre with an obstruction proximal to the jejuno-jenunal anastomosis. None of the patients exhibited symptoms or tested positive for the COVID-19 virus.

Conclusions

With appropriate precautions and protocols, it is feasible and safe to resume BMS, with no increased risk to bariatric patients during the COVID-19 pandemic. This is particularly encouraging for other units in UK to offer BMS after the current lockdown.

Nation-wide vector surveillance on Zika and Dengue did not indicate transmission of the American lineage-pandemic Zika virus in India

OBJECTIVES

Following the Public Health Emergency of International Concern declared on Zika by the World Health Organization during 2016, the Indian Council of Medical Research carried out nationwide vector surveillance for Zika and Dengue viruses (ZIKV and DENV) in India as a preparedness measure in 2016-19.

METHODS

High-risk zones distributed to 49 Districts in 14 states/union territories were included in the study. Seven ICMR institutions participated, following a standard operating protocol. Aedes specimens sampled weekly were processed by multiplex reverse transcriptase-polymerase chain reaction (RT-PCR) for ZIKV/DENV and random samples crosschecked with real-time RT-PCR for ZIKV.

RESULTS

Altogether, 79 492 Aedes specimens in 6492 pools were processed; 3 (0.05%) and 63 (0.97%) pools, respectively, were found positive for ZIKV and DENV. ZIKV infections were recorded in Aedes aegypti sampled during the 2018 sporadic Zika outbreak in Jaipur, Rajasthan. However, these belonged to the Asian lineage of the virus, already circulating in the country. Both Ae. aegypti and Aedes albopictus distributed to 8 states/union territories were found to be infected with DENV. Both sexes of Ae. albopictus were infected, indicating transovarial transmission.

CONCLUSION

This investigation evinced no active transmission of the American lineage-pandemic Zika virus in India during the pandemic period.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

30-Day Morbidity and Mortality of Bariatric Surgery During the COVID-19 Pandemic: a Multinational Cohort Study of 7704 Patients from 42 Countries

BACKGROUND

There are data on the safety of cancer surgery and the efficacy of preventive strategies on the prevention of postoperative symptomatic COVID-19 in these patients. But there is little such data for any elective surgery. The main objectives of this study were to examine the safety of bariatric surgery (BS) during the coronavirus disease 2019 (COVID-19) pandemic and to determine the efficacy of perioperative COVID-19 protective strategies on postoperative symptomatic COVID-19 rates.

METHODS

We conducted an international cohort study to determine all-cause and COVID-19-specific 30-day morbidity and mortality of BS performed between 01/05/2020 and 31/10/2020.

RESULTS

Four hundred ninety-nine surgeons from 185 centres in 42 countries provided data on 7704 patients. Elective primary BS (n = 7084) was associated with a 30-day morbidity of 6.76% (n = 479) and a 30-day mortality of 0.14% (n = 10). Emergency BS, revisional BS, insulin-treated type 2 diabetes, and untreated obstructive sleep apnoea were associated with increased complications on multivariable analysis. Forty-three patients developed symptomatic COVID-19 postoperatively, with a higher risk in non-whites. Preoperative self-isolation, preoperative testing for SARS-CoV-2, and surgery in institutions not concurrently treating COVID-19 patients did not reduce the incidence of postoperative COVID-19. Postoperative symptomatic COVID-19 was more likely if the surgery was performed during a COVID-19 peak in that country.

CONCLUSIONS

BS can be performed safely during the COVID-19 pandemic with appropriate perioperative protocols. There was no relationship between preoperative testing for COVID-19 and self-isolation with symptomatic postoperative COVID-19. The risk of postoperative COVID-19 risk was greater in non-whites or if BS was performed during a local peak.

Safety and feasibility of resuming bariatric surgery under the cloud of COVID-19

INTRODUCTION

Because of the COVID-19 pandemic, numerous bariatric surgical units globally have halted weight loss surgery. Obesity itself has been shown to be a predictor of poor outcome in people infected with the virus. The aim of this study was to report our experience as a high-volume bariatric institution resuming elective weight loss surgery safely amidst emergency admissions of COVID-19-positive patients.

METHODS

A standard operating procedure based on national guidance and altered to accommodate local considerations was initiated across the hospital. Data were collected prospectively for 50 consecutive patients undergoing bariatric surgery following recommencement of elective surgery after the first national lockdown in the UK.

RESULTS

Between 28 June and 5 August 2020, a total of 50 patients underwent bariatric surgery of whom 94% were female. Median age was 41 years and median body mass index was 43.8 (interquartile range 40.0-48.8)kg/m2. Half of the patients (n = 25/50) underwent laparoscopic sleeve gastrectomy and half underwent Roux-en-Y gastric bypass (RYGB). Of these 50 patients, 9 (18%) had revisional bariatric surgery. Overall median length of hospital stay was 1 day, with 96% of the study population being discharged within 24h of surgery. The overall rate of readmission was 6% and one patient (2%) returned to theatre with an obstruction proximal to jejuno-jejunal anastomosis. None of the patients exhibited symptoms or tested positive for COVID-19.

CONCLUSION

With appropriately implemented measures and precautions, resumption of bariatric surgery during the COVID-19 pandemic appears feasible and safe with no increased risk to patients.

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.

Complicated Acute Cholecystitis: The Role of C-Reactive Protein and Neutrophil-Lymphocyte Ratio as Predictive Markers of Severity

Objectives The clinical diagnosis of complicated acute cholecystitis (CAC) remains difficult with several pathological or ultrasonography criteria used to differentiate it from uncomplicated acute cholecystitis (UAC). This study aims to evaluate the use of combined inflammatory markers C-reactive protein (CRP) and neutrophil-to-lymphocyte ratio (NLR) as surrogate markers to differentiate between UAC and CAC. Methods We identified 600 consecutive patients admitted with biliary symptoms during an acute surgical take from our electronic prospectively maintained database over a period of 55 months. Only patients undergoing emergency cholecystectomy performed during the index admission were included. The primary outcome was the finding of CAC versus UAC. Results A total of 176 patients underwent emergency laparoscopic cholecystectomy (ELC) during the index admission, including 118 (67%) females with a median age of 51 years (range: 21-97 years). The proportion of UAC (130 [74%]) and CAC (46 [26%]) was determined along with demographic data. Multivariate regression analysis showed that patient's age (OR=1.047; p=0.003), higher CRP (OR=1.005; p=0.012) and NLR (OR=1.094; p=0.047) were significant independent factors associated with severity of cholecystitis. Receiver operating characteristic (ROC) analysis for CRP showed an AUC (area under the curve) of 0.773 (95% CI: 0.698- 0.849). Using a cut-off value of 55 mg/L for CRP, the sensitivity of CAC was 73.9% and specificity was 73.1% in predicting CAC. The median post-operative length of stay was four days. The conversion rate from laparoscopic cholecystectomy to open surgery was 2% (4/176), and 5% (9/176) patients suffered post-operative complications with no mortality at 30 days. Conclusion CRP, NLR and age were independent factors associated with the severity of acute cholecystitis. NLR and CRP can be used as surrogate markers to predict patients at risk of CAC during emergency admission, which can inform future guidelines. Moreover, ELC for CAC can be safely performed under the supervision of dedicated upper GI surgeons.

Molecular modelling analysis of T219A mutant envelope protein revealed novel virulence enhancing factors in Dengue virus isolated from Kerala state, India

Dengue virus (DENV) is an emerging health threat and its envelope glycoprotein E, is involved in the anchoring and fusion mechanisms. Anchoring followed by conformational changes of E-protein are responsible for the fusion and entry of DENV into host. The variation in the conformation of the E-protein due to mutations, results in its altered binding with antibodies (Abs) and also its receptors. This leads to failure of neutralization of DENV and enhance the infection. In our earlier studies we have identified T219A mutation in the E-protein of DENV and the present study is focused on the impact of this mutation on the conformation of E-protein and also its binding variation with Abs and Fc-γ receptor. A comparative molecular modelling studies of wild type and T219A mutant E-proteins revealed that, the mutation induced several conformational variations in the E-protein and resulted in the variable binding orientation with altered affinities. Further, the mutation was also observed to enhance the fusion mechanism by Fc-γ receptors that mediate the efficient entry of DENV into host cell through altered membrane fusion mechanism. Such conformational variations of E-protein could be the responsible factors for enhanced virulence of DENV infections.

Critical number of lymph node involvement in esophageal and gastric cancer and its impact on long-term survival-A single-center 8-year study

BACKGROUND

Nodal disease in esophageal and gastric cancer is associated with poor survival.

OBJECTIVES

To determine the critical level of lymph node involvement where survival becomes significantly compromised.

METHODS

Survival analyses using multivariable Cox regression and receiver operator characteristics (ROC) were undertaken to determine what number of positive lymph nodes were most sensitive and specific in predicting survival.

RESULTS

A total of 317 patients underwent esophagectomy (n = 190, 59.9%) and gastrectomy (n = 127, 40.1%) for adenocarcinoma. At multivariable analyses, four nodes positivity (irrespective of T-category) was associated with nearly a fivefold increased risk of mortality when compared to node-negative patients (hazard ratio [HR], 4.9; interquartile range 2.0-11.5; P < .001). A positive ratio of up to 50.0% was not associated with worse survival than having four nodes positive (HR, 4.6; 95% confidence interval, 2.6-8.1; P < .001). ROC analysis demonstrated four lymph nodes positive to have a sensitivity of 80.5%, a specificity of 60.1%, and an accuracy of 77.8 (P < .001).

CONCLUSION

The absolute number of nodes positive for cancer is more important than the proportion of positive nodes in predicting survival in esophageal/gastric cancer. Four positive lymph nodes are associated with a fivefold increase in mortality. Beyond this, increasing numbers of positive lymph nodes make no appreciable difference to survival.

SARS-CoV-2 and the pandemic of COVID-19

SARS-CoV-2 is a virus that is the cause of a serious life-threatening disease known as COVID-19. It was first noted to have occurred in Wuhan, China in November 2019 and the WHO reported the first case on December 31, 2019. The outbreak was declared a global pandemic on March 11, 2020 and by May 30, 2020, a total of 5 899 866 positive cases were registered including 364 891 deaths. SARS-CoV-2 primarily targets the lung and enters the body through ACE2 receptors. Typical symptoms of COVID-19 include fever, cough, shortness of breath and fatigue, yet some atypical symptoms like loss of smell and taste have also been described. 20% require hospital admission due to severe disease, a third of whom need intensive support. Treatment is primarily supportive, however, prognosis is dismal in those who need invasive ventilation. Trials are ongoing to discover effective vaccines and drugs to combat the disease. Preventive strategies aim at reducing the transmission of disease by contact tracing, washing of hands, use of face masks and government-led lockdown of unnecessary activities to reduce the risk of transmission.

A Systematic Review and Meta-Analysis of the Effect of Roux-en-Y Gastric Bypass on Barrett's Esophagus

BACKGROUND

Obesity is associated with a twofold risk of gastroesophageal reflux disease (GERD) and thrice the risk of Barrett's esophagus (BE). Roux-en-Y gastric bypass (RYGB) leads to weight loss and improvement of GERD in population with obesity, but its effect on BE is less clear.

METHODS

Bibliographic databases were searched systematically for relevant articles till January 31, 2019. Studies evaluating the effect of RYGB on BE with preoperative and postoperative endoscopy and biopsy were included. Study quality was assessed using the Methodological Index for Non-Randomized Studies (MINORS) tool. Meta-analysis was conducted using Mantel-Haenszel, random effects model and presented as risk difference (RD) or odds ratio (OR) with 95% confidence intervals.

RESULTS

Eight studies with 10,779 patients undergoing RYGB reported on 117 patients with BE with follow-up of > 1 year. Significant regression of BE after RYGB was observed (RD - 0.56.95% c.i. - 0.69 to - 0.43; P < 0.001). Subgroup analysis showed regression of both short-segment BE [ssBE] (RD - 0.51.95% c.i. - 0.68 to - 0.33; P < 0.001) and long-segment BE [lsBE] (RD - 0.46.95% c.i. - 0.71 to - 0.21; P < 0.001). RYGB also caused improvement in GERD in patients of BE (RD - 0.93, 95% c.i. - 1.04 to - 0.81; P < 0.001). RYGB was strongly associated with regression of BE compared with progression (OR 31.2.95% c.i. 11.37 to 85.63; P < 0.001).

CONCLUSIONS

RYGB leads to significant improvement of BE at > 1 year after surgery in terms of regression and resolution of the associated GERD. Both ssBE and lsBE improve after RYGB significantly.

Heizmannia rajagopalani n. sp. (Diptera: Culicidae) in Kerala, India, a species previously misidentified as Hz. metallica (Leicester)

The original description of Heizmannia (Heizmannia) metallica (Leicester) from Malaysia, and specimens collected in India that were provisionally identified as Hz. metallica, were re-examined for their taxonomic status. Heizmannia metallica from Malaysia was found by Mattingly (1970) to be a junior synonym of Hz. indica (Theobald), whereas we found the specimens identified as Hz. metallica from India to differ distinctly from the holotype of Hz. metallica. We collected adults near Malabar Coast, Western Ghats which corresponded with Indian Hz. metallica sensu auctorum and here describe the previously misidentified species as Hz. (Hez.) rajagopalani n. sp. The adult male and female of the new species, and their genitalia, are described and illustrated.

Meta-analysis of the effect of bariatric surgery on physical activity

BACKGROUND

Obesity leads to impairment of physical activity as measured by an inability to perform activities of daily living. Literature on the effect of bariatric surgery on physical activity is conflicting.

OBJECTIVE

The aim of this study was to perform a meta-analysis of the effect of bariatric surgery on physical activity from studies employing objective measurement and self-reporting of physical activity before and after bariatric surgery.

METHODS

Bibliographic databases were searched systematically for relevant literature until December 31, 2018. Studies employing objective and self-reported measurement of physical activity were included. Study quality was assessed using Risk of Bias in Nonrandomized Studies - of Interventions tool. Meta-analysis was performed using random effects model and presented as standardized mean difference (SMD) with 95% confidence intervals (CI).

RESULTS

Twenty studies identified 5886 patients suitable for the analysis. Physical activity showed significant improvement at 0-6 months (SMD: .50; 95% CI: .25-.76; P = .0001), >6-12 months (SMD: .58; 95% CI: .26-.91; P = .0004), and >12-36 months (SMD: .82; 95% CI: .27-1.36; P = .004) after bariatric surgery. Self-reported assessment after bariatric surgery showed significant improvement at 0-6 months (SMD: .65; 95% CI: .29-1.01; P = .0004), >6 to 12 months (SMD: .53; 95% CI: .18-.88; P = .003), and >12-36 months (SMD: .51; 95% CI: .46-.55; P < .00001). Objective assessment after bariatric surgery did not show improvement at 0-6 months (SMD: .31; 95%CI:-.05-.66; P = .09), but showed significant improvement at >6-12 months (SMD: .85; 95% CI:-.07-1.62; P = .03), and >12-36 months (SMD: 1.99; 95% CI: 1.13-2.86; P < .00001) after bariatric surgery.

CONCLUSIONS

Bariatric surgery improves physical activity significantly in a population with obesity up to 3 years after surgery. Objective measurement of physical activity does not show significant improvement within 6 months of bariatric surgery but begins to improve at >6 months. Self-reported measurement of physical activity begins to show improvement within 6 months of a bariatric procedure.

Insecticide resistance status of three vectors of Japanese encephalitis in east central India

Japanese encephalitis (JE) has been reported in different districts of Odisha state (east central India) since 1992. During 2016, a major outbreak of JE and acute encephalitis syndrome (AES) occurred in the Malkangiri district of Odisha, causing 103 deaths in children, of which 37 were caused by JE and 66 by AES. Information on insecticide resistance in JE vectors is important for the selection of appropriate insecticides for use in vector control. The present study was designed to determine the resistance status of three important vectors of JE, Culex vishnui, Culex tritaeniorhynchus and Culex bitaeniorhynchus (Diptera: Culicidae), against dichlorodiphenyltrichloroethane (DDT), malathion and deltamethrin in three districts of Odisha state affected by JE. Female adult mosquitoes were collected using mouth aspirators both indoors and outdoors in JE-affected villages and used in susceptibility bioassays following World Health Organization guidelines. Knock-downs were recorded every 10 min up to 1 h and mortality rates were recorded at 24 h post-exposure. Culex vishnui and Cx. tritaeniorhynchus showed resistance to DDT, malathion and deltamethrin, whereas Cx. bitaeniorhynchus was susceptible in all study districts. The information generated by this study will be highly useful in the planning and implementing of appropriate vector control operations for the prevention and control of JE in east central India.

Bridging the gap in outreach and compliance with mass drug administration for lymphatic filariasis elimination in an endemic district in Kerala, India: an intervention research approach

Lymphatic filariasis (LF), a neglected tropical disease is targeted for elimination globally by 2020. National Health Policy of India set the goal by 2017 and annual single-dose mass drug administration (MDA) with anti-filarial drugs is in operation in endemic districts since 2004. Performance and effectiveness of MDA was diverse across the nation and prevalence of infection continues above threshold level in 50% of endemic districts which requires alternative strategies. National programme aims at achieving >65% consumption for transmission control. Post 10 rounds of MDA in an endemic district of Kerala state, a three-arm study identified determinants in gap in outreach and consumption, based on which context-dependent intervention using social group work and networking (SGWN) was implemented and impact assessed. A spill over effect with overall increase in coverage and consumption rates irrespective of arms apparently is due to inclusive improvement in MDA programme whereas, significant relative improvement in intervention arm reflects effectiveness of SGWN strategy. Though reduction in microfilaria prevalence in all arms was observed, it was significant between intervention and comparison arm. This study highlights need for context-dependent communication strategy to improve MDA for accelerating LF elimination by the targeted 2020.

Impact of ‘two-week wait’ referral pathway on the diagnosis, treatment and survival in upper and lower gastrointestinal cancers

Background

The ‘two-week wait’(2WW) referral pathway was introduced in the United Kingdom to reduce waiting times for treatment of cancer. There has been a debate regarding the efficacy of 2WW pathway since its implementation.

Methods

A singleinstitutional analysis of upper gastrointestinal(UGI) and lower gastrointestinal(LGI) malignancies treated between 1April 2015 and 31March 2017 was undertaken to analyse the impact of 2WWreferral pathway on the diagnosis, treatment and survival.

Results

2WW referral does not achieve an earlier diagnosis compared with non-2WW routes of referral in UGI (χ2(3)=2.6, p=0.458) and LGI (χ2(3)=0.884, p=0.829) malignancies. 2WW referral does not lead to an improvement in curative treatment in UGI (OR1.48, 95%CI0.68to3.21, p=0.321) and LGI (OR1.59, 95%CI0.97to2.62, p=0.067) malignancies. No improvement in survival is seen in UGI (HR0.99, 95%CI0.56to1.75, p=0.963) and LGI (HR1.10, 95%CI0.60to1.99, p=0.764) malignancies by virtue of 2WW referral. Emergency presentation is the most common presenting route in UGI malignancy(40%) and is associated with poor survival (HR0.55, 95%CI0.30to0.97, p=0.045).Non-emergency route of presentation is associated with higher rates of curative treatment in UGI malignancies (OR3.49, 95%CI1.57to7.76, p=0.002). Lower rate of curative treatment (OR 0.27, 95%CI0.16to0.43, p<0.001) and poor survival (HR0.44, 95%CI0.26to0.76, p=0.003) is also observed in emergency presentation of LGI malignancy(29%) which is the secondmost common route of presentation in this group.

Conclusion

2WW referral does not achieve early diagnosis nor does it lead to an improvement in the rate of curative treatment in UGI and LGI malignancies. No improvement in short-term survival is seen in UGI malignancies nor in LGI malignancies on multivariate analysis by virtue of 2WW referral.

Perforated gastric carcinomatosis following invasive lobular cancer of the breast

Current guidelines do not advocate a routine search for gastric metastasis in known patients of breast cancer. This makes it challenging to suspect them clinically as they progress over many years. Gastric carcinomatosis from primary invasive lobular cancer can perforate leading to life-threatening abdominal emergency necessitating surgery.

Description of the adult male, larva and pupa of Topomyia (Topomyia) aureoventer (Diptera: Culicidae) in India

The original description of Topomyia aureoventer by Theobald (1910) included only the adult female. Description of the adult male, pupa and larva, with figures of the male genitalia, pupa and larva, are provided. The larva is predacious with well-developed mandibles and inhabits leaf axils of Colocasia plants.

Determinants of transmission hotspots and filarial infection in households after eight rounds of mass drug administration in India

OBJECTIVES

Lymphatic filariasis (LF) elimination through mass drug administration (MDA) of DEC and albendazole have resulted in very low levels of infection in most endemic districts in India. But small pockets with residual microfilaraemia in the community and antigeneamia in children ('hotspots') are a cause of concern. We aimed to identify the determinants of such transmission hotspots and filarial infection in households using data from 33 communities.

METHODS

The filariasis vector Culex quinquefasciatus was collected from 627 randomly selected households using gravid traps. Parallel data on environmental, entomological, demographical, socio-economical and behavioural factors were analysed to identify the determinants of hotspots and household-level infection.

RESULTS

Hotspots and non-hotspots did not differ significantly in terms of socio-economical and behavioural aspects, but did differ in terms of demographical and environmental factors. Logistic regression revealed that tiled and concrete houses increased the risk of an area being a hotspot by 2.0 and 2.9 times respectively. Presence of Culex breeding habitats was significantly associated with elevated risk of being a hotspot. Proximity of U-drains to a house increased the risk of filarial infection 5.8 times.

CONCLUSIONS

An environment suitable to Culex breeding influences continued transmission despite eight rounds of MDA, particularly in hotspots. Proximity to U-drains increases the risk of infection in households. Implementing localised vector control measures may help interrupt low-level transmission, thereby reducing the risk of resurgence in the absence of MDA.

Meta-analysis of the effect of bariatric surgery on physical function

BACKGROUND

Obesity leads to an impairment of physical function that limits the ability to perform basic physical activities affecting quality of life. Literature on the effect of bariatric surgery on physical function is confounding and generally of low quality.

METHODS

A comprehensive search was undertaken using MEDLINE, Scopus (including Embase), CENTRAL, PubMed, SPORTDiscus, Scirus and OpenGrey for published research and non-published studies to 31 March 2017. Studies employing objective measurement and self-reporting of physical function before and after bariatric surgery were included. The magnitude of experimental effect was calculated in terms of the standardized mean difference (MD), and confidence intervals were set at 95 per cent to reflect a significance level of 0·05.

RESULTS

Thirty studies including 1779 patients met the inclusion criteria. Physical function improved after bariatric surgery at 0-6 months (MD 0·90, 95 per cent c.i. 0·60 to 1·21; P < 0·001), more than 6 to 12 months (MD 1·06, 0·76 to 1·35; P < 0·001) and more than 12 to 36 months (MD 1·30, 1·07 to 1·52; P < 0·001). Objective assessment of physical function after bariatric surgery showed improvement at 0-6 months (MD 0·94, 0·57 to 1·32; P < 0·001), more than 6 to 12 months (MD 0·77, 0·15 to 1·40; P = 0·02) and more than 12 to 36 months (MD 1·04, 0·40 to 1·68; P = 0·001). Self-reported assessment of physical function showed similar improvements at 0-6 months (MD 0·80, 0·12 to 1·47; P = 0·02), more than 6 to 12 months (MD 1·42, 1·23 to 1·60; P < 0·001) and more than 12 to 36 months (MD 1·41, 1·20 to 1·61; P < 0·001) after a bariatric procedure.

CONCLUSION

Bariatric surgery improves physical function significantly within 6 months of the procedure and this effect persists over time to 36 months after surgery, whether measured objectively or by self-reporting.

Uranotaenia pseudostricklandi, a new species in subgenus Pseudoficalbia (Diptera: Culicidae) from Kerala, India

The female and male adults, male genitalia, pupa and larva of Uranotaenia (Pseudoficalbia) pseudostricklandi sp. nov. (Diptera: Culicidae) are described from specimens collected in India.

Prevalence and spatial distribution of Ixodid tick populations in the forest fringes of Western Ghats reported with human cases of Kyasanur forest disease and monkey deaths in South India

Kyasanur forest disease (KFD) is a major tick-borne viral haemorrhagic fever caused by KFD virus (KFDV) (Flaviviridae). The disease was reported to be confined to five districts of Karnataka state India until 2011. During 2012-2016, emergence of KFD has been reported in newer areas of Karnataka and adjoining states. Therefore, survey of tick vectors was carried out in these new areas of Karnataka and adjoining states reported with monkey deaths and human cases of KFD. In all selected sites, ticks from the forest floor were collected by lint clothes using flagging method. Tick samples were tested for KFDV nucleic acid by real-time RT-PCR. A total of 4772 ticks, comprising eight species of genus Haemaphysalis and one species each of genus Amblyomma, Ixodes and Rhipicephalus was collected. Haemaphysalis spinigera, the principal vector of KFDV was the predominant tick species (59.5%) collected followed by H. turturis (8.6%). The abundance of H. spinigera ranged from 9.2 to 33.9 per man-hour in the six districts surveyed. Of 214 (4418 tick samples) pools screened by real-time RT-PCR, two pools of H. spinigera were positive for KFDV. High abundance of Haemaphysalis vectors in the six districts indicated that the districts are receptive for KFD outbreaks. KFDV was detected in the tick vectors in the new foci of the KFD. Data on tick distribution will be useful in creating KFD risk map for strengthening the ongoing preventive measures such as vaccination and supply of insect repellents to the high risk groups and intensive health education.

Bionomics of Anopheles fluviatilis and Anopheles culicifacies (Diptera: Culicidae) in Relation to Malaria Transmission in East-Central India

The southern districts of Odisha State in east-central India have been highly endemic for falciparum malaria for many decades. However, there is no adequate information on the abundance of the vector species or their bionomics in relation to space and time in these districts. Therefore, a study was carried out on the entomological aspects of malaria transmission to generate such information. Collections of mosquitoes were made once during each of the three seasons in 128 villages selected from eight districts. Villages within the foot-hill ecotype had a significantly greater abundance of Anopheles fluviatilis James s. l., whereas the abundance of Anopheles culicifacies Giles s. l. was significantly greater in the plain ecotype. The abundance of An. fluviatilis was maximum during the cold season, whereas An. culicifacies abundance was highest during summer and rainy seasons. The maximum likelihood estimation of the malaria infection rate in An. fluviatilis was 1.78%, 6.05%, and 2.6% in Ganjam, Kalahandi, and Rayagada districts, respectively. The infection rate of An. culicifacies was 1.39% only in Kandhamal district; infected females were not detected elsewhere. Concurrently, the annual malaria parasite incidence (MPI) was significantly higher in hill-top (17.6) and foot-hill (14.4) villages compared to plain villages (4.1). The districts with more villages in hill-top and foot-hill ecotypes also had a greater abundance of An. fluviatilis, the major malaria vector, and exhibited a higher incidence of malaria than villages within the plain ecotype, where An. culicifacies was the most abundant vector.

Domestic dogs as reservoir hosts for Leishmania donovani in the southernmost Western Ghats in India

The peripheral blood samples from domestic dogs (n=47) and wild rats (n=25) in the Kani Tribe settlements, located southernmost part of the Western Ghats, Thiruvananthapuram district, Kerala, India were examined for Leishmania infection. This area is known for cases of leishmaniasis with cutaneous manifestations and sandfly abundance. The tribes domesticate dogs to protect them from untoward activities of wild animals. Leishmania donovani parasite DNA was detected only from 6.4% (n=3) of the blood samples collected from the domestic dogs by amplification of the diagnostic kinetoplast mini-circle DNA and PCR-RFLP analysis of the UTR region of heat shock protein 70 (hsp70) gene. None of the blood samples collected from rats was positive. Through sequencing, L. donovani infection among dogs was confirmed. The DNA sequences generated for hsp70 were deposited with the GenBank. The GenBank accession numbers of these samples are KR905363, KR905364 and KR905365 for hsp70 genes. The results indicated that the DNA isolates from dog blood samples matched precisely with that of our earlier isolates from skin lesions of Kani tribes and also from P. argentipes vector. Thus, the role of dogs as reservoirs for L. donovani parasite in the Kani tribe settlements is confirmed.

Descriptions of three new species of <i>Uranotaenia</i> (Pseudoficalbia) Diptera: Culicidae) from India

Female and male adults, male genitalia, pupa and larva of Uranotaenia (Pseudoficalbia) maikalensis, Ur. (Pfc.) dandakaranyensis and Ur. (Pfc.) satpuraensis, three new mosquito species, are described from India.

Field performance of malaria rapid diagnostic test for the detection of Plasmodium falciparum infection in Odisha State, India

BACKGROUND & OBJECTIVES

Rapid diagnostic tests (RDTs) have become an essential surveillance tool in the malaria control programme in India. The current study aimed to assess the performance of ParaHIT-f, a rapid test in diagnosis of Plasmodium falciparum infection through detecting its specific antigen, histidine rich protein 2 (PfHRP-2), in Odisha State, India.

METHODS

The study was undertaken in eight falciparum malaria endemic southern districts of Odisha State. Febrile patients included through active case detection, were diagnosed by Accredited Social Health Activists (ASHAs) for P. falciparum infection using the RDT, ParaHIT-f. The performance of ParaHIT-f was evaluated using microscopy as the gold standard.

RESULTS

A total of 1030 febrile patients were screened by both microscopy and the RDT for P. falciparum infection. The sensitivity of ParaHIT-f was 63.6% (95% CI: 56.0-70.6) and specificity was 98.9% (95% CI: 97.9-99.5), with positive and negative predictive values (PPV and NPV) of 92.6% (95% CI: 86.0-96.3) and 93.0% (95% CI: 91.0-94.5), respectively. When related to parasitaemia, the RDT sensitivity was 47.8% at the low parasitaemia of 4 to 40 parasites/µl of blood.

INTERPRETATION & CONCLUSIONS

The results showed that the performance of the RDT, ParaHIT-f, was not as sensitive as microscopy in detecting true falciparum infections; a high specificity presented a low frequency of false-positive RDT results. t0 he sensitivity of ParaHIT-f was around 60 per cent. It is, therefore, essential to improve the efficiency (sensitivity) of the kit so that the true falciparum infections will not be missed especially in areas where P. falciparum has been the predominant species causing cerebral malaria.

Triple insecticide resistance in Anopheles culicifacies: A practical impediment for malaria control in Odisha State, India

Background & objectives:

In Odisha State, the control of malaria vectors has become dependent on synthetic pyrethroids, which are used for treatment of all approved long-lasting insecticidal nets (LLINs). The vast use of just one class of insecticide has led to the problem of resistance to insecticides in malaria vectors. One of the major malaria vectors in Odisha State is Anopheles culicifacies Giles. The aim of this study was to determine the resistance status of An. culicifacies to deltamethrin, a synthetic pyrethroid and other common insecticides used by the National Vector Borne Diseases Control Programme (NVBDCP) for indoor residual spraying in Odisha State.

Methods:

Mosquitoes were collected during April 2014 - June 2014 from 15 randomly selected villages in five Plasmodium falciparum endemic southern districts of Odisha State. The blood-fed wild caught females were exposed to the diagnostic dosage of DDT (4.0%), malathion (5.0%) and deltamethrin (0.05%) for one hour. Mortality was recorded at 24 h after the exposure.

Results:

Results indicated that An. culicifacies was resistant to all the three insecticides used in the malaria control programme in the five districts of Odisha State.

Interpretation & conclusions:

Resistance management strategy by appropriate rotation of different groups of insecticides including carbamates and incorporating a synergist with synthetic pyrethroids for treating mosquito nets should be considered for the control of malaria vectors in the area, especially where An. culicifacies is predominant. Periodical monitoring of susceptibility/resistance status of An. culicifacies to different insecticides is warranted.

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

An outbreak of Kyasanur forest disease in the Wayanad and Malappuram districts of Kerala, India

Kyasanur forest disease (KFD) is a zoonotic viral haemorrhagic fever and has been endemic to Karnataka State, India. Outbreaks of KFD were reported in new areas of Wayanad and Malappuram districts of Kerala, India during 2014-2015. Investigation of the outbreaks was carried out in these districts during May 2015. The line-list data of KFD cases available with District Medical Office, Wayanad were analysed. Case investigation was carried out to determine the risk factors associated with the outbreak and possible site of contraction infections. Ticks from the forest floor were collected in areas associated with monkey deaths by flagging method to estimate species abundance. Of 102 confirmed cases of KFD reported in Wayanad, 91% were adults aged >15years. About 43% of the cases were from the areas of Poothady Primary Health Centre (PHC) followed by Chethalayam PHC (22%). Most of the affected individuals belong to Kattunayakan tribe, dependent on forest for their livelihood. Those tribes are engaged in trench digging and fire line works in summer months and hence are at a higher risk. In Malappuram, the Cholanaickan tribe, are under high risk of exposure to infected ticks as they live deep in the forest and trap monkeys for game meat. High abundance of Haemaphysalis spinigera and H. turturis, the established vectors of KFD virus was recorded in all affected areas. Incidence of KFD cases/monkey deaths and high abundance of Haemaphysalis vectors in the forest ranges of Wayanad and Malappuram districts indicate that the area has become receptive for KFD outbreaks. Preventive measures (vaccination of high risk groups) coupled with intensive health education should be carried out prior to transmission season.

Description of a new species of the genus Hulecoeteomyia (Diptera: Culicidae) from Meghalaya, India

Female and male adults, female and male genitalia, pupa and larva of Hulecoeteomyia cherrapunjiensis, a new mosquito species, are described from Meghalaya, India. Keys to separate larvae and adults are provided.

Computational screening and characterization of putative vaccine candidates of Plasmodium vivax

Plasmodium vivax is the most prevalent species of malaria affecting millions of people annually worldwide and demands effective interventions to develop a successful vaccine. In this milieu, we have dedicated noteworthy efforts to characterize the proteome of P. vivax to give a lead for the epitope-based vaccine development. Membrane proteins of P. vivax were collected from SWISS PROT database and 10 antigenic proteins were identified among them by in silico analysis using multiple servers. T-cell and B-cell epitopes were identified and their immunity was assessed. Their ability to trigger humoral and cell-mediated responses was determined. Three dimensional models were constructed for the antigenic proteins using Modeller, Phyre2, and Modloop tools and their quality was validated using PROCHECK and ProSA-web validation servers. Further, the binding affinity and molecular interactions of these antigenic proteins were characterized by performing protein-protein docking against transmission-blocking anti-malaria antibody Fab2A8 (PDB ID: 3S62) using Z-dock module of Discovery Studio 4.0. The presence of potential B & T-cell epitopes, major histocompatibility complex-binding sites, and their efficient interactions with Fab2A8 antibody suggests the use of predicted antigenic proteins for the construction of multi-epitope peptide vaccine against P. vivax.

Fly ash based Bacillus thuringiensis var. israelensis formulation for use against Culex quinquefasciatus, the vector of filariasis in natural ecosystems

BACKGROUND & OBJECTIVES

Fly ash is produced in huge quantities by the various thermal power stations in India. This thermal waste has been employed as a carrier material in the preparation of a biopesticidal water dispersible powder (WDP) formulation for use against mosquitoes. In the present investigation, this newly developed fly ash based WDP formulation was evaluated in natural breeding habitats of mosquito.

METHODS

Fly ash based WDP formulation of Bacillus thuringiensis var. israelensis (VCRC B17) was evaluated for its efficacy and residual activity in aquatic habitats supporting breeding of Culex quinquefasciatus, the vector of lymphatic filariasis in Neyveli Township, Neyveli Lignite Corporation, India for a period of one month.

RESULTS

At an application rate of 10 kg/ha, the WDP was effective for five days regardless of the habitat, and provided 80-100% reduction in larval abundance of Cx. quinquefasciatus.

INTERPRETATION & CONCLUSION

The study indicates that for continued control of immature density and prevention of adult emergence, a weekly application of this formulation is necessary. This study also showed that fly ash based formulations can be used for immediate control of mosquitoes in different types of habitats and has also brought out a new avenue for the utilization of coal ash.