Patient education in atopic dermatitis: a scoping review

BACKGROUND

Atopic dermatitis (AD) is a chronic inflammatory skin disease that affects children and adults. Poor treatment adherence in AD requires interventions to promote self-management; patient education in chronic diseases is key to self-management. Many international AD management guidelines published to date include a recommendation for educating patients as part of their treatment but there are no formal recommendations on how to deliver this knowledge. MAIN: We performed a scoping review to map the existing literature on patient education practices in AD and to highlight the clinical need for improved patient education in AD. The literature search was performed with the online databases MEDLINE, Embase, Grey Matters, ClinicalTrails.gov and the International Clinical Trials Registry Platform (ICTRP). The search strategy yielded 388 articles. Of the 388 articles screened, 16 studies met the eligibility criteria, and the quantitative data was summarized by narrative synthesis. The majority of studies were randomized controlled trials conducted in Europe, Asia and North America. Since 2002, there have been limited studies evaluating patient education in the treatment of AD. Frequent education methods used included group-based educational programs, educational pamphlets, individual consultations and online resources. Education was most commonly directed at caregivers and their children. Only one study compared the efficacy of different education methods. In all included studies, the heterogenous nature of outcome measures and study design limited the consistency of results. Despite the heterogeneity of studies, patient education was shown to improve quality of life (QoL), disease severity and psychological outcomes in AD patients.

CONCLUSION

This scoping review highlights that patient education is effective in a variety of domains relevant to AD treatment. Further comparative studies and randomized trials with longer-term follow-up are needed to provide validated and consistent patient education recommendations for AD; these may depend on age and population.

Co-application of biochar and compost with decreased N fertilizer reduced annual ammonia emissions in wetland rice

Ammonia (NH3) emission from rice fields is a dominant nitrogen (N) loss pathway causing negative impacts on farm profitability and the environment. Reducing N fertilizer application to compensate for N inputs in organic amendments was evaluated for effects on N loss via volatilization, rice yields and post-harvest soil properties in an annual irrigated rice (Boro) – pre-monsoon rice (Aus) – monsoon (Aman) rice sequence. That experiment was conducted using the integrated plant nutrition system (IPNS; nutrient contents in organic amendments were subtracted from the full recommended fertilizer dose i.e., RD of chemical fertilizers) where six treatments with four replications were applied in each season: (T1) no fertilizer (control), (T2) RD, (T3) poultry manure biochar (3 t ha−1; pyrolyzed at 450°C) + decreased dose of recommended fertilizer (DRD), (T4) rice husk ash (3 t ha−1) + DRD, (T5) compost (3 t ha−1) + DRD, and (T6) compost (1.5 t ha−1)+ biochar (1.5 t ha−1) + DRD. The N loss via volatilization varied twofold among seasons being 16% in irrigated rice and 29% in the pre-monsoon rice crop. In irrigated rice, T6 had significantly lower NH3 emissions than all other treatments, except the control while in pre-monsoon and monsoon seasons, T6 and T3 were alike. Pooling the three seasons together, biochar (T3) or biochar plus compost (T6) reduced NH3 loss via volatilization by 36-37% while compost alone (T5) reduced NH3 loss by 23% relative to RD. Biochar (T3) and biochar plus compost mixture (T6) reduced yield-scaled NH3 emissions by 40 and 47% relative to the RD of chemical fertilizer (T2). The organic amendments with IPNS reduced the quantity of N fertilizer application by 65, 7, 24, and 45% in T3, T4, T5, and T6 treatments, respectively, while rice yields and soil chemical properties in all seasons were similar to the RD. This study suggests that incorporation of biochar alone or co-applied with compost and decrease of N fertilizer on an IPNS basis in rice-based cropping systems can reduce N application rates and NH3 emissions without harming yield or soil quality.

Evaluation of prognostic risk models for postoperative pulmonary complications in adult patients undergoing major abdominal surgery: a systematic review and international external validation cohort study

BACKGROUND

Stratifying risk of postoperative pulmonary complications after major abdominal surgery allows clinicians to modify risk through targeted interventions and enhanced monitoring. In this study, we aimed to identify and validate prognostic models against a new consensus definition of postoperative pulmonary complications.

METHODS

We did a systematic review and international external validation cohort study. The systematic review was done in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. We searched MEDLINE and Embase on March 1, 2020, for articles published in English that reported on risk prediction models for postoperative pulmonary complications following abdominal surgery. External validation of existing models was done within a prospective international cohort study of adult patients (≥18 years) undergoing major abdominal surgery. Data were collected between Jan 1, 2019, and April 30, 2019, in the UK, Ireland, and Australia. Discriminative ability and prognostic accuracy summary statistics were compared between models for the 30-day postoperative pulmonary complication rate as defined by the Standardised Endpoints in Perioperative Medicine Core Outcome Measures in Perioperative and Anaesthetic Care (StEP-COMPAC). Model performance was compared using the area under the receiver operating characteristic curve (AUROCC).

FINDINGS

In total, we identified 2903 records from our literature search; of which, 2514 (86·6%) unique records were screened, 121 (4·8%) of 2514 full texts were assessed for eligibility, and 29 unique prognostic models were identified. Nine (31·0%) of 29 models had score development reported only, 19 (65·5%) had undergone internal validation, and only four (13·8%) had been externally validated. Data to validate six eligible models were collected in the international external validation cohort study. Data from 11 591 patients were available, with an overall postoperative pulmonary complication rate of 7·8% (n=903). None of the six models showed good discrimination (defined as AUROCC ≥0·70) for identifying postoperative pulmonary complications, with the Assess Respiratory Risk in Surgical Patients in Catalonia score showing the best discrimination (AUROCC 0·700 [95% CI 0·683-0·717]).

INTERPRETATION

In the pre-COVID-19 pandemic data, variability in the risk of pulmonary complications (StEP-COMPAC definition) following major abdominal surgery was poorly described by existing prognostication tools. To improve surgical safety during the COVID-19 pandemic recovery and beyond, novel risk stratification tools are required.

FUNDING

British Journal of Surgery Society.

970 FRAILTY IS INVERSELY CORRELATED WITH SERUM ALBUMIN IN ACUTE HIP FRACTURE

Introduction

Frailty and sarcopenia have been shown to significantly increase the risk of falls, traumatic hip fractures and all-cause mortality in the elderly. The assessment of frailty using a validated clinical frailty scale such as that proposed by Rockwood et al., therefore, continues to remain an important step in determining post-operative prognosis in patients undergoing hip fracture surgery. The purpose of this study was to examine the relationship between frailty and serum albumin—an independent biochemical predictor of survival in hip fracture patients (1).

Method

This retrospective cross-sectional study analysed 190 patients, aged above 60 years, admitted to Queen’s Hospital Burton (QHB) between the 1st January and 28th December 2019 with a newly diagnosed hip fracture. Pre-operative serum albumin levels (g/L) and Rockwood clinical frailty scores (rCFS) were recorded from electronic medical records (EMR). Using the SPSS 27 statistical package, Pearson’s correlation co-efficient and linear regression analysis were carried out using these variables.

Results

A total of 190 patients were included in the study (57 male, 133 female). Mean patient age was 82.2 ± 8.47 years. More than 50% of patients had a Rockwood CFS ≥5. Mean serum albumin (g/L) was 37.3 ± 6.56. A statistically significant inverse correlation was demonstrated between pre-operative serum albumin levels and Rockwood CFS (r = −0.243, p < 0.001).

Conclusion

This study showed how serum albumin, a negative acute phase reactant and marker of chronic malnutrition, is inversely associated with frailty in hip fracture patients and the important role of Rockwood CFS and pre-operative serum albumin levels in the prognostication of hip fractures in the elderly. References 1) Bohl D, Shen M, Hannon C, Fillingham Y, Darrith B, Della Valle C. Serum Albumin Predicts Survival and Postoperative Course Following Surgery for Geriatric Hip Fracture. Journal of Bone and Joint Surgery. 2017;99(24):2110–2,118.

Impact of Surgery on the Hemangiogenic Profile, Especially VEGF Levels, in Lung Cancer Patients

Introduction: Lung cancer was considered to be rare at the beginning of the 20th century, but it has now reached almost epidemic proportions. It is the leading cause of cancer deaths in developed countries and is also rising at alarming rates in developing countries. Introduction: Coronavirus disease 2019 (COVID-19) is an emerging viral infection without any approved treatment. Investigational therapies for COVID-19 may cause clinically important drug-drug interactions (DDIs). We aimed to study drug-drug interactions (DDIs) and their risk factors in hospitalised COVID-19 patients. Aim: The aim of our study is to establish an effect on serum levels of vascular endothelial growth factor (VEGF) after surgery in lung cancer patients. Methods:This was a prospective study. For the estimation of VEGF, 50 lung cancer patients were studied. Both preoperative and postoperative levels of VEGF were estimated for all subjects. Blood samples were obtained from all cases both preoperatively and postoperatively (four weeks after surgery). Blood samples of 100 age and sex matched healthy controls were collected from the Outpatient Departments of SKIMS to establish normal serum VEGF levels. Conclusion: Our findings show that serum VEGF levels are higher as the tumor stage progresses and tumor size increases, which explains the lower serum VEGF levels observed by us in the operable patient group.

AB0616 RISK FACTORS FOR PREVALENT VERTEBRAL FRAGILITY FRACTURES - STUDY IN A LONDON URBAN BOROUGH

Background:

Vertebral fragility fractures (VFFs) are commonly underdiagnosed, often resulting in chronic pain and reduced quality of life. It is particularly important to identify and manage VFFs, as they are important predictors of future VFFs and non-VFFs. Patients with VFFs often have multiple risk factors, which are important to identify to formulate a tailored and appropriate management plan. There is a paucity of studies that have investigated risk factors specifically for VFFs.

Objectives:

To identify the prevalence of osteoporosis risk factors in patients with VFFs.

Methods:

Retrospective review of patients seen between July 2018 and July 2019 at Purley Memorial Hospital, covering a large urban borough. Patients included in the study had prevalent moderate and severe VFFs (defined by Ghent criteria).

Results:

84 patients were included, of which there were 71 females and 13 males. Median age was 76 (IQR 67 – 82) and BMI was 25 (IQR 21 – 27), with 6% of patients noted to be underweight (BMI <18.5). 38% of patients had a family history of osteoporosis and 21% of patients reported a history of parental hip fracture. 21% of patients had experienced recurrent falls. Over half (56%) of patients were noted to have had 2-or-more previous fragility fractures. Of the female cohort, 24% had early menopause, 13% were nulliparous and 1% had late menarche. Of the modifiable risk factors, alcohol (24%), sedentary lifestyle (21%) and smoking (13%) were the most common. Thyroid-disease (18%) was the most common medical condition associated, followed by coeliac/malabsorption (7%), endocrinopathy (6%) and COPD (6%). Proton Pump Inhibitors (PPIs) and steroids were the most common medications associated with 16% and 14% of cases respectively. 73% of patients had good calcium intake and 62% had calcium supplements. Overall, 27 patients had 3-or-fewer risk factors, 35 patients had 4-to-6 risk factors, 19 had 7-to-9 risk factors, and 3 had greater than 10 risk factors.

Conclusion:

Our study identified several risk factors and their prevalence. The majority of patients were female, of which 24% had early menopause. Several modifiable risk factors such as low BMI, alcohol, smoking and sedentary lifestyle were commonly seen, emphasising the need to identify these risk factors in the initial consultation. Over half of patients (56%) had had 2-or-more previous non-VFFs, suggesting the need to screen for VFFs in patients with multiple fragility fractures at baseline assessment. A number of co-existing medical conditions were also observed with thyroid disease being the most prevalent. PPIs and steroids were found to be important risk factors, which may lead to the consideration of alternative medications. Overall, it was found that patients had multiple risk factors, thus it is important to have a holistic assessment of VFF patients and a multi-system management approach to prevent future fractures.

Disclosure of Interests:

None declared.

Application of 15N tracing for estimating nitrogen cycle processes in soils of a constructed wetland

Integrated Constructed Wetlands (ICW) area technology for the attenuation of contaminants such as organic carbon (C), nitrogen (N), phosphorous (P) and sulphur (S) in water coming from point or diffuse sources. Currently there is a lack of knowledge on the rates of gross N transformations in soils of the ICW bed leading to losses of reactive N to the environment. In addition, the kinetics of these processes need to be studied thoroughly for the sustainable use of ICW for removal of excessive N in the treatment of waste waters. Gross N transformation processes were quantified at two soil depths (0-15 and 30-45 cm) in the bed of a surface flow ICW using a ¹⁵N tracing approach. The ICW, located in Dunhill village at Waterford in Southeastern Ireland, receives 500 person equivalent waste waters containing large quantities of organic pollutants (ca. mean annual C, N, P and S contents of 240, 60, 5 and 73 mg L^-1). Soil was removed from these depths in December 2014 and incubated anaerobically in the laboratory, with either ¹⁵N labeled ammonium (NH₄⁺) or nitrate (NO₃^-), differentially labeled with ¹⁴NH₄¹⁵NO₃ and ¹⁵NH₄¹⁴NO₃ in parallel setups, enriched to 50 atm% ¹⁵N. Results showed that at both soil depths, NO₃^- production rates were small, which may have resulted in lower NO₃^- reduction by either denitrification or dissimilatory NO₃^- reduction to ammonium (DNRA). However, despite being low, the DNRA rates were greater than denitrification rates. Direct transformation of organic N to NO₃^-, without mineralization to NH₄⁺, was a prevalent pathway of NO₃^- production accounting for 28-33% of the total NO₃^- production. Relative contribution of this process to the total N mineralization was negligible at depth 1 (0.01%) but dominant at depth 2 (99.7%). Total NO₃^-production to total immobilization of NH₄⁺ and NO₃^- was very small (<0.50%) suggesting that ICW soils are not a source of NO₃^-. Despite a large potential of N immobilization existed at both the layers, relative N immobilization to the total N conversion was higher at depth 2 (ca. 2.2) than at depth 1 (ca. 1.5). The NH₄⁺ desorption rate at 30-45 cm was high. However, immobilization in the recalcitrant and labile organic N pools was higher. Mineralization and immobilization of NH₄⁺ processes showed that recalcitrant organic N was the predominant source in ICW soils whereas the labile organic N was comparatively small. Source apportionment of N₂O production showed that the majority of the N₂O produced through denitrification (ca. 92.5%) followed by heterotrophic nitrification (ca. 5.5%), co-denitrification (ca. 1.90%) and nitrification (0.20%). These results revealed that application of a detailed ¹⁵N tracing method can provide insights on the underlying processes of ecosystem based abundances of reactive N. A key finding of this study was that both investigated ICW layers were characterised by large N immobilization which restricts production of NO₃^- and further gaseous N losses.

Impact of pelvic immobilization techniques on the outcomes of primary and secondary closures of classic bladder exstrophy

INTRODUCTION

A potential determinant of successful bladder closures in patients with classic bladder exstrophy (CBE) is the postoperative pelvic immobilization technique. This study investigates the success rates of primary and secondary bladder closures based on various immobilization techniques from a high-volume exstrophy center.

METHODS

A prospectively maintained institutional exstrophy-epispadias complex database of 1336 patients was reviewed for patients with CBE who have undergone primary or secondary closures between 1975 and 2018 and subsequently had a known method of pelvic immobilization. Patients were divided into two groups: primary and secondary closures. Associations between closure outcomes and immobilization techniques were determined.

RESULTS

A total of 476 patients with primary closures and 101 patients with secondary closures met the inclusion criteria. In total, 343 (72.1%) primary closures were successful. As shown in the table, the success rates of primary closures were highest in patients immobilized with modified Buck's and Bryant's traction (95.0% and 79.3%, respectively) and lowest in those with spica cast (49.6%). A propensity score-adjusted logistic regression (adjusting for osteotomy status, period of closure, location of closure, and closure type) revealed that modified Buck's traction had a 5.60 (95% confidence interval 1.74-23.1, p = 0.008) greater odds of success compared to spica casting during the primary closure. For the secondary closure group, there were 92 (92.1%) successful secondary closures. Success rates were highest in modified Buck's traction (97.3%) and lowest with spica casting (66.7%).

DISCUSSION

This study confirms previous findings of better outcomes when patients are immobilized with external fixation and Buck's traction after adjusting for potential confounding factors. Immobilization with modified Buck's or Bryant's traction yielded significantly higher primary closure success rates when compared to spica casting. It is the authors' belief that despite a longer hospital length of stay, external fixation with Buck's traction provides the best chance of a successful closure and, thus, a financially responsible method to care for these children in the postoperative period.

CONCLUSIONS

Success rates for primary closures were highest when using modified Buck's traction with external fixation and lowest for spica casts. Similarly, for secondary closures, the best outcomes were achieved using modified Buck's traction with external fixation and the lowest success rates were associated with spica casts.

The BiZiFED project: Biofortified zinc flour to eliminate deficiency in Pakistan

Zinc deficiency is a global public health problem, affecting ~17% of the world's population, with the greatest burden in low- and middle-income countries. An increasing body of evidence suggests that biofortification may be a cost-effective and sustainable approach to reducing zinc and other micronutrient deficiencies. Biofortification enhances the nutritional quality of food crops through conventional plant breeding techniques and agronomic practices. This paper presents ongoing research on biofortification in Pakistan, where over 40% of women are zinc deficient. The Biofortified Zinc Flour to Eliminate Deficiency (BiZiFED) project aims to investigate the impact of biofortification as a strategy to alleviate zinc deficiency in Pakistan. The project is supported by the Biotechnology and Biological Sciences Research Council (BBSRC) Global Challenges Research Fund from May 2017 to April 2019. This paper outlines the four objectives and work packages within the BiZiFED project: (1) a double-blind, randomised controlled trial to examine the effect of consuming flour made from a high zinc variety of biofortified wheat (Zincol-2016/NR-421) on dietary zinc intake and status; (2) a cost-effectiveness study to assess the health and economic impact of agronomic biofortification of wheat; (3) a mixed methods study to explore the cultural acceptability and sustainability of biofortification in Pakistan; (4) capacity building and development of long-term research partnerships in Pakistan. The findings will contribute to the evidence base for the potential impact of biofortification to alleviate zinc deficiency among the poorest communities.

Clinical and laboratory features of seventy-eight UK patients with Good's syndrome (thymoma and hypogammaglobulinaemia)

Good’s syndrome (thymoma and hypogammaglobulinaemia) is a rare secondary immunodeficiency disease, previously reported in the published literature as mainly individual cases or small case series. We use the national UK‐Primary Immune Deficiency (UKPID) registry to identify a large cohort of patients in the UK with this PID to review its clinical course, natural history and prognosis. Clinical information, laboratory data, treatment and outcome were collated and analysed. Seventy‐eight patients with a median age of 64 years, 59% of whom were female, were reviewed. Median age of presentation was 54 years. Absolute B cell numbers and serum immunoglobulins were very low in all patients and all received immunoglobulin replacement therapy. All patients had undergone thymectomy and nine (12%) had thymic carcinoma (four locally invasive and five had disseminated disease) requiring adjuvant radiotherapy and/or chemotherapy. CD4 T cells were significantly lower in these patients with malignant thymoma. Seventy‐four (95%) presented with infections, 35 (45%) had bronchiectasis, seven (9%) chronic sinusitis, but only eight (10%) had serious invasive fungal or viral infections. Patients with AB‐type thymomas were more likely to have bronchiectasis. Twenty (26%) suffered from autoimmune diseases (pure red cell aplasia, hypothyroidism, arthritis, myasthenia gravis, systemic lupus erythematosus, Sjögren’s syndrome). There was no association between thymoma type and autoimmunity. Seven (9%) patients had died. Good’s syndrome is associated with significant morbidity relating to infectious and autoimmune complications. Prospective studies are required to understand why some patients with thymoma develop persistent hypogammaglobulinaemia.

Role of Dual Energy X-ray Absorptiometry (DEXA) Scan in the Diagnosis of Chronic Low Back Pain - a Prospective Randomized Controlled Study in Osteoporotic Patients Hospitalized in a Tertiary Care Institute

Objectives

Osteoporosis is a skeletal disorder characterized by a decrease in bone mass, with accompanying microarchitectural damage that increases the risk of bone fracture. The aim of this study is to evaluate various risk factors for osteoporosis and the role of DEXA scan in diagnosing the problem in an earlier stage.

Materials and methods

About 100 patients who presented with complaint of low back pain in our outpatient department were studied and subjected to a DEXA scan.

Results

The age range of patients included in this study was between 35 and 70 years. Of all subjects, 85.10% (n=57) were females and 78.80% (n=26) males. The number of those with significant medical or surgical history was 31% (n=31). The anthropometric characteristics of the studied group included weight, height, and also BMI in kg/m2, which was 20.23, 21.06 in male subjects and 19.343, 20.42 in female ones. Regarding DEXA measurements, the bone mineral density was 0.97±0.27 (0.48, 1.96) for males and 0.83±0.21(0.01, 1.60) for females, with a total of 0.88±0.24 (0.01, 1.96).

Conclusion

Low back pain is highly prevalent in postmenopausal women. DEXA is a widely accepted radiological tool used to detect osteoporotic changes in bones earlier, with a higher accuracy than plain radiographs of skeletal system. It is relatively cheap, needs no special preparation and involves less radiation hazard.

A critical role of ultrasonography in management of liver abscesses

Aims and objectives: to see the efficacy of ultrasonography in the management of amoebic liver abscess. We assessed whether patient required surgery or can be managed with drainage procedure on ultrasonography basis.Materials and Methods: This is a prospective study done from July 2014 to May 2015, in a medical college in remote area. A total of 88 patients diagnosed with liver abscess were included in the study for ultrasound-guided percutaneous aspiration or pigtail drainage management. All patients had been treated with antibiotics or antimicrobials for at least 2 weeks if treated conservatively and were still being continued for another 6 weeks.Results: A total of 88 patients with liver abscess were successfully treated, consisting 79 males and 9 female. The age ranged from 18 to 82 years with a mean of 43.6 years. A total number of 76 (86.36%) cases undergone percutaneous catheter drainage and 12 (13.6%) underwent needle aspiration. A total of 73 (82.95%) patients had single large abscess, while 8 (9%) had two and 7 (7.9%) had multiple abscesses. The abscesses were commonly located on the right lobe of liver. The Pigtail catheters of sizes 10 F to 18 F was introduced either directly under the guidance of the guide wire with safety precautions. The volume of pus aspirated averaged from 70 - 1200 ml, while the period of catheter drainage ranged from 7 to 24 days with the follow up on ultrasonography.Conclusion: This study shows a success rate of ultrasonography almost 98 % by avoiding unnecessary surgical intervention. It was confirmed that needle aspiration in small abscesses and catheter drainage in large abscesses offers the safest and best modality.Bangladesh Journal of Medical Science Vol.17(2) 2018 p.258-262

The Safety and Efficacy of Clipless versus Conventional Laparoscopic Cholecystectomy - our Experience in an Indian Rural Center

Background

Laparoscopic cholecystectomy is one of the most common surgeries performed nowadays. There are lot of advances in closure of cystic duct and artery (clip ligation, suture ligation), but it remains an enigma regarding efficacy, safety and postoperative complications for using non-absorbable suture material or Liga clip for the operating surgeon in laparoscopic cholecystectomy.

Objectives

Our study aimed to evaluate the efficacy, safety and complications of non-absorbable sutures ligation versus clips application in laparoscopic cholecystectomy, and to compare the operative time and cost effectiveness of the two surgical approaches in laparoscopic cholecystectomy.

Methods

This prospective study was performed between August 2014 and February 2015 in M. M. Institute of Medical Science and Research, in a rural center, Mullana, India. The study included 160 patients who were diagnosed with chronic cholecystitis in a single unit. Subjects were divided into two groups and all cases were operated by a single surgeon. The cystic pedicle was tied with non-absorbable material (silk 2-0) in group A and with Titanium clips using a clip applicator in group B.

Results

The application of silk and clips for cystic duct and artery ligation in laparoscopic cholecystectomy can be safely used. The mean time for ligation of cystic duct was 2.50 (SD ±0.25) in group A and 1.50 min (SD ±1.85) in group B, with P<0.001, which was significant. Similarly, the mean time for ligation of cystic artery was 1.50 min (SD±0.20) in group A and 1.36 min (SD ±0.11) in group B, with P>0.001. There were no postoperative complications, such as wound infection or bile leakage, in any of the two methods. The cost of material for silk suture (40-60 Rupees or 0.62-0.92 $) is definitely much lower than that for Liga clips (790-1000 Rupees or 12.28-15.55 $). For the use of clips, a clip applicator is required, but in case of silk ligation no special instrument is required and silk is also easily available.

Conclusion

In laparoscopic cholecystectomy, ligation of cystic duct and cystic artery with clips takes less time than by silk suture. We conclude that both ligation techniques can be safely and effectively used. Training for junior surgeons is necessary to avoid potential complications.

Amoebic Colonic Perforation Presenting as Peritonitis in Emergency, Incidence and Outcome: Our Experience

OBJECTIVES

Amoebiasisis a common parasitic infection and fulminant amoebic colitis remains a very rare complication of this disease. The objective of the present study was to find the incidence and outcome of perforation peritonitis due to amoebic colitis in MMIMSR, Mullana, Ambala, India.

MATERIAL AND METHODS

200 patients with perforation peritonitis were studied retrospectively, out of which 22 cases had colonic perforation, were selected over a period of five years, between 2012 to 2017, at MMIMSR Mullana. All patients had undergone emergency laparotomy and cases with amoebic colonic perforation established on histopathology were studied in terms of incidence, clinical presentation and outcomes.

RESULTS

Out of 200 emergency exploratory laparotomies carried out during 2012-2017 at MMIMSR, Mullana, 22 (11%) patients had amoebic colonic perforation. The disease was more common among men as compared to women (21:1). The mean age of patients was 60±10 years. Symptom duration ranged from 1 to 8 days. 15 (68%) patients had historyof chronic alcohol intake and 2 (9%) had a recent episode of loose stools. Chest X-ray showed free gas under the diaphragm in 45% (10/22) of patients. Ultrasonography whole abdomen showing associated liver abscess was seen in 8/22 (36%) patients. Intraoperatively caecal perforation was seen in 20 cases, out of which 16 had concomitant ascending colon perforation and 2 sigmoid colon perforation. Bowel resection was performed depending upon the site and extent of the colon involved- right hemicolectomy (16), limited ileocolic resection (4) and sigmoidectomy (2). Proximal diversion stoma was made in all cases. Postoperative complications encountered were wound infection in 20 (91%) cases, followed by burst abdomen in 8 (36%) cases, stoma related complication in 6 (27%) cases. The overall mortality rate due to sepsis was 54% (12/22).

CONCLUSION

Although amoebiasis is a common parasitic infection, fulminant amoebic colitis remains a very rare complication with a reported incidence of 1%. Even with aggressive management of this entity, patients have got a poor prognosis. Resection with exteriorization of bowel is the current gold standard treatment in such cases.

Intussusception of Small Intestine as a Result of Inflammatory Fibroid Polyp Causing Small Bowel Obstruction in an Adult Patient

Intussusception is the telescoping of one segment of bowel into the adjacent segment. It is more commonly seen in children,however rarely encountered in adult patients. Proximal segment of bowel is called intussusceptum which is intussuscepted into the lumen of the adjacent distal segment known as intussuscipiens. There is always a lead point causing this disorder especially in adults. We presented a case of a 45 year old man who presented in emergency department of our institute with history and clinical features of acute intestinal obstruction since 10 days. Patient was resuscitated, investigated and taken for exploratory laparotomy under General anaesthesia. Segment of involved small gut was resected and well circumscribed polypoidal mass was found in intussuscepted bowel. Histopathological examination of the specimen revealed the features of inflammatory fibroid polyp.

To compare the efficacy of tamsulosin and alfuzosin as medical expulsive therapy for ureteric stones

Aims and Objectives:

This study aims to evaluate the efficacy of tamsulosin and alfuzosin for the distal ureteral stone. This study assessed the spontaneous passage and expulsion of the stone.

Materials and Methods:

The study was conducted in the Department of Surgery at Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, from May 2013 to May 2014. A total number of 136 patients diagnosed as distal ureteric stone (US) of size <10 mm were included in this study. It was divided into two groups (I and II) out of which 36 cases were excluded. Group I received tablet tamsulosin 0.4 mg/day, and Group II received alfuzosin 10 mg/day. The efficacy of tamsulosin and alfuzosin as an adjunctive medical therapy was determined.

Results:

Both the drugs can be safely used for the distal USs. The stone expulsion rate was seen in 36 patients (72.0%) in Group I, and in 34 patients (68.0%) in Group II (P = 0.545). The passage of stones noticed by 32 patients in each Groups I and II (P = 1.000). The mean number of pain attacks was 2.91 ± 1.01 for Group I, and 1.8 ± 0.83 for Group II (P < 0.001 and P < 0.001). Thus, we propagate the use of alfuzosin significantly lower number of pain attacks. The drug-related side-effects were postural hypertension (four in Group I and one in Group II) and retrograde ejaculation (eight in Group I, and one in Group II). Thus, the difference was statistically significant in terms of retrograde ejaculation but insignificant for postural hypotension.

Conclusion:

There is no difference between both medications in term of efficacy (passing stones) for the management of distal ureteral stones. Both medications are safe and effective. In addition, alfuzosin was better tolerated than tamsulosin as it has fewer side effects.

Unusual location of primary hydatid cyst diagnosed on aspiration cytology

Hydatid cyst (HC) is a parasitic infection caused by Echinococcus granulosus. It occurs frequently in liver and lungs. Hydatid cyst of neck is extremely rare occurrence, and here, we report it with this unusual location. A 25-year-old male nonhypertensive and nondiabetic presented with slowly growing painless swelling in right side of neck for 4-5 years. The swelling measured 5 × 3 cm and was of soft to firm consistency. Fine needle aspiration cytology yielded fluid aspirate and smear showed features suggestive of HC. The intact cyst was removed surgically, and histopathological examination confirmed the diagnosis of hydatid cyst.

Unusual Entities of Appendix Mimicking Appendicitis Clinically - Emphasis on Diagnosis and Treatment

BACKGROUND

Abdomen is considered a magic box or a Pandora box where you will get different, unexpected pathologies along with rare entities. Appendicitis is the commonest emergency in surgery which presents challenges to surgeons because of a myriad list of differential diagnosis including both medical and gynaecological pathologies. Preoperative imaging plays an important role in diagnosis and management.

AIMS AND OBJECTIVES

To study the rare atypical anatomical and surgical presentations of appendix in patients with clinical features of appendicitis. We focus on the clinical features and the role of investigations for the radiological part and management.

MATERIAL AND METHODS

This study was done in M.M. Institute of Medical Sciences and Research, Mullana, Ambala, from November 2014 to July 2016. This was a retrospective study. We found 168 cases with the diagnosis of appendicitis, out of which 19 were with rare entities.

RESULTS

Subjects of both genders were aged between 20 and 60 years. Out of 19, 15 were males and 4 females. Four patients were operated for inguinal hernia but incidentally we found appendix in the hernial sac termed as Amyand's hernia. Another patient presented with obstruction and appendix was forming a band diagnosed as torsion of appendix. Two most interesting cases were diagnosed as appendicular neuralgia and relieved by appendectomy. Out of 19 cases, 7 cases were operated for appendicitis diagnosed as appendicolith. In all the cases appendectomy was done without encountering any complications. Symptom free patients were operated for appendicular neuralgia. No malignancy was found in mucocele appendix at follow up. There were no complications by the 6-month follow-up.

CONCLUSION

As we came across with different entities of appendix presented with appendicitis, patients should be investigated before proceeding for surgery. In our study, there were incidental findings for which surgeons were not aware of the diagnosis and even for the patient. In inguinal hernia, ultrasonography was not done, diagnosis being made on clinical basis. Clinical and radiological investigations play an important part in early diagnosis and management.

Comparative Evaluation of Intra-Operative Peritoneal Lavage with Super Oxidized Solution and Normal Saline in Peritonitis Cases; Randomized Controlled Trial

AIM

To investigate the efficacy of super-oxidized solution (SOS) over normal saline in peritonitis cases. Our objectives are to present the potential clinical impact of intraperitoneal lavage with solutions for early recovery of the patient by reducing the infection rate.

MATERIAL AND METHODS

A double-blind random clinical trial was performed in 240 cases diagnosed as peritonitis at MM Institute of Medical Sciences and Research, Mullana, Ambala, India, from December 2013 to November 2015. Subjects were categorized into 2 groups, i.e. 120 cases in the group I and 120 cases in the group II. Both the groups underwent peritoneal lavage; the group I underwent normal saline lavage and group II received SOS. The effectiveness of both the solutions was compared.

RESULTS

In both the groups majority of the patients (50.0%) were in the 21 - 40 years of age. The mean age in our study was 45.28 years, median was 45 and the standard deviation was 14.07. The bacterial load was higher in the group II as compared to the group I after the lavage with SOS solution. The superficial wound infection rate was higher in the group II (48 cases) compared to the group I (32). These data was significant with p value (0.040). Wound pain was found in 59 cases in group II as compared to 42 in group I. This difference was found to be statistically significant with p value 0.036. Post-operatively the morbidity and mortality was less in the group I as compared to group II.

CONCLUSION

SOS significantly reduced the wound pain and infection hence resulting in early recovery. SOS is a high level disinfectant, non-flammable and no special training is required to handle it.

A Study of Evaluation and Management of Rare Congenital Breast Diseases

INTRODUCTION

Polymastia and polythelia may be asymptomatic or cause pain, restriction of arm movement, milk discharge, cosmetic problems or anxiety. Cosmesis is the main indication for surgical excision of accessory breasts in axilla. In addition it also confirms the diagnosis and allays the patient's fear of harbouring a malignancy.

AIM

To evaluate the presentation of symptoms, investigations required for diagnosis and the management to improve the treatment protocols in patients with breast diseases.

MATERIALS AND METHODS

This retrospective study on breast diseases presenting as supernumerary breasts and nipples was conducted in the Department of Surgery between January 2013 and January 2016 at MMIMS Research and hospital, Mullana, Ambala. Patients were evaluated for breast diseases, either benign or malignant in both genders. A total of 32 cases diagnosed as accessory breasts disease were retrieved from the hospital archive. The clinical and radiological evaluation was done in the form of ultrasound and mammography wherever necessary. Accessory breast tissues were excised under general anesthesia and histopathological examinations were done.

RESULTS

Out of 32 cases: 1(3.125%) male patient had unilateral and 1(3.125%) male had bilateral accessory nipple, 7 (21.87%) females had unilateral and 1(3.125%) had bilateral accessory nipple, 1 (3.125%) diagnosed as accessory axillary fibroadenoma in female, 16(50%) presented as unilateral and 5 (15.62%) had bilateral swelling in the axilla as accessory breast. Patients underwent surgical excision and in 8(25%) cases z- shaped incision was made in view of better cosmesis. Patients were followed up upto 6 months postoperatively. There were no residual swelling and movements of the arm over the shoulder joint were normal. In 3(9.37%) cases, wound dehiscence occurred; in 2 (6.25%) cases lymphoedema formation was seen. These were successfully managed conservatively.

CONCLUSION

As breast swellings either fibroadenoma or carcinoma are common entities to come across everywhere but accessory breasts are rarely encountered especially in rural areas because of less awareness. The study found that there was tendency to neglect the swelling as there were minimal symptoms present. We also came across a rare entity, accessory breast and accessory nipples. A clinician should not ignore such cases taking as simple swelling because of chances of discovering a malignancy can occur.

No Need of Fascia Closure to Reduce Trocar Site Hernia Rate in Laparoscopic Surgery: A Prospective Study of 200 Non-Obese Patients

Background

Laparoscopy is widely practiced and offers realistic benefits over conventional surgery. Port closure is important after a laparoscopic procedure to prevent port site incisional hernia. Larger port size and increasing numbers of ports needed to perform more complex laparoscopic procedures are likely to increase the incidence of port site hernias (PSHs). PSHs tend to develop more frequently at umbilical and midline port sites due to the thinness of the umbilical skin and weaknesses in the linea alba. More than 90% of PSHs occur through 10 mm and large ports can occur through 5 mm ports also. The aim was to study the outcomes and complications in laparoscopic surgery without fascial sheath closure of port site. We compared the results with another group in which fascial closure was done by a standard method.

Methods

This was a prospective study carried out in the Department of Surgery, MMIMSR, Mullana, Ambala, from August 2013 to 2015 in a single unit by a single surgeon. A total of 200 patients were selected randomly for the different laparoscopic procedures. Patients were divided into group A (only skin closure was done without fascia closure) and group B (fascial closure of the port in addition to skin closure). In both groups, we used blunt trocar for the 10 mm port. Skin of the 5 mm port was closed simply. The results in two groups were compared in terms of complications like PSH, bleeding, and wound infection.

Results

The outcomes in two groups were compared with and without fascia closure of 10 mm trocar port site. Patients operated for lap cholecystectomy were 170 (85%), 10 (5%) for lap appendicectomy, and 20 (10%) for lap hernia. The study compared the results in two groups mainly for PSH formation. The P value was insignificant and Fischer’s exact test result came as 1.00. There were no significant differences between the two groups in terms of PSH, bleeding and infection in non-obese cases.

Conclusion

In both groups, blunt trocar was introduced into the abdomen. We concluded that this is safe, without visceral injury, and no bleeding was seen in both the groups. We had not encountered any case with PSH formation in follow-up of 6 - 8 months. There was no infection over the port site.

Development and in-vitro Evaluation of Once Daily Tablet Dosage Form of Loxoprofen Sodium

Purpose: To formulate and characterize once daily controlled release tablet of loxoprofen sodium.Methods: Eudragit RS-100, hydroxylpropyl methylcellulose (HPMC) and pectin were used as release retarding polymers. All the formulations were prepared by direct compression method. Various precompression studies were carried out to determine Hausner’s ratio, Carr’s index, angle of repose, bulk density and tapped density Differential scanning calorimetry (DSC) studies and also post-compression studies to evaluate hardness, friability, weight variation, drug content, in-vitro drug release were conducted on the tablets. The drug release data were subjected to kinetic models, including zero order, first order, Hixon Crowell, Higuchi and Korsmeyer-Peppas.Results: Compressibility index (7.6 ± 1.32 - 12.5 ± 1.43%), Hausner’s ratio (1.08 ± 0.04 - 1.14 ± 0.03), angle of repose (27.78 ± 0.47 - 30.49 ± 0.46°), hardness (6.25 ± 0.27 - 7.21±0.21 kg/cm2), friability (0.14 ± 0.06 - 0.28 ± 0.0 %), weight variation (249.5 ± 2.09 - 251.35 ± 2.41 mg) and drug content  (97.30 ± 0.28 - 103.70 ± 0.31 %) were within generally accepted limits for the pre-and post-compression formulations, respectively. The tablets having the maximum amount of among the three polymers tested as matrix materials, HPMC, represented by F3 tablets, exerted better sustained release properties after 12 h. Release pattern was more of Fickian diffusion followed by Higuchi mechanism.Conclusion: The release of the loxoprofen sodium was optimized up to 12 h.Keywords: Loxoprofen, Sustained release, hydroxypropyl methylcelluose, Pectin, Eudragit, Matrix tablets

The effect of urease and nitrification inhibitors on ammonia and nitrous oxide emissions from simulated urine patches in pastoral system: a two-year study

This field study evaluated the effects of applying a combination of urease (UI) and nitrification inhibitors (NI) on ammonia (NH3) and nitrous oxide (N2O) emission from urine patches, using zeolite, single superphosphate (SSP) and urea fertilizer as a carrier. The trial was conducted on a Typic Haplustepts silt loam soil, near Lincoln, Canterbury, New Zealand during 2009-11. The treatments in 2009 included: a control (no urine or inhibitor), urine alone at 600 kg N ha(-1), and urine with either double inhibitor (DI) a mixture (1:7 ratio w/w) of UI (N-(n-butyl) thiophosphoric triamide (nBTPT - trade name Agrotain®) and NI, dicyandiamide (DCD) or DCD alone at 10 kg ha(-1) using zeolite and SSP as carriers. In 2010 trials, both zeolite and urea were used as carriers for DI and DCD. DI-zeolite and DI-urea were equally effective and reduced the average NH3 losses from applied urine over two years by 34.6% in autumn and 40% in spring respectively. The nBTPT in DI-SSP was decomposed by the free acid produced during its dissolution and therefore increased NH3 emission as does DCD alone. DCD consistently increased NH3 emissions by 39% and 15.6% in autumn and spring respectively. Spring application resulted in NH3-N losses of 16.9% as a percentage of the total N applied compared to 8.4% in autumn. Over the two years, the DI reduced N2O emissions by 53% in autumn and 46% in spring over urine alone treatment; the equivalent reductions for DCD were 42% and 39% for autumn and spring, respectively. These results suggest that applying DI in autumn and spring using zeolite or urea carrier five days prior to grazing has the most potential to reduce NH3 and N2O losses from specific urination event than using DCD alone; and therefore warrants further research to improve its longevity.

Denitrification and N2O:N2 production in temperate grasslands: processes, measurements, modelling and mitigating negative impacts

In this review we explore the biotic transformations of nitrogenous compounds that occur during denitrification, and the factors that influence denitrifier populations and enzyme activities, and hence, affect the production of nitrous oxide (N2O) and dinitrogen (N2) in soils. Characteristics of the genes related to denitrification are also presented. Denitrification is discussed with particular emphasis on nitrogen (N) inputs and dynamics within grasslands, and their impacts on the key soil variables and processes regulating denitrification and related gaseous N2O and N2 emissions. Factors affecting denitrification include soil N, carbon (C), pH, temperature, oxygen supply and water content. We understand that the N2O:N2 production ratio responds to the changes in these factors. Increased soil N supply, decreased soil pH, C availability and water content generally increase N2O:N2 ratio. The review also covers approaches to identify and quantify denitrification, including acetylene inhibition, (15)N tracer and direct N2 quantification techniques. We also outline the importance of emerging molecular techniques to assess gene diversity and reveal enzymes that consume N2O during denitrification and the factors affecting their activities and consider a process-based approach that can be used to quantify the N2O:N2 product ratio and N2O emissions with known levels of uncertainty in soils. Finally, we explore strategies to reduce the N2O:N2 product ratio during denitrification to mitigate N2O emissions. Future research needs to focus on evaluating the N2O-reducing ability of the denitrifiers to accelerate the conversion of N2O to N2 and the reduction of N2O:N2 ratio during denitrification.

Quantification of reductions in ammonia emissions from fertiliser urea and animal urine in grazed pastures with urease inhibitors for agriculture inventory: New Zealand as a case study

Urea is the key nitrogen (N) fertiliser for grazed pastures, and is also present in excreted animal urine. In soil, urea hydrolyses rapidly to ammonium (NH4(+)) and may be lost as ammonia (NH3) gas. Unlike nitrous oxide (N2O), however, NH3 is not a greenhouse gas although it can act as a secondary source of N2O, and hence contribute indirectly to global warming and stratospheric ozone depletion. Various urease inhibitors (UIs) have been used over the last 30 years to reduce NH3 losses. Among these, N-(n-butyl) thiophosphoric triamide (nBTPT), sold under the trade name Agrotain®, is currently the most promising and effective when applied with urea or urine. Here we conduct a critical analysis of the published and non-published data on the effectiveness of nBTPT in reducing NH3 emission, from which adjusted values for FracGASF (fraction of total N fertiliser emitted as NH3) and FracGASM (fraction of total N from, animal manure and urine emitted as NH3) for the national agriculture greenhouse gas (GHG) inventory are recommended in order to provide accurate data for the inventory. We use New Zealand as a case study to assess and quantify the overall reduction in NH3 emission from urea and animal urine with the application of UI nBTPT. The available literature indicates that an application rate of 0.025% w/w (nBTPT per unit of N) is optimum for reducing NH3 emissions from temperate grasslands. UI-treated urine studies gave highly variable reductions (11-93%) with an average of 53% and a 95% confidence interval of 33-73%. New Zealand studies, using UI-treated urea, suggest that nBTPT (0.025% w/w) reduces NH3 emissions by 44.7%, on average, with a confidence interval of 39-50%. On this basis, a New Zealand specific value of 0.055 for FracGASF FNUI (fraction of urease inhibitor treated total fertiliser N emitted as NH3) is recommended for adoption where urea containing UI are applied as nBTPT at a rate of 0.025% w/w. Only a limited number of published data sets are available on the effectiveness of UI for reducing NH3 losses from animal urine-N deposited during grazing in a grazed pasture system. The same can be said about mixing UI with urine, rather than spraying UI before or after urine application. Since it was not possible to accurately measure the efficacy of UI in reducing NH3 emissions from animal urine-N deposited during grazing, we currently cannot recommend the adoption of a FracGASM value adjusted for the inclusion of UI.

Iron status in children with febrile seizure

This hospital based cross sectional analytic study was carried out in department of Pediatrics Dhaka Medical College Hospital and Combined Military Hospital from July 2009 to June 2010 to find out the relationship of iron status with febrile seizure in children. Sixty children aged 6 months to 5 years having febrile seizure were enrolled as cases after taking proper consent by purposive sampling. Sixty age matched children with fever but no seizures were taken as control after taking proper consent. Children having a febrile seizure, developmental delay, hemorrhagic disorder, severe malnutrition or micronutrient deficiency and abnormal CSF findings were excluded from the study. In cases after control of seizure 2 ml of CSF was taken for cytology, biochemistry, Gram & AFB staining. Two milliliter of blood from cases as well as control was collected, released to EDTA bottle for Hb, MCV and MCHC. Again 2 ml of blood was taken in plain test tube for testing serum iron, TIBC and for serum ferritin. Serum iron, TIBC, serum ferritin was estimated by automated analyzer (PENTRA for serum iron, DADE BEHRING for TIBC, IMMULITE 1000 for serum ferritin). There was no significant difference between two groups regarding age (p>0.05), sex (p>0.05). High fever (p<0.001) and continuous fever (p<0.001) was significantly associated with febrile seizure. Seizure was generalized in all with positive family history in 83.3% cases. The Mean±SD of blood Hb (Case 9.8±1.6; Control 10.7±0.9), MCH (Case 22.1±2.3; Control 24.3±3.6) & serum ferritin (Case 55.1±29.3; Control 99.6±81.9) level were significantly low associated with febrile seizure (p<0.05). No significant difference was found between cases and control regarding MCV, serum iron and serum TIBC.

Cardiac tamponade and heart failure secondary to ventriculo-pleural shunt malfunction: a rare presentation

We report an unusual case of a patient with a ventriculo-pleural shunt presenting with signs and symptoms of heart failure due to massive pericardial effusion. Imaging revealed the distal shunt catheter end within the middle mediastinum to have migrated from the pleural space. The patient underwent a shunt revision procedure resulting in complete resolution of the presenting pathology. We intend to draw the reader's attention to this rare presentation of ventriculo-pleural shunt malfunction.

Riverbank Erosion and Population Resettlement in Bangladesh

Two images of Bangladesh as a country are commonplace in the West and often simplistically intertwined—a land of overpopulation and poverty, and a land cursed by natural disaster. Bangladesh is one of the poorest countries in the world with an estimated per capita income equivalent to only U.S. $180. It is also one of the world's most crowded countries. One hundred thirteen million people live in Bangladesh, an area about the size of Wisconsin, with an average density close to two thousand people per square mile. Since only 13% of the population is urban, this tremendous population, currently growing at a rate of 2.8% per annum, exerts especially great pressure on resources in the rural areas.

A review of 50 cases of aphakic detachment in Peshawar, North West Frontier Province of Pakistan

BACKGROUND

This prospective study was conducted at Khyber Teaching Hospital Peshawar, North West Frontier Province (NWFP) of Pakistan over the period of 16 months. It was to assess the demographic pattern, mode of presentation, treatment modalities and postoperative result of aphakic retinal detachment. This study also compared the incidence of aphakic retinal detachment in intracapsular versus extracapsular cataract extraction as well as the duration between cataract surgery and retinal detachment.

PATIENTS AND METHOD

A total of 50 patients were recruited in this prospective study. A Proforma was specially designed for this purpose. Detailed history with reference to age, sex, presenting complaints, spectacle wear, previous ocular surgery, duration of surgery/laser treatment, systemic and family history was taken. All patients had detailed ophthalmic examination, underwent conventional retinal reattachment surgery, and were followed up for 6 months.

RESULTS

Of the total number studied, 86% of the patients were males; only 14% were females, with a mean age of 58 years. The overall anatomical success was achieved in 40 (80%) eyes. The visual acuity of 6/12 and better was achieved in 8 (16%) eyes. 20 (40%) eyes attained a vision of 6/18 to 6/36. 12 (24%) eyes had a vision between 6/60 to CF 3m. The vision could not be improved beyond CF 3m in 10 (20%) eyes.

CONCLUSION

Vitreous loss during cataract surgery is the most common cause of aphakic retinal detachment. The risk is maximal in the first and second year. The overall anatomical attachment achieved through conventional retinal detachment surgery is 80%.