Rapid implementation of triaging system for assessment of breast referrals from primary care centres during the COVID-19 pandemic.

OBJECTIVE: The aim of this study was to establish a triaging system for assessment of breast referrals from primary care to ensure safe and effective breast services without compromising breast cancer management. BACKGROUND: COVID-19 was officially declared a global pandemic on 11 March 2020, and with no effective treatment available, preventing spread has been paramount. Previously, all referrals from primary care were seen in the rapid-access breast clinic (RABC). Clinic appointments exposed patients and healthcare professionals to risk. METHOD: Initial triage during the lockdown was in line with national governing body guidance, rejected low risk referrals and streamed remaining patients through a telephone consultation to RABC or discharge. A modified triage pathway streamed all patients through virtual triage to RABC, telephone clinic or discharge with advice and guidance categories. Demographics, reasons for referral and outcomes data were collected and presented as median with range and frequency with percentages. RESULTS: Initial triage (23 March-23 April 2020) found fewer referrals with a higher percentage of breast cancer diagnoses. Modified triage (22 June-17 July 2020) resulted in a 35.1% (99/282) reduction in RABC attendance. Overall cancer detection rate remained similar at 4.2% of all referrals pre-COVID (18/429) and 4.3% (12/282) during modified triage. After six months follow-up of patients not seen in RABC during the modified triage pathway, 18 patients were re-referred to RABC and none were diagnosed with cancer. CONCLUSION: A modified triage pathway has the potential to improve triage efficiency and prevent unnecessary visits during the COVID-19 pandemic. Further refinement of pathway is feasible in collaboration with primary care.

Microbiology of Chronic Suppurative Otitis Media in a Tertiary Care Hospital in Bangladesh.

This cross sectional prospective study was carried out in the Department of Otolaryngology-Head & Neck Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU) and Department of Microbiology, University of Dhaka from July 2012 to June 2013. The objectives of this study were to identify the common microorganisms involved and the antibiograms of chronic suppurative otitis media (CSOM) patients in this tertiary care hospital in Bangladesh. A total of 117 patients clinically diagnosed of CSOM were enrolled in the study. They had chronic ear discharge & had not received any topical or systemic antibiotics for the previous five days. Swabs was taken and cultured for bacteria. The standard of isolation and identification was followed. Antimicrobial susceptibility of all aerobic bacterial isolates was performed by using modified Kirby Bauer Disk diffusion method. There were 186 positive cultures for organism from 117 patients. The most common causal organisms isolated were S. aureus (47.30%) and Pseudomonas spp. (27.40%) followed by S. epidermidis (16.10%), Klebsiella spp. (8.10%) and Escherichia coli. (1.10%). Gentamicin showed the highest sensitivity (89.8%) to S. aureus whereas erythromycin showed the lowest sensitivity (14.8%) with highest resistance (67%) to S. aureus. Pseudomonas spp. showed highest sensitivity against ciprofloxacin (78.4%) and highest resistance against cloxacillin (96.1%). Novobiocin showed the highest sensitivity (100%) followed by chloram phenicol (94.1%) to S. epidermidis. Klebsiella spp. and E. coli showed highest sensitivity against chloram phenicol. This study suggests that Staphylococcus aureus and Pseudomonas are the commonest bacteria involved in CSOM in Bangladesh and Ciprofloxacin is an important tool in the management of active CSOM.

Tube ileostomy for faecal diversion in elective distal colorectal anastomosis: a systematic review and pooled analysis.

AIM: Tube ileostomy may be an alternative technique to loop ileostomy for protection of distal anastomosis, but its evidence base has not yet been established. This systematic review aims to evaluate the use of tube ileostomy and compare the outcomes associated with it. METHOD: A systematic literature search of MEDLINE, EMBASE, Web of Science and the Cochrane database was conducted. Studies reporting on elective left-sided/colorectal anastomosis were included. Studies which reported on emergent surgery, small bowel anastomosis or tube ileostomy as a bridging procedure were excluded. The intra-operative technique, postoperative management and complications were assessed. Outcome measures included anastomotic leak, reoperation and complications related to the stoma or tube ileostomy. RESULTS: Seven studies met the inclusion criteria. Three were case series with 101 patients and four were nonrandomized comparative studies with 665 patients. Pooled analyses of three comparative studies, comparing tube ileostomy (n = 278) with loop ileostomy (n = 254), revealed no significant differences in anastomotic leak rates (pooled OR 0.85, 95% CI 0.41-1.75; I(2) = 0%, P = 0.43). CONCLUSION: There is a re-emergence of interest in the use of tube ileostomy to defunction a distal anastomosis. Pooled analyses of studies comparing tube ileostomy with loop ileostomy do not show statistically significant differences in anastomotic leak rates. Further refinement of this technique and randomized controlled studies are necessary for this technique to be routinely taken up by surgeons.

Nuclear export and expression of human T-cell leukemia virus type 1 tax/rex mRNA are RxRE/Rex dependent.

Human T-cell leukemia virus type 1 (HTLV-1) is a complex retrovirus associated with the lymphoproliferative disease adult T-cell leukemia/lymphoma (ATL) and the neurodegenerative disorder tropical spastic paraparesis/HTLV-1-associated myelopathy (TSP/HAM). Replication of HTLV-1 is under the control of two major trans-acting proteins, Tax and Rex. Previous studies suggested that Tax activates transcription from the viral long terminal repeat (LTR) through recruitment of cellular CREB and transcriptional coactivators. Other studies reported that Rex acts posttranscriptionally and allows the cytoplasmic export of unspliced or incompletely spliced viral mRNAs carrying gag/pol and env only. As opposed to HIV's Rev-responsive element (RRE), the Rex-responsive element (RxRE) is present in all viral mRNAs in HTLV-1. However, based on indirect observations, it is believed that nuclear export and expression of the doubly spliced tax/rex RNA are Rex independent. In this study, we demonstrate that Rex does stimulate Tax expression, through nuclear-cytoplasmic export of the tax/rex RNA, even though a Rex-independent basal export mechanism exists. This effect was dependent upon the RxRE element and the RNA-binding activity of Rex. In addition, Rex-mediated export of tax/rex RNA was CRM1 dependent and inhibited by leptomycin B treatment. RNA immunoprecipitation (RNA-IP) experiments confirmed Rex binding to the tax/rex RNA in both transfected cells with HTLV-1 molecular clones and HTLV-1-infected T cells. Since both Rex and p30 interact with the tax/rex RNA and with one another, this may offer a temporal and dynamic regulation of HTLV-1 replication. Our results shed light on HTLV-1 replication and reveal a more complex regulatory network than previously anticipated.

Junctures to the therapeutic goal of diabetes mellitus: Experience in a tertiary care hospital of Kolkata.

INTRODUCTION: The World Health Organization has declared India as the "diabetic capital" of the world. In controlling of such chronic, mostly asymptomatic disease, patients' role can't be overemphasized. AIMS: To assess the level of compliance to anti-diabetic therapies and to ascertain the determinants of non-compliance, if any. MATERIALS AND METHODS: A cross-sectional observational study was conducted for 3 months in a diabetic clinic of R G Kar Medical College and Hospital, Kolkata. Data were collected by interviewing the patients, examining their prescriptions and laboratory reports and anthropometry after obtaining informed consent. RESULTS: Blood report at the point of data collection revealed controlled glucose homeostasis in 38.93% patients but evaluation of past 3 months report showed only 24.3% had control over hyperglycemia. Glycemic control was seen to be positively related to short duration of disease, compliance to therapies, and high knowledge about diabetes. Compliance to therapies found in 32.22% of study subjects was in turn associated with short duration of disease. House-wives showed poor compliance; insulin treatment with or without oral-anti-diabetic agent showed better compliance. Knowledge of diabetes was significantly high among higher educated; poor among women, house-wives, and rural people. CONCLUSION: Patient-providers collaboration is to be developed through a patient-centered care model based on the mutual responsibility of both so that each patient is considered in the mesh of his/her other goals of life and helped to promote empowerment to take informed decision for behavioral change conducive to control the disease.

Transabdominal impalement: absence of visceral or vascular injury a rare possibility.

BACKGROUND: Abdominal impalement injuries are usually associated with visceral and vascular injury, causing significant morbidity and mortality. The management of these injuries poses specific challenges in prehospital care, transport, and management strategies. OBJECTIVE: We report a case of transabdominal impalement with no injury to intra-abdominal visceral or vascular structures, demonstrating a chance occurrence. The literature regarding abdominal impalement injury is reviewed and the management of these injuries is discussed. CASE REPORT: A 35-year-old man with a transabdominal impalement injury after an accidental fall from a tree on to a wooden fence was brought to the Accident and Emergency Department. The wooden fence piece was impaled and in situ. Laparotomy revealed no intra-abdominal visceral or vascular injury. CONCLUSION: Transabdominal impalement injuries pose peculiar challenges in prehospital care, transport to hospital, and management. Operative intervention is required in all cases for a conclusive and safe management, as the possibility of escaping intra-abdominal injury is very rare.

An evaluation of the referral transport system of Patna, Bihar.

OBJECTIVES: The key objective of the study was to evaluate the coverage and functioning of the referral transport system under NRHM in block PHCs of district Patna in Bihar. METHODS: A cross-sectional descriptive study was conducted during October-November, 2008 in 16 block PHCs in Patna. In-depth interviews were conducted at 811 households where there was an occasion to transfer a patient to a hospital in the previous two months time. Medical officer in-charge and civil surgeon of the district were also interviewed. Besides, focus group discussions were conducted with the community members and leaders regarding the functioning of referral transport. RESULTS: Availability of the referral transport services was irregular mainly due to deputation of the vehicles for flood relief activities or other purposes. 93 (11.5%) of respondents used the PHC transport facilities, of which 52.7% got it instantaneously. 'Dial an ambulance 102' services were mainly used by urban clients. The system was following an arbitrary cost structure. 84.2% of the clients belonging to below poverty line had to pay for the service and are afraid of availing the services. CONCLUSION: Inadequate number of ambulances in PHCs, unequipped ambulances, lack of life saving equipments, 24 hours duty by single driver, arbitrary cost frame work and urban preference for services were some of the factors leading to unpopularity of the scheme.

An assessment of institutional deliveries under JSY at different levels of health care in Jaipur District, Rajasthan.

BACKGROUND & OBJECTIVE: Janani Suraksha Yojana (JSY) has been implemented in the country to enhance institutional deliveries. This study assess the gaps in delivery services and utilization of resources at Basic and Comprehensive Emergency Obstetric Care Centers (BEmOCs, & CEmOCs), accredited sub centers and private hospitals in district Jaipur, Rajasthan. METHODS: The study was undertaken during October-December 2008 in 31 selected health facilities (5 CEmOCs, 4 BEmOCs, 14 accredited subcentres and 8 accredited private hospitals) in district Jaipur. Both primary and secondary data was collected using qualitative and quantitative techniques, by facility survey, interview of service providers (specialists, medical officers, and paramedical staff) and beneficiaries. RESULTS: There is an increase in institutional deliveries following implementation of JSY. Though the normal deliveries were conducted 24 hours by the BEmOCs and CEmOCs however the necessary drugs like parental antibiotics, mesoprostol, magsulf etc were in short supply and use of partograph was absent at the health facilities. The quality of emergency obstetric care services was still poor due to the lack of blood storage units and anesthetists in CEmOCs. Private accredited hospitals fared better as they had the manpower and managed more complicated cases as compared to government facilities, for caesarean sections. The accredited sub centers were nonfunctional negating the very objective of accreditation. Community is still unaware of the 24 hour stay post delivery and provision of grievance redressal system. CONCLUSION: The quality aspects of institutional deliveries are far from desired level mostly because of lack of resources, both manpower and materials; non achievement of IPHS standards etc. The service quality related to antenatal, intranatal and postnatal care need to be improved. The JSY is perceived as an effective scheme by the beneficiaries but gaps in resources and lack of quality of services needs to be adequately dealt with.

An assessment of performance based incentive system for ASHA Sahyogini in Udaipur, Rajasthan.

OBJECTIVES: To assess the performance based incentive system for ASHA Sahyogini in Udaipur district of Rajasthan. METHODS: This cross-sectional study was conducted in three blocks (one each from rural, urban and tribal area) of Udaipur district during October-December 2008. From each block 60 ASHAs were selected randomly, thus a tola of 180 ASHAs were included. Besides interviewing the ASHAs, focus group discussions were also conducted for primary data collection. The study assessed the performance based incentives system to ASHAs during the last six months. RESULTS: The study revealed that almost 50% ASHA's in the studied blocks were covering population ranging from 1000-1500. All the ASHA has good coordination with local community and they are participating in community meetings regularly. All the ASHAs received incentives for the cases of sterilization; 55.5 percent urban, 85.7 percent rural and 82.7% tribal ASHAs received it on the same day when sterilization was done. Half of the urban, 35% of the rural and 56.7% of tribal ASHAs got incentive less than Rs. 250 in last 6 months (less than 50/- per month). Common cause identified for dissatisfaction was less incentives compared to their work, especially for the ASHA working in tribal areas. CONCLUSION: Timely release of incentives, adequate cooperation from staff such as ANMs, AWW, hospital staff and improved community awareness are needed for better performance of ASHAs.

Perception regarding quality of services in urban ICDS blocks in Delhi.

The good quality of the services is an important determinant for acceptance of a programme in a community. It not only enhances the credibility of a worker at the ground level but also generate the demand for the services. In this paper perception for the quality of the services was assessed through the exit interview of the beneficiaries at the Anganwadi centres (AWCs). 200 beneficiaries were included from 20 AWCs in a period of one and half month. 52.5% respondents were dissatisfied for the services provided from the AWC for one or more reason. The most common reason mentioned was the not easy accessibility of the AWC and less space available at the AWC (68.6%), followed by the poor quality of the food distributed (66.7%) and irregular pre school education (57.1%) from AWCs.

Glomerular basement membrane thickness in normal adults and its application to the diagnosis of thin basement membrane disease: an Indian study.

Microscopic hematuria of non-urologic origin warrants ultrastructural study of renal biopsy. Thinning and variations in the texture of glomerular basement membrane (GBM) are difficult to be recognized under light microscope; transmission electron microscope (TEM) therefore plays a vital role in identifying such changes. Ultrastructural morphometry is a valuable diagnostic aid when GBM is suspected of being abnormally thin. In an effort to determine the normal GBM thickness (GBMT) in Indian adults and to determine the cutoff value of GBMT for a diagnosis of thin basement membrane disease (TBMD), we determined GBM thickness in 25 normal adults. Postmortem biopsies of 25 normal adults (16 males and 9 females) aging between 18-58 years were included in the study. GBM thickness was determined through ultrastructural morphometry on accurately enlarged electron micrographs as harmonic mean of 50 orthogonal intercepts across the GBM in each case. Study revealed a mean GBM thickness of 321 nm with a standard deviation (SD) of 28 nm. Mean-2SD (321-56), that is 265 nm, was fixed as cutoff value of GBMT for the diagnosis of TBMD. A systematic split study of control subjects revealed thicker GBM (329+/-38 nm) in higher age group (35-60 years) as compared to GBMT (316+/-21 nm) in lower age group (18-30 years). Males in higher age group also revealed thicker GBM (males: 343+/-39 nm versus females: 300+/-12 nm). Ten patients with non-urologic hematuria and having GBMT<265 nm were diagnosed as cases of TBMD. Patients with TBMD revealed significantly attenuated GBM as compared to age and sex matched controls (214 +/- 40 nm versus 311 +/- 17 nm; p<0.0005). No overlap was observed in the distribution of GBMT in patients of TBMD and age and sex matched controls. Ultrastructural morphometry is the ultimate and appropriate method for diagnosing TBMD.

Incidence of lamivudine resistance associated mutations in pol-gene of HIV-1 in patients from north India: a preliminary report.

Screening of drug-resistant variants is very important for the effective clinical management of HIV-infected patients and development of new strategies. The present study was aimed to detect codon-184 mutations in the pol-gene of HIV leading to resistance to lamivudine (3-TC) by nested cum ARMS-PCR approach in 10 treated and 9 treatment naive patients. For correlation the whole blood CD4/CD8 cell counts and the soluble TNFRII levels in plasma were also determined. Of the 19 patients tested, mutant variants were observed in 2 patients (Met Val in one and Met Val & lle in second) both being treated with 3-TC. No mutations were detected in the treatment-naive patients. The results confirmed that, drug resistant variants of codon-184 emerge rapidly in patients receiving 3-TC containing regimens including our population, which is mainly infected with subtypeC of the virus that could be detected along with wild viral population using sensitive approaches such as ARMS-PCR.

Cellular and serological markers of disease activity in Indian patients with HIV/AIDS.

There has been an exponential rise of HIV positive patients as observed at the surveillance center of Nehru Hospital. Most patients are poor and cannot afford repeated viral load assays. Therefore, there is a need to identify cost effective and reliable surrogate markers of disease activity. In the present study absolute number of CD4 cells, beta2 micro-globulin, circulating nucleosomes were studied in 30 patients of AIDS, 30 seropositives and 30 healthy controls. In addition viral load, P-24 assay, and TNFR-II assays were done in seropositive and AIDS patients. The mean CD4 cells in patients with AIDS were 69.66 +/- 68.25 mm3 while in seropositives values was 370 +/- 201.29 mm3. The mean CD4 cells in healthy controls were however 690 +/- 198 mm3. The differences in all the groups were highly significant (p<0.001). The mean CD4 values in Indians are significantly lower than reported from the west. The lower number of CD4 cells in healthy population is interpreted to be due to immune activation. The CD8 cell number in controls was 650 +/- 207 mm3 this figure is also higher than that observed in the west. P-24 assay failed to delineate between seropositives and patients with AIDS. Although, beta2 microglobulin levels were significantly higher in AIDS than in seropositives and higher in seropositives than in controls yet with the best possible cut off, it had a sensitivity of only 70% in delineating the two conditions. The correlation between CD4 cells and viral load was more significant when the CD4 cells were below 200 mm3. Five out of 30 patients with a CD4 of 300-600 mm3 had a viral load of over 1 x 10(5) cop/ml. The difference in TNF R-II levels between seropositives and AIDS was however more impressive. With a cut off of 550 pg/ml it had a sensitivity of 95% in delineating HIV from AIDS. It is concluded that a combination of absolute number of CD4 cells and TNF R-II assay along with clinical evaluation may be used to monitor therapy in resource poor countries where frequent viral load assay is unaffordable.

Effect of heat stress on gastro-intestinal motility in young albino rats.

Motility of the gastrointestinal tract was studied by barium meal technique in control and heat exposed young and adult albino rats. As compared to the controls, the gastric emptying and the intestinal transit were significantly increased in heat exposed young rats, while in vivo intestinal absorption of D-glucose and L-proline was significantly decreased in heat exposed young rats. The rapid transit of meal through small intestine in heat exposed young rats could be responsible for decreased absorptive capacity of small intestine by reducing the exposure time for nutrients.

Antimicrobial effect of protein(s) isolated from a marine mollusc Telescopium telescopium.

Ammonium sulfate precipitated protein (SF-50) isolated from the spermatheca gland of Telescopium telescopium, an invertebrate marine snail, showed antimicrobial effect on Escherichia coli. The antimicrobial effect varied with the concentration of "SF-50" used and the effect was found to be comparable to antibiotics like amikacin, contrimoxazole and gentamycin in disc diffusion test. The "SF-50" was devoid of erythrocyte haemolysis property.

The prevalence of the arcuate artery: a cadaveric study of 72 feet.

The purpose of this study was to quantify the occurrence of the arcuate artery. The arcuate artery was defined as that artery branching off the dorsalis pedis artery at or below the level of the tarsometatarsal joint, tending laterally across the bases of metatarsals 2 through 4, and supplying dorsal metatarsal arteries 2 through 4. The arcuate artery was present in 16.7% of 72 cadaver feet that were dissected and examined, suggesting that the arcuate artery is not the primary blood supply to dorsal metatarsal arteries 2 through 4 as is commonly described. It was determined that the lateral tarsal artery supplied dorsal metatarsal arteries 2 through 4 more frequently (47.2%) than the arcuate artery. The proximal perforating arteries as well as various combinations of all three sources were also found to contribute complete blood supply to dorsal metatarsal arteries 2 through 4. Therefore, a consistent dorsal arterial network, which differentiates throughout development, better explains the blood supply of the dorsal forefoot than the arcuate artery.

Immune functions in splenectomized thalassaemic children.

A prospective study to assess the immune functions in splenectomized thalassaemic children. Children were those registered in the Thalassemia major. There were 10 splenectomized children (Group 1), 10 non-splenectomized children and 6 age-matched control (Group 3). All children were shown to be HIV seronegative. The mean concentrations of serum IgG and IgA were higher in Group 1 as compared to Groups 2 and 3 but the differences were not statistically significant. Nitroblue tetrazolium (NBT) dye reduction by stimulated polymorphonuclear leukocytes was normal in both study and control groups and the differences were not statistically significant. However, NBT reduction in the unstimulated state was much higher in Group 2 as compared to Groups 1 and 3. Phytohaemagglutinin induced mitogen proliferation was normal in all 3 groups. Children in Group 1 not only had a significantly higher absolute lymphocyte count but also had a lower CD4/CD8 ratio as compared to Groups 2 and 3. Splenectomy does appear to alter the immune status of thalassemic children but the exact mechanism by which this occurrence is not clear.

Characterization of the regulatory region of the human testis-specific form of the pyruvate dehydrogenase alpha-subunit (PDHA-2) gene.

The alpha-subunit of human pyruvate dehydrogenase (E(1)) is encoded by two separate genes. The gene located on chromosome X (PDHA-1) is expressed in somatic tissues, whereas the second gene (PDHA-2), located on chromosome 4, is expressed only in post-meiotic spermatogenic cells. A genomic fragment harboring the human gene encoding PDHA-2 has been isolated and approximately 800 nucleotides of the promoter region have been characterized. Functional studies of the promoter indicate the presence of both enhancer and repressor elements that are common to other genes that are only expressed in mature sperm.

Genetic correlation in otosclerosis.

PURPOSE: The aim of this study was to determine the relationship of HLA typing in patients with otosclerosis. MATERIALS AND METHODS: We used a prospective study in which HLA typing of 100 surgically confirmed otosclerosis patients were compared with age and sex matched normal individuals. RESULTS: HLA-A3, HLA-A9, HLA-A11, and HLA-B13 were found to be significantly higher (P < .05, .01, and .01, respectively). HLA-A9 and HLA-A11 were found to be higher (P < .01) in patients with a positive family history, indicating genetic heterogenicity. CONCLUSIONS: Higher values of HLA-A9, HLA-11, and HLA-B13 in patients with otosclerosis compared with normal individuals strongly suggests a genetic, HLA-related component.