Comparison of the analgesic efficacy of two different fascial blocks in patients undergoing laparoscopic inguinal hernia surgery: A randomized control trial.

Background and Aims: Moderate-to-severe intensity pain is reported on the first day following lower abdominal surgery. No study has compared transversus abdominis plane (TAP) block with retrolaminar block (RLB) in laparoscopic inguinal hernia surgery for postoperative pain relief. Material and Methods: In this prospective, randomized trial, 42 male patients of American Society of Anesthesiologists (ASA) physical status I and II, aged 18-65 years, and having a BMI <40 kg/m2 received TAP or RLB following laparoscopic inguinal hernia surgery. A standard general anesthetic technique was performed. Patients were randomized into two groups: single-shot TAP block (group I) (n = 21) or the RLB (group II) (n = 21) with bilateral 20 ml of 0.375% ropivacaine. Postoperatively, IV paracetamol 1 g was administered as rescue analgesia. Postoperative cumulative Visual Analogue Scale (VAS) score 24 hours after surgery was considered as the primary outcome. Results: Postoperative cumulative VAS score at rest at 24 h, represented as mean ± S.D (95% CI), in the TAP block group was 3.54 ± 3.04 (2.16-4.93) and in the RLB group was 6.09 ± 4.83 (3.89-8.29). P value was 0.112 and VAS on movement was 7.95 ± 3.41 (6.39-9.50 [2.5-15.0]) in TAP block group, whereas P value was 0.110 and VAS on movement was 10.83 ± 5.51 (8.32-13.34) in the RLB group. Conclusion: Similar postoperative cumulative pain score on movement at 24 h was present in patients receiving TAP block or RLB. However, VAS score at rest and on movement was reduced in patients receiving TAP block at 18 and 24 h postoperatively.

Pharmacovigilance Study of Anticancer Drugs in a Tertiary Care Teaching Hospital in North India: A Retrospective Study.

INTRODUCTION: Anticancer agents are responsible for a majority of adverse drug reactions (ADRs) in cancer patients. ADR reporting with anticancer drugs is very rare in India due to the lack of awareness and knowledge about the Pharmacovigilance Programme of India. Hence, this study was done to assess the pattern of ADRs with anticancer agents in cancer patients and to increase awareness about ADR monitoring among healthcare professionals. MATERIALS AND METHODS: This is an observational, retrospective and non-interventional study conducted in an ADR monitoring centre (AMC) in Govt. Guru Gobind Singh Medical College and Hospital, Faridkot, Punjab, North India. Voluntarily reported ADR forms with anticancer drugs as suspected drugs over a period of seven years from January 2016 to December 2022 were analyzed. Various parameters were analyzed, which include demographic details of the patients, type of ADR, department reporting ADR and suspected drug. Causality assessment, severity assessment and preventability assessment were done according to the World Health Organization Uppsala Monitoring Centre (WHO-UMC) scale, modified Hartwig and Siegel scale and modified Schumock and Thornton scale, respectively. RESULTS: The maximum numbers of ADRs were reported in the age group of 41-60 years (68.29%) and in females (59.75%). The maximum number of ADRs was reported with the use of taxanes (docetaxel and paclitaxel) (24.39%), targeted drugs (geftinib, imatinib, bortezomib, bevacizumab, rituximab and pazopanib) (24.39%) and platinum co-ordination complexes (cisplatin, oxaliplatin and carboplatin) (17.07%). Majority of the ADRs reported were shivering and ADRs on the skin. Majority of the ADRs were probable (64.70%), mild in nature (85.29%), definitely preventable (45.58%) and probably preventable (45.58%). CONCLUSION: ADR monitoring is needed to increase the outcome of anticancer drug treatment in cancer patients. The quality of treatment in cancer patients can be improved through the timely management of these ADRs. It is a need of the present era to inform healthcare professionals about the Pharmacovigilance Programme to increase the reporting of ADRs due to anticancer drugs.

Dosimetric Comparison of Different Dose Calculation Algorithms in Postmastectomy Breast Cancer Patients Using Conformal Planning Techniques.

Background: The aim of the current study was to compare three different dose-calculating algorithms, i.e., superposition (SP), fast SP (FSP), and convolution (CV), for breast cancer patients treated with intensity-modulated radiotherapy (IMRT) and field-in-Field forward plan IMRT (FiF-FP-IMRT). Materials and Methods: The current retrospective study involved 100 postmastectomy breast cancer patients who were given radiotherapy using IMRT and FiF-FP-IMRT planning techniques. All the initially SP-calculated plans were recalculated with the same monitor units for FSP and CV algorithm without change in any of the other planning parameters. The isodose distribution and various plan evaluating parameters, for example, conformity index (CI), homogeneity index, and uniformity index target volume and normal structure doses were compared and analyzed for all the different algorithm calculated plans. Results: In the IMRT plans, all the target and normal structure dose-volume parameters showed a significant difference between all the three different algorithms with P < 0.05. In the FiF-FP-IMRT plans, CV algorithm showed a significant difference in most of the target and normal structure dose-volume parameters. Among quality indexes, only CI showed a significant difference between all the algorithms in both the planning techniques. R50 showed a significant difference with the CV algorithm in both the planning techniques. Conclusion: The change in the dose calculation algorithm resulted in dosimetric changes which must be evaluated by the medical physicists and oncologists while evaluating treatment plans. In the current study with breast patients, the results obtained for target and normal structure doses using the CV algorithm are overestimated as compared to SP and FSP algorithms, producing variable results in air and bony normal structures. However, the ipsilateral lung V5 parameter and the ipsilateral humeral head mean dose were found to be underestimated by the CV algorithm as compared to the SP and FSP algorithm in both the planning techniques.

Automated Detection and Segmentation of Exudates for the Screening of Background Retinopathy.

Exudate, an asymptomatic yellow deposit on retina, is among the primary characteristics of background diabetic retinopathy. Background diabetic retinopathy is a retinopathy related to high blood sugar levels which slowly affects all the organs of the body. The early detection of exudates aids doctors in screening the patients suffering from background diabetic retinopathy. A computer-aided method proposed in the present work detects and then segments the exudates in the images of retina acquired using a digital fundus camera by (i) gradient method to trace the contour of exudates, (ii) marking the connected candidate pixels to remove false exudates pixels, and (iii) linking the edge pixels for the boundary extraction of exudates. The method is tested on 1307 retinal fundus images with varying characteristics. Six hundred and forty-nine images were acquired from hospital and the remaining 658 from open-source benchmark databases, namely, STARE, DRIVE MESSIDOR, DiaretDB1, and e-Ophtha. The exudates segmentation method proposed in this research work results in the retinal fundus image-based (i) accuracy of 98.04%, (ii) sensitivity of 95.345%, and (iii) specificity of 98.63%. The segmentation results for a number of exudates-based evaluations depict the average (i) accuracy of 95.68%, (ii) sensitivity of 93.44%, and (iii) specificity of 97.22%. The substantial combined performance at image and exudates-based evaluations proves the contribution of the proposed method in mass screening as well as treatment process of background diabetic retinopathy.

Improving the segmentation of digital images by using a modified Otsu's between-class variance.

Image segmentation is a critical stage in the analysis and pre-processing of images. It comprises dividing the pixels according to threshold values into several segments depending on their intensity levels. Selecting the best threshold values is the most challenging task in segmentation. Because of their simplicity, resilience, reduced convergence time, and accuracy, standard multi-level thresholding (MT) approaches are more effective than bi-level thresholding methods. With increasing thresholds, computer complexity grows exponentially. A considerable number of metaheuristics were used to optimize these problems. One of the best image segmentation methods is Otsu's between-class variance. It maximizes the between-class variance to determine image threshold values. In this manuscript, a new modified Otsu function is proposed that hybridizes the concept of Otsu's between class variance and Kapur's entropy. For Kapur's entropy, a threshold value of an image is selected by maximizing the entropy of the object and background pixels. The proposed modified Otsu technique combines the ability to find an optimal threshold that maximizes the overall entropy from Kapur's and the maximum variance value of the different classes from Otsu. The novelty of the proposal is the merging of two methodologies. Clearly, Otsu's variance could be improved since the entropy (Kapur) is a method used to verify the uncertainty of a set of information. This paper applies the proposed technique over a set of images with diverse histograms, which are taken from Berkeley Segmentation Data Set 500 (BSDS500). For the search capability of the segmentation methodology, the Arithmetic Optimization algorithm (AOA), the Hybrid Dragonfly algorithm, and Firefly Algorithm (HDAFA) are employed. The proposed approach is compared with the existing state-of-art objective function of Otsu and Kapur. Qualitative experimental outcomes demonstrate that modified Otsu is highly efficient in terms of performance metrics such as PSNR, mean, threshold values, number of iterations taken to converge, and image segmentation quality.

Primary Cutaneous Mucormycosis: A Necrotising Soft Tissue Infection with Poor Prognosis.

BACKGROUND: Cutaneous mucormycosis is an unusual fungal infection that continues to occur. It needs aggressive surgical debridement and timely administration of antifungals due to its high fatality rate. High clinical suspicion on the part of a surgeon is required to prevent the same. CASE PRESENTATION: We present two cases of cutaneous mucormycosis in which the patients succumbed to death, highlighting the seriousness of the condition. One patient had a lower leg ulcer and was diabetic, and the other patient had a gluteal abscess following an intramuscular injection. Tissue samples grew Rhizopus arrhizus and Apophysomyces sp., respectively. Both patients were treated with amphotericin B, and extensive debridement was performed. DISCUSSION: Cutaneous mucormycosis can be reported in immunocompetent people, and there is a need for early recognition of the entity as a differential diagnosis of any nonhealing necrotic ulcer. CONCLUSION: Proper training and education of technical and clinical staff should be done at peripheral primary and secondary care centres so as not to miss out on cases of mucormycosis and for better prognosis in a cutaneous variety of mucormycosis in surgical patients.

Metapangenomics of wild and cultivated banana microbiome reveals a plethora of host-associated protective functions.

BACKGROUND: Microbiomes are critical to plants, promoting growth, elevating stress tolerance, and expanding the plant's metabolic repertoire with novel defense pathways. However, generally microbiomes within plant tissues, which intimately interact with their hosts, remain poorly characterized. These endospheres have become a focus in banana (Musa spp.)-an important plant for study of microbiome-based disease protection. Banana is important to global food security, while also being critically threatened by pandemic diseases. Domestication and clonal propagation are thought to have depleted protective microbiomes, whereas wild relatives may hold promise for new microbiome-based biological controls. The goal was to compare metapangenomes enriched from 7 Musa genotypes, including wild and cultivated varieties grown in sympatry, to assess the host associations with root and leaf endosphere functional profiles. RESULTS: Density gradients successfully generated culture-free microbial enrichment, dominated by bacteria, with all together 24,325 species or strains distinguished, and 1.7 million metagenomic scaffolds harboring 559,108 predicted gene clusters. About 20% of sequence reads did not match any taxon databases and ~ 62% of gene clusters could not be annotated to function. Most taxa and gene clusters were unshared between Musa genotypes. Root and corm tissues had significantly richer endosphere communities that were significantly different from leaf communities. Agrobacterium and Rhizobium were the most abundant in all samples while Chitinophagia and Actinomycetia were more abundant in roots and Flavobacteria in leaves. At the bacterial strain level, there were > 2000 taxa unique to each of M. acuminata (AAA genotype) and M. balbisiana (B-genotype), with the latter 'wild' relatives having richer taxa and functions. Gene ontology functional enrichment showed core beneficial functions aligned with those of other plants but also many specialized prospective beneficial functions not reported previously. Some gene clusters with plant-protective functions showed signatures of phylosymbiosis, suggesting long-standing associations or heritable microbiomes in Musa. CONCLUSIONS: Metapangenomics revealed key taxa and protective functions that appeared to be driven by genotype, perhaps contributing to host resistance differences. The recovery of rich novel taxa and gene clusters provides a baseline dataset for future experiments in planta or in vivo bacterization or engineering of wild host endophytes.

Real-life temocillin use in Greater Paris area, effectiveness and risk factors for failure in infections caused by ESBL-producing Enterobacterales: a multicentre retrospective study.

Background: Temocillin is a ß-lactam that is not hydrolysed by ESBLs. Objectives: To describe the real-life use of temocillin, to assess its effectiveness in infections caused by ESBL-producing Enterobacterales, and to identify risk factors for treatment failure. Methods: Retrospective multicentric study in eight tertiary care hospitals in the Greater Paris area, including patients who received at least one dose of temocillin for ESBL infections from 1 January to 31 December 2018. Failure was a composite criterion defined within 28 day follow-up by persistence or reappearance of signs of infection, and/or switch to suppressive antibiotic treatment and/or death from infection. A logistic regression with univariable and multivariable analysis was performed to identify risks associated with failure. Results: Data on 130 infection episodes were collected; 113 were due to ESBL-producing Enterobacterales. Mean age was 65.2 ±â€Š15.7 years and 68.1% patients were male. Indications were mostly urinary tract infections (UTIs) (85.8%), bloodstream infections (11.5%), respiratory tract infections (RTIs) (3.5%) and intra-abdominal infections (3.5%). Bacteria involved were Escherichia coli (49.6%), Klebsiella pneumoniae (44.2%) and Enterobacter cloacae (8.8%). Polymicrobial infections occurred in 23.0% of cases. Temocillin was mostly used in monotherapy (102/113, 90.3%). Failure was found in 13.3% of cases. Risk factors for failure in multivariable analysis were: RTI (aOR 23.3, 95% CI 1.5-358.2) and neurological disease (aOR 5.3, 95% CI 1.5-18.6). Conclusions: The main use of temocillin was UTI due to ESBL-producing E. coli and K. pneumoniae, with a favourable clinical outcome. The main risk factor for failure was neurological disease.

Risk factors for leak after omentopexy for duodenal ulcer perforations.

AIMS: Duodenal ulcer perforations are frequently encountered but there is limited literature regarding risk factors for leak after omentopexy. METHODOLOGY: The record of 100 patients of duodenal ulcer perforation undergoing omentopexy by open approach was prospectively maintained to identify any significant factors contributing towards leak. RESULTS: Out of 100 patients undergoing omentopexy, 9 (9%) developed leak; when leak occurred, the mortality was very high (44.4%). Patients who developed leak (09) were compared against those who did not (91), and it was seen that seen that duration of symptoms before surgery (> 3 days), amount of intra-abdominal contamination (> 2 L), low body mass index (BMI < 19.35 kg/m2), serum creatinine (> 1.5 mg/dl), and deranged International Normalized Ratio (INR) were found to be significant on univariate analysis; however, multivariate analysis revealed only low BMI and high creatinine to be contributory towards leak. CONCLUSION: Leak after omentopexy carries a high morbidity and mortality. Identification of risk factors may help in optimizing patients at risk and reduce the incidence of leak and its sequelae. TRIAL REGISTRATION NUMBER: CTRI/2020/03/023798.

Multi-exposure microscopic image fusion-based detail enhancement algorithm.

Traditional microscope imaging techniques are unable to retrieve the complete dynamic range of a diatom species with complex silica-based cell walls and multi-scale patterns. In order to extract details from the diatom, multi-exposure images are captured at variable exposure settings using microscopy techniques. A recent innovation shows that image fusion overcomes the limitations of standard digital cameras to capture details from high dynamic range scene or specimen photographed using microscopy imaging techniques. In this paper, we present a cell-region sensitive exposure fusion (CS-EF) approach to produce well-exposed fused images that can be presented directly on conventional display devices. The ambition is to preserve details in poorly and brightly illuminated regions of 3-D transparent diatom shells. The aforesaid objective is achieved by taking into account local information measures, which select well-exposed regions across input exposures. In addition, a modified histogram equalization is introduced to improve uniformity of input multi-exposure image prior to fusion. Quantitative and qualitative assessment of proposed fusion results reveal better performance than several state-of-the-art algorithms that substantiate the method's validity.

Hypocalcaemia - A rare complication of ileostomy.

Hypocalcaemia is an uncommon complication of ileostomy. We present one such case where significant symptoms only resolved on reversal of the ileostomy.

A Comparative Study Of Concurrent Chemo-Radiotherapy With or Without Neoadjuvant Chemotherapy in Treatment of Locally Advanced Non Small Cell Lung Cancer.

INTRODUCTION: The standard treatment for unresectable stage III non-small-cell lung cancer (NSCLC) is concurrent chemoradiotherapy. This study was undertaken to evaluate whether induction chemotherapy along with concurrent chemoradiotherapy would result in better tumor control, improved symptom control and any variation in toxicity as compared to concurrent chemoradiotherapy alone. PATIENTS AND METHODS: Between February 2015 to September 2016, 25 patients each were randomized to control group, in which they received concurrent chemoradiotherapy with weekly cisplatin 40 mg/m2 intravenous, during chest radiotherapy of 66Gy in 33 fractions for 6.5 weeks, and study group, in which patients received three cycles of induction chemotherapy with Cisplatin 75 mg/m2and Paclitaxel 175 mg/m2administered every 21 days followed by identical chemoradiotherapy. RESULTS: The two groups of patients (with induction vs. without induction chemotherapy) were similar in age, performance status, histology, grade, and stage. At 6thmonth follow-up, complete response was seen in 6 patients in control arm and 7 patients in study arm (?2 = 1.603, p = 0.205) and partial response was seen in 13 and 12 patients in control and study arms respectively (?2 = 1.932, p = 0.165). Symptom control of cough, hemoptysis, chest pain and dyspnoea were also similar in both groups. DISCUSSION: In our study, no difference in treatment outcome with respect to the two groups was observed, which was similar to studies which have been conducted previously. Radiation is a good modality for symptom control of cough, hemoptysis, chest pain and dyspnoea. In toxicities, pneumonitis and hematological toxicity was slightly higher in study group even at 6th month follow up. CONCLUSION: Slight increase in toxicity with no added benefit in locoregional tumor control and symptom regression, was seen in patients receiving induction chemotherapy followed by chemoradiotherapy. Concurrent chemoradiotherapy alone can thus be used as only modality of treatment in unresectable stage III NSCLC.

Peritonitis-associated hyperlactatemia for evaluating mortality in secondary peritonitis.

BACKGROUND: In sepsis, lactate measurements correlate with mortality; however, the role of lactate in predicting mortality in patients of secondary peritonitis is not yet fully established. METHODS: Data were maintained prospectively on 224 patients of secondary peritonitis over a period of 10 years. Arterial lactate measurements were performed twice in each patient - once, initially on admission (ALI ) and the other, 24 h after surgery (AL24 ); from these values, percentage lactate clearance was calculated. These lactate indices and other demographic factors were correlated with mortality. RESULTS: Overall mortality was 16.07% (36 patients) and morbidity was 63.39% (pulmonary complications commonest); preoperative lactate (more than 2.35 mmol/L), 24-h postoperative lactate (more than 2.05 mmol/L), need for vasopressors and mechanical ventilation independently correlated with morbidity and mortality. A simple prognostic scale constructed using cut-off values of ALI , AL24 , need for vasopressor support and mechanical ventilation showed a sensitivity of 97.22% and specificity of 52.13% for predicting mortality. CONCLUSION: Preoperative and postoperative arterial lactate levels, need for vasopressors and mechanical ventilation, are independent predictors of mortality. Using these parameters, it may be possible to identify high risk patients that can benefit from early, goal directed therapy to reduce the mortality of secondary peritonitis.

Mucor as a cause of surgical site infection.

Mucor is an uncommon cause of surgical site infection. We present such a case after intramedullary nailing of the femur and discuss its presentation and management.

Determinants of Mortality in Necrotizing Soft Tissue Infections.

BACKGROUND: Necrotizing soft tissue infections (NSTI) are frequently encountered, with a high mortality despite advances in health care. MATERIAL AND METHODS: Patients presenting with NSTI were prospectively followed up in an attempt to identify factors that were significantly associated with mortality. RESULTS: There were a total of 86 patients [65 males (75.6%) and 21 females (24.4%)] with an overall mortality of 33.7% (29 patients). The average age was 50.37 years and trauma was the commonest aetiology (34 patients, 66.7%). The average duration of symptoms prior to presentation was 10.56 days; the lower limb was most commonly involved (62 patients, 72.09%). Fifty nine patients had comorbidities (commonest being diabetes mellitus in 41). Age above 50 years, symptoms for more than 8.5 days, involved surface area more than 15.5%, of the total body surface, on-admission pulse rate more than 99 beats/minute, systolic blood pressure less than 103 mm Hg, Glasgow scale less than 12, need for inotropes, low hemoglobin, high leukocyte counts, uraemia, deranged coagulation, low serum albumin, and high levels of lactic acid were significant for mortality. On multivariate analysis, only age above 50 years, presence of acidosis and low serum albumin significantly affected survival. CONCLUSION: NSTI carry high mortality. The identification of potential risk factors associated with mortality might help in guiding and optimizing the management of patients who present with NSTI.

Systemic inflammatory response syndrome outcome in surgical patients.

INTRODUCTION: The problems of inflammation and infection as a leading cause of organ dysfunction and failure is a major problem after injury or operations. When systemic inflammatory response syndrome (SIRS) progress to multiple organ failure (MOF), the mortality reach up to 30-80% depending on the number of failed organs. Recent discoveries and improvement in patient care, a reasonable question then arises, are the incidence of MOF decreasing? The literature suggests a decrease in mortality of patients with severe organ failure and a decrease in elective surgical mortality in patients. METHODS: This is prospective study of 50 patients who underwent surgical procedure. They were followed up till date of termination with daily SIRS monitoring, development of MODS and MOF. Risk factors for MOF are addressed. RESULTS: There are total 31 patients who develop SIRS, of whom 7 patients develop severe sepsis and 4 went into MOF. CONCLUSION: Early detection of SIRS helps us to prevent multiple organ dysfunction syndrome (MODS)/MOF, leading to lesser hospital stay and better outcome.