Caveats of Local Fasciocutaneous Flaps for Distal Leg Defects-Anatomical Study and Clinical Application.

The present trend for the management of distal leg defects is to opt for a free flap with local flaps being relegated to the backseat. We studied the perforator anatomy of the distal leg in the Indian population to see if there were any ethnic differences and then correlated it with a clinical study of local flaps used for the coverage of distal leg defects. A prospective observational study was carried out in 2 phases-anatomical study and clinical study from December 2018 to March 2020. In the anatomical study, 8 fresh cadavers, i.e., 16 lower limbs were dissected and the perforator anatomy in the distal leg was identified. In the clinical study, all patients undergoing local, pedicled fasciocutaneous flap cover for defects involving distal third leg were included with ages between 15 and 60 years. In the anatomical study, posterior tibial artery perforators in the distal-most part were found as a group of up to 3 perforators. In the clinical study, a total of 47 patients were included with a mean age of 38.0 ± 10.9 (range 17-55) years and female:male ratio being 1:2.6. The largest defect size was 120 cm2 (mean 28.2 ± 23.8 [range 6-120] cm2) and the most commonly used flap was the reverse sural artery flap in 20 (42.6%) cases. Overall, complications were seen in 7 (14.9%) cases and there was no case of flap failure. Thus, local flaps are an excellent option for coverage of distal leg defects and offer results comparable to free flaps.

Coverage of childhood vaccination among children aged 12-23 months, Tamil Nadu, 2015, India.

BACKGROUND & OBJECTIVES: District-Level Household Survey-4 (DLHS-4) indicated that during 2012-2013, only 56 per cent of children aged 12-23 months in Tamil Nadu were fully vaccinated, which were lesser than those reported in earlier national surveys. We, therefore, conducted cluster surveys to estimate coverage of childhood vaccination in the State, and also to identify the factors associated with low coverage. METHODS: Cross-sectional surveys were conducted in 15 strata [municipal corporation non-slum (n=1), municipal corporation slum (n=1), hilly (n=1), rural (n=6) and urban (n=6)]. From each stratum, 30 clusters were selected using probability proportional to the population size linear systematic sampling; seven children aged 12-23 months were selected from each cluster and their mothers/care-takers were interviewed to collect information about vaccination status of the child. A child was considered fully vaccinated if he/she received bacillus Calmette-Guérin (BCG), three doses of pentavalent, three doses of oral polio vaccine and one dose of measles vaccine, and appropriately vaccinated if all vaccine doses were given at right age and with right interval. Further, coverage of fully vaccinated children (FVC) as per vaccination cards or mothers' recall, validated coverage of FVC (V-FVC) among those having cards, and coverage of appropriately vaccinated children (AVC) were estimated using survey data analysis module with appropriate sampling weights. RESULTS: A total of 3150 children were surveyed, of them 2528 (80.3%) had vaccination card. The weighted coverage of FVC, V-FVC and AVC in the State was 79.9 per cent [95% confidence interval (CI): 78.2-81.5], 78.8 per cent (95% CI: 76.9-80.5) and 69.7 per cent (95% CI: 67.7-71.7), respectively. The coverage of individual vaccine ranged between 84 per cent (measles) and 99.8 per cent (BCG). About 12 per cent V-FVC were not vaccinated as per the vaccination schedule. INTERPRETATION & CONCLUSIONS: The coverage of FVC in Tamil Nadu was high, with about 80 per cent children completing primary vaccination. Efforts to increase vaccination coverage in the State need to focus on educating vaccinators about the need to adhere to the national vaccination schedule and strengthening supervision to ensure that children are vaccinated appropriately.

Single stage management of Gustilo type III A/B tibia fractures: Fixed with nail & covered with fasciocutaneous flap.

PURPOSE: To evaluate the role of immediate and definitive management of Gustilo type III A/B tibia fractures with intramedullary nailing and fasciocutaneous flap. METHODS: From August 2010 to July 2012, 22 patients with Gustilo Grade III A/B tibia fractures were managed with a single stage treatment of ipsilateral fasciocutaneous flap & reamed intramedullary nailing and were included in the study. The severity of the injury was calculated with Ganga Hospital injury severity score. RESULTS: The mean age of patients was 41 years and the follow-up time ranged from six months to one year. Among the 22 patients, 73% were type III B fractures with upper leg involved in 55% of them. The time interval from injury to completion of surgery was 8-14 h. The incidence of bone infection requiring secondary procedure was 9%; the major and minor soft tissue complication rate was 9% and 14% respectively. The limb salvage rate was 100%. CONCLUSION: Multidisciplinary management of severe lower limb trauma is important and provides good outcomes. Intramedullary nailing and immediate flap fixation can achieve early bone union and good soft tissue coverage, leading to good outcomes in patient with Grade III A & B tibia fractures.

Epidemiology of Soil-Transmitted Helminth Infections among Primary School Children in the States of Chhattisgarh, Telangana, and Tripura, India, 2015-2016.

Soil-transmitted helminth (STH) infections are highly prevalent in many developing countries, affecting the poorest and most deprived communities. We conducted school-based surveys among children studying in first to fifth standard in government schools in the Indian States of Chhattisgarh, Telangana, and Tripura to estimate the prevalence and intensity of STH infections during November 2015 and January 2016. We adopted a two-stage cluster sampling design, with a random selection of districts within each agro-climatic zone in the first stage. In the second stage, government primary schools were selected by probability proportional to size method from the selected districts. We collected information about demographic details, water, sanitation, and hygiene (WASH) characteristics and stool samples from the school children. Stool samples were tested using Kato-Katz method. Stool samples from 3,313 school children (Chhattisgarh: 1,442, Telangana: 1,443, and Tripura: 428) were examined. The overall prevalence of any STH infection was 80.2% (95% confidence interval [CI]: 73.3-85.7) in Chhattisgarh, 60.7% (95% CI: 53.8-67.2) in Telangana, and 59.8% (95% CI: 49.0-69.7) in Tripura. Ascaris lumbricoides was the most prevalent STH infection in all three states. Most of the STH infections were of light intensity. Our study findings indicate that STH infections were highly prevalent among the school children in Chhattisgarh, Telangana, and Tripura, indicating the need for strengthening STH control program in these states. The prevalence estimates from the survey would serve as a baseline for documenting the impact of the National Deworming Day programs in these states.

Assessment of the scale, coverage and outcomes of the Avahan HIV prevention program for female sex workers in Tamil Nadu, India: is there evidence of an effect?

BACKGROUND: Avahan, the India AIDS Initiative, a large-scale HIV prevention program, using peer-mediated approaches and STI services, was implemented for high-risk groups for HIV in six states in India. This paper describes the assessment of the program among female sex workers (FSWs) in the southern state of Tamil Nadu. METHODS: An analytical framework based on the Avahan impact evaluation design was used. Routine program monitoring data, two rounds of cross-sectional biological and behavioural surveys among FSWs in 2006 (Round 1) and 2009 (Round 2) and quality assessments of clinical services for sexually transmitted infections (STIs) were used to assess trends in coverage, condom use and prevalence of STIs, HIV and their association with program exposure. Logistic regression analysis was used to examine trends in intermediate outcomes and their associations with intervention exposure. RESULTS: The Avahan program in Tamil Nadu was scaled up and achieved monthly reported coverage of 79% within four years of implementation. The cross-sectional survey data showed an increasing proportion of FSWs being reached by Avahan, 54% in Round 1 and 86% in Round 2 [AOR=4.7;p=0.001]. Quality assessments of STI clinical services showed consistent improvement in quality scores (3.0 in 2005 to 4.5 in 2008). Condom distribution by the program rose to cover all estimated commercial sex acts. Reported consistent condom use increased between Round 1 and Round 2 with occasional (72% to 93%; AOR=5.5; p=0.001) and regular clients (68% to 89%; AOR=4.3; p=0.001) while reactive syphilis serology declined significantly (9.7% to 2.2% AOR=0.2; p=0.001). HIV prevalence remained stable at 6.1% between rounds. There was a strong association between Avahan exposure and consistent condom use with commercial clients; however no association was seen with declines in STIs. CONCLUSIONS: The Avahan program in Tamil Nadu achieved high coverage of FSWs, resulting in outcomes of improved condom use, declining syphilis and stabilizing HIV prevalence. These expected outcomes following the program logic model and declining HIV prevalence among general population groups suggest potential impact of high risk group interventions on HIV epidemic in Tamil Nadu.

Does the morbidity management and disability prevention (MMDP) clinic serve the filarial lymphedema (FLE) patients' preeminent expectation?

Advocacy and training on "Home care" for filarial lymphoedma (FLE) patients are provided through morbidity management and disability prevention (MMDP) clinic commonly known as filariasis clinic and clinical improvement is assessed by follow-up visits. While the physicians aim at reducing the recurrent ADL (coined as ADLA in 1997) episodes, the patients expect reduction in LE volume. The objective of the present study was to know whether the MMDP clinic serves the primary expectation of the FLE patients. LE patients who attended the clinic for at least four follow-up consultations and had LE volume measurements at three points of time during the one year period of observation were considered for analysis. Clinical assessment was done for LE grading and LE volume was measured by water displacement volumetry. Sixty-three patients who fulfilled the follow up criteria were included. It was observed that the median LE volume was 914ml (IQR 269 - 1935) at first visit of the observation period which reduced to 645ml (IQR 215- 1666) and 752ml (IQR 215 - 1720) at first and second follow-up visits respectively. Over all, in short span of one year, 21 of the 63 patients (33.3%) who visited MMDP clinic at least four times in a year were benefitted through the MMDP advocacy and the National filariasis control programme need to emphasise on the importance of follow up visits to FLE patients.

High prevalence of soil-transmitted helminth infections among primary school children, Uttar Pradesh, India, 2015.

BACKGROUND: Soil-transmitted helminth (STH) infections often affect the poorest and most deprived communities. In order to generate reliable data for planning a school based deworming program, we conducted a survey among primary school children studying in government schools in the Indian state of Uttar Pradesh. The objectives of our survey were to estimate the prevalence and intensity of STH infections. METHODS: We conducted a cross-sectional survey among children studying in 130 primary schools from 9 agro-climatic zones, during May - August 2015. Information about socio-demographic details, defecation and hand-hygiene practices, and stool samples were collected from the school children. Stool samples were examined using the Kato-Katz method. RESULTS: Stool samples from 6421 school children were examined. The overall weighted prevalence of any STH in the State was 75.6% (95% CI: 71.2-79.5). The prevalence was more than 50% in six of the nine agro-climatic zones. A. lumbricoides was the most prevalent STH (prevalence: 69.6%), followed by hookworm (prevalence: 22.6%) and T. trichura (4.6%). The majority of the STH infections were of low intensity. The practice of open defecation and not washing hands with soap after defecation and residence in kutcha house were significant risk factors of STH infection. CONCLUSIONS: STH prevalence among primary school children in Uttar Pradesh was high. Given the WHO guidelines on deworming frequency according to STH prevalence, Govt of Uttar Pradesh needs to implement a school-based deworming program with bi-annual frequency. The findings of our survey would also help monitor the performance of school based deworming programme.

Lot quality assurance sampling (LQAS) for monitoring leprosy elimination in an endemic district in Tamilnadu.

This paper examines whether the health administration can use lot quality assurance sampling (LQAS) for identifying high prevalence areas for leprosy for initiating necessary corrective measures. The null hypothesis was that leprosy prevalence in the district was at or above ten per 10,000 and the alternative hypothesis was that it was at or below five per 10,000. A total of 25,500 individuals were to be examined with 17 as an acceptable maximum number of cases (critical value). Two-stage cluster sample design was adopted. The sample size need not be escalated as the estimated design effect was 1. During the first phase, the survey covered a population of 4,837 individuals out of whom 4,329 (89.5%) were examined. Thirty-five cases were detected and this number far exceeded the critical value. It was concluded that leprosy prevalence in the district should be regarded as having prevalence of more than ten per 10,000 and further examination of the population in the sample was discontinued. LQAS may be used as a tool by which one can identify high prevalence districts and target them for necessary strengthening of the programme. It may also be considered for certifying elimination achievement for a given area.

Synthesis, crystal growth and physical characterizations of organic nonlinear optical crystal: Ammonium hydrogen L-malate.

An organic nonlinear optical crystal ammonium hydrogen l-malate (AHM) has been synthesized. Single crystals of AHM have successfully been grown by the slow evaporation solution method. Optically clear single crystals having dimensions up to 23×9×4mm(3) have been grown. Single crystal X-ray diffraction study confirms that the AHM crystallizes in orthorhombic crystal system with space group P212121. The powder X-ray diffraction pattern of the grown crystal has been recorded. FT-IR spectrum was recorded to identify the various functional groups of AHM. The UV-vis-NIR transmission was analyzed for grown crystal. Thermal analysis was performed to find out thermal stability of the compound. Vickers microhardness measurements were carried and also work hardening coefficient has been found. The crystalline perfection of the grown crystal has been analyzed by HRXRD measurements. The second harmonic efficiency of AHM was found to be 1.2 times that of KDP.

Perception of HIV testing among attendees at an STD clinic in India.

This study reports perception of STD clinic attendees of Government General hospital, Chennai, India towards free HIV testing. All STD clinic attendees who were eligible for the study (511), from January to April 2001 formed the study subjects. In all, 362 (71%) subjects responded to the question on perception of risk in getting HIV/AIDS. Among them 36% perceived that they were at risk of getting infected with HIV. There was a significant difference (P=0.01) between the genders, as more males perceived risk of getting HIV than females and, with the increase in number of sexual partners in a lifetime there was an increasing trend (p<0.0001) in the perception of risk. There were 244 (55%) subjects willing for HIV testing. A significant difference between the genders (p<0.0001) was observed, as more females were willing to accept free HIV testing than males. When adjusting the effect of co-variates such as gender, age, marital status and perception of risk in getting HIV, persons having two or more sexual partners in their life time were four times more willing to be HIV tested than persons with one sexual partner (OR=4; p=0.001). The findings in this study will help optimize HIV testing in at risk patient populations in India.