Randomized trial comparing general anesthesia with anesthesiologist-administered deep sedation for ERCP in average-risk patients.

BACKGROUND AND AIMS: General anesthesia (GA) or monitored anesthesia care (MAC) is increasingly used to perform ERCP. The definitive choice between the 2 sedative types remains to be established. This study compared outcomes of GA with MAC in ERCP performed in patients at average risk for sedation-related adverse events (SRAEs). METHODS: At a tertiary referral center, patients with American Society of Anesthesiologists (ASA) class ≤III were randomly assigned to undergo ERCP with MAC or GA. The main outcome was a composite of hypotension, arrhythmia, hypoxia, hypercapnia, apnea, and procedural interruption or termination defined as SRAEs. In addition, ERCP procedural time, success, adverse events, and endoscopist and patient satisfaction were compared. RESULTS: Of 204 randomized, 203 patients were evaluated for SRAEs (MAC, n = 96; GA, n = 107). SRAEs developed in 35% of the MAC cohort (34/96) versus 9% in the GA cohort (10/107), which was statistically significant (P < .001). Mean induction time for GA was significantly longer than that for MAC (10.3 ± 10 minutes vs 6.5 ± 10.8 minutes, respectively; P < .001). ERCP procedure time, recovery time, cannulation time and success, and procedure-related adverse events were not statistically different between the 2 sedative groups. The use of GA improved endoscopist and patient satisfaction (P < .001). CONCLUSION: GA is safe with fewer SRAEs than MAC in patients with ASA scores ≤III undergoing ERCP. Apart from prolonging induction time, use of GA does not change the procedural success or ERCP-related adverse events and offers greater endoscopist and patient satisfaction. Hence, GA is a consideration in patients undergoing ERCP in this population group. (Clinical trial registration number: NCT04099693.).

Robot-assisted vs open radical cystectomy for bladder cancer in adults.

BACKGROUND: It has been suggested that, in comparison with open radical cystectomy (ORC), robot-assisted radical cystectomy (RARC) results in less blood loss, shorter convalescence and fewer complications, with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits. OBJECTIVES: To assess the effects of RARC vs ORC in adults with bladder cancer. SEARCH METHODS: We conducted a comprehensive search, with no restrictions on language of publication or publication status, for randomized controlled trials (RCTs) that compared RARC with ORC. The date of the last search was 1 July 2018. Databases searched included the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We also searched the following trial registers: ClinicalTrials.gov (clinicaltrials.gov/); BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com); and the World Health Organization International Clinical Trials Registry Platform. The review was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (Clavien grade III to V). Secondary outcomes were minor postoperative complications (Clavien grades I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive surgical margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk-of-bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data. RESULTS: We included in the review five RCTs comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively. We found that RARC and ORC may result in a similar time to recurrence (hazard ratio 1.05, 95% confidence interval [CI] 0.77 to 1.43; two trials, low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar rates of major complications (risk ratio [RR] 1.06, 95% CI 0.76 to 1.48; five trials, low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence because of study limitations and imprecision. We were very uncertain whether RARC reduces minor complications (very-low-certainty evidence). We downgraded the certainty of evidence because of study limitations and very serious imprecision. RARC probably results in substantially fewer transfusions than ORC (RR 0.58, 95% CI 0.43 to 0.80; two trials, moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations. RARC may result in a slightly shorter hospital stay than ORC (mean difference -0.67, 95% CI -1.22 to -0.12; five trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in a similar quality of life (standardized mean difference 0.08, 95% CI 0.32 lower to 0.16 higher; three trials, low-certainty evidence). We downgraded the certainty of evidence because of study limitations and imprecision. RARC and ORC may result in similar positive surgical margin rates (RR 1.16, 95% CI 0.56 to 2.40; five trials, low-certainty evidence). This corresponds to eight more (95% CI 21 fewer to 67 more) positive surgical margins per 1000 participants, based on 48 positive surgical margins per 1000 participants for ORC. We downgraded the certainty of evidence because of study limitations and imprecision. CONCLUSIONS: We conclude that RARC and ORC may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive surgical margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very-low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.

Robotic versus open radical cystectomy for bladder cancer in adults.

BACKGROUND: It has been suggested that in comparison with open radical cystectomy, robotic-assisted radical cystectomy results in less blood loss, shorter convalescence, and fewer complications with equivalent short-term oncological and functional outcomes; however, uncertainty remains as to the magnitude of these benefits. OBJECTIVES: To assess the effects of robotic-assisted radical cystectomy versus open radical cystectomy in adults with bladder cancer. SEARCH METHODS: Review authors conducted a comprehensive search with no restrictions on language of publication or publication status for studies comparing open radical cystectomy and robotic-assisted radical cystectomy. The date of the last search was 1 July 2018 for the Cochrane Central Register of Controlled Trials, MEDLINE (1999 to July 2018), PubMed Embase (1999 to July 2018), Web of Science (1999 to July 2018), Cancer Research UK (www.cancerresearchuk.org/), and the Institute of Cancer Research (www.icr.ac.uk/). We searched the following trials registers: ClinicalTrials.gov (clinicaltrials.gov/), BioMed Central International Standard Randomized Controlled Trials Number (ISRCTN) Registry (www.isrctn.com), and the World Health Organization International Clinical Trials Registry Platform. SELECTION CRITERIA: We searched for randomised controlled trials that compared robotic-assisted radical cystectomy (RARC) with open radical cystectomy (ORC). DATA COLLECTION AND ANALYSIS: This study was based on a published protocol. Primary outcomes of the review were recurrence-free survival and major postoperative complications (class III to V). Secondary outcomes were minor postoperative complications (class I and II), transfusion requirement, length of hospital stay (days), quality of life, and positive margins (%). Three review authors independently assessed relevant titles and abstracts of records identified by the literature search to determine which studies should be assessed further. Two review authors assessed risk of bias using the Cochrane risk of bias tool and rated the quality of evidence according to GRADE. We used Review Manager 5 to analyse the data. MAIN RESULTS: We included in the review five randomised controlled trials comprising a total of 541 participants. Total numbers of participants included in the ORC and RARC cohorts were 270 and 271, respectively.Primary outomesTime-to-recurrence: Robotic cystectomy and open cystectomy may result in a similar time to recurrence (hazard ratio (HR) 1.05, 95% confidence interval (CI) 0.77 to 1.43); 2 trials; low-certainty evidence). In absolute terms at 5 years of follow-up, this corresponds to 16 more recurrences per 1000 participants (95% CI 79 fewer to 123 more) with 431 recurrences per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision.Major complications (Clavien grades 3 to 5): Robotic cystectomy and open cystectomy may result in similar rates of major complications (risk ratio (RR) 1.06, 95% CI 0.76 to 1.48); 5 trials; low-certainty evidence). This corresponds to 11 more major complications per 1000 participants (95% CI 44 fewer to 89 more). We downgraded the certainty of evidence for study limitations and imprecision.Secondary outcomesMinor complications (Clavien grades 1 and 2): We are very uncertain whether robotic cystectomy may reduce minor complications (very low-certainty evidence). We downgraded the certainty of evidence for study limitations and for very serious imprecision.Transfusion rate: Robotic cystectomy probably results in substantially fewer transfusions than open cystectomy (RR 0.58, 95% CI 0.43 to 0.80; 2 trials; moderate-certainty evidence). This corresponds to 193 fewer transfusions per 1000 participants (95% CI 262 fewer to 92 fewer) based on 460 transfusion per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations.Hospital stay: Robotic cystectomy may result in a slightly shorter hospital stay than open cystectomy (mean difference (MD) -0.67, 95% CI -1.22 to -0.12); 5 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision.Quality of life: Robotic cystectomy and open cystectomy may result in a similar quality of life (standard mean difference (SMD) 0.08, 95% CI 0.32 lower to 0.16 higher; 3 trials; low-certainty evidence). We downgraded the certainty of evidence for study limitations and imprecision.Positive margin rates: Robotic cystectomy and open cystectomy may result in similar positive margin rates (RR 1.16, 95% CI 0.56 to 2.40; 5 trials; low-certainty evidence). This corresponds to 8 more (95% CI 21 fewer to 67 more) positive margins per 1000 participants based on 48 positive margins per 1000 participants for ORC. We downgraded the certainty of evidence for study limitations and imprecision. AUTHORS' CONCLUSIONS: Robotic cystectomy and open cystectomy may have similar outcomes with regard to time to recurrence, rates of major complications, quality of life, and positive margin rates (all low-certainty evidence). We are very uncertain whether the robotic approach reduces rates of minor complications (very low-certainty evidence), although it probably reduces the risk of blood transfusions substantially (moderate-certainty evidence) and may reduce hospital stay slightly (low-certainty evidence). We were unable to conduct any of the preplanned subgroup analyses to assess the impact of patient age, pathological stage, body habitus, or surgeon expertise on outcomes. This review did not address issues of cost-effectiveness.

The surgeon as educator: fundamentals of faculty training in surgical specialties.

OBJECTIVE: To explore faculty training in the field of surgical specialities with a focus on the educational aspect of faculty training. Teaching is an important commitment for academic surgeons alongside duties of patient care, research and continuing professional development. Educating surgical faculty in the skills of teaching is becoming increasingly important and the realisation that clinical expertise does not necessarily translate to teaching expertise has led to the notion that faculty members require formal training in teaching methods and educational theory to teach effectively. The aim of faculty training or development is to increase knowledge and skills in teaching, research and administration of faculty members. MATERIALS AND METHODS: A range of resources, e.g. journal articles, books and online literature was reviewed to investigate faculty development programmes in surgery. Various issues were addressed, e.g. the need for faculty development, evaluating the various types of training programmes and their outcomes, and exploring barriers to faculty training. Recommendations were provided based on the findings. RESULTS: There is increased recognition that faculty members require basic training in educational theory and teaching skills to teach effectively. Most faculty training programmes are workshops and short courses, which use participant satisfaction as an outcome measure. However, there is growing consensus that longer term interventions, e.g. seminar series, longitudinal programmes and fellowships, produce more sustainable change in learning, behaviour and organisational culture. Barriers to faculty development include lack of protected time, reward and recognition for teaching. CONCLUSION: Recommendations are made including better documentation of faculty training interventions within surgery, further investigation into the effectiveness of long- vs short-term interventions, improved methodology, and increased recognition and reward for educational accomplishments.

Current status of validation for robotic surgery simulators - a systematic review.

To analyse studies validating the effectiveness of robotic surgery simulators. The MEDLINE(®), EMBASE(®) and PsycINFO(®) databases were systematically searched until September 2011. References from retrieved articles were reviewed to broaden the search. The simulator name, training tasks, participant level, training duration and evaluation scoring were extracted from each study. We also extracted data on feasibility, validity, cost-effectiveness, reliability and educational impact. We identified 19 studies investigating simulation options in robotic surgery. There are five different robotic surgery simulation platforms available on the market. In all, 11 studies sought opinion and compared performance between two different groups; 'expert' and 'novice'. Experts ranged in experience from 21-2200 robotic cases. The novice groups consisted of participants with no prior experience on a robotic platform and were often medical students or junior doctors. The Mimic dV-Trainer(®), ProMIS(®), SimSurgery Educational Platform(®) (SEP) and Intuitive systems have shown face, content and construct validity. The Robotic Surgical SimulatorTM system has only been face and content validated. All of the simulators except SEP have shown educational impact. Feasibility and cost-effectiveness of simulation systems was not evaluated in any trial. Virtual reality simulators were shown to be effective training tools for junior trainees. Simulation training holds the greatest potential to be used as an adjunct to traditional training methods to equip the next generation of robotic surgeons with the skills required to operate safely. However, current simulation models have only been validated in small studies. There is no evidence to suggest one type of simulator provides more effective training than any other. More research is needed to validate simulated environments further and investigate the effectiveness of animal and cadaveric training in robotic surgery.

Retrospective Analysis of Characteristics, Indications and Outcomes of Endoscopic Retrograde Cholangiopancreatography (ERCP) in a Tertiary Referral Center in Saudi Arabia.

BACKGROUND:  Endoscopic retrograde cholangiopancreatography (ERCP) is an advanced endoscopic procedure that is an essential tool in the management of pancreaticobiliary diseases. There is limited data available on the indications and outcomes of ERCP from this region. Therefore, we aim to report the characteristics of patients, indications and outcomes of ERCP in Saudi Arabia.  Methods: We retrospectively looked at ERCP procedures done at a tertiary referral center covering the western region of Saudi Arabia from August 2018 until July 2020. Data were collected from the hospital's electronic patient record and endoscopy database. RESULTS:  Of 1001 ERCPs performed, full data was available on 712 procedures on 581 patients that were included in the final analysis. Mean age was 53.1 years. Four hundred four (56.7%) were female. Board-certified consultants performed all ERCPs. The most common intervention was sphincterotomy, which was performed in 563 (96.9%) patients who underwent first-ever ERCP, followed by dilatation and stenting. The commonest indication of ERCP was confirmed or suspected choledocholithiasis (52.6%), followed by replacement or removal of a biliary stent (15.7%), 55 (7.7%) for suspected ascending cholangitis, 54 (7.5%) for acute biliary pancreatitis and 15 (2%) for suspected sphincter of Oddi dysfunction. The commonest finding among all patients was choledocholithiasis in 57.9%, debris in 15.2% and biliary stricture in 14.8%. The commonest complication was pancreatitis in 22 (3.1%) followed by post-sphincterotomy bleeding in 16 (2.2%) and perforation in nine (1.2%). Bleeding was controlled by endoscopic intervention in four (25%) and one (6.2%) patient underwent surgery. One (0.14%) patient had procedure-related mortality secondary to post-procedure pulmonary embolism and one had significant morbidity and prolonged hospitalization because of complicated perforation. The deeper common bile duct (CBD) cannulation rate was 97.3%. CONCLUSION: Our study results revealed that ERCP performed in the western region of Saudi Arabia has similar indications and findings as reported in the international literature. ERCP is successful in achieving the therapeutic objectives with complication rates consistent with published data.

Analysis of Complications After Robot-Assisted Radical Cystectomy Between 2002-2021.

OBJECTIVE: To identify trends in complications following robot-assisted radical cystectomy (RARC) using a multi-institutional database, the International Robotic Cystectomy Consortium (IRCC). METHODS: A retrospective review of the IRCC database was performed (2976 patients, 26 institutions from 11 countries). Postoperative complications were categorized as overall or high grade (≥ Clavien Dindo III) and were further categorized based on type/organ site. Descriptive statistics was used to summarize the data. Multivariate analysis (MVA) was used to identify variables associated with overall and high-grade complications.  Cochran-Armitage trend test was used to describe the trend of complications over time. RESULTS: 1777 (60%) patients developed postoperative complications following RARC, 51% of complications occurred within 30 days of RARC, 19% between 30-90 days, and 30% after 90 days. 835 patients (28%) experienced high-grade complications. Infectious complications (25%) were the most prevalent, while bleeding (1%) was the least. The incidence of complications was stable between 2002-2021. Gastrointestinal and neurologic postoperative complications increased significantly (P < .01, for both) between 2005 and 2020 while thromboembolic (P = .03) and wound complications (P < .01) decreased. On MVA, BMI (OR 1.03, 95%CI 1.01-1.05, P < .01), prior abdominal surgery (OR 1.26, 95%CI 1.03-1.56, P = .03), receipt of neobladder (OR 1.52, 95%CI 1.17-1.99, P < .01), positive nodal disease (OR 1.33, 95%CI 1.05-1.70, P = .02), length of inpatient stay (OR 1.04, 95%CI 1.02-1.05, P < .01) and ICU admission (OR 1.67, 95%CI 1.36-2.06, P < .01) were associated with high-grade complications. CONCLUSION: Overall and high-grade complications after RARC remained stable between 2002-2021. GI and neurologic complications increased, while thromboembolic and wound complications decreased.

Late onset congenital central hypoventilation syndrome after exposure to general anesthesia.

PURPOSE: Prolonged postoperative hypoventilation presents a challenge to anesthesiologists with regard to assessing etiology and related treatment. We present a case of recurrent episodes of postoperative hypoventilation in a previously asymptomatic child after uneventful general anesthesia. In this case, the child eventually required lifelong ventilatory support during sleep. CLINICAL FEATURES: A case of postoperative hypoventilation in a previously asymptomatic six-year-old child was investigated to determine the possible etiology. After uneventful general anesthesia for dental surgery, the child experienced recurrent episodes of hypoventilation associated with sleep. The child's lungs were mechanically ventilated due to failure of all trials of weaning. Clinical examination was unremarkable and laboratory investigations excluded the possibility of thyroid, hepatic, renal, and neuromuscular diseases. Computerized tomography, magnetic resonance imaging, and electroencephalogram studies were within normal limits. A negative pyridostigmine trial ruled out myasthenia. The child was finally diagnosed as having "late onset congenital central hypoventilation syndrome". Genetic testing revealed a PHOX2B mutation consistent with this diagnosis. The child was discharged home on mechanical ventilatory support during sleep. CONCLUSION: Congenital central hypoventilation syndrome is a rare lifelong multisystem disorder which may occur during the neonatal period as a result of severe genetic mutation in the PHOX2B gene. In mild mutations, a triggering factor, such as sedation or anesthesia, may be required for the syndrome to manifest itself. These patients often require lifelong mechanical ventilatory support, particularly during sleep.

Total Pelvic Exenteration for Locally Advanced and Recurrent Rectal Cancer: Urological Outcomes and Adverse Events.

BACKGROUND: Little has been reported on urological complications of total pelvic exenteration (TPE) for locally advanced or recurrent rectal cancer. OBJECTIVE: To assess urological reconstructive outcomes and adverse events in this setting. DESIGN, SETTING, AND PARTICIPANTS: A total of 104 patients underwent TPE from 2004 to 2016 in this single-centre, retrospective study. Electronic and paper records were evaluated for data extraction. Mean follow-up was 36.5 mo. INTERVENTION: TPE. OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS: Urological complications were analysed using two-tailed t and chi-square tests, binary logistic regression analysis. RESULTS AND LIMITATIONS: Sixty-three (61%) patients received radiotherapy prior to TPE. Incontinent diversions included ileal conduit (n = 95), colonic conduits (n = 4), wet colostomy (n = 1), and cutaneous ureterostomy (n = 1). Three patients had a continent diversion. The overall urological complication rate was 54%. According to Clavien-Dindo classification, 30 patients, five patients, and one patient had grade III, IV, and V complications, respectively. The commonest complication was urinary tract infection (in 32 [31%] patients). Anastomotic leaks were seen in 14 (13%) cases, of which eight (8%) were urinary leaks. Fistulas were seen in three (3%) patients, involving the urinary system. A return to theatre was required in 12 (12%) patients. Ureteroenteric strictures were seen in seven (7%). No differences were seen in urological outcomes in patients with primary or recurrent rectal cancer (p = 0.69), or by radiation status (p = 0.24). The main limitation is the retrospective nature of the study. CONCLUSIONS: TPE is complex with recognised high risk of morbidity. In this cohort, there was no significant difference in outcomes between primary and recurrent disease, and surgery after radiation. PATIENT SUMMARY: In this study, we assessed urological complications following total pelvic exenteration. Urinary complications affected more than half of patients. Urinary tract infection is the commonest risk. Approximately one-third of patients required surgical, radiological, or endoscopic intervention ± intensive care admission. Radiation prior to the operation did not affect urinary complications.

Opioid prescribing and risk of drug-opioid interactions in older discharged patients with polypharmacy in Australia.

Background Opioids are commonly prescribed to managing chronic pain in older persons. However, these patients are often at risk of drug-opioid interactions due to polypharmacy. Objectives To identify the prevalence of opioid prescribing and drug-opioid interactions in poly-medicated older patients and factors associated with opioid prescribing. Setting Patients were included if they were admitted to the Royal Adelaide Hospital between September 2015 and August 2016, aged ≥ 75 years and took ≥ 5 medications at discharge. Methods After ethics approval, data of were retrospectively collected from case notes. The Charlson Comorbidity Index and Drug Burden Index were determined and opioids were classified as strong or weak. The association between opioid use and concurrent medications was computed using logistic regression and the results presented as odds ratios (OR) and 95% confidence intervals (95% CI), adjusted for age, sex, Charlson Comorbidity Index, number of prescribed medications and modified-Drug Burden Index. Main outcome measure Association between concurrent medications and opioid prescribing. Results 15,000 geriatric admissions were identified, of which 1192 were included. A total of 283 (23.7%) patients were prescribed opioids, with oxycodone accounting for 56% of these prescriptions. Opioid users were prescribed more medications (11.2 vs. 9.0, P < 0.001) and had higher Drug Burden Index (1.2 vs. 0.14, P < 0.001) compared to non-users. Opioid use was associated with concurrent prescription of antiepileptics (OR = 1.7, 95% CI 1.1-2.6), and negatively associated with Charlson Comorbidity Index (OR = 0.9, 95% CI 0.8-0.98) and concurrent use of antipsychotics (OR = 0.5, 95% CI 0.3-0.9) and beta blocking agents (OR = 0.4, 95% CI 0.3-0.6). Conclusions Strong opioids were prescribed more often than weak opioids and opioid users presented with characteristics and concurrent medications which increased the risk of opioid related adverse drug effects.

RP-HPLC Estimation of Flavonol Derivatives and Phenolic Acids in Capsicum annuum L. and their Correlation with In Vitro Anti-Inflammatory Activity.

BACKGROUND: Flavonol derivative and phenolic acids derived from the plants function as free radical scavengers, reducing agents, and quenchers for the formation of singlet oxygen. Flavonoids and phenolic constituents also play an important role in various human diseases and disorders primarily through modulation of inflammatory responses. OBJECTIVE: To estimate the Flavonol Derivatives (FD) and phenolic acids (PA) in Capsicum annuum (CA) and other important phytochemicals having an anti-inflammatory effect. METHODS: In the present study, FD and PA were estimated in CA and in vitro anti-inflammatory activity (pilot study) was determined and correlation was established. RESULTS: The results were found to be significant using RP-HPLC. FD and PA were found to be 0.0659±0.0058 and 0.0862±0.0.0134 mg/gram dry weight, respectively. For in vitro anti-inflammatory activity, the inhibition of albumin denaturation and antiproteinase activity was found to be maximum in Quercetin (QE) with 98.230±1.589% and 59.906±1.529%, respectively. Heat-induced hemolysis of erythrocytes was found to be maximum in salicylic acid (SA) (71.830±2.838%). Hypotonicity-induced hemolysis showed significant activity with QE (76.770±3.475%). Lipoxygenase and cyclooxygenase inhibition was found to be maximum in QE with 56.930±4.069% and 61.660±3.135%, respectively. CONCLUSION: A strong positive correlation of 0.9 was observed between the extract of CA and standard QE and SA against the anti-inflammatory activity. Therefore, the role of FD and PA has been postulated to be an active phytochemical of CA accountable for its anti-inflammatory activity. However further work is desirable to fully elucidate the phytochemicals responsible for their anti-inflammatory activity and to develop better herbal drug formulations.

Hexylaminolaevulinate 'blue light' fluorescence cystoscopy in the investigation of clinically unconfirmed positive urine cytology.

OBJECTIVE: To investigate the value of photodynamic diagnosis (PDD) using hexylaminolaevulinate (Hexvix, PhotoCure, Oslo, Norway) in the investigation of patients with positive urine cytology who have no evidence of disease after standard initial investigations. PATIENTS AND METHODS: Twenty-three patients referred with positive urine cytology but no current histological evidence of cancer were investigated between April 2005 and January 2007 with PDD, using Hexvix and the D-light system (Karl Storz, Tuttlingen, Germany) to detect fluorescence. The bladder was mapped initially under white light and then under 'blue-light'. Biopsies were taken from abnormal urothelium detected by white light, fluorescence, or both. All cytological specimens were reviewed by a reference cytopathologist unaware of the result of the PDD. RESULTS: Twenty-five PDD-assisted cystoscopies were carried out on 23 patients (20 men/3 women; median age 64 years, range 24-80 years). Of the 23 patients, 17 (74%) were previously untreated for transitional cell carcinoma (TCC), whilst six were under surveillance for previous TCC. Nineteen of the 23 (83%) cytology specimens were confirmed as suspicious or positive by the reference pathologist. TCC of the bladder or preneoplastic lesions were diagnosed in six patients, i.e. six (26%) of those investigated and six of 19 (32%) with confirmed positive cytology. Four of the six were under surveillance for previous bladder tumour. Additional pathology was detected by fluorescence in five of the six patients, including two carcinoma in situ (CIS), one CIS + G3pT1 tumour, and two dysplasia. Diagnoses in PDD-negative cases included one upper tract TCC and four patients with stones. In addition, one patient had CIS diagnosed on both white light and PDD 6 months later. CONCLUSION: Additional pathology was detected by HAL fluorescence cystoscopy in 32% of patients with confirmed positive urinary cytology. PDD is a key step in the management of patients with positive urinary cytology and no evidence of disease on conventional tests.

Efficacy of Three Types of Plaque Control Methods During Fixed Orthodontic Treatment: A Randomized Controlled Trial.

AIM: The aim of this study was to evaluate and compare the efficacy of three types of plaque control methods among 13- to 35-year-old subjects receiving fixed orthodontic treatment in Coorg Institute of Dental Sciences, Virajpet, Coorg district, Karnataka, India. MATERIALS AND METHODS: A total of 111 subjects who fulfilled the inclusion and exclusion criteria were randomly included in the study. The subjects were recalled after 1 month of the commencement of fixed orthodontic treatment for the recording of baseline data including plaque index (PI), gingival index (GI), and modified papillary bleeding index (MPBI). After recording of the baseline data, the subjects were randomly allocated into each of the intervention groups, i.e., group A (manual tooth brush), group B (powered tooth brush), and group C (manual tooth brush combined with mouthwash) by lottery method. Further, all the subjects were recalled after 1 and 2 months for recording the data. RESULTS: Regarding plaque levels, it was seen that there was a highly statistically significant difference between the three groups (P = 0.001), with the manual tooth brush combined with chlorhexidine mouthwash group recording the lowest mean PI score of 0.5 ± 0.39. A comparison of the mean GI scores among the groups at the end of 2 months shows a highly statistically significant difference (P = 0.001). The mean MPBI scores at the end of 2 months were highly statistically significant among the three groups (P = 0.001), with the group C recording the lowest mean MPBI score of 0.3 ± 0.3. CONCLUSION: The powered tooth brush group subjects exhibited significantly lesser PI, GI, and MPBI scores than the manual tooth brush group at the end of 2 months, whereas the manual tooth brush combined with chlorhexidine mouth wash group subjects showed maximum improvement, having significantly lesser PI and GI scores than the powered tooth brush group.

An over-view of robot assisted surgery curricula and the status of their validation.

INTRODUCTION: Robotic surgery is a rapidly expanding field. Thus far training for robotic techniques has been unstructured and the requirements are variable across various regions. Several projects are currently underway to develop a robotic surgery curriculum and are in various stages of validation. We aimed to outline the structures of available curricula, their process of development, validation status and current utilization. METHODS: We undertook a literature review of papers including the MeSH terms "Robotics" and "Education". When we had an overview of curricula in development, we searched recent conference abstracts to gain up to date information. RESULTS: The main curricula are the FRS, the FSRS, the Canadian BSTC and the ERUS initiative. They are in various stages of validation and offer a mixture of theoretical and practical training, using both physical and simulated models. DISCUSSION: Whilst the FSRS is based on tasks on the RoSS virtual reality simulator, FRS and BSTC are designed for use on simulators and the robot itself. The ERUS curricula benefits from a combination of dry lab, wet lab and virtual reality components, which may allow skills to be more transferable to the OR as tasks are completed in several formats. Finally, the ERUS curricula includes the OR modular training programme as table assistant and console surgeon. CONCLUSION: Curricula are a crucial step in global standardisation of training and certification of surgeons for robotic surgical procedures. Many curricula are in early stages of development and more work is needed in development and validation of these programmes before training can be standardised.

Learning curves for cardiothoracic and vascular surgical procedures--a systematic review.

OBJECTIVES: The aim of this systematic review is to evaluate the learning curve (LC) literature and identify the LC of cardiothoracic and vascular surgical procedures. SUMMARY AND BACKGROUND: The LC describes an observation that a learner's performance improves over time during acquisition of new motor skills. Measuring the LC of surgical procedures has important implications for surgical innovation, education, and patient safety. Numerous studies have investigated LCs of isolated operations in cardiothoracic and vascular surgeries, but a lack of uniformity in the methods and variables used to measure LCs has led to a lack of systematic reviews. METHODS: The MEDLINE®, EMBASE™, and PsycINFO® databases were systematically searched until July 2013. Articles describing LCs for cardiothoracic and vascular procedures were included. The type of procedure, statistical analysis, number of participants, procedure setting, level of participants, outcomes, and LCs were reviewed. RESULTS: A total of 48 studies investigated LCs in cardiothoracic and vascular surgeries. Based on operating time, the LC for coronary artery bypass surgery ranged between 15 and 100 cases; for endoscopic vessel harvesting and other cardiac vessel surgery between 7 and 35 cases; for valvular surgery, which included repair and replacement, between 20 and 135 cases; for video-assisted thoracoscopic surgery, between 15 and 35 cases; for vascular neurosurgical procedures between 100 and 500 cases, based on complications; for endovascular vessel repairs between 5 and 40 cases; and for ablation procedures between 25 and 60 cases. However there was a distinct lack of standardization in the variables/outcome measures used, case selection, prior experience, and supervision of participating surgeons and a range of statistical analyses to compute LCs was noted. CONCLUSION: LCs in cardiothoracic and vascular procedures are hugely variable depending on the procedure type, outcome measures, level of prior experience, and methods/statistics used. Uniformity in methods, variables, and statistical analysis is needed to derive meaningful comparisons of LCs. Acknowledgment and application of learning processes other than those reliant on volume-outcomes relationship will benefit LC research and training of surgeons.

Phospholipids: a novel adjuvant in herbal drug delivery systems.

Phytoconstituents have been used extensively in modern science because of their various pharmacological actions with few side effects. Regardless of their excellent therapeutic activity, several phytoconstituents have shown poor bioavailability in vivo. Phytoconstituents possess properties such as poor lipid solubility, large molecular size, and degradation in the gut due to the acidic environment. Gastric enzymes always limit their use. Phospholipids seem to be a major carrier for plant active molecules, which not only interact with the plant constituents on a molecular level but also protect the active components of the plant from degradation and increase the bioavailability of the active components by imparting lipid solubility to them. Complexation techniques enable researchers to convert the phytophospholipids into various dosage forms, including tablets and capsules. In the cosmetic industry, however, these complexes have acquired wider applicability in the form of gels and emulsions. Complexation of phospholipids with active components of plants improves their bioavailability and is being extensively studied by researchers, and further research in this regard is expected in the future. This review highlights the unique property of phospholipids in drug delivery, their health benefits, and their use in the herbal medicine systems to improve the bioavailability of active herbal components.

Management of ureteropelvic junction obstruction in adults.

Ureteropelvic junction obstruction (UPJO) is characterized by impaired flow of urine from the renal pelvis to the ureter. Untreated disease can result in renal impairment making effective management crucial. A combination of CT imaging and diuretic renography is typically used for diagnosis. CT is the investigation of choice for obtaining anatomical information about UPJO and can help to identify potential causes. Diuretic renography is best for providing functional information about UPJO. A variety of open and minimally invasive surgical techniques are available for treatment of UPJO. Traditionally open pyeloplasty has been the standard of care but minimally invasive surgical techniques have become increasingly popular. Endopyelotomy has a lower success rate than other modalities (42-90% depending on the approach), but is associated with reduced pain and shorter convalescence. Laparoscopic pyeloplasty and robot-assisted pyeloplasty have similar success rates to open pyeloplasty (>90%), with the additional advantages of significantly reduced morbidity and shorter convalescence. More long-term outcome data for minimally invasive surgical techniques are awaited.

Development and evaluation of porous chitosan nanoparticles for treatment of enterotoxigenic Escherichia coil infection.

Enterotoxigenic Escherichia coil (ETEC) infections result in large mortality rate and usually a frequent cause of diarrhea in infants and a major cause of economic losses in the swine industry. To prevent enterotoxigenic Escherichia coli infections animal needs an active mucosal immunity at the moment of weaning. In the present study, F4 loaded porous chitosan nanoparticles were prepared by spray drying method for oral vaccination. In order to prevent the release the antigen in upper GI tract and to release it at target site nanoparticles were coated with Eudragit L100 which protect the antigen against the detrimental effects in the gastro-intestinal tract. Average size of prepared nanoparticles varied between 548 +/- 2.3 to 98 +/- 1.1 nm with a polydispersity index ranging from 0.767 +/- 0.023 to 0.209 +/- 0.021. Zeta potential for prepared nanoparticles was found to be in range from +18.3 +/- 2.5 to +29.5 +/- 2.8 mV. SEM studies completely revealed that the drug loaded nanoparticles were found to be distinct, spherical in shape with pores formed. Practicability of NPs was compared to vaccination with F4 fimbriae in solution. Mucosal immune response study revealed that, immune response were elicited in solution was well as in NPs group but colonization of the small intestine by F4+ ETEC upon oral solution challenge could not be prevented. However animals vaccinated with porous NPs group reveal a significant reduction in excretion of F4+ E. coli. Studies indicate that a solid vaccine formulation will be more efficient as compared to oral solutions. These systems can contribute to the development of oral vaccines in veterinary as well as in human medicines.

Gold nanoparticles: a paradigm shift in biomedical applications.

In the medical field, majority of the active ingredients exists in the form of solid particle (90% of all medicines). Nanotechnology had grabbed the attention of many scientists working in different aspects and gave them a vivid imagination in order to utilize the nanotechnology in an innovative way according to their needs. One of the major applications of nanotechnology is drug delivery through nanoparticles which is on boom for the researchers and gives a challenging environment for the researchers. Among them upcoming challenge is the use of inorganic nanoparticles for the drug delivery and related aspects. There is growing interests in usage of inorganic nanoparticles in medicine due to their size, and unique physical properties that make them different from other nanoparticulate systems. This review will lay special emphasis on the uniqueness of inorganic nanoparticles especially gold nanoparticles as a drug delivery vehicle and moreover will present a wide spread scenario of gold nanoparticles that has been used for treatment of life threatening diseases like cancer.