Preoperative assessment and optimisation for pelvic exenteration in locally advanced and recurrent rectal cancer: A review.

The pre-operative phase in planning a pelvic exenteration or extended resections is critical to optimising patient outcomes. This review summarises the key components of preoperative assessment and planning in patients with locally advanced rectal cancer (LARC) and locally recurrent rectal cancer (LLRC) being considered for potential curative resection. The preoperative period can be considered in 5 key phases: 1) Multidisciplinary meeting (MDT) review and recommendation for neoadjuvant therapy and surgery, 2) Anaesthetic preoperative assessment of fitness for surgery and quantification of risk, 3) Shared decision making with the patient and the process of informed consent, 4) Prehabilitation and physiological optimisation 5) Technical aspects of surgical planning. This review will focus on patients who have been recommended for surgery by the MDT and have completed neoadjuvant therapy. Other important considerations beyond the scope of this review are the various neoadjuvant strategies employed which in this patient group include Total Neo-adjuvant Therapy and reirradiation. Critical to improving perioperative outcomes is the dual aim of achieving a negative resection margin in a patient fit enough for extended surgery. Advanced, realistic communication is required pre-operatively and should be maintained throughout recovery. Optimising patient's physiological and psychological reserve with a preoperative prehabilitation programme is important, with physiotherapy, psychological and nutritional input. From a surgical perspective, image based technical preoperative planning is important to identify risk points and ensure correct surgical strategy. Careful attention to the entire patient journey through these 5 preoperative phases can optimise outcomes with the accumulation of marginal gains at multiple timepoints.

Role of IL-17 gene polymorphism in Indian kala-azar.

BACKGROUND & OBJECTIVES: Visceral leishmaniasis or kala-azar is a fatal protozoan disease caused by an obligate intracellular parasite, Leishmania donovani. Susceptibility, establishment of infection and severity of this disease depend upon many factors, but it is the host immune system that plays decisive role in disease progression. Keeping this view into consideration, we investigated the probable relationship between polymorphisms rs2275913 and rs8193036 in IL-17 gene, and its association as a risk factor for kala-azar in an endemic population of Assam, India. METHODS: A total of 209 subjects, 76 kala-azar cases (male: 46, female: 30, mean age ± SD: 34.60 ± 12.61) and 133 controls (male: 66, female: 67, mean age ± SD: 33.35 ± 14.48) were included in this study. We analysed the polymorphisms, rs2275913 and rs8193036 by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) technique. The data were analysed using logistic regression analysis and SPSS software. RESULTS: The results revealed that the mutant rs8193036 TT genotype conferred 4.7-fold higher risk for kala-azar (p = 0.00991, OR = 4.72, 95% CI = 1.330-16.911). A significant difference was found between the allele frequencies of rs8193036 (p = 0.029, OR = 1.64, 95% CI = 1.04-2.57) when comparisons were done using the genetic models of association. When stratification analysis was done on the basis of active and past cases we found that during active infection rs2275913 A allele was significantly associated with increased risk of kala-azar (p = 0.016, OR = 3.95, 95% CI = 1.21-12.87). INTERPRETATION & CONCLUSION: The findings revealed that IL-17 genetic variant, rs8193036 is an independent risk factor for kala-azar infection and may contribute in pathogenesis of the disease. Further, rs2275913 polymorphism of IL-17 gene is associated with kala-azar during active infection.

The clinical significance of a pathologically positive lymph node at the circumferential resection margin in rectal cancer.

BACKGROUND: This study aimed to determine if the nature of circumferential resection margin (CRM) involvement, either by tumour or lymph nodes, had an impact upon local recurrence and survival in rectal cancer. METHODS: A retrospective analysis of a prospectively collected database was performed. Consecutive patients with stage I-III rectal cancer having curative surgery were included. All specimens were analysed by a single histopathologist. Statistical analysis was performed using chi-squared test and Kaplan-Meier. RESULTS: Of 265 patients, 29 (11%) had a positive CRM. Compared to patients with a negative CRM, a positive margin due to tumour was associated with a higher 5-year cumulative incidence of local recurrence (43.7% versus 8.8%, p = 0.001) and distant metastases (62% versus 13.6%, p = 0.001) with poorer 5-year cancer-specific survival (32% versus 87.8%, p = 0.001). Although patients with margin positivity due to lymph nodes had a higher rate of distant metastases (41.3% versus 13.6%, p = 0.004) and poorer 5-year cancer-specific survival (59.3% versus 87.8%, p = 0.038), the rate of local recurrence was comparable to that of patients with negative margins (8.3% versus 8.8%, p = 0.694). CONCLUSIONS: Our findings suggest that the nature of CRM involvement may be important in determining prognosis in rectal cancer. Local recurrence is higher only when there is tumour present at the margin. Lymph node involvement of the margin confers similar risk of local recurrence to patients with CRM-negative, node-positive disease. These results need further evaluation in multicentre, prospective studies.

Role of IL-21 in host pathogenesis in experimental visceral leishmaniasis.

Visceral leishmaniasis (VL) is a major global health problem but still remains one of the neglected tropical diseases. Currently available chemotherapeutics are associated with severe toxicity and increased drug resistance. There is a need to explore for novel therapeutic strategies that could modulate host immune responses or work in synergy with chemotherapy of VL. Therefore, understanding the host immunological changes that play a vital role in disease pathology is a prerequisite for designing any interventions. We have investigated the role of IL-21 during the course of Leishmania donovani infection and after drug treatment. BALB/c mice were used to investigate the mRNA levels of IL-21 during active Leishmania donovani infection and after treatment using real time polymerase chain reaction (RT-PCR). Mice were divided in four groups i.e. Control (Group A), Infected (Group B), Uninfected treated (Group C) and Infected treated (Group D). Animals of Group C and D were treated with Amphotericin B. IL-21 mRNA levels in the spleen were estimated on days 1, 3, 7, 14, 17, 21, 28, 35, 45 and 60 post infection and also during course of treatment. We found that IL-21 mRNA levels was significantly up-regulated in the infected group with a fourfold increase at D60 p.i. (p < 0.001) and it was decreased significantly after the treatment. Our results suggest that IL-21 mRNA is associated with pathogenesis of Leishmania donovani infection and that therapeutics designed to suppress IL-21 could provide promising antileishmanial activity.

Report of Amblyomma testudinarium in mithuns (Bos frontalis) from eastern Mizoram (India).

Physical examination of semi-domesticated, free ranging mithuns (Bos frontalis) during an animal health check-up and treatment camp organized at Khuwangleng village in the Champhai district of Mizoram, India and adjacent to Myanmar Border revealed presence of unusually large blood engorged ticks attaching to the dewlap and inner aspects of thighs. On the basis of morphological study, the ticks were found indistinguishable from female Amblyomma testudinarium. Prevalence rate of the tick species in mithuns living in the forests was 9.09 % which was recorded as the highest of all reports made earlier from the North Eastern region of India. Medical and veterinary significance of the tick is discussed in the light of available literature.

Gastrointestinal nematode larvae in the grazing land of cattle in Guwahati, Assam.

AIM: To know the prevalence of gastrointestinal nematode larvae (L3) in the grazing land of cattle in Guwahati, Kamrup district, Assam. MATERIALS AND METHODS: Pastures were collected and examined for the presence of nematode larvae (L3) from six localities of Guwahati at monthly interval from August 2012 to July 2013. The counted larvae were then expressed as per kg dry matter of herbage (L3/kg DM). RESULTS: Examination of pastures revealed presence of nematode larvae (L3) in pastures throughout the year which varied from 4.5 L3/kg DM in January to a maximum of 106.33 L3/kg DM in August. The L3 of Haemonchus contortus, Trichostrongylus spp., Oesophagostomum spp., Cooperia spp., and Mecistocirrus spp. were recovered from pastures. The average pasture larval burden (PLB) was 34.75±3.48 L3/kg DM. Season-wise PLB revealed the presence of 23.89±3.01, 67.54±5.41, 26.67±1.92, and 7.28±0.89 L3/kg DM during pre-monsoon, monsoon, post-monsoon, and winter seasons, respectively. Monsoon season has significant (p<0.05) effect on PLB. However, analysis of variance of different locations with respect to season revealed that there was no significant difference but season-wise it was highly significant (p<0.01). Pearson correlation of environmental variables (temperature, relative humidity, and rainfall) with PLB revealed correlation was statistically significant with rainfall (p<0.05). CONCLUSION: This study reveals the presence of five nematode larvae (L3) in the pastures of Guwahati, Assam throughout the year, statistically significant during monsoon season.

Prevalence of lymphatic filariasis in a tea garden worker population of Dibrugarh (Assam), India after six rounds of mass drug administration.

BACKGROUND & OBJECTIVES: Lymphatic filariasis (LF) is endemic in the state of Assam and mass drug administration (MDA) programme for LF elimination is being implemented in the state since 2004. A study on prevalence of microfilaria (mf), disease endemicity and vector infection was carried out in a tea garden population of Dibrugarh, Assam (India) to assess the effect of ongoing MDA programme on elimination of LF. METHODS: Finger prick thick blood smears (20 mm3) were made from individuals aged ≥2 yr old during night blood survey in between 2000-0000 hrs during the period of November 2012 to February 2013. Blood smears were dehaemoglobinised, stained with Giemsa and examined under microscope for presence of mf. Indoor resting mosquitoes were collected during 0600-1000 hrs and female Culex quinquefasciatus were dissected and examined under microscope for larval forms of the parasite. RESULTS: A total of 634 blood smears were collected and screened for mf and 47 (7.41%) individuals were found microfilaraemic, with predominance of males (74.5%). Highest mf rate (20.0%) was seen in the males of 30-39 yr age group while in females, age group of 10-19 yr recorded maximum mf rate (5.48%). Entomological collection and dissection of Cx. quinquefasciatus revealed presence of larval stages of the parasite and infection and infectivity rates recorded were 13.20 and 3.70%, respectively. Chronic clinical manifestations in the form of elephantiasis and hydrocele were recorded in 33 (5.73%) subjects of the 575 examined. INTERPRETATION & CONCLUSION: Mass drug administration data showed six rounds of MDA with drug distribution coverage in between 63.42 and 95.93% in the study population. Out of 634 individuals examined 47 were found microfilaraemic giving an overall infection rate of 7.41%. Mosquito vector infection and infectivity rates were 13.20 and 3.70%, respectively. Presence of high mf rate, vector infectivity rate and clinical cases in the study population after six rounds of MDA warrants concerted efforts to be made for effective implementation and monitoring of MDA for success of LF elimination programme.

Microfilarial periodicity of Wuchereria bancrofti in Assam, Northeast India.

BACKGROUND & OBJECTIVES: Wuchereria bancrofti has shown nocturnal periodicity in India and other endemic countries of the world except pacific regions where non-periodic or diurnal sub-periodic forms have been reported. Presence of sub-periodic form of W. bancrofti in Andaman and Nicobar Islands, India and a case report of sub- periodic form of W. bancrofti from Mysore, India provide basis for exploring the periodicity pattern of microfilaria of W. bancrofti prevalent in Assam, Northeastern region of India. State of Assam has unique geographical location as its Northeastern region shares international boundaries with Nepal, China, Bhutan, Myanmar and Bangladesh. Evolutionary association of W. bancrofti found in Assam is not known and possibility of its link with W. bancrofti form, prevalent in neighbouring countries may not be ruled out. Hence, this study was undertaken to know the microfilarial periodicity of W. bancrofti in Assam. METHODS: Ten microfilaria positive adult male individuals having moderate to high microfilaraemia were selected. Informed written consent from each participant was obtained. The presence of microfilaria was observed at two hourly intervals over a period of 24 h using 50 µl of finger prick peripheral blood samples. Peripheral blood smears were processed, stained and examined under microscope and microfilaria counts were recorded. RESULTS: Data collected were calculated and analyzed using modified statistical method, and the periodicity curve was prepared. Typical nocturnal periodicity was observed at a peak time of 0003 hrs with a periodicity index of 136.2. INTERPRETATION & CONCLUSION: Analysis of the data revealed nocturnal periodicity of the W. bancrofti prevalent in the Assam with peak periodicity about one hour ahead of the other states in India. Findings will be helpful in evaluation and monitoring of ongoing MDA programme for elimination of LF in Assam.

Diversity of Eimeria spp. in dairy cattle of Guwahati, Assam, India.

AIM: To determine the prevalence and diversity of Eimeria spp. in dairy cattle present in and around Guwahati, Kamrup district, Assam, India. MATERIALS AND METHODS: A total of 2339 fecal samples of calves (535), heifer (641) and adult (1163) cattle were screened for 1 year present in and around Guwahati, Assam for detection of Eimeria oocysts by flotation techniques. Sporulation of the oocyst was done in 2.5% potassium dichromate solution for identification of the Eimeria species. RESULTS: Examination of fecal samples revealed an overall prevalence of 11.97% Eimeria infection in dairy cattle of Guwahati, Assam. Age-wise, 33.2%, 45.4%, and 21.4% infections were recorded in calves (<1 year), heifer (1-3 years) and adult (>3 years) cattle, respectively. Season-wise, infection was recorded highest during post-monsoon (16.29%), followed by monsoon (15%), winter (9.44%), and pre-monsoon (7.49%) season. Seven species of Eimeria were recorded viz. Eimeria bovis, Eimeria zuernii, Eimeria subspherica, Eimeria bukidnonensis, Eimeria auburnensis, Eimeria ellipsoidalis and Eimeria alabamensis. The oocyst count per gram of feces ranged from 50 to 1500 in infected cattle. CONCLUSION: This study indicates that there is the prevalence of seven species of Eimeria in dairy cattle of Guwahati, Assam and mostly prevalent during the post-monsoon season.

Babesia infection in naturally exposed pet dogs from a north-eastern state (Assam) of India: detection by microscopy and polymerase chain reaction.

The objective of the study was to detect Babesia infections in pet dogs of a north-eastern state of India. The diagnostic efficacy of Babesia infection by polymerase chain reaction (PCR) technique has been compared with microscopy examination. For this, a total of 111 blood samples of pet dogs presented at clinical complex of the College of Veterinary Science, Guwahati, Assam with clinical signs suspected for Babesia infection subjected to the study. A total of 44 (39.63 %) dogs were diagnosed as positive for Babesia infections after microscopic examination. Among these, Babesia canis infection was diagnosed in 5 dogs (4.50 %) and B. gibsoni infection in 39 (35.13 %) dogs microscopically in Giemsa stained blood smears. Molecular diagnosis using PCR detected 63 (56.75 %) dogs positive for Babesia infection. Single infection with B. canis was found in 9 (8.10 %) dogs while B. gibsoni alone was detected in 3 (2.70 %) dogs. Mixed infections by both these species were detected in 51 (45.94 %) dogs. Overall, PCR detected 54 (48.64 %) dogs as B. gibsoni and 60 (54.05 %) dogs as B. canis positive.

Human consumption of rumen flukes of cattle in India.

The practice of eating rumen flukes of cattle by a section of people living in Meghalaya, a north eastern State of India, is reported in this communication. Economically backward, some rural people belonging to Khasi, Jaintia, Garo, and Karbi tribes of Christian and Nepali communities who eat beef are accustomed to consuming cooked flukes during breakfast, meals, and also along with rice beer or alcohol. Inspection of the rumens of cattle during slaughter indicated a prevalence of flukes belonging to Cotylophoron, Paramphistomum, Calicophoron, Gastrothylax, and Fischoederius genera in 74% cases, and their collection from rumen ranged approximately from 50 g to 600 g. Biochemical analysis of flukes found 12.60% total protein, 0.78% fat, and 0.87% ash on fresh weight basis. High prevalence of flukes, easy visualization in rumen, their bulk collection, presence of nutritive value, absence of any ill effect, and lack of imminent danger of transmissibility are believed to be the rationales influencing their consumption by people. It is suggested that dietary benefits obtained from flukes might contribute to the energy transfer and inclusion in the food web.

Psychological well-being and morbidity in parents of narcotic-dependant males.

In the description of parental psychopathology in narcotic dependence, emphasis has hitherto largely lain on the identification of addictogenic characteristics rather than on the identification of psychological distress. In an attempt to remedy the situation, we compared the parents of 21 male narcotic dependant patients with an equal number of matched controls. Using the General Health Questionnaire and the Subjective Well Being Inventory, we found the 'narcotic parents' experienced more (clinically significant) psychological discuss than did controls, and that this impairment was greater in 'narcotic mothers' than in their husbands. This distress was an ostensible result of having to cope with the burden of a narcotic dependant offspring. In view of these findings, and considering the poor prognosis associated with this diagnosis, we suggest' that management programmes for narcotic dependence include psychotherapeutic intervention directed towards reducing distress experienced by the parents. Possible lines for such intervention are suggested.