Minimally invasive surgery and its impact on 30-day postoperative complications, unplanned readmissions and mortality.

BACKGROUND: A critical appraisal of the benefits of minimally invasive surgery (MIS) is needed, but is lacking. This study examined the associations between MIS and 30-day postoperative outcomes including complications graded according to the Clavien-Dindo classification, unplanned readmissions, hospital stay and mortality for five common surgical procedures. METHODS: Patients undergoing appendicectomy, colectomy, inguinal hernia repair, hysterectomy and prostatectomy were identified in the American College of Surgeons National Surgical Quality Improvement Program database. Non-parsimonious propensity score methods were used to construct procedure-specific matched-pair cohorts that reduced baseline differences between patients who underwent MIS and those who did not. Bonferroni correction for multiple comparisons was applied and P < 0·006 was considered significant. RESULTS: Of the 532 287 patients identified, 53·8 per cent underwent MIS. Propensity score matching yielded an overall sample of 327 736 patients (appendicectomy 46 688, colectomy 152 114, inguinal hernia repair 59 066, hysterectomy 59 066, prostatectomy 10 802). Within the procedure-specific matched pairs, MIS was associated with significantly lower odds of Clavien-Dindo grade I-II, III and IV complications (P ≤ 0·004), unplanned readmissions (P < 0·001) and reduced hospital stay (P < 0·001) in four of the five procedures studied, with the exception of inguinal hernia repair. The odds of death were lower in patients undergoing MIS colectomy (P < 0·001), hysterectomy (P = 0·002) and appendicectomy (P = 0·002). CONCLUSION: MIS was associated with significantly fewer 30-day postoperative complications, unplanned readmissions and deaths, as well as shorter hospital stay, in patients undergoing colectomy, prostatectomy, hysterectomy or appendicectomy. No benefits were noted for inguinal hernia repair.

Below the poverty line and non-communicable diseases in Kerala: The Epidemiology of Non-communicable Diseases in Rural Areas (ENDIRA) study.

INTRODUCTION: India carries the greatest burden of global non-communicable diseases (NCDs). Poverty is strongly associated with NCDs but there are few prevalence studies which have measured poverty in India, particularly in rural settings. METHODS: In Kerala, India, a population of 113,462 individuals was identified. The "Epidemiology of Non-communicable Diseases in Rural Areas" (ENDIRA) study was conducted via ASHAs (Accredited Social Health Activists). Standardised questionnaires were used in household interviews of individuals ≥18years during 2012 to gather sociodemographic, lifestyle and medical data for this population. The Government of Kerala definition of "the poverty line" was used. The association between below poverty line (BPL) status, NCDs and risk factors was analysed in multivariable regression models. RESULTS: 84,456 adults were included in the analyses (25.4% below the poverty line). The prevalence of NCDs was relatively common: myocardial infarction (MI) 1.4%, stroke 0.3%, respiratory diseases 5.0%, and cancer 1.1%. BPL status was not associated with age (p=0.96) or gender (p=0.26). Compared with those above the poverty line (APL), the BPL group was less likely to have diabetes, hypertension or dyslipidaemia (p<0.0001), and more likely to smoke (p<0.0001). Compared with APL, BPL was associated with stroke (OR 1.33, 1.04-1.69; p=0.02) and respiratory disease (OR 1.23, 1.15-1.32; p<0.0001) in multivariable analyses, but not MI or cancer. CONCLUSIONS: In rural Kerala, BPL status was associated with stroke and respiratory diseases, but not with MI and cancer although it was associated with smoking status, compared with above poverty line status.

The epidemiology of fractures in adolescents with reference to social deprivation.

A relationship between social deprivation and the incidence of fracture in adolescents has not previously been shown. We have used a complete fracture database to identify adolescents who sustained fractures in 2000. The 2001 Scottish census was used to obtain age-specific population and deprivation data according to the Carstairs score. Regression analysis determined the relationship between the incidence of fractures and social deprivation. We analysed 1574 adolescents with fractures (1083 male, 491 female). The incidence of fractures in this group was 21.8 per thousand (31.0 male, 13.1 female). Social deprivation predicted the incidence in adolescent males and females. The incidence of fractures of the proximal upper limb and distal radius in females was overwhelmingly influenced by socioeconomic factors. Males of 15 to 20 years of age were more likely to sustain fractures of the hand and carpus if they lived in economically depressed neighbourhoods.

Cost comparison of orchiectomy and leuprolide in metastatic prostate cancer.

PURPOSE: We objectively compare the costs associated with the medical and surgical treatment of metastatic prostate cancer. MATERIALS AND METHODS: We analyzed and compared itemized billing statements for 28 men with metastatic adenocarcinoma of the prostate. Half of the men were treated medically with the luteinizing hormone-releasing hormone analogue leuprolide, while the other half underwent bilateral therapeutic orchiectomy. In addition, differences in hospital cost to treat these men were calculated. RESULTS: During a mean followup of 24 months leuprolide treated patients were charged $500.00 per month of treatment compared to average monthly expenditure of $226.00 for orchiectomy patients during a 23-month interval. By 9 months charges incurred by both groups were equal and by 20 months medically treated patients accumulated urological charges twice that of the surgically treated patients. The true hospital cost to treat these patients followed the same trend, that is the medically treated group cost twice as much to treat by 15 months. For the average stage D2 case leuprolide therapy charges were $9,420, or 63%, more than orchiectomy. Similarly, leuprolide cost the hospital $8,924 more than surgery. CONCLUSIONS: Medical management of metastatic prostate cancer is expensive. With broadening applications and androgen deprivation being initiated earlier in the course of disease, the amount spent on medical therapy will continue to escalate. For patients with a life expectancy of more than 9 months orchiectomy is the most cost-effective treatment option.

Coping with global environmental change -- role of science and democracy.

PIP: The world's population increased form about 3 billion in 1960 to 4 billion in 1974, to 5 billion in 1987, and it is projected to grow to 6 billion by 1991 and to 8 billion by 1992. Finite, nonrenewable resources have to satisfy the increased need for sustenance of this population excess in a sustainable economic development mold. Human activity has upset natural processes with negative environmental effects: Minamata disease in Japan caused by heavy metal pollution, global deforestation, and acid rain. The 1972 Conference on Human Environment in Stockholm dealt with industrial pollution. The UN Environment Programme (UNEP) was established subsequently. The theory of global warming caused by emissions of carbon dioxide, methane, nitrogen oxides, and halogens as predicted by a Swedish scientist decades ago is accumulating a body of evidence. The International Geosphere Biosphere Programme (IGBP) of the International Council of Scientific Unions attempt to explore the Earth's physical, chemical, and biological processes to predict global environmental changes. Success mandates data availability. Paleoclimatic evidence indicates previous cataclysms caused by climate change, thus agriculture could be affected massively by global warming. Improved scientific analysis of greenhouse gas emissions and crop simulation models for major agricultural areas are needed. The North-South dialogue in UN forums has been acrimonious without much success, although international cooperation has been fruitful with the adoption of the Montreal Protocol on phasing out ozone-depleting chlorofluorocarbons. Such cooperation is needed on energy consumption and sources.^ieng

An electromyographic method for the assessment of naloxone-induced abstinence in morphine-dependent rats.

The electromyographic (EMG) activities of suprahyoideal muscle were recorded to measure naloxone-precipitated abstinence signs in morphine-dependent rats anesthetized with urethane (1 g/kg). Rats were rendered dependent on morphine by implanting 2 morphine pellets (75 mg each) and abstinence signs were induced by intravenous injections of various doses of naloxone at different times after pellet implantation. Three precipitated abstinence signs, a) myoclonic twitch activity (MTA), b) mastication, and c) body shakes were observed on EMG recordings after the injection of naloxone. Of these symptoms, only the MTA induced by naloxone (10 microgram/kg) occurred 4h after pellet implantation and its sensitivity to naloxone increased with prolonged pellet implantation. Both mastication and precipitated shakes could be induced at 24h. However, higher doses of naloxone were required to produce the shakes than is required to induce mastication. There appears to be a positive correlation between the intensity of naloxone-induced MTA and the degree of physical dependence on morphine. Since the MTA and mastication can be induced by low doses of naloxone in morphine-dependent rats, we suggest that these two parameters may be used to detect morphine abstinence signs in this species.

Tetracycline asthma--a case report.

A mechanic working in the antibiotic capsuling section of a pharmaceutical company developed asthmatic attacks 1 year after starting work. His occupation involved exposure to a variety of chemical agents including tetracycline. He developed immediate weal and flare reaction to the intradermal test and an immediate (type 1) asthmatic response to intradermal, inhalation and oral challenge tests with tetracycline. On leaving the tetracycline plant he became symptom free.