Predictors of Severity of Influenza-Related Hospitalizations: Results From the Global Influenza Hospital Surveillance Network (GIHSN).

BACKGROUND: The Global Influenza Hospital Surveillance Network (GIHSN) has since 2012 provided patient-level data on severe influenza-like-illnesses from >100 participating clinical sites worldwide based on a core protocol and consistent case definitions. METHODS: We used multivariable logistic regression to assess the risk of intensive care unit admission, mechanical ventilation, and in-hospital death among hospitalized patients with influenza and explored the role of patient-level covariates and country income level. RESULTS: The data set included 73 121 patients hospitalized with respiratory illness in 22 countries, including 15 660 with laboratory-confirmed influenza. After adjusting for patient-level covariates we found a 7-fold increase in the risk of influenza-related intensive care unit admission in lower middle-income countries (LMICs), compared with high-income countries (P = .01). The risk of mechanical ventilation and in-hospital death also increased by 4-fold in LMICs, though these differences were not statistically significant. We also find that influenza mortality increased significantly with older age and number of comorbid conditions. Across all severity outcomes studied and after controlling for patient characteristics, infection with influenza A/H1N1pdm09 was more severe than with A/H3N2. CONCLUSIONS: Our study provides new information on influenza severity in underresourced populations, particularly those in LMICs.

Expert opinion on diagnosis and management of Severe Asthma in low and middle income countries (LMIC) with focus on India.

OBJECTIVE: In this document, 9 Indian experts have evaluated the factors specific to LMICs when it came to Severe Asthma (SA) diagnosis, evaluation, biologic selection, non-biologic treatment options, and follow-up. DATA SOURCES: A search was performed using 50 keywords, focusing on the Indian/LMICs perspective, in PubMed, Cochrane Library, and Google Scholar. The key areas of the search were focused on diagnosis, phenoendotyping, non-biological therapies, selecting a biologic, assessment of treatment response, and management of exacerbation. STUDY SELECTIONS: The initial search revealed 1826 articles, from these case reports, observational studies, cohort studies, non-English language papers, etc., were excluded and we short-listed 20 articles for each area. Five relevant articles were selected by the experts for review. RESULTS: In LMICs, SA patients may be referred to the specialist for evaluation a little late for Phenoendotyping of SA. While biologic therapy is now a standard of care, pulmonologists in LMICs may not have access to all the investigations to phenoendotype SA patients like fractional exhaled nitric oxide (FeNO), skin prick test (SPT), etc., but phenotyping of SA patients can also be done with simple blood investigations, eosinophil count and serum immunoglobulin E (IgE). Choosing a biologic in the overlapping phenotype of SA and ACO patients is also a challenge in the LMICs. CONCLUSIONS: Given the limitations of LMIC, it is important to select the right patient and explain the potential benefits of biological therapy. Non-biologic add-on therapies can be attempted in a resource-limited setting where biological therapy is not available/feasible for patients.

Prevalence of dementia in India: National and state estimates from a nationwide study.

INTRODUCTION: Prior estimates of dementia prevalence in India were based on samples from selected communities, inadequately representing the national and state populations. METHODS: From the Longitudinal Aging Study in India (LASI) we recruited a sample of adults ages 60+ and administered a rich battery of neuropsychological tests and an informant interview in 2018 through 2020. We obtained a clinical consensus rating of dementia status for a subsample (N = 2528), fitted a logistic model for dementia status on this subsample, and then imputed dementia status for all other LASI respondents aged 60+ (N = 28,949). RESULTS: The estimated dementia prevalence for adults ages 60+ in India is 7.4%, with significant age and education gradients, sex and urban/rural differences, and cross-state variation. DISCUSSION: An estimated 8.8 million Indians older than 60 years have dementia. The burden of dementia cases is unevenly distributed across states and subpopulations and may therefore require different levels of local planning and support. HIGHLIGHTS: The estimated dementia prevalence for adults ages 60+ in India is 7.4%. About 8.8 million Indians older than 60 years live with dementia. Dementia is more prevalent among females than males and in rural than urban areas. Significant cross-state variation exists in dementia prevalence.

Prevalence and Population-Attributable Risk for Chronic Airflow Obstruction in a Large Multinational Study.

Rationale: The Global Burden of Disease program identified smoking and ambient and household air pollution as the main drivers of death and disability from chronic obstructive pulmonary disease (COPD). Objectives: To estimate the attributable risk of chronic airflow obstruction (CAO), a quantifiable characteristic of COPD, due to several risk factors. Methods: The Burden of Obstructive Lung Disease study is a cross-sectional study of adults, aged ≥40, in a globally distributed sample of 41 urban and rural sites. Based on data from 28,459 participants, we estimated the prevalence of CAO, defined as a postbronchodilator FEV1-to-FVC ratio less than the lower limit of normal, and the relative risks associated with different risk factors. Local relative risks were estimated using a Bayesian hierarchical model borrowing information from across sites. From these relative risks and the prevalence of risk factors, we estimated local population attributable risks. Measurements and Main Results: The mean prevalence of CAO was 11.2% in men and 8.6% in women. The mean population attributable risk for smoking was 5.1% in men and 2.2% in women. The next most influential risk factors were poor education levels, working in a dusty job for ≥10 years, low body mass index, and a history of tuberculosis. The risk of CAO attributable to the different risk factors varied across sites. Conclusions: Although smoking remains the most important risk factor for CAO, in some areas, poor education, low body mass index, and passive smoking are of greater importance. Dusty occupations and tuberculosis are important risk factors at some sites.

A tailored approach to abdominoperineal resection for rectal cancer: multicentre analysis of short-term outcomes and impact on oncological survival.

PURPOSE: Abdominoperineal resection of the rectum has evolved over the last century, with few modifications until 2007, when extralevator abdominoperineal resection was introduced, which improved local disease control but resulted in a significant rise in perineal complications. We adopted a modified approach in which dissection was tailored according to magnetic resonance-defined tumour involvement. The aim of this study was to assess short-term and long-term oncological outcomes following a tailored abdominoperineal resection (APR) approach. METHODS: This study was a retrospective review of prospectively maintained databases at three centres: Portsmouth NHS Trust (UK), Poole General Hospital (UK) and Champalimaud's Cancer Foundation, Portugal. The study included consecutive patients who underwent abdominoperineal resection from October 2008 until April 2018 under the supervision of the senior author. Oncological outcomes, including overall survival and disease-free survival, were used as the main outcome measures. RESULTS: A total of 584 patients underwent rectal cancer surgery during the study period. The APR ratio was 65/584 (11%). The median age was 66 years. Neoadjuvant treatment was administered to 74% of patients. Of the patients, 91% underwent surgery via a minimally invasive approach. The median hospital stay was 7 days. Patients were followed up for a median of 41 months. Only four patients had positive resection margins. The 5-year overall and disease-free survival rates were 64% and 62%, respectively. CONCLUSION: Our data suggest that tailored APR has similar short-term and long-term oncological outcomes compared with extralevator abdominoperineal resection but reduced perineal wound complications. We believe this approach could be a safe alternative but recommend a larger sample size to accurately assess its effectiveness.

Trends in Incidence, and Mortality of Acute Exacerbation of Chronic Obstructive Pulmonary Disease in the United States Emergency Department (2010-2018).

Literature regarding trends of incidence, mortality, and complications of acute exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency departments (ED) is limited. What are trends of COPD exacerbation in ED? Data were obtained from the Nationwide Emergency Department Sample (NEDS) that constitutes a 20% sample of hospital-owned EDs and inpatient sample in the US. All ED encounters were included in the analysis. Complications of AECOPD were obtained by using ICD codes. Out of 1.082 billion ED encounters, 5,295,408 (mean age 63.31 ± 12.63 years, females 55%) presented with COPD exacerbation. Among these patients, 353,563(6.7%) had AECOPD-plus (features of pulmonary embolism, acute heart failure and/or pneumonia) while 4,941,845 (93.3%) had exacerbation without associated features or precipitating factors which we grouped as AECOPD. The AECOPD-plus group was associated with statistically significantly higher proportion of cardiovascular complications including AF (5.6% vs 3.5%; p < 0.001), VT/VF (0.14% vs 0.06%; p < 0.001), STEMI (0.22% vs 0.11%; p < 0.001) and NSTEMI (0.65% vs 0.2%; p < 0.001). The in-hospital mortality rates were greater in the AECOPD-plus population (0.7% vs 0.1%; p < 0.001). The incidence of both AECOPD and AECOPD-plus had worsened (p-trend 0.004 and 0.0003) and the trend of mortality had improved (p-trend 0.0055 and 0.003, respectively). The prevalence of smoking for among all COPD patients had increased (p-value 0.004), however, the prevalence trend of smoking among AECOPD groups was static over the years 2010-2018. There was an increasing trend of COPD exacerbation in conjunction with smoking; however, mortality trends improved significantly. Moreover, the rising burden of AECOPD would suggest improvement in diagnostics and policy making regarding management.

Adipose-Derived Stem Cells (ADSCs) Loaded Gelatin-Sericin-Laminin Cryogels for Tissue Regeneration in Diabetic Wounds.

Healing in wounds like pressure ulcers, diabetic ulcers, venous ulcers, and arterial insufficiency ulcers is immensely hampered and causes both an economic burden and morbidity to patients. These wounds face a plethora of hostile conditions like elevated reactive oxygen species (ROS), impaired angiogenesis, senescent fibroblasts, and deficient stem cells that significantly diminish the probability of self-healing in these wounds. Adipose-derived stem cell therapy (ADSC) presents a promising approach to achieve efficient healing in such cases. To address the complex scenario of chronic wounds, we propose a combinatorial approach of delivering ADSCs on antioxidant gelatin-sericin (GS) scaffolds coated with laminin (GSL), an endothelial basement protein to improve angiogenesis. The synthesized GS scaffolds showed values of compression modulus, pore size, porosity, and the swelling ratio in the range of 65 kPa, 158 ± 48.8 µm, 91.1% ± 1.25, and 28 ± 2.5, respectively. A DPPH assay revealed GS scaffolds exhibit around 20% more scavenging as against gelatin (G) scaffolds and better protection against free radical assault, thus enhancing cell viability and the metabolic index of fibroblast cells. Different cells, namely, fibroblasts, keratinocytes, and ADSCs, cultured on GS scaffolds had better metabolic activity as compared with G scaffolds. Laminin coating onto the scaffolds leads to improved attachment and tube formation of endothelial cells as depicted in scanning electron microscopy images. Finally, we validated the applicability of the ADSCs loaded laminin-coated GS scaffolds in a diabetic ulcer rat model. Hematoxylin and eosin, Masson's trichrome, and picrosirius red staining showed better regeneration and collagen remodeling in ADSCs loaded GSL scaffolds. Immunostaining of CD31 staining demonstrates enhanced angiogenesis in GSL-ADSC as compared with other groups.

Morbidity and mortality from road injuries: results from the Global Burden of Disease Study 2017.

BACKGROUND: The global burden of road injuries is known to follow complex geographical, temporal and demographic patterns. While health loss from road injuries is a major topic of global importance, there has been no recent comprehensive assessment that includes estimates for every age group, sex and country over recent years. METHODS: We used results from the Global Burden of Disease (GBD) 2017 study to report incidence, prevalence, years lived with disability, deaths, years of life lost and disability-adjusted life years for all locations in the GBD 2017 hierarchy from 1990 to 2017 for road injuries. Second, we measured mortality-to-incidence ratios by location. Third, we assessed the distribution of the natures of injury (eg, traumatic brain injury) that result from each road injury. RESULTS: Globally, 1 243 068 (95% uncertainty interval 1 191 889 to 1 276 940) people died from road injuries in 2017 out of 54 192 330 (47 381 583 to 61 645 891) new cases of road injuries. Age-standardised incidence rates of road injuries increased between 1990 and 2017, while mortality rates decreased. Regionally, age-standardised mortality rates decreased in all but two regions, South Asia and Southern Latin America, where rates did not change significantly. Nine of 21 GBD regions experienced significant increases in age-standardised incidence rates, while 10 experienced significant decreases and two experienced no significant change. CONCLUSIONS: While road injury mortality has improved in recent decades, there are worsening rates of incidence and significant geographical heterogeneity. These findings indicate that more research is needed to better understand how road injuries can be prevented.

Aligned Chitosan-Gelatin Cryogel-Filled Polyurethane Nerve Guidance Channel for Neural Tissue Engineering: Fabrication, Characterization, and In Vitro Evaluation.

Recent trends in peripheral nerve regeneration are directed toward the development of nerve guidance channels to assist the regeneration of the nerves across critical size defects. Advanced nerve guidance channels (aNGCs) should possess multifunctional properties to direct the axonal regeneration from proximal to distal end, allow the concentration of growth factors secreted by the injured nerve end, and attenuate the ingrowth of scar tissue at the site of injury. The design of the nerve guidance channel (NGC) is critical for providing the necessary topographical, chemotactic, as well as haptotactic cues for efficient nerve regeneration. In this study, we have designed and fabricated clinically relevant aNGCs comprising an antioxidant polyurethane (PUAO) conduit filled with aligned chitosan-gelatin (CG) cryogel filler for peripheral nerve regeneration. The effects of temperature, polymer concentration, and cross-linker concentration on the physicochemical properties of the CG cryogel filler were studied. The synthesized scaffolds were evaluated by scanning electron microscopy (SEM) and compression testing to obtain the matrix best suited to form the aNGC. The nanofibrous PUAO conduit was fabricated by electrospinning with a wall thickness of 114.16 ± 26.91 µm, which was filled with CG (1.2/6.4%)-aligned cryogel matrix to obtain the aNGCs. The aNGCs with 2.01 ± 0.04 mm internal diameter, 15 mm length, and internal CG filler with a pore diameter of 29.60 ± 9.83 µm were fabricated. The aNGCs were evaluated by SEM and in vitro neuronal culture for biocompatibility and cellular alignment. In vitro dorsal root ganglion cultures showed the aligned growth and cellular migration along the aligned pores of aNGCs. With this study, we conclude that this clinically relevant aligned porous aNGC will have a promising effect in repair and regeneration of peripheral nerve injuries.

European consensus on the standardization of robotic total mesorectal excision for rectal cancer.

AIM: Surgery for rectal cancer is challenging for both technical and anatomical reasons. The European Academy of Robotic Colorectal Surgery (EARCS) provides a competency-based training programme through a standardized approach. However, there is no consensus on technical standards for robotic surgery when used during surgery for rectal cancer. The aim of this consensus study was to establish operative standards for anterior resection incorporating total mesorectal excision (TME) using robotic techniques, based on recommendations of expert European colorectal surgeons. METHOD: A Delphi questionnaire with a 72-item statement was sent through an electronic survey tool to 24 EARCS faculty members from 10 different countries who were selected based on expertise in robotic colorectal surgery. The task was divided into theatre setup, colonic mobilization and rectal dissection, and each task area was further divided into several subtasks. The levels of agreement (A* > 95% agreement, A > 90%, B > 80% and C > 70%) were considered adequate while agreement of < 70% was considered inadequate. Once consensus was reached, a draft document was compiled and sent out for final approval. RESULTS: The average length of experience of robotic colorectal surgery for participants in this study was 6 years. Initial agreement was 87%; in nine items, it was < 70%. After suggested modifications, the average level of agreement for all items reached 94% in the second round (range 0.75-1). CONCLUSION: This is the first European consensus on the standardization of robotic TME. It provides a baseline for technical standards and structured training in robotic rectal surgery.

Expert consensus on a train-the-trainer curriculum for robotic colorectal surgery.

AIM: Robotic techniques are being increasingly used in colorectal surgery. There is, however, a lack of training opportunities and structured training programmes. Robotic surgery has specific problems and challenges for trainers and trainees. Ergonomics, specific skills and user-machine interfaces are different from those in traditional laparoscopic surgery. The aim of this study was to establish expert consensus on the requirements for a robotic train-the-trainer curriculum amongst robotic surgeons and trainers. METHOD: This is a modified Delphi-type study involving 14 experts in robotic surgery teaching. A reiterating 19-item questionnaire was sent out to the same group and agreement levels analysed. A consensus of 0.8 or higher was considered to be high-level agreement. RESULTS: Response rates were 93-100% and most items reached high levels of agreement within three rounds. Specific requirements for a robotic faculty development curriculum included maximizing dual-console teaching, theatre team training, nontechnical skills training, patient safety, user-machine interface training and telementoring. CONCLUSION: A clear need for the development of a train-the-trainer curriculum has been identified. Further research is needed to assess feasibility, effectiveness and clinical impact of a robotic train-the-trainer curriculum.

Peptide-Based Scaffold for Nitric Oxide Induced Differentiation of Neuroblastoma Cells.

Nitric oxide is a gaseous messenger involved in neuronal differentiation, development and synaptogenesis, in addition to many other physiological functions. Therefore, it is imperative to maintain an optimal nitric oxide concentration to ensure its biochemical function. A sustained nitric oxide releasing scaffold, which supports neuronal cell differentiation, as determined by morphometric analysis of neurite outgrowth, is described. Moreover, the effect of nitric oxide on the neuroblastoma cell line was also confirmed by immunofluorescent analysis of neuronal nuclear protein (NeuN), specific neuronal marker and neurofilament (NF) protein, which revealed a significant increase in their expression levels, in comparison with undifferentiated cells.

Respiratory viruses in returning Hajj & Umrah pilgrims with acute respiratory illness in 2014-2015.

BACKGROUND & OBJECTIVES: Respiratory tract infections are common among Hajj and Umrah pilgrims which pose a public health risk of spread of respiratory infections. Influenza has been reported from Indian Hajj and Umrah returning pilgrims, but data on other respiratory pathogens are sparse in India. Here we report the presence of common respiratory viral pathogens in returning Hajj and Umrah pilgrims suffering from acute respiratory illness (ARI) in 2014-2015. METHODS: Respiratory specimens (nasopharyngeal and throat swabs) were collected from 300 consenting pilgrims with ARI in the past one week and tested for influenza and Middle East Respiratory Syndrome coronavirus (MERS-CoV) and other respiratory viruses using in-house standardized quantitative real-time reverse-transcription polymerase chain reaction. Clinical features among the pathogen positive and negative patients were compared. The patients received symptomatic treatment and antivirals where appropriate and were followed telephonically to collect data on illness outcome. RESULTS: Ninety seven (32.3%) of the 300 participants were tested positive for any virus, most common being influenza viruses (n=33, 11%). Other respiratory viruses that were detected included human coronaviruses [n=26, 8.7%; OC43 (n=19, 6.3%) and C229E (n=7, 2.3%)], rhinovirus (n=20, 6%), adenoviruses (n=8, 2.6%), parainfluenza viruses (n=7, 2.3%), respiratory syncytial virus (n=3, 1%) and bocaviruses (n=2, 0.6%). Clinical features observed in pathogen positive and pathogen negative patients did not differ significantly. Eighteen influenza positive patients were treated with oseltamivir. INTERPRETATION & CONCLUSIONS: Pilgrims returning from mass gatherings are often afflicted with respiratory pathogens with a potential to facilitate transmission of respiratory pathogens across international borders. The study reinforces the need for better infection prevention and control measures such as vaccination, health education on cough etiquette and hand hygiene.

The association between chronic airflow obstruction and poverty in 12 sites of the multinational BOLD study.

Poverty is strongly associated with mortality from COPD, but little is known of its relation to airflow obstruction.In a cross-sectional study of adults aged ≥40 years from 12 sites (N=9255), participating in the Burden of Obstructive Lung Disease (BOLD) study, poverty was evaluated using a wealth score (0-10) based on household assets. Obstruction, measured as forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) (%) after administration of 200 µg salbutamol, and prevalence of FEV1/FVC

Unemployment in chronic airflow obstruction around the world: results from the BOLD study.

We aimed to examine associations between chronic airflow obstruction (CAO) and unemployment across the world.Cross-sectional data from 26 sites in the Burden of Obstructive Lung Disease (BOLD) study were used to analyse effects of CAO on unemployment. Odds ratios for unemployment in subjects aged 40-65 years were estimated using a multilevel mixed-effects generalised linear model with study site as random effect. Site-by-site heterogeneity was assessed using individual participant data meta-analyses.Out of 18 710 participants, 11.3% had CAO. The ratio of unemployed subjects with CAO divided by subjects without CAO showed large site discrepancies, although these were no longer significant after adjusting for age, sex, smoking and education. The site-adjusted odds ratio (95% CI) for unemployment was 1.79 (1.41-2.27) for CAO cases, decreasing to 1.43 (1.14-1.79) after adjusting for sociodemographic factors, comorbidities and forced vital capacity. Of other covariates that were associated with unemployment, age and education were important risk factors in high-income sites (4.02 (3.53-4.57) and 3.86 (2.80-5.30), respectively), while female sex was important in low- to middle-income sites (3.23 (2.66-3.91)).In the global BOLD study, CAO was associated with increased levels of unemployment, even after adjusting for sociodemographic factors, comorbidities and lung function.

Robotic vs laparoscopic rectal surgery in high-risk patients.

AIM: Laparoscopic rectal surgery is associated with a steep learning curve and high conversion rate despite progress in equipment design and consistent practice. The robotic system has shown an advantage over the laparoscopic approach due to stable three-dimensional views, improved dexterity and better ergonomics. These factors make the robotic approach more favourable for rectal surgery. The aim of this study was to compare the perioperative outcomes of laparoscopic and robotic rectal cancer surgery in high-risk patients. METHOD: A prospectively collected dataset for high-risk patients who underwent rectal cancer surgery between May 2013 and November 2015 was analysed. Patients with any of the following characteristics were defined as high risk: a body mass index ≥30, male gender, preoperative chemoradiotherapy, tumour <8 cm from the anal verge and previous abdominal surgery. RESULTS: In total, 184 high-risk patients were identified: 99 in the robotic group and 85 in the laparoscopic group. Robotic surgery was associated with a significantly higher sphincter preservation rate (86% vs 74%, P = 0.045), shorter operative time (240 vs 270 min, P = 0.013) and hospital stay (7 vs 9 days, P = 0.001), less blood loss (10 vs 100 ml, P < 0.001) and a smaller conversion rate to open surgery (0% vs 5%, P = 0.043) compared with the laparoscopic technique. Reoperation, anastomotic leak rate, 30-day mortality and oncological outcomes were comparable between the two techniques. CONCLUSION: Robotic surgery in high-risk patients is associated with higher sphincter preservation, reduced blood loss, smaller conversion rates, and shorter operating time and hospital stay. However, further studies are required to evaluate this notion.

Port Placement for Laparoscopic Colonic Resections - Video Vignette.

Laparoscopic colonic resections often require manipulation and surgical action in all abdominal quadrants. Port placement, a fundamental part of a successful procedure, often varies widely among surgeons and is currently dictated by individual experience and preference. This variability may be suboptimal for the operation at hand, can be confusing for trainees and many times provide inadequate working posture for the surgeons, resulting in discomfort due to muscular fatigue in the hands, arms, shoulders and cervical spine. This article is protected by copyright. All rights reserved.

Amelioration of hyperglycaemia and modulation of antioxidant status by Alcea rosea seeds in alloxan-induced diabetic rats.

CONTEXT: Alcea rosea L. (Malvaceae) has various medicinal uses including anticancer, anti-inflammatory and analgesic properties. However, there is no report on its antidiabetic activity. OBJECTIVE: Alcea rosea seed extracts were evaluated for antihyperglycaemic and antioxidative potential in diabetic rats. MATERIALS AND METHODS: Single intra-peritoneal injection of alloxan (130 mg/kg b.w.) was used for induction of diabetes in Albino Wistar rats. Antihyperglycaemic and antioxidant activities of methanol and aqueous extracts of Alcea rosea seed (100 and 300 mg/kg b.w.), administered orally on daily basis for 15 days, were assessed in vivo for fasting blood glucose level and antioxidant status of liver and pancreas. Metformin was used as a positive control. RESULTS: Aqueous and methanol extracts (300 mg/kg b.w.) decreased blood glucose level in diabetic rats by 24% and 46%, respectively. Administration of aqueous and methanol extracts at 300 mg/kg b.w. significantly (p < 0.01) modulated the antioxidant status of liver in diabetic rats by increasing levels of GR (22.5 ± 1.0, 24.4 ± 1.02 µg GSSG utilized/min/mg of protein), GPx (20.7 ± 1.2, 23.6 ± 2.04 µg GSH utilized/min/mg of protein), SOD (36.1 ± 1.7, 39.05 ± 1.5 units/mg of protein) and CAT (1744.5 ± 132.5, 1956.6 ± 125.2 nmol H2O2 decomposed/min/mg of protein), respectively. Similar results were observed for pancreas. DISCUSSION AND CONCLUSIONS: Antihyperglycaemic and antioxidative potentials of Alcea rosea seeds suggest its usefulness in management of diabetes and its complications. This is the first report on antidiabetic activity of this plant.

Totally robotic rectal resection: an experience of the first 100 consecutive cases.

INTRODUCTION: Robotic surgery provides an alternative option for a minimal access approach. It provides a stable platform with high definition three-dimensional views and improved access, which enhances the capabilities for precise dissection in a narrow surgical field. These distinctive features have made it an attractive option for colorectal surgeons. AIM: The aim of this study was to present a standardised technique for single-docking robotic rectal resection and to analyse clinical outcomes of the first 100 robotic rectal procedures performed in a single centre between May 2013 and April 2015. METHOD: Prospectively collected data related to 100 consecutive patients who underwent single-docking robotic rectal surgery was analysed for surgical and oncological outcomes. RESULTS: Sixty-six patients were male, the median age was 67 years (range-24-92). Eighteen patients had neo-adjuvant chemoradiotherapy whilst 23 patients had BMI >30. Procedures performed included anterior resection (n = 74), abdominoperineal resection (n = 10), completion proctectomy (n = 9), restorative proctectomy with ileal pouch-anal anastomosis (IPAA) (n = 5) and Hartmann's procedure (n = 2). The median operating time was 240 min (range-135-456), and median blood loss was 10 ml (range 0-200). There was no conversion or intra-operative complication. Median length of stay was 7 days (range, 3-48) and readmission rate was 12 %. Thirty-day mortality was zero. Postoperatively, two patients had an anastomotic leak whilst two had small bowel obstruction. The median lymph node harvest was 18 (range, 6-43). CONCLUSION: The single-docking robotic technique should be considered as an alternative option for rectal surgery. This approach is safe and feasible and in our study it has demonstrated favourable clinical outcomes.