Comparative Study of Common Bile Duct Diameter between Normal and Post Cholecystectomy Cases Using Trans-abdominal Ultrasonography.

Background Increase in common bile duct diameter can occur because of different causes. Post cholecystectomy status is one of the potential causes. Many studies done in the past show different results and are hence inconclusive. Objective To see if the post cholecystectomy cases would have a statistically significant change in common bile duct diameter. Method We carried out a study in 100 cases (46 post cholecystectomy cases and 54 cases with intact gall bladder, measuring their common bile duct diameters and performing an unpaired t test to see if the mean in common bile duct among these two groups of cases was statistically significant. Result One hundred cases, 46 post cholecystectomy cases and 54 cases with intact gall bladder were included in our study. An unpaired t-test was used to compare the common bile duct diameters in these two groups. Our findings showed that the difference in common bile duct diameter between the cases with intact gall bladder and those who underwent cholecystectomy was significant for both one tailed and two tailed studies (p < 0.001). Hence, it can be stated that post cholecystectomy status increases the common bile duct diameter. Conclusion An increased Common bile duct diameter in post cholecystectomy case could be because of the post cholecystectomy status itself and not due to some other obstructive cause. So careful decision is necessary before subjecting the patient to further invasive/non-invasive investigations and treatments.

Randomized clinical trial of accelerated enhanced recovery after minimally invasive colorectal cancer surgery (RecoverMI trial).

BACKGROUND: Minimally invasive surgery (MIS) and enhanced recovery protocols (ERPs) have improved postoperative recovery and shortened length of hospital stay (LOS). Telemedicine technology has potential to improve outcomes and patient experience further. This study was designed to determine whether the combination of MIS, ERP and a structured telemedicine programme (TeleRecovery) could shorten total 30-day LOS by 50 per cent. METHODS: This was a phase II prospective RCT at a large academic medical centre. Eligible patients aged 18-80 years undergoing minimally invasive colorectal resection using an ERP were randomized after surgery. The experimental arm (RecoverMI) included accelerated discharge on postoperative day (POD) 1 with or without evidence of bowel function and a televideoconference on POD 2. The control arm was standard postoperative care. The primary endpoint was total 30-day LOS (postoperative stay plus readmission/emergency department/observation days). Secondary endpoints included patient-reported outcomes measured by EQ-5D-5L™, Brief Pain Inventory (BPI) and a satisfaction questionnaire. RESULTS: Thirty patients were randomized after robotic (21 patients) or laparoscopic (9) colectomy, including 14 patients in the RecoverMI arm. Median 30-day total LOS was 28·3 (i.q.r. 23·7-43·6) h in the RecoverMI arm and 51·5 (43·8-67·0) h in the control arm (P = 0·041). There were no differences in severe adverse events or EQ-5D-5L™ score between the study arms. The BPI revealed low pain scores regardless of treatment arm. Satisfaction was high in both arms. CONCLUSION: In patients having surgery for colorectal neoplasms, the trimodal combination of MIS, ERP and TeleRecovery can reduce 30-day LOS while preserving patients' quality of life and satisfaction. Registration number: NCT02613728 ( https://clinicaltrials.gov).

ANTECEDENTES: La cirugía mínimamente invasiva (minimally invasive surgery, MIS) y los protocolos de recuperación intensificada (enhanced recovery protocols, ERP) han mejorado la recuperación postoperatoria y acortan la duración de la estancia (length of stay, LOS). La tecnología de la telemedicina tiene potencial para mejorar aún más los resultados y la experiencia del paciente. Este estudio se diseñó para determinar si la combinación de MIS, ERP y un programa estructurado de telemedicina (TeleRecovery) podría acortar la LOS total a los 30 días en un 50%. MÉTODOS: Se efectuó un ensayo controlado aleatorizado, prospectivo, de fase II en un gran centro médico académico. Los pacientes elegibles de 18-80 años de edad que se sometieron a resección colorrectal MIS mediante ERP se asignaron al azar después de la resección quirúrgica. El brazo experimental (RecoverMI) incluyó el alta acelerada en el día 1 del postoperatorio (postoperative day, POD) con o sin evidencia de recuperación del tránsito intestinal y una televideoconferencia en el día 2 POD. Los pacientes en el grupo control recibieron los cuidados postoperatorios habituales. El criterio de valoración principal fue la LOS total (estancia postoperatoria más reingreso/estancia en urgencias/días de observación) a los 30 días. Los criterios de valoración secundarios incluyeron los resultados referidos por los pacientes medidos por los cuestionarios EQ-5D-5L, el Cuestionario Breve del Dolor (Brief Pain Inventory, BPI) y un cuestionario de satisfacción. RESULTADOS: Treinta pacientes fueron aleatorizados después de una colectomía robótica (21) o laparoscópica (9), incluidos 14 pacientes en el grupo de RecoverMI. La mediana de la LOS total a los 30 días fue de 28,3 horas (rango intercuartílico, RIQ 23,7-43,6) en el grupo de RecoverMI y de 51,5 horas (RIQ 43,8-67,0) en el grupo control (P = 0,04). No hubo diferencias entre los grupos de estudio en los eventos adversos graves o en las puntuaciones del EQ-5D-5L. El BPI mostró puntuaciones bajas de dolor independientemente del grupo de tratamiento. La satisfacción fue alta en ambos grupos. CONCLUSIÓN: Entre los pacientes que se someten a cirugía por cáncer colorrectal, la combinación trimodal de MIS, ERP y TeleRecovery puede reducir la LOS a los 30 días, preservando la calidad de vida y la satisfacción del paciente.

Early initiation of community-based programmes in Nepal: a historic reflection.

Community-based programmes have long been an integral part of Nepal's health sector strategy and has contributed to the progress seen in maternal and child health. This paper reviews three early community-based programmes - the acute respiratory infection programme and its evolution to the fully scaled-up community-based integrated management of childhood illness programme, the national vitamin A programme and the female community health volunteer programme - and how the Government of Nepal rapidly accepted them to address pressing maternal and child health issues in an evidence-informed manner, moving rapidly from research to feasibility studies, to implementation and scale-up.

Understanding how women's groups improve maternal and newborn health in Makwanpur, Nepal: a qualitative study.

Women's groups, working through participatory learning and action, can improve maternal and newborn survival. We describe how they stimulated change in rural Nepal and the factors influencing their effectiveness. We collected data from 19 women's group members, 2 group facilitators, 16 health volunteers, 2 community leaders, 21 local men, and 23 women not attending the women's groups, through semi-structured interviews, group interviews, focus group discussions and unstructured observation of groups. Participants took photographs of their locality for discussion in focus groups using photoelicitation methods. Framework analysis procedures were used, and data fed back to respondents. When group members were compared with 11 184 women who had recently delivered, we found that they were of similar socioeconomic status, despite the context of poverty, and caste inequalities. Four mechanisms explain the women's group impact on health outcomes: the groups learned about health, developed confidence, disseminated information in their communities, and built community capacity to take action. Women's groups enable the development of a broader understanding of health problems, and build community capacity to bring health and development benefit.

The association between nutritional status and handgrip strength in older Rwandan refugees.

OBJECTIVES: To investigate the association between nutritional status and handgrip strength in older Rwandan refugees. DESIGN: Cross-sectional study. SETTING: Rwandan refugee camp located in Karagwe district in the north-west of Tanzania. The study was carried out in the post-emergency phase. The response rate was 85%. SUBJECTS: A total of 413 men and 415 women aged 50-92 y participated in the study. METHODS: Weight, height, mid-upper-arm circumference (MUAC) and triceps skinfold were obtained using standard techniques. For people with visible kyphosis, height was estimated from armspan using regression equations developed from non-kyphotic subjects within the sample. Handgrip was measured using a mechanical handgrip dynamometer. Information regarding physical activity and health status was obtained by interview and clinical screening. RESULTS: Handgrip strength (kg) was significantly higher in men than in women (30.3+/-6.7 vs 22.3+/-5.1), and significantly lower in each older age group in both sexes. Handgrip strength was positively correlated to BMI (body mass index) and AMA (arm muscle area). The relative risk of impaired handgrip strength in individuals with poor nutritional status (BMI<18.5 kg/m(2)) compared with those of adequate nutritional status was 1.75. After controlling for potential confounders (sex, age and height), BMI remained a significant contributor to the variation in handgrip strength. CONCLUSION: Poor nutritional status is associated with poor handgrip strength independent of sex, age and height, in this refugee population. This may indicate that underweight older people are likely to have more difficulties in functioning independently in the community. Research is needed to investigate if improving nutritional status can lead to better functional ability. SPONSORSHIP: Department for International Development (UK) and HelpAge International.

Steroidal alkaloids from the leaves of Sarcococca coriacea of Nepalese origin.

Two new steroidal alkaloids, (-)-vaganine D (1) [(20S)-20-(N,N-dimethylamino)-3 beta-(senecioylamino)-5 alpha-pregn-16-en-4 beta-yl acetate], and (+)-nepapakistamine A (2) [(20S)-20-(N-methylamino)-3 beta-(tigloylamino)-5 alpha-pregn-16-en-2 beta,4 beta-diacetate], were isolated from the leaves of Sarcococca coriacea. Their structures were elucidated on the basis of their spectral properties. Compounds 1 and 2 were found to be cholinesterase inhibitors.

The nutritional status of older Rwandan refugees.

OBJECTIVE: To assess the nutritional status of older people in an unstable situation. DESIGN: Anthropometric and socioeconomic data were collected cross-sectionally. Body mass index (BMI), arm muscle area (AMA) and arm fat area (AFA) were calculated to evaluate nutritional status. For 41 subjects with kyphosis, height was estimated from arm span using sex-specific regression equations from the non-kyphotic group. SETTING: The study was carried out in the post-emergency phase in a Rwandan refugee camp in Karagwe district, north-west Tanzania. SUBJECTS: Measurements were obtained from 413 men and 415 women aged 50-92 years. RESULTS: The prevalence of undernutrition (BMI < 18. 5) was 19.5% in men and 13.1% in women and was higher above age 60 years in both sexes: in men the prevalences were 23.2% and 15.0% (P < 0.05) and in women 15.1% and 10.9% for the older and younger age groups respectively. AMA, which is important in relation to the ability to remain active and independent, was also significantly lower in older age groups. No difference was found in AFA. The proportion with low BMI was much higher in the group with kyphosis. CONCLUSIONS: Even in this population of older Rwandans who managed to reach the camp and survive in exile for more than a year, undernutrition does occur and is more prevalent at an advanced age. The higher prevalence of undernutrition in kyphotic people illustrates the importance of including this group in nutritional status assessments.

Weight, skinfolds and circumference characteristics of poor elderly people in Mumbai, India.

This paper describes the anthropometric characteristics of 1,335 (males 545, females 790) people of low socio-economic classes aged 50-97 years (mean age 60 years) living in slums and tenement blocks around a major teaching hospital in central Mumbai (Bombay). Descriptive statistics for weight, mid-upper arm and calf circumferences, and biceps, triceps, subscapular and suprailiac skinfolds are presented. Subjects were much lighter, thinner and had smaller circumferences than their age- and sex- matched American counterparts but were similar to nationally representative Indian slum groups, as well as other Asian groups. Men were significantly heavier than women and had larger circumferences whereas women had significantly fatter skinfoldss. Age was significantly but non-linearly related to all variables in women but only to mid-upper arm and calf circumferences in men : there was a marked step effect with the age cut-off 70 years. Reliability for all measurements was high (R > 0.95), with technical errors of measurement highest for skinfolds, especially the suprailiac. The overall prevalence of oedema was 2.8%. In the whole sample, men were significantly older than women, probably because men are more likely to be out working than women, especially below 65 years old. A good participation rate was achieved (78%), with women more likely to participate than men. Almost half of the non-participancy can be attributed to work-related activity, particularly in men. Discussion focuses on practical issues of taking anthropometric measurements in elderly people living in the community, reliability, and non-participant bias.

The SH3-domain protein Bem1 coordinates mitogen-activated protein kinase cascade activation with cell cycle control in Saccharomyces cerevisiae.

The mating mitogen-activated protein kinase (MAPK) cascade has three major outputs prior to fusion: transcriptional activation of many genes, cell cycle arrest in the G1 phase, and polarized growth. Bem1 localizes near the cortical actin cytoskeleton and is essential for polarized growth during mating. Here we show that Bem1 is required for efficient signal transduction and coordinates MAPK cascade activation with G1 arrest and mating. bem1delta null mutants are defective in G1 arrest and transcriptional activation in response to mating pheromone. Bem1 protein stimulates Fus3 (MAPK) activity and associates with Ste5, the tethering protein essential for activation of the MAPK kinase kinase Ste11. Bem1-Ste5 complexes also contain Ste11, Ste7 (MAPK kinase), and Fus3, suggesting that Ste5 localizes the MAPK cascade to Bem1. Strikingly, Bem1 also copurifies with Far1, a Fus3 substrate required for G1 arrest and proper polarized growth during mating. These and other results suggest that Bem1 may cross-link the Ste5-MAPK cascade complex to upstream activators and specific downstream substrates at the shmoo tip, thus enabling efficient circuitry for G1 arrest and mating.

Methotrexate: assessment of in vivo clastogenicity and carcinogenicity.

The genotoxic and oncogenic potentials of methotrexate were studied in Sprague-Dawley rats. The rats received 0.1, 0.2, or 0.4 mg/kg of methotrexate as dietary admixtures on a 5 days on, 9 days off, regimen for 23 months. In the females of the high-dose group, there was a significant increase in mortality starting at 18 months. Significant increases in the number of rats with focal pulmonary interstitial fibrosis were seen in both sexes at the high-dose level. At the mid- and high-dose levels of both sexes, there was a significantly increased number of rats with myeloid and erythroid bone marrow hypoplasia. There was no evidence of either early onset or increased incidence of any tumor type in the treatment groups. Therefore, it is concluded that methotrexate does not have oncogenic potential. Also, at terminal sacrifice, bone marrow cells were harvested from selected animals on the last day of the 5-day dosing cycle and cytogenetic evaluation was performed. No significant increase in chromosomal aberrations was seen in any dose group relative to the control group. This observation further substantiates the absence of oncogenic potential due to methotrexate in rats.

A guide for mutagenicity testing using the dominant lethal assay.

The dominant lethal assay has been used and continues to be used to provide information about the effects of chemicals on the gonadal cells of male animals. Guidelines for conducting this test are useful but as with any guideline scientists should avoid interpreting them as protocols. Thus this document is a general approach to dominant lethal testing and should be used in conjunction with other available protocols and procedures.

Control of epidemic group A meningococcal meningitis in Nepal.

During the first six months of 1983, an epidemic of serogroup A meningococcal meningitis occurred in the Kathmandu valley of Nepal, resulting in 875 cases and 95 deaths. The annual attack rate was 103 cases per 100,000 population, with a peak attack rate occurring in April. Epidemic meningococcal disease had not been recognized previously in Nepal. Early in 1984, a review of hospital-based data on pyogenic meningitis in Kathmandu showed three times as many cases per month compared with the same period the previous year, suggesting that a recurrent epidemic was unfolding. Beginning in February 1984, a vaccination campaign directed at a high-risk target population of people aged 1-24 years was launched; over 329,000 doses of bivalent A/C meningococcal vaccine were given, achieving approximately 64% coverage of the target population. A dramatic decline in the number of new meningitis cases occurred coincident with the initiation of the mass vaccination campaign. This experience demonstrates that it is possible, with appropriate surveillance efforts, to detect an evolving epidemic of meningococcal disease early in its course and to institute control measures in advance of the expected epidemic peak.

Genetic toxicology evaluation of the novel semi-synthetic antibiotic piperacillin.

Piperacillin (T-1220, Pipracil) a semi-synthetic antibiotic was evaluated in a battery of genetic toxicology assays. The assays employed were: the microbial assay, the host mediated assay, the microbial assay incorporating urine samples from mice dosed with piperacillin, the in vivo cytogenetic assay, and the dominant lethal assay. In all assays, piperacillin produced consistent negative results indicating that piperacillin does not have mutagenic potential.

Genetic toxicology profile of the new antineoplastic drug mitoxantrone in the mammalian test systems.

As part of safety evaluation and drug development, 1,4-dihydroxy-5,8-bis[[2-[(2-hydroxyethyl) amino]-ethyl]amino]-9,10-anthracenedione dihydrochloride (mitoxantrone, NSC 301739, CL 232,315, Novantrone) was tested in the mammalian test systems to determine its mutagenic potential. Mitoxantrone produced significant clastogenic effect in bone marrow of rats treated for 5 days at greater than or equal to 0.5 mg/kg i.p. It produced apparent increases in DNA repair in the rat hepatocyte UDS (unscheduled DNA synthesis) test and increased SCEs (sister chromatid exchanges) in CHO cells and mutant frequencies in mouse lymphoma assay. In the cell transformation test using C3H/10T 1/2 cl 8 cells, mitoxantrone did not produce significant increases in type II or type III transformed foci. In the dominant lethal test in rats, mitoxantrone administered 2 mg/kg/d i.p. affected matings of treated males, however, total implantations as well as early deaths resulting from matings with surviving males were unaffected. These results show the potential of mitoxantrone to produce genetic activity in vitro and in the somatic cells in vivo but inability of the drug to cause morphological transformation in vitro or genotoxic effect in the germinal cells in vivo. The biological significance of findings such as above is uncertain. Examination of genetic end-points such as chromosomal assays in rodents on life time studies which are currently being completed will delineate the significance, if any, of these findings.

Current status of bioassays in genetic toxicology--the dominant lethal assay. A report of the U.S. Environmental Protection Agency Gene-Tox Program.

The term dominant lethal may be defined as death of the heterozygote arising through multiple chromosomal breaks. The assay is generally conducted by treating male animals, usually mice or rats, acutely (1 dose), subacutely (5 doses), or over the entire period of spermatogenesis. Animals treated acutely or subacutely are mated at weekly intervals to females for a sufficient number of weeks to cover the period of spermatogenesis. Those treated for the entire spermatogenic cycle are mated for 1 or 2 successive weeks at the termination of treatment. Females usually are killed at 14 days of pregnancy and examined for the number of total implantations in the uterus, the number of implantations classified as early deaths, and, in some cases, the number of corpora lutea. The category of early death is the most significant index of dominant lethality. A total of 249 papers were reviewed and 140 chemicals were evaluated. Of the 140 chemicals, 65 were positive by the criteria used by the Work Group in evaluating each publication. The category of "positive" includes those responses of a borderline nature. 99 chemicals were declared negative. There is considerable overlap of chemicals in both categories, which accounts for the incongruity in the total number of chemicals tested and the number considered positive and negative. A total of 44 animal carcinogens have been tested in the dominant lethal assay, 26 of which were positive and 18 negative for a correlation of 59%. The role of the assay should be that of confirming positive results from lower tier chromosomal aberration-detecting systems (confirming in the sense of indicating the ability of the chemical to penetrate gonadal tissue and to produce cytogenetic damage). The dominant lethal assay should not be used as a risk assessment method.

Effects of prolactin on the dorsolateral lobe of the rat prostate gland.

Intact mature young rats (8 to 10 weeks old) or older rats (16 to 18 weeks old) were used to study the effects of various doses of prolactin on the dorsolateral lobes of the prostate. Prolactin (50 or 150 IU per kg) administered subcutaneously for 5 days in intact mature young rats caused increases in wet weight, protein levels, and nucleic acid levels in the dorsolateral lobes of the prostate. Similar results were obtained when rats were given injections of prolactin for a period of 10 days. When injecting only a 5 IU per kg dose of prolactin, no significant changes were evident in the tissue weight, protein levels, or nucleic acid levels of the prostate gland; however, this same dose produced increases in these biochemical parameters in the dorsolateral lobe of the prostate of older rats.