Robot-assisted and conventional urology surgical procedures: comparison of average length of stay, economic status, operative time and patient's expenditure in a tertiary care hospital of North India.

Robot-assisted surgeries allows the surgeons to operate using remote-controlled robotic arms that are more effective in comparison to conventional (open/laparoscopic) surgeries. However, there is substantial lack of evidence on the effectiveness of robot-assisted surgeries in low to middle income countries (LMICs) like India. A study was conducted with an aim to evaluate the average length of stay (ALOS), Operative time, economic status (patient's) and cost borne by the patient (patient's expenditure) for undergoing robot-assisted surgeries and conventional surgeries. Grouping of the surgical procedures was done wherein patients who were treated with robot-assisted surgical procedures were placed in Group-01 whereas those treated with conventional surgical procedures were placed under Group-02. Comparative evaluation of the two surgical groups revealed that in robot-assisted surgical procedure, the ALOS was less (18.43 vs. 23.14 days, p = 0.06) whereas operative time (316.7 vs. 252.63 min, p = 0.05) and patient's expenditure were more (INR 70,654.29 vs. INR 41,314.73, p = 0.00). However, there was no significant difference between the economic statuses of patients in both groups. The study concluded that in this era of rapidly expanding health care scenario; targeted, regular, rigorous and repeated training programmes in future may shorten the learning curve thereby paving a way to reduce the cost as well as the operative time of robot-assisted surgeries in LMICs.

Urinary adenosine triphosphate and nitric oxide levels in patients with underactive bladder: a preliminary study.

INTRODUCTION: Various in vitro and in vivo animal studies have shown that adenosine triphosphate (ATP) has a stimulatory role and nitric oxide (NO) has an inhibitory role in modulating bladder contractility. However, it is not known what happens to the urinary levels of ATP and NO in humans with underactive bladder (UAB). METHODS: In this prospective case-control study, we compared ATP and NO levels in twenty six male patients of UAB with a bladder contractility index (BCI) of < 100 and 18 healthy male volunteers without any lower urinary tract symptoms (LUTS). RESULTS: The mean urinary ATP levels were significantly lower in cases compared to controls (546.1 ± 37.3 pg/µl vs. 610.7 ± 24.9 pg/µl, p value < 0.001) and the mean NO levels were significantly higher in cases compared to controls (1233.4 ± 91.2 pg/µl vs. 1126.3 ± 91.3.4 pg/µl, p value < 0.001). The mean NO/ATP ratio in cases was significantly higher than that of controls (2.26 ± 0.2 vs. 1.84 ± 0.18, p value < 0.000). Using receiver operating curve (ROC) analysis, we noted the area under the curve (AUC) for NO/ATP ratio to be 0.91 in the diagnosis of cases. A cut-off value of 2.06 for NO/ATP ratio had sensitivity, specificity and diagnostic accuracy of 88.5%, 88.9% and 88.6%, respectively, in diagnosing patients with UAB. CONCLUSION: Patients with UAB have significantly higher levels of urinary NO and decreased levels of urinary ATP. Urinary NO/ATP levels can be considered as a noninvasive alternate test for diagnosing bladder underactivity.

Development, evaluation and validation of machine learning algorithms to detect atypical and asymptomatic presentations of Covid-19 in hospital practice.

BACKGROUND: Diagnostic methods for Covid-19 have improved, both in speed and availability. Because of atypical and asymptomatic carriage of the virus and nosocomial spread within institutions, timely diagnosis remains a challenge. Machine learning models trained on blood test results have shown promise in identifying cases of Covid-19. AIMS: To train and validate a machine learning model capable of differentiating Covid-19 positive from negative patients using routine blood tests and assess the model's accuracy against atypical and asymptomatic presentations. DESIGN AND METHODS: We conducted a retrospective analysis of medical admissions to our institution during March and April 2020. Participants were categorized into Covid-19 positive or negative groups based on clinical, radiological features or nasopharyngeal swab. A machine learning model was trained on laboratory parameters and validated for accuracy, sensitivity and specificity and externally validated at an unconnected establishment. RESULTS: An Ensemble Bagged Tree model was trained on data collected from 405 patients (212 Covid-19 positive) producing an accuracy of 81.79% (95% confidence interval (CI) 77.53-85.55%), the sensitivity of 85.85% (CI 80.42-90.24%) and specificity of 76.65% (CI 69.49-82.84%). Accuracy was preserved for atypical and asymptomatic subgroups. Using an external data set for 226 patients (141 Covid-19 positive) accuracy of 76.82% (CI 70.87-82.08%), sensitivity of 78.38% (CI 70.87-84.72%) and specificity of 74.12% (CI 63.48-83.01%) was achieved. CONCLUSION: A machine learning model using routine laboratory parameters can detect atypical and asymptomatic presentations of Covid-19 and might be an adjunct to existing screening measures.

Corrosion performance of various deformed surfaces of implant steel for coronary stent applications: Effect of protein concentration.

This work was done to systematically elucidate the corrosion behavior of austenitic stainless steel subjected to various degree of cold deformation (10 %, 20 % & 30 %). The experiments were performed in phosphate buffer saline (PBS) solution having different concentrations of bovine serum albumin (0.2, 0.5, 1.0, 2.0, 4.0 g L-1). Potentiodynamic polarization tests and electrochemical impedance spectroscopy (EIS) analysis were performed to obtain the corrosion parameters. Scanning electron microscopy with energy dispersive X-ray (SEM-EDX), atomic force microscopy (AFM) and X-ray photoelectron spectroscopy (XPS) were used to determine the surface morphologies and chemical compositions of the surface films. Contact angle analysis was also used to detect the hydrophilic character of sample surfaces. The BSA had a considerable effect of inhibition on the corrosion of SSs in annealed as well as in deformed state due to its adsorption on surface of steel. For annealed samples, at 4.0 g L-1BSA concentration, the corrosion resistance was drastically decreased but interestingly not for sample with more than 10 % deformation and the concentration effect of BSA is also not very significant after 0.5 g L-1 for deformed surfaces. The breakdown potential for 30 % deformed sample is quite higher in presence of BSA even at 4.0 g L-1 while it is lowest for annealed samples in the same condition. The variation in contact angle with deformation is very less after adsorption of BSA. On the basis of the obtained results, mechanism aspect for corrosion of steel in presence of protein is also deliberated.

Diuretic lounge and the impact on hospital admissions for treatment of decompensated heart failure.

BACKGROUND: Heart failure is a prevalent condition associated with frequent and costly hospital admissions. Hospitalizations are primarily related to worsening fluid retention and often require admission for decongestion with intravenous diuretics. OBJECTIVE: To assess the safety of an outpatient intravenous diuresis service for heart failure patients, and its impact on emergency admissions and the cost of treatment. METHODS: We conducted a prospective observational cohort registry study on patients referred to the diuretic lounge at our acute hospital between May 2017 and April 2018. RESULTS: We analysed 245 patients treated in the diuretic lounge, of which 190 (77.6%) avoided hospitalization or any adverse events during the 60 days of follow up (77.6% vs. 22.4%; P < 0.001). The diuretic lounge service resulted in a significant decrease in emergency heart failure admissions compared to the previous 12 months (823 vs. 715 per annum; 68.6 ± 10.1 vs. 59.6 ± 14 per month; P = 0.04), and a numerical reduction in readmission rates (17.3% vs. 16.2%). The 13.1% decrease in admissions lead to financial savings of £315 497 per annum and £2921 per admission avoided. During the same time period, at the other acute hospital site in our trust, where no diuretic lounge service is available, the number of admissions did not significantly change (457 vs. 450 per annum; 37.5 ± 7.0 vs. 38.1 ± 7.6 per month; P = 0.81). CONCLUSION: Ambulatory administration of intravenous diuretics reduces emergency admissions and is a safe and cost-effective alternative to treat acute decomposition in heart failure patients.

An overview of non-invasive imaging modalities for diagnosis of solid and cystic renal lesions.

Renal imaging is an essential investigative tool and preliminary task for determining a suitable sanative option for the treatment of kidney cancer. In recent decades, with the increasing usage of abdominal imaging, there is an upsurge in the number of adrenal incidentalomas. Among these accidentally revealed lesions, most of them are complex that warrant immediate aggressive treatment planning due to their malignant potential. The guidelines given by the American Urological Association (AUA), American College of Radiology (ACR), and European Association of Urology (EAU) vary concerning the use of ideal preliminary imaging modality to investigate the patients with suspected flank pain, hematuria, or palpable mass in the abdomen. Initially, an effort has been made to discriminate cystic and solid renal lesions which are helpful in separating benign and malignant nature as different imaging patterns are observed on distinct imaging modalities for solid and cystic renal lesions. Various attempts have been made to improve the accuracy of cancer diagnosis by employing different imaging modalities. The primary aim of this article is to study the capabilities of different imaging techniques for detecting and differentiating solid and cystic lesions to facilitate treatment planning based on computed tomography (CT), ultrasonography (US), magnetic resonance imaging (MRI), positron emission tomography (PET), and optical coherence tomography (OCT). Further, the advantages, disadvantages, new advancements, and future scope of each of the imaging modality have also been highlighted so that one can make a correct choice of imaging technique for diagnosis of a specific type of lesion. Additionally, some recommendations have also been mentioned by listing the requirements for the perfect imaging modality. Graphical abstract.

Fluidized bed combustion bottom ash: A better and alternative geo-material resource for construction.

Though the majority of research on fly ash has proved its worth as a construction material, the utility of bottom ash is yet questionable due to its generation during the pulverized combustion process. The bottom ash produced during the fluidized bed combustion (FBC) process is attracting more attention due to the novelty of coal combustion technology. But, to establish its suitability as construction material, it is necessary to characterize it thoroughly with respect to the geotechnical as well as mineralogical points of view. For fulfilling these objectives, the present study mainly aims at characterizing the FBC bottom ash and its comparison with pulverized coal combustion (PCC) bottom ash, collected from the same origin of coal. Suitability of FBC bottom ash as a dike filter material in contrast to PCC bottom ash in replacing traditional filter material such as sand was also studied. The suitability criteria for utilization of both bottom ash and river sand as filter material on pond ash as a base material were evaluated, and both river sand and FBC bottom ash were found to be satisfactory. The study shows that FBC bottom ash is a better geo-material than PCC bottom ash, and it could be highly recommended as an alternative suitable filter material for constructing ash dikes in place of conventional sand.

Scratch to state-of-the-art: setting up a new robotic facility in a developing country.

The potential challenges encountered for setting up a robotic assisted surgical facility in developing country like India are many. We describe the initial hurdles and troubleshooting in establishing a facility of such kind. This experience might help to decrease initial hiccups in setting up such an innovative technology at other institutes.

Effect of age and sex in determining cognitive ability in Vanaraja chickens.

(1) To evaluate the cognitive ability of male and female Vanaraja birds, three hundred and sixty 1-d-old sexed chickens were reared under similar conditions in three treatment groups with 4 replicates in each group: 120 females in Treatment 1, 120 males in Treatment 2 and both males and females (60 + 60) as a mixed group in Treatment 3. (2) To assess learning ability, the birds were trained in T- and Y-mazes and tested at 3-week intervals in 4 test schedules (21, 42, 63 and 84 d). The birds were put into tonic immobility (TI) in each test schedule. (3) In each maze test, the latency to find the feed was regarded as a successful completion of the task. In the TI-test, the time taken to stabilise on a plane surface after swinging in the hanging cradle for 20-25 s was recorded. (4) The results indicated that male birds appeared to be cognitively superior to females in terms of learning and cognitive evolution in all the mazes, but by d 84, the females performed as well as the males. With increasing age, spatial memory gathering and processing improved. In the TI-test, the effect of sex or grouping system had no significant effect on the performance of birds at the various ages.

Outcome of Endoscopic Variceal Band Ligation.

INTRODUCTION: Bleeding from esophageal varices in cirrhosis is an emergent condition with high mortality. One of the preferred modality of treating esophageal varices is EVL. We aimed to find out the outcome of EVL in controlling acute esophageal variceal bleeding, prophylactic banding to prevent future bleeding and the number of sessions required for complete eradication of varices. METHODS: This descriptive observational study was carried out in Gastroenterology and Hepatology unit of Bir Hospital, NAMS from June 2016 to May 2017. Consecutive cases who presented in emergency room with acute variceal bleeding due to liver cirrhosis and cases of liver cirrhosis with large varices and red color signs on endoscopic examination were enrolled. They underwent EVL and subsequent re-endoscope at one month interval till the eradication of varices was achieved. RESULTS: Among 83 patients, 15 (18.1%) were of Child Pugh class A, 29 (34.9%) B and 39 (47%) were of C. In 20 (24.1%) cases varices could be eradicated in one session of EVL while 57 (68.7%) required two sessions and in 6 (7.2%) cases it took three sessions. Total average EVL session required for obliteration of esophageal varices was 1.84±0.53. There was only one (1.2%) of early re-bleeding post EVL. CONCLUSIONS: EVL is an effective modality of treatment in controlling acute esophageal variceal bleeding, in preventing future variceal bleeding as well as in eradicating esophageal varices with very few complications.

Acute Upper Gastrointestinal Bleeding in a Tertiary Care Centre of Nepal.

INTRODUCTION: AUGIB is characterized by hematemesis or melena or both. Peptic ulcers and variceal bleed account for majority of cases. Use of proton pump inhibitors in current era is associated with a gradual reduction in burden of peptic ulcer disease. We conducted this study to look into the cause of AUGIB in our community. METHODS: We studied 100 patients in one year period who presented to us with hematemesis or melena. The study was conducted in department of Gastroenterology, Bir hospital, Kathmandu. We identified the culprit lesions by upper gastrointestinal endoscopy. RESULTS: The average age of patients with AUGIB was 51.6 years with 59 (59%) males. Duodenal ulcers are most common 29 (29%), followed by varices 23 (23%) and gastric ulcers 14 (14%). More than one lesion was identified in 38 (38%) patients. Patients with variceal bleed were more likely to present with hematemesis alone as compared to those with ulcer bleed (P=0.005). Variceal bleed patients presented earlier to the hospital (P=0.005), had lower MAP at presentation (P=0.0002), had lower hemoglobin level (P=0.0001) and higher serum creatinine level at presentation (P=0.001). Patients with variceal bleed were more likely to have consumed alcohol 20 (86.9%) and patients with ulcer bleed were more likely to be smokers 29 (67.4%) or consume tobacco 14 (32.5%) (P=0.006). CONCLUSIONS: Ulcer related bleeding is still the most common cause of AUGIB. Many patients with AUGIB have more than one lesions identified during upper gastrointestinal endoscopy.

Colorectal Cancer in Different Age Groups in a Tertiary Hospital in Nepal.

INTRODUCTION: Some studies have suggested that colorectal cancer at a younger age had distinct biological characteristics: different clinical presentations, more advanced stage at time of diagnosis and poorly differentiated carcinoma. The aim of the study is to analyze clinical and histopathological differences between younger (≤40 years of age) and older (>40 years of age) colorectal cancer patients. METHODS: A cross-sectional analysis was conducted amongst the colorectal cancer patients who visited Bir Hospital between July 2015 and April 2017. All colonoscopically diagnosed and histopathologically proven cases of colon cancer were included. Chi-square test and independent t - test was performed to analyze the difference between clinical presentations and histopathological findings among two groups of patients and P value of <0.05 was considered as significant. RESULTS: Thirty younger patients and thirty older patients were enrolled without any differences in gender proportion. There were no statistical differences between clinical presentation and histological grade and type in younger and older patients. The younger patients had more complaints of altered bowel habit (P <0.001) while older patients mostly presented with per rectal bleeding (P< 0.008). CONCLUSIONS: In this study, colorectal cancer at younger ages showed similar characteristics to those of older patients except altered bowel habit was more common in younger patients while per rectal bleeding was more common in older patients. Although colorectal cancer incidence increases with age, younger patients with altered bowel habits, weight loss, anemia and anorexia should also be given due medical attention and undergo evaluation promptly.

Efficacy of Prophylactic use of Ciprofloxacin and Metronidazole in Mild and Moderately Severe Acute Pancreatitis.

INTRODUCTION: There are new concepts and developments in the diagnosis and management of acute pancreatitis. Current evidence suggests that there is no role of prophylactic antibiotics use in acute pancreatitis. However, it is still a common practice to administer prophylactic antibiotics in a country like Nepal. So, we have conducted a study in mild and moderately severe acute pancreatitis to study the efficacy of prophylactic antibiotics. METHODS: A case control study was conducted among 76 patients comparing efficacy of prophylactic antibiotics versus no antibiotics in patients with mild and moderately severe acute pancreatitis. RESULTS: The two most common etiology of acute pancreatitis in AG and NAG were alcohol 21 (55.2%) vs. 24 (63.1%) and biliary 10 (26.3%) vs. 4 (10.5%) respectively. Pancreatic necrosis was seen in five (13.1 %) in AG and four (10.5%) in NAG. Four (10.5%) developed extra pancreatic complications in AG and five (13.1%) in NAG. There was one (2.6%) death in AG and no death in NAG. Abdominal pain improvement seen in AG vs. NAG was 3.2 days vs. 2.4 days (P=0.002). The hospital stay was 7.7±2.23 days in AG and 7.5±1.85 days in NAG (P=0.65). CONCLUSIONS: The routine use of prophylactic antibiotics for mild and moderately severe acute pancreatitis is not associated with improvement in meaningful clinical outcomes.

Ureteric injury after lumbosacral microdiscectomy: A case report and review of literature.

Microdiscectomy is considered a very safe procedure with few serious complications. Ureteric injury following microdiscectomy is rarely reported in the literature. We report a rare case of iatrogenic ureteric injury following L5-S1 microdiscectomy for prolapsed intervertebral disc which was detected early and managed in time.

Production of thermal insulation blocks from bottom ash of fluidized bed combustion system.

The issues of disposal and environmental problems are increased by the generation of bottom ash from the thermal power plants day by day; hence, its recycling is required. The present study aimed to make thermal insulation blocks using as raw material bottom ash and iron ore slime as a binder and to characterize their engineering properties. Two different fineness values of bottom ash were considered with varying amounts of iron ore slime (0-10%) to make the blocks. Blocks were dried followed by firing at 1000, 1100 and 1200°C, respectively. Cold crushing strength, density and thermal conductivity of these fired blocks showed increasing behaviour with firing temperature, fineness of bottom ash and iron ore slime content. In contrast, a reverse trend was observed in the case of porosity. With increasing firing temperature, the formation of lower melting phases like iron silicate followed by iron aluminium silicate was observed, which imparts the strength inside the blocks. The coarser particles of bottom ash increase the interparticle spaces, which enhances the apparent porosity, resulting in higher thermal insulation property in the blocks. Blocks having better thermal insulation property could be possible to make effectively from coarse bottom ash by adding iron ore slime as a binder.

Growing Teratoma Syndrome.

Growing teratoma syndrome, a disease characterized by presence of benign metastasis increasing in size and number after chemotherapy, is infrequent occurrence. Being unfamiliar with the disease entity, many oncologists misinterpret it as disease progression. Though the exact etio-pathognesis of the disease is still unidentified, but clinical characteristics are well defined. Being a chemo and radio-resistant disease, surgery offers only cure. We present a case of ovarian immature teratoma, who after chemotherapy presented with increased tumor size. Resected specimen confirms the diagnosis of mature teratoma leading to recognition of GTS. Surgery resulted in cure.

SINE polymorphism reveals distinct strains of Entamoeba histolytica from North India.

Entamoeba histolytica is an intestinal parasite causing significant morbidity and mortality in the developing world. More tools are needed to understand the epidemiology and molecular pathogenesis of amebiasis. Virulence pattern of E. histolytica could be linked with the genotype of a strain. Several loci showing insertion polymorphism of retrotransposable short interspersed nuclear elements EhSINE1 and EhSINE2 have been reported among laboratory strains of E. histolytica. The present study was undertaken to validate this observation in clinical isolates from north India. Our results indicate that the Indian samples show a different propensity of SINE retention or loss at two of the polymorphic loci compared with non-Indian samples. Statistical analysis of different loci revealed Locus 17 of EhSINE1as a potential geographical marker for distinguishing Indian isolates from non Indian isolates.

Postradiotherapy small cell neuroendocrine carcinoma of base of tongue: An unusual clinical and site presentation.

Small cell neuroendocrine carcinoma (NEC) of the tongue is an extremely rare entity with only seven cases reported in literature till date. These are high-grade tumors with a dismal prognosis. There is much ambiguity regarding the classification, treatment protocols and prognostic factors of these tumors due to the paucity of studies. We describe an exceptionally rare and unusual case of small cell NEC of the base of tongue arising in an elderly man 6 years after receiving radiotherapy for the treatment of squamous cell carcinoma at the same site. The diagnosis was confirmed on histopathological examination and supported by immunohistochemical positivity for neuron-specific enolase, synaptophysin, chromogranin, pan-cytokeratin, and cytokeratin 7. To the best of our knowledge, this is the first case of intraoral NEC arising many years later within the irradiated field of the initial tumor.