Health care seeking among individuals with cough and tuberculosis: a population-based study from rural India.

SETTING: Ujjain district, Madhya Pradesh, India. OBJECTIVE: To describe and compare health care seeking among men and women with cough of >3 weeks, with special focus on the utilisation of private and public health care. DESIGN: A population-based cross-sectional survey including 45 719 individuals aged > or = 15 years. RESULTS: The prevalence of cough was respectively 2.8% and 1.2% among men and women. The majority of men and women reported seeking health care for their symptoms (69% vs. 71%), but only 23% visited a public provider at some point during their illness. A similar health care seeking pattern was found for patients diagnosed with tuberculosis (TB) in our survey. No significant differences in health care seeking were found between men and women. Only 13% of those seeking care reported having had a sputum smear examination since the onset of cough. Factors associated with sputum examination were history of TB, haemoptysis and visiting a public provider. CONCLUSION: The low utilisation of public health care services and the few sputum examinations reported in this rural Indian setting illustrate the need for improved diagnostic practices as well as involvement of private providers in TB control activities.     

Mechanism of antithrombin III inhibition of factor VIIa/tissue factor activity on cell surfaces. Comparison with tissue factor pathway inhibitor/factor Xa-induced inhibition of factor VIIa/tissue factor activity

Recent studies have shown that antithrombin III (AT III)/heparin is capable of inhibiting the catalytic activity of factor VIIa bound either to relipidated tissue factor (TF) in suspension or to TF expressed on cell surfaces. We report studies of the mechanism of which by AT III inhibits factor VIIa bound to cell surface TF and compare this inhibitory mechanism with that of tissue factor pathway inhibitor (TFPI)-induced inhibition of factor VIIa/TF. AT III alone and AT III/heparin to a greater extent reduced factor VIIa bound to cell surface TF. Our data show that the decrease in the amount of factor VIIa associated with cell surface TF in the presence of AT III was the result of (1) accelerated dissociation of factor VIIa from cell surface TF after the binding of AT III to factor VIIa/TF complexes and (2) the inability of the resultant free factor VIIa-AT III complexes to bind effectively to a new cell surface TF site. Binding of TFPI/factor Xa to cell surface factor VIIa/TF complexes markedly decreased the dissociation of factor VIIa from the resultant quaternary complex of factor VIIa/TF/TFPI/factor Xa. Addition of high concentrations of factor VIIa could reverse the AT III-induced inhibition of cell surface factor VIIa/TF activity but not TFPI/factor Xa-induced inhibition of factor VIIa/TF activity.     

Diabetic foot ulcers—where do we stand microbiologically?

Foot ulcers in diabetics are prone to polymicrobial infection by bacteria as well as fungi. Infection retards healing of ulcers leading to gangrene and ultimately, amputation of the extremity. The choice of empiric antibiotic therapy is extrapolated from results of studies from other regions, western literature or infection at other sites which may be inappropriate. Thus, a study was conducted to determine microbial aetiology of diabetic foot ulcers and their susceptibility patterns. Pus aspirates or wound swabs were collected from foot ulcers of 70 diabetics at the time of admission and processed for isolation of bacteria (aerobic and anaerobic) and fungi according to standard protocols. Organisms were identified upto species level. Antimicrobial susceptibility testing was performed by Kirby Bauer disk diffusion method as per CLSI standards. One hundred forty-seven organisms were isolated from 70 specimens. Seventy-three percent showed polymicrobial growth. The proportion of Gram negative bacilli, Gram positive cocci, anaerobes and fungi were 57 %, 27 %, 4 % and 12 % respectively. Enterobacteriaceae were the predominant Gram negative bacilli and S.aureus, the predominant Gram positive cocci. Clostridium and Candida species were the commonest among anaerobes and fungi respectively. Twenty-three percent of S.aureus were MRSA and 23 % of Enterobacteriaceae were ESBL producers. Ps.aeruginosa strains demonstrated good susceptibility to antipseudomonal antimicrobials and 16.5 % strains were meropenem resistant. Due to the associated risk of increased morbidity and mortality in infected diabetic ulcers, the wide spectrum of organisms associated with it and their differing susceptibility profile, treatment should be individualised based on microbial culture and antimicrobial susceptibility results.     

Neonatal Gastric Perforations: Are They Really Spontaneous?

Case Report

We report a case of 4-day-old male infant who developed rapid abdominal distension with progression to shock. Abdominal radiography showed free gas under diaphragm for which emergency laparotomy was done revealing a perforation in the greater curvature of the stomach that was sutured after excising surrounding ischemic stomach wall.     

Intrathoracic anastomosis after oesophageal resection for cancer

Cervical anastomosis has been advocated to avoid the pulmonary complications and life-threatening anastomotic disruptions following intrathoracic oesophagogastric anastomosis. This is a retrospective review of 111 oesophageal resections followed by an intrathoracic anastomosis. These resections were performed between September 1993 and August 1994 within a residency training program. The left thoracoabdominal approach was used for distal tumours and the Ivor Lewis technique for more proximal tumours. Squamous cell carcinoma accounted for 72% patients (n = 80), adenocarcinoma for 25% (n = 28), and others for 2.7% patients (n = 3). Of the patients, 69% had pathologic Stage III tumours. Operative mortality rate was 1.8% (two patients). Perioperative complications occurred in 39 patients, including anastomotic leak in 10 patients and myocardial infarction in 2 patients. In the absence of a leak, there were no major pulmonary complications requiring intensive care or ventilatory support. Of those patients with anastomotic disruption, 89% were salvaged by early clinical diagnosis and appropriate treatment. We conclude that transthoracic oesophagectomy with an intrathoracic anastomosis is a safe procedure that can be performed with low mortality and acceptable morbidity. © 1996 Wiley-Liss, Inc.     

Impact of a structured training program to enhance skills in phacoemulsification surgery

Purpose:The aim of this study was to determine whether the introduction of a structured short-term phacoemulsification training program improved the ICO-OSCAR (International Council of Ophthalmology’s Ophthalmology Surgical Competency Assessment Rubric) score and the learning curve of the trainees and decreased the complication rates of the cases.Methods:This study was a retrospective, observational study conducted in a tertiary eye care hospital in India. The study was conducted from March 2018 to October 2019 based on a structured phacoemulsification training program introduced in January 2019. The trainees enrolled in the phacoemulsification training program were divided into two groups: Group 1 (n = 33), who underwent training before the introduction of the structured program, and Group 2 (n = 29), who underwent the training after the introduction of the structured training program. Each trainee performed 20 cases. Group 1 training consisted of wet-lab and phacoemulsification surgeries. Group 2 training program comprised three modules over 5 weeks and a preassessment examination. Premodule 1 imparted cognitive skills; Module 1 was on structured wet-lab, Module 2 was about phacoemulsification step surgery, and Module 3 had independent complete surgeries. Group 2 also underwent compulsory Observation of cases being performed in the operation theater, surgical video recording review, and formative feedback. Mean OSCAR score comparison was done for both the groups. The OSCAR score was also calculated case-wise to obtain the learning curve with respect to the entry and exit levels, by classifying the trainees in each group as Novice, Beginner, Advanced Beginner, or Competent. A comparison of the posterior capsular rupture (PCR) rates and vision at discharge of all the cases was done.Results:Group 2 had a significantly better mean OSCAR score than Group 1 (4.03 and 3.43, respectively; P < 0.001). The PCR rate of the cases was significantly lower in Group 2 than in Group 1 (9.14% and 20.30%, respectively; P < 0.001). Group 2 had a significantly better visual acuity outcome of the cases than Group 1. Group 1 started as Novice (OSCAR score: 2), whereas Group 2 started as Beginner (OSCAR score: 3). Group 2 reached the Advanced Beginner level eight to 10 cases prior to Group 1.Conclusion:A structured training curriculum can make a significant difference in the training experience of the trainees and enable better surgical outcomes and a decrease in the complication rates.     

Implementation of amplitude-integrated electroencephalography in tertiary Canadian Neonatal Intensive Care Units—a longitudinal study

AimTo investigate the implementation of amplitude-integrated electroencephalography (aEEG) as bedside monitoring tool of cerebral function in tertiary Canadian Neonatal Intensive Care Units (NICU) over the past decade.MethodsLongitudinal study consisting of online surveys of neonatologists on the use of aEEG in 2009 and 2018.ResultsThe response rate to the survey was 72 of 149 (49%) in 2009 and 18 of 30 (60%) in 2018, respectively. aEEG has been implemented in almost all (2009: 62.5%; 2018: 94%) tertiary Canadian NICUs. Two-thirds (2009: 67%; 2018: 71%) of the respondents considered information from aEEG tracing helpful in clinical practice. The main indications for aEEG were term neonates with hypoxic ischemic encephalopathy (2009 and 2018: 76%) and seizure detection/surveillance (2009: 88%; 2018: 94%). Teaching on aEEG has been implemented for neonatologists (2018: 100%) and health care providers (2018: 50%) in tertiary Canadian NICUs but there is a lack of standardization of training. Use of aEEG in preterm neonates (2009: 37%, 2018: 33%) and application of aEEG in research (18% reported occasional use) is less common.ConclusionaEEG is well established in tertiary Canadian NICUs to monitor cerebral function and detect seizure activity. There is a need to develop formalized aEEG training programs and methods to assess competence. Further implementation of aEEG in preterm neonates and research is desirable.