One solution to the arsenic problem: a return to surface (improved dug) wells

Arsenic contamination in drinking-water in Bangladesh is a major catastrophe, the consequences of which exceed most other man-made disasters. The national policy encourages the use of surface water as much as possible without encountering the problems of sanitation that led to the use of groundwater in the first place. This paper describes the success of the Dhaka Community Hospital (DCH) team and the procedure in implementing sanitary, arsenic-free, dugwells. The capital cost for running water is US$ 5-6 per person. Sixty-six sanitary dugwells were installed in phases between 2000 and 2004 in Pabna district of Bangladesh where there was a great need of safe water because, in some villages, 90% of tubewells were highly contaminated with arsenic. In total, 1,549 families now have access to safe arsenic-free dugwell water. Some of them have a water-pipe up to their kitchen. All of these were implemented with active participation of community members. They also pay for water-use and are themselves responsible for the maintenance and water quality. The DCH helped the community with installation and maintenance protocol and also with monitoring water quality. The bacteria levels are low but not always zero, and studies are in progress to reduce bacteria by chlorination.     

Thromboembolism after treatment with 4-factor prothrombin complex concentrate or plasma for warfarin-related bleeding

Limited data exist in large, representative populations about whether the risk of thromboembolic events varies after receiving four-factor human prothrombin complex concentrate (4F-PCC) versus treatment with human plasma for urgent reversal of oral vitamin K antagonist therapy. We conducted a multicenter observational study to compare the 45-day risk of thromboembolic events in adults with warfarin-associated major bleeding after treatment with 4F-PCC (Kcentra®) or plasma. Hospitalized patients in two large integrated healthcare delivery systems who received 4F-PCC or plasma for reversal of warfarin due to major bleeding from January 1, 2008 to March 31, 2020 were identified and were matched 1:1 on potential confounders and a high-dimensional propensity score. Arterial and venous thromboembolic events were identified up to 45 days after receiving 4F-PCC or plasma from electronic health records and adjudicated by physician review. Among 1119 patients receiving 4F-PCC and a matched historical cohort of 1119 patients receiving plasma without a recent history of thromboembolism, mean (SD) age was 76.7 (10.5) years, 45.6% were women, and 9.4% Black, 14.6% Asian/Pacific Islander, and 15.7% Hispanic. The 45-day risk of thromboembolic events was 3.4% in those receiving 4F-PCC and 4.1% in those receiving plasma (P = 0.26; adjusted hazard ratio 0.76; 95% confidence interval 0.49–1.16). The adjusted risk of all-cause death at 45 days post-treatment was lower in those receiving 4F-PCC compared with plasma. Among a large, ethnically diverse cohort of adults treated for reversal of warfarin-associated bleeding, receipt of 4F-PCC was not associated with an excess risk of thromboembolic events at 45 days compared with plasma therapy.

     

Use of fibula pedicle as a composite interposition vascular graft to salvage large skin paddle with anomalous vascular supply

We report a case of free fibula osteomyocutaneous flap whose skin paddle had a dominant blood supply from a soleus musculocutaneous perforator which originated in the posterior tibial artery in addition to contribution from the peroneal septocutaneous perforators and was managed by two sets of anastomosis on either side of the neck, one for the peroneal vessels and the other for the dominant musculocutaneous perforator. The second anastomosis was achieved by using the excess length of the flap pedicle vessels (peroneal) as composite (both artery and vein) autologous interposition vascular graft to reach the opposite side of the neck.     

Comparative Study Between Omentopexy and Omental Plugging in Treatment of Giant Peptic Perforation

Giant peptic perforation is a life threatening surgical emergency with high mortality.. This study aims to compare the success rate between omental plugging and standard omentopexy in the emergency management of giant perforations. A prospective non-randomized study of 23 patients with giant peptic perforation (≥2 cm in diameter) was carried out over a period of 18 months. The highest incidence was seen in the age group of 41–50 years. Intestinal fistula occurred in 23.08% of the omentopexy group compared to none in the omental plugging group. The mean hospital stay was slightly higher in the omentopexy group. Three patients died in the omentopexy group post operatively after 24 h compared to none in the omental plugging group and this was statistically significant (p < 0.05). Omental plugging is associated with lesser morbidity and mortality compared to omentopexy in the management of giant peptic perforations.     

Long-term neurological and functional outcome in Nipah virus infection

OBJECTIVE: Nipah virus (NiV) is an emerging zoonosis. Central nervous system disease frequently results in high case-fatality. Long-term neurological assessments of survivors are limited. We assessed long-term neurologic and functional outcomes of 22 patients surviving NiV illness in Bangladesh. METHODS: During August 2005 and May 2006, we administered a questionnaire on persistent symptoms and functional difficulties to 22 previously identified NiV infection survivors. We performed neurologic evaluations and brain magnetic resonance imaging (MRI). RESULTS: Twelve (55%) subjects were male; median age was 14.5 years (range 6-50). Seventeen (77%) survived encephalitis, and 5 survived febrile illness. All but 1 subject had disabling fatigue, with a median duration of 5 months (range, 8 days-8 months). Seven encephalitis patients (32% overall), but none with febrile illness had persistent neurologic dysfunction, including static encephalopathy (n = 4), ocular motor palsies (2), cervical dystonia (2), focal weakness (2), and facial paralysis (1). Four cases had delayed-onset neurologic abnormalities months after acute illness. Behavioral abnormalities were reported by caregivers of over 50% of subjects under age 16. MRI abnormalities were present in 15, and included multifocal hyperintensities, cerebral atrophy, and confluent cortical and subcortical signal changes. INTERPRETATION: Although delayed progression to neurologic illness following Nipah fever was not observed, persistent fatigue and functional impairment was frequent. Neurologic sequelae were frequent following Nipah encephalitis. Neurologic dysfunction may persist for years after acute infection, and new neurologic dysfunction may develop after acute illness. Survivors of NiV infection may experience substantial long-term neurologic and functional morbidity.     

Free anterolateral thigh flap for reconstruction of complex craniofacial defects after resection of tumors of the fronto-orbitomaxillary complex

Tumors of the fronto-orbitomaxillary segment are complex and pose a significant challenge for radical resection and subsequent reconstruction. With evolution in surgical reconstructive techniques, better reconstruction of these complex defects is now possible and facilitates more aggressive surgical management. The anterolateral thigh (ALT) flap has features particularly suited for this reconstruction. We review our single institutional experience with this technique. Sixteen consecutive patients with defects of the fronto-orbitomaxillary segment (from radical resection of craniofacial tumors of this region) were reconstructed using the free ALT flap. The demographic features, radiology, histology, and surgical technique as well as the perioperative events were reviewed retrospectively from a prospective database of all craniofacial resections performed. There were 9 males and 7 females with a mean age of 35 years. Eleven had previously undergone surgery. Dura was resected in 6 and inadvertently breached in another 2. Gross total resection was achieved in 14 (87.5%) of the 16 patients, of which 8 had microscopically negative margins. Thirteen musculocutaneous flaps and 3 chimeric flaps were performed. The mean duration of surgery was 9.4 hours. The average total blood loss was 2000 mL. There was no perioperative mortality. Major complications occurred in 2 patients in the form of venous thrombosis on the next day of surgery. These were detected and salvaged promptly by urgent re-exploration and redo of venous anastomosis, ultimately requiring skin grafting for partial flap loss. In our experience, the free ALT flap is a suitable reconstructive choice for complex craniofacial defects and has favorable results.     

Bridging the Gap for Nonmetropolitan STEMI Patients Through Implementation of a Pharmacoinvasive Reperfusion Strategy

Background

Timely primary percutaneous coronary intervention (PCI) is the preferred reperfusion strategy in ST-elevation myocardial infarction (STEMI). However, universal access is limited outside metropolitan centres and portends worse outcomes for rural patients. This study evaluates the outcomes of STEMI patients treated in a metropolitan and nonmetroplitan setting within Vital Heart Response, an integrated reperfusion program developed to reduce reperfusion delay in Central and Northern Alberta.

Methods

From October 2006 to March 2011, data on consecutive STEMI patients was prospectively recorded. Clinical characteristics, in-hospital management, and outcomes grouped by site of presentation are described.

Results

There were 1990 metropolitan and 1602 nonmetropolitan STEMI patients. Metropolitan were older (62.7 vs 60.4 years; P < 0.001) and had more: angina (21.2% vs 16.5%; P < 0.001), dyslipidemia (45.3% vs 39.6%; P = 0.001), and hypertension (49.9% vs 46.6%; P = 0.047). The reperfusion strategy for metropolitan and nonmetropolitan: primary PCI (57.4% vs 22.9%; P < 0.001), fibrinolysis (26.3% vs 61.2%; P < 0.001), and no reperfusion (16.3% vs 15.9%; P = 0.855). First medical contact to reperfusion was delayed in nonmetropolitan with fibrinolysis and PCI, 8 and 125 minutes. A rescue PCI or coronary angiography within 24 hours was completed in 41.4% and 46.2%, respectively. Nonmetropolitan patients had fewer deaths (4.1% vs 6.8%; P = 0.001) with no difference in the composite outcome (death, reinfraction, congestive heart failure, cardiogenic shock) (16.8% vs 15.1%; P = 0.161) or major bleeding (7.9% vs 8.0%; P = 0.951).

Conclusions

Systematic application of a pharmacoinvasive strategy appears to be safe and effective for patients in whom a delay in mechanical reperfusion is anticipated.