Managing the Injury Burden in Nepal

Nepal loses about 530,000 disability adjusted life years (DALYs) per year to injury, predominantly due to falls. It takes 30,000 Nepali rupees (NR), or approximately US$430 at 70 rupees per $US saved per DALY to achieve primary prevention and 6000 NR per DALY if we invest in hospitals, versus 1000 NR invested in prehospital care, because simpler less expensive actions performed early have a greater impact on outcome than more complex measures later. A system for prehospital services was planned for medical emergencies at a national level meeting at the Medical University of Nepal to promote healthcare to victims in inaccessible regions by empowered or enlightened citizens. Feasible actions for common emergencies were defined and a tutorial required to help the majority of such victims was created and packaged. The knowledge and attitude component of the tutorial will be delivered through a web site to citizens motivated to learn and help with emergencies. The knowledge will be tested through a net-based Multiple Choice Questions (MCQ) test. Practical training in medical triage skills will be provided to those who qualify for the test at the University or its designated affiliates. A mobile phone-based information system will be created and used to make these enlightened citizens available to the victim at the site/time of the emergency. Each author certifies that he or she has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article.

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Preferences for in-person disclosure: Patients declining telephone disclosure characteristics and outcomes in the multicenter Communication Of GENetic Test Results by Telephone study

Telephone disclosure of cancer genetic test results is noninferior to in-person disclosure. However, how patients who prefer in-person communication of results differ from those who agree to telephone disclosure is unclear but important when considering delivery models for genetic medicine. Patients undergoing cancer genetic testing were recruited to a multicenter, randomized, noninferiority trial (NCT01736345) comparing telephone to in-person disclosure of genetic test results. We evaluated preferences for in-person disclosure, factors associated with this preference and outcomes compared to those who agreed to randomization. Among 1178 enrolled patients, 208 (18%) declined randomization, largely given a preference for in-person disclosure. These patients were more likely to be older (P = 0.007) and to have had multigene panel testing (P < 0.001). General anxiety (P = 0.007), state anxiety (P = 0.008), depression (P = 0.011), cancer-specific distress (P = 0.021) and uncertainty (P = 0.03) were higher after pretest counseling. After disclosure of results, they also had higher general anxiety (P = 0.003), depression (P = 0.002) and cancer-specific distress (P = 0.043). While telephone disclosure is a reasonable alternative to in-person disclosure in most patients, some patients have a strong preference for in-person communication. Patient age, distress and complexity of testing are important factors to consider and requests for in-person disclosure should be honored when possible.     

Anti-Mullerian Hormone: A New Marker of Ovarian Function

Objectives

The aim of this study was to determine day 3 Serum AMH, FSH, LH, Estradiol (E₂), Inhibin B levels, ovarian volume, and antral follicular count to assess ovarian function.

Methods

This study was conducted on 130 infertile women between age 18 and 43 years. Day 3 Serum AMH level was estimated by sandwich enzyme immunoassay; Serum FSH, S. LH, S. E₂, by solid-phase two-site chemiluminescent immunometric assay; Inhibin B by ELISA; and Ovarian volume and AFC, by transvaginal ultrasonography.

Results

With advancing age, Serum AMH level (p < 0.0001), AFC (p < 0.05), ovarian volume (>0.05), and Inhibin B (>0.05) were decreased, and Serum FSH (p < 0.05), LH (p > 0.05), and E₂ (p < 0.05) were increased. Serum AMH level was 4–6.8 ng/ml with optimal fertility in 26.15 % cases and 2.2–4.0 ng/ml with satisfactory fertility in 53.85 % cases. Serum AMH levels were more strongly correlated with AFC (p < 0.0001) and ovarian volume (p < 0.0001).

Conclusion

Serum AMH levels were more robustly correlated with AFC than FSH, LH, E₂, and Inhibin B on day 3 of the cycle. This suggested that serum AMH might be taken as single test to reflect ovarian reserve.     

Epidemiology of breast cancer in Indian women

Breast cancer has ranked number one cancer among Indian females with age adjusted rate as high as 25.8 per 100,000 women and mortality 12.7 per 100,000 women. Data reports from various latest national cancer registries were compared for incidence, mortality rates. The age adjusted incidence rate of carcinoma of the breast was found as high as 41 per 100,000 women for Delhi, followed by Chennai (37.9), Bangalore (34.4) and Thiruvananthapuram District (33.7). A statistically significant increase in age adjusted rate over time (1982–2014) in all the PBCRs namely Bangalore (annual percentage change: 2.84%), Barshi (1.87%), Bhopal (2.00%), Chennai (2.44%), Delhi (1.44%) and Mumbai (1.42%) was observed. Mortality‐to‐incidence ratio was found to be as high as 66 in rural registries whereas as low as 8 in urban registries. Besides this young age has been found as a major risk factor for breast cancer in Indian women. Breast cancer projection for India during time periods 2020 suggests the number to go as high as 1797900. Better health awareness and availability of breast cancer screening programmes and treatment facilities would cause a favorable and positive clinical picture in the country.     

Is prophylactic placement of drains necessary after subtotal gastrectomy？

AIM： To determine the evidence-based values of prophylactic drainage in gastric cancer surgery.
METHODS： One hundred and eight patients, who underwent subtotal gastrectomy with D1 or D2 lymph node dissection for gastric cancer between January 2001 and December 2005, were divided into drain group or no-drain group. Surgical outcome and post-operative complications within four weeks were compared between the two groups.
RESULTS： No significant differences were observed between the drain group and no-drain group in terms of operating time （171 ± 42 rain vs 156 ± 39 rain）, number of post-operative days until passage of flatus （3.7 ± 0.5 d vs 3.5 ± 1.0 d）, number of post-operative days until initiation of soft diet （4.9±0.7 d vs 4.8±0.8 d）, length of post-operative hospital stay （9.3±2.2 d vs 8.4±2.4 d）, mortality rate （5.4% vs 3.8%）, and overall postoperative complication rate （21.4% vs 19.2%）.
CONCLUSION： Prophylactic drainage placement is not necessary afer subtotal gastrectomy for gastric cancer since it does not offer additional benefits for the patients.     

Celiac Disease with Splenic Calcifications

Celiac disease is an immune mediated enteropathy due to irreversible gluten sensitivity. It has protean manifestations involving gastrointestinal (GI) as well as non GI manifestations. Calcifications in the cerebral cortex are well defined entity in celiac disease known as CEC syndrome (Celiac disease, Epilepsy and Cerebral Calcification). Calcification has not been described in any other organ. Splenic calcifications are a rare manifestation in childhood. The authors are reporting a case of celiac disease with multiple foci of calcification in the spleen without evidence of cerebral calcification.     

Foreign Body Esophagus: When Endoscopic Removal Fails…

Aspiration or ingestion of a foreign body has frequently been reported in the pediatric and in the adult population. Among many foreign bodies to be ingested, artificial denture is one to be impacted in the esophagus, especially among the elderly. Radiolucency of dental prosthesis complicates early diagnosis of an impacted or ingested dental prosthesis. Rigid and flexible esophagoscopes have been used to retrieve the foreign body from the esophagus but the need for open surgery to remove the foreign body as a rescue procedure to endoscopy or the primary procedure has not been well defined. Here we report a case of impacted foreign body esophagus which was managed primarily by surgery and another case where surgery was performed after trials of endoscopic approach had failed.