Why do patients with limb ischaemia present late to a vascular surgeon? A prospective cohort study from the developing world

OBJECTIVE: To look into the factors responsible for delay in presentation of Iimb ischemia patients to a vascular surgeon. METHODS: The prospective cohort study was conducted at the Aga Khan University Hospital, Karachi, from October 01, 2016, to August 10, 2018. Patients coming with delayed presentation of both acute and chronic limb ischemia were included. All the patients were assessed by qualified vascular surgeons. SPSS 23 was used for data analysis. RESULTS: Of the 55 patients, 33(60%) had acute and 22(40%) had chronic limb ischaemia. Mean age of acute cases was 44±23.72 years and it was 60±12.49 years for chronic cases. Overall, the commonest reason behind delay was non-referral by primary physician which was the case with 11(33.3%) patients in the acute group, and 13(59%) in the chronic group. The limb loss in the acute group was 20(60%) and 8(36%) in the chronic group.. CONCLUSION: Delayed presentation of patients with limb ischaemia is mainly due to non-referral. A robust campaign needs to be launched to reduce the rate of limb loss

Surface-Functionalized Magnetic Silica-Malachite Tricomposite (Fe-M-Si tricomposite): A Promising Adsorbent for the Removal of Cypermethrin

This study assessed the efficacy of adsorption for eliminating the agricultural pesticide cypermethrin (CP) from wastewater using various adsorbents: silica, malachite, and magnetite. Magnetic nanocomposites (NCs) (with varying amounts of Fe3O4 0.1, 0.25, 0.5, 1.0, and 1.5 wt/wt %) were synthesized, including Fe3O4 nanoparticles (NPs), bicomposites, and tricomposites, calcined at 300 and 500 °C, and then tested for CP removal. The study was conducted in two phases, with the objective of initially assessing how effectively each individual NP performed and then evaluating how effectively the NCs performed when used for the adsorption of CP. Notably, the Fe3O4–malachite combination exhibited superior CP removal, with the 0.25-Fe–M NC achieving the highest adsorption at 635.4 mg/g. This success was attributed to the large surface area, magnetic properties of Fe3O4, and adsorption capabilities of malachite. The Brunauer–Emmett–Teller (BET) isotherm analysis indicated that the NCs had potential applications in adsorption and separation processes. The scanning electron microscopy and transmission electron microscopy revealed the spherical, irregular shaped morphology of the synthesized NPs and NCs. However, the X-ray diffraction (XRD) pattern of surface functionalized materials such as surface functionalized malachite [Cu2CO3(OH)2] with Fe3O4 and SiO2 may be complicated by the specific functionalization method used and the relative amounts and crystallographic orientations of each component. Therefore, careful interpretation and analysis of the XRD pattern, along with other techniques, are necessary for accurate identification and characterization of the functionalized material. The originality of this study lies in its comprehensive investigation of several adsorbents and NCs for CP removal at neutral pH. The innovation stems from the synergistic action of Fe3O4 and malachite, which results in improved CP removal due to their combined surface properties and magnetic characteristics. The application of magnetic NCs in adsorption and separation, as validated by BET isotherm analysis, highlights the potential breakthrough in addressing pesticide contamination

Enhancement of Solar PV Hosting Capacity in a Remote Industrial Microgrid: A Methodical Techno-Economic Approach

To meet the zero-carbon electricity generation target as part of the sustainable development goals (SDG7), remote industrial microgrids worldwide are considering the uptake of more and more renewable energy resources, especially solar PV systems. Estimating the grid PV hosting capacity plays an essential role in designing and planning such microgrids. PV hosting capacity assessment determines the maximum PV capacity suitable for the grid and the appropriate electrical location for PV placement. This research reveals that conventional static criteria to assess the PV hosting capacity fail to ensure the grid’s operational robustness. It hence demands a reduction in the theoretical hosting capacity estimation to ensure grid compatible post-fault voltage and frequency recovery. Energy storage technologies, particularly fast-responsive batteries, can potentially prevent such undesirable scenarios; nevertheless, careful integration is required to ensure an affordable cost of energy. This study proposes a novel methodical techno-economic approach for an off-grid remote industrial microgrid to enhance the PV hosting capacity by integrating battery energy storage considering grid disturbance and recovery scenarios. The method has been validated in an industrial microgrid with a 2.6 MW peak demand in a ready-made garment (RMG) factory having a distinctive demand pattern and unique constraints in remote Bangladesh. According to the analysis, integrating 2.5 MW of PV capacity and a 1.2 MVA battery bank to offset existing diesel and grid consumption would result in an energy cost of BDT 14.60 per kWh (USD 0.1719 per kWh). For high PV penetration scenarios, the application of this method offers higher system robustness, and the financial analysis indicates that the industries would not only benefit from positive environmental impact but also make an economic profit

Antimicrobial resistance among migrants in Europe: a systematic review and meta-analysis

BACKGROUND: Rates of antimicrobial resistance (AMR) are rising globally and there is concern that increased migration is contributing to the burden of antibiotic resistance in Europe. However, the effect of migration on the burden of AMR in Europe has not yet been comprehensively examined. Therefore, we did a systematic review and meta-analysis to identify and synthesise data for AMR carriage or infection in migrants to Europe to examine differences in patterns of AMR across migrant groups and in different settings. METHODS: For this systematic review and meta-analysis, we searched MEDLINE, Embase, PubMed, and Scopus with no language restrictions from Jan 1, 2000, to Jan 18, 2017, for primary data from observational studies reporting antibacterial resistance in common bacterial pathogens among migrants to 21 European Union-15 and European Economic Area countries. To be eligible for inclusion, studies had to report data on carriage or infection with laboratory-confirmed antibiotic-resistant organisms in migrant populations. We extracted data from eligible studies and assessed quality using piloted, standardised forms. We did not examine drug resistance in tuberculosis and excluded articles solely reporting on this parameter. We also excluded articles in which migrant status was determined by ethnicity, country of birth of participants' parents, or was not defined, and articles in which data were not disaggregated by migrant status. Outcomes were carriage of or infection with antibiotic-resistant organisms. We used random-effects models to calculate the pooled prevalence of each outcome. The study protocol is registered with PROSPERO, number CRD42016043681. FINDINGS: We identified 2274 articles, of which 23 observational studies reporting on antibiotic resistance in 2319 migrants were included. The pooled prevalence of any AMR carriage or AMR infection in migrants was 25·4% (95% CI 19·1-31·8; I2 =98%), including meticillin-resistant Staphylococcus aureus (7·8%, 4·8-10·7; I2 =92%) and antibiotic-resistant Gram-negative bacteria (27·2%, 17·6-36·8; I2 =94%). The pooled prevalence of any AMR carriage or infection was higher in refugees and asylum seekers (33·0%, 18·3-47·6; I2 =98%) than in other migrant groups (6·6%, 1·8-11·3; I2 =92%). The pooled prevalence of antibiotic-resistant organisms was slightly higher in high-migrant community settings (33·1%, 11·1-55·1; I2 =96%) than in migrants in hospitals (24·3%, 16·1-32·6; I2 =98%). We did not find evidence of high rates of transmission of AMR from migrant to host populations. INTERPRETATION: Migrants are exposed to conditions favouring the emergence of drug resistance during transit and in host countries in Europe. Increased antibiotic resistance among refugees and asylum seekers and in high-migrant community settings (such as refugee camps and detention facilities) highlights the need for improved living conditions, access to health care, and initiatives to facilitate detection of and appropriate high-quality treatment for antibiotic-resistant infections during transit and in host countries. Protocols for the prevention and control of infection and for antibiotic surveillance need to be integrated in all aspects of health care, which should be accessible for all migrant groups, and should target determinants of AMR before, during, and after migration. FUNDING: UK National Institute for Health Research Imperial Biomedical Research Centre, Imperial College Healthcare Charity, the Wellcome Trust, and UK National Institute for Health Research Health Protection Research Unit in Healthcare-associated Infections and Antimictobial Resistance at Imperial College London

Surgical site infection after gastrointestinal surgery in high-income, middle-income, and low-income countries: a prospective, international, multicentre cohort study

Background: Surgical site infection (SSI) is one of the most common infections associated with health care, but its importance as a global health priority is not fully understood. We quantified the burden of SSI after gastrointestinal surgery in countries in all parts of the world. Methods: This international, prospective, multicentre cohort study included consecutive patients undergoing elective or emergency gastrointestinal resection within 2-week time periods at any health-care facility in any country. Countries with participating centres were stratified into high-income, middle-income, and low-income groups according to the UN's Human Development Index (HDI). Data variables from the GlobalSurg 1 study and other studies that have been found to affect the likelihood of SSI were entered into risk adjustment models. The primary outcome measure was the 30-day SSI incidence (defined by US Centers for Disease Control and Prevention criteria for superficial and deep incisional SSI). Relationships with explanatory variables were examined using Bayesian multilevel logistic regression models. This trial is registered with ClinicalTrials.gov, number NCT02662231. Findings: Between Jan 4, 2016, and July 31, 2016, 13 265 records were submitted for analysis. 12 539 patients from 343 hospitals in 66 countries were included. 7339 (58·5%) patient were from high-HDI countries (193 hospitals in 30 countries), 3918 (31·2%) patients were from middle-HDI countries (82 hospitals in 18 countries), and 1282 (10·2%) patients were from low-HDI countries (68 hospitals in 18 countries). In total, 1538 (12·3%) patients had SSI within 30 days of surgery. The incidence of SSI varied between countries with high (691 [9·4%] of 7339 patients), middle (549 [14·0%] of 3918 patients), and low (298 [23·2%] of 1282) HDI (p < 0·001). The highest SSI incidence in each HDI group was after dirty surgery (102 [17·8%] of 574 patients in high-HDI countries; 74 [31·4%] of 236 patients in middle-HDI countries; 72 [39·8%] of 181 patients in low-HDI countries). Following risk factor adjustment, patients in low-HDI countries were at greatest risk of SSI (adjusted odds ratio 1·60, 95% credible interval 1·05–2·37; p=0·030). 132 (21·6%) of 610 patients with an SSI and a microbiology culture result had an infection that was resistant to the prophylactic antibiotic used. Resistant infections were detected in 49 (16·6%) of 295 patients in high-HDI countries, in 37 (19·8%) of 187 patients in middle-HDI countries, and in 46 (35·9%) of 128 patients in low-HDI countries (p < 0·001). Interpretation: Countries with a low HDI carry a disproportionately greater burden of SSI than countries with a middle or high HDI and might have higher rates of antibiotic resistance. In view of WHO recommendations on SSI prevention that highlight the absence of high-quality interventional research, urgent, pragmatic, randomised trials based in LMICs are needed to assess measures aiming to reduce this preventable complication

Primitive myxoid mesenchymal tumor of infancy with brain metastasis: First reported case

Introduction: Primitive myxoid mesenchymal tumor of infancy (PMMTI) is a recently diagnosed entity, with only a handful of cases reported to date. Case description: Herein, we present the occurrence of this tumor in a 2-year-old boy, initially diagnosed as primitive neuroectodermal tumor of the extremity and treated with chemotherapy and surgical resection. He later presented with a cerebellar lesion, and biopsy was consistent with PMMTI: Conclusion: While there have been previous cases of PMMTI reported with loco-regional metastatic spread, to our knowledge, there is no known incidence of distant metastasis with involvement of the central nervous system, which makes this case the first of its kind

Correction: Samad, N., et al. Behavioral and Biochemical Effects of Mukia madrespatana Following Single Immobilization Stress in Rats. Medicina 2020, 56, 350

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Operative techniques to prevent dialysis access-associated steal syndrome in high-risk patients undergoing surgery for hemodialysis access: A systematic review

Up to 10% of patients suffer from various degrees of dialysis access-associated steal syndrome (DASS) after surgery for hemodialysis access. This systematic review was conducted to find out optimal intra-operative techniques to prevent DASS in high-risk patients. This systematic review is registered with PROSPERO (2017:CRD42017060804). It was conducted at Department of Surgery, Aga Khan University Hospital, Karachi. All types of studies conducted on intra-operative techniques to prevent DASS in high-risk population (Age \u3e 60 years, female gender, diabetes mellitus, peripheral arterial disease and previous DASS) undergoing access creation from January 1990 till April 2019 were included in the systematic review. Thorough search was conducted on Pubmed, Google Scholar and Cochrane databases to identify relevant articles. Included studies reviewed for success of various techniques to prevent dialysis access steal syndrome are summarized. Out of 125 studies in the initial search, six met the inclusion criteria. Five were retrospective case series while one was a case report. The largest study sample size was 32. All but one study had arterio-venous access creation on an arm. Proximalization of arterial inflow was described in three and prophylactic distal revascularization and interval ligation (DRIL) procedure in two studies to prevent DASS. Only one patient out of these studies developed DASS at an overall follow-up of 7-42 months. Proximalization of inflow has been reported as the most common procedure performed to prevent DASS followed by extension technique and DRIL procedure. All three procedures have satisfactory outcome with no clear superiority of one over the other