Studies in the Brahmanas.

The study is concerned in the first place with an investigation of evidence for clan exogamy during the period of the Brahmanas, an the allied question of relationship-terminology. In the second place it deals with an elucidation of the complex problem of the Vratyas. An intermediary chapter is devoted to a description of the social and functional groups. Finally, a discussion of the available evidence for 'sapinda' restrictions is added. With regard to clan exogamy the word 'Aril in the Rgveda is of particular significance. 'Jana' and 'jami in the Brahmanas have also been found to be of similar importance in as such as the former signifies the marriage- able exogamous group and the latter the non-marriageable group. In the context of relationship-terminology the words 'agredidhisu' (the woman wooed before) 'didhistrpatil (the husband of 'agredidhisu') 'parivitta' (the unmarried elder brother) 'parivividana' (the younger brother married while the elder brother remains a bachelor) 'anujavara' (the posthumous son, or the younger brother of inferior status) 'bhrarvya' (the brother-in-law) and 'sajata' (fellow-clansman), are analysed. Amon the social and functional groups the distinction between those of the 'Taksan' and the 'Rathakgra' has be-n noticed. In dealing with the problem of the 'Vratyast', firstly former contributions in this field have be n reviewed in detail. Secondly, previous suggestions in connection with the etymologioal explanation of the word Vratyal have been considered. Thirdly, it has been pointed out that the 'Viatya' book of the Atharvaveda is, in all probability, compiled from fragments of a lost Brahmana text. Fourthly, the references to the 'Vratyas' in the Tandya and Jaiminiya have been duly noted and inter-pretations hitherto proposed, scrutinised. Lastly, the conolusion is arrived at, that the 'Vratyas were non-Brahmanical Aryans, possibly similar to the Ksatriyas, and having alien ritual practices. In conclusion it has been conjectured that the passage in the Satapatha bearing on 'Sapiada' restrictions ex-presses diapproval of the marriage-practice to which it refers

A service evaluation of FIT and anaemia for risk stratification in the two week wait pathway for colorectal cancer

Introduction: New national guidance on urgent referral for investigation for Colorectal Cancer (CRC) included faecal occult blood testing in 2015. We evaluated faecal immunochemical testing (FIT) and anaemia as risk stratification tools in symptomatic patients suspected of having CRC.Methods: Postal FIT was incorporated into the CRC two week wait (2WW) pathway for all patients without rectal bleeding in 2016. Patients were investigated in the 2WW pathway as normal and outcomes of investigations were prospectively recorded. Anaemia was defined as haemoglobin less than 120g/L in women and less than 130g/L in men.Results: FIT kits were sent to 1106 patients with an 80.9% return rate; 810 patients completed investigation with 40 CRCs diagnosed (4.9%). Median FIT results were significantly higher in patients who were anaemic (median 4.8 iqr 0.8-34.1 versus 1.2 iqr 0-6.4, Mann-Whitney p less than 0.001).Some 538 (60.4%) had a result of less than 4 µgHb/gFaeces (limit of detectability) and 621 (69.7%) a result less than 10 µgHb/gFaeces. Sixty per cent of CRCs had a FIT reading of >150 µgHb/gFaeces. Five CRCs diagnosed in patients with a FIT4 µgHb/gFaeces had 97.5% sensitivity and 64.5% specificity for CRC diagnosis. A FIT result of >4 µgHb/gFaeces and/or anaemia had a 100% sensitivity and 45.3% specificity for CRC diagnosis.Conclusion: FIT is most useful at the extremes of detectability; strongly positive readings predict high rates of CRC and other significant pathology, whilst very low readings in the absence of anaemia or palpable rectal mass identify a group with very low risk. High return rates for FIT within this 2WW pathway indicate its acceptability

Planned surgery in the COVID-19 pandemic: a prospective cohort study from Nottingham

PurposeGlobally planned surgical procedures have been deferred during the current COVID-19 pandemic. The study aimed to report the outcomes of planned urgent and cancer cases during the current pandemic using a multi-disciplinary prioritisation group.MethodsA prospective cohort study of patients having urgent or cancer surgery at a NHS Trust from 1st March to 30th April 2020 who had been prioritised by a multi-disciplinary COVID Surgery group. Rates of post-operative PCR positive and suspected COVID-19 infections within 30 days, 30-day mortality and any death related to COVID-19 are reported.ResultsOverall 597 patients underwent surgery with a median age of 65 years (interquartile range (IQR) 54–74 years). Of these, 86.1% (514/597) had a current cancer diagnosis. During the period, 60.8% (363/597) of patients had surgery at the NHS Trust whilst 39.2% (234/597) had surgery at Independent Sector hospitals. The incidence of COVID-19 in the East Midlands was 193.7 per 100,000 population during the study period. In the 30 days following surgery, 1.3% (8/597) of patients tested positive for COVID-19 with all cases at the NHS site. Overall 30-day mortality was 0.7% (4/597). Following a PCR positive COVID-19 diagnosis, mortality was 25.0% (2/8). Including both PCR positive and suspected cases, 3.0% (18/597) developed COVID-19 infection with 1.3% at the independent site compared to 4.1% at the NHS Trust (p=0.047).ConclusionsRates of COVID-19 infection in the post-operative period were low especially in the Independent Sector site. Mortality following a post-operative diagnosis of COVID-19 was high

“Low FIT” Colorectal Cancer: A four-year comparison of the Nottingham “4F” protocol with FIT10 in symptomatic patients.

Aim:To evaluate colorectal cancer outcomes after “low” (sub-threshold) Faecal Immunochemical Test (FIT) results in symptomatic patients tested in primary care.Method:Retrospective audit of 35,289 patients with FIT results, having consulted their general practitioner with lower gastrointestinal symptoms, and subsequent colorectal cancer (CRC) diagnoses. The Rapid Colorectal Cancer Diagnosis pathway was introduced in November 2017 to allow incorporation of FIT into clinical practice. The local “4F” protocol combined FIT results with blood tests and digital rectal examination (DRE): FIT, Full blood count (FBC), Ferritin and Finger.Outcome: Detection rates of CRC, missed CRC and time to diagnosis in local “4F” protocols for patients with a sub-threshold faecal Haemoglobin (fHb) result compared to thresholds of 10 and 20µgHb/g Faeces.Results:A single threshold of 10 µgHb/g Faeces identifies a population in whom the risk of CRC is 0.2% but would have missed 63 (10.5%) of 599 CRCs in this population. The Nottingham “4F” protocol would have missed fewer CRCs (42 of 599 (7%)) despite using a threshold of 20 µgHb/g Faeces for patients with normal blood tests. Subthreshold FIT results in patients subsequently diagnosed with a palpable rectal tumour yielded the longest delays.Conclusion:Combination of FIT with blood results and DRE (“4F”) reduced the risk of missed or delayed diagnosis. Further studies on the impact of such protocols on the diagnostic accuracy of FIT are expected. The value of adding blood tests to FIT may be restricted to specific parts of the fHb result spectrum

‘Low’ faecal immunochemical test (FIT) colorectal cancer: a 4-year comparison of the Nottingham ‘4F’ protocol with FIT10 in symptomatic patients

Aim: The aim of this work was to evaluate colorectal cancer (CRC) outcomes after ‘low’ (sub-threshold) faecal immunochemical test (FIT) results in symptomatic patients tested in primary care. Method: This work comprised a retrospective audit of 35 289 patients with FIT results who had consulted their general practitioner with lower gastrointestinal symptoms and had subsequent CRC diagnoses. The Rapid Colorectal Cancer Diagnosis pathway was introduced in November 2017 to allow incorporation of FIT into clinical practice. The local ‘4F’ protocol combined FIT results with blood tests and digital rectal examination (DRE): FIT, full blood count, ferritin and finger [DRE]. The outcome used was detection rates of CRC, missed CRC and time to diagnosis in local 4F protocols for patients with a subthreshold faecal haemoglobin (fHb) result compared with thresholds of 10 and 20 μg Hb/g faeces. Results: A single threshold of 10 μg Hb/g faeces identifies a population in whom the risk of CRC is 0.2%, but this would have missed 63 (10.5%) of 599 CRCs in this population. The Nottingham 4F protocol would have missed fewer CRCs [42 of 599 (7%)] despite using a threshold of 20 μg Hb/g faeces for patients with normal blood tests. Subthreshold FIT results in patients subsequently diagnosed with a palpable rectal tumour yielded the longest delays in diagnosis. Conclusion: A combination of FIT with blood results and DRE (the 4F protocol) reduced the risk of missed or delayed diagnosis. Further studies on the impact of such protocols on the diagnostic accuracy of FIT are expected. The value of adding blood tests to FIT may be restricted to specific parts of the fHb results spectrum

GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham

ObjectiveService evaluation of GP access to Faecal Immunochemical Test (FIT) for colorectal cancer (CRC) detection in Nottinghamshire and use of FIT for “rule out”, “rule in” and “first test selection”.DesignRetrospective audit of FIT results, CRC outcomes and resource utilisation before and after introduction of FIT in Primary Care in November 2017. Data from the new pathway up to December 2018 was compared with previous experience.ResultsBetween November 2017 and December 2018, 6747 GP FIT test requests yielded 5733 FIT results, of which 4082 (71.2%) were [less than]4.0 μg Hb/g faeces, 579 (10.1%) were 4.0–9.9 μg Hb/g faeces, 836 (14.6%) were 10.0–149.9 μg Hb/g faeces, and 236 (4.1%) were ≥150.0 μg Hb/g faeces. The proportion of “rule out” results [less than]4.0 μg Hb/g faeces was significantly higher than in the Getting FIT cohort (71.2% vs 60.4%, Chi squared 42.8, p [less than] 0.0001) and the proportion of “rule in” results ≥150.0 μg Hb/g faeces was significantly lower (4.1% vs 8.1%, Chi squared 27.3,P [less than] 0.0001).There was a 33% rise in urgent referrals across Nottingham overall during the evaluation period. 2 CRC diagnoses were made in 4082 patients who had FIT[less than]4.0 μg Hb/g faeces. 58.4% of new CRC diagnoses associated with a positive FIT were early stage cancers (Stage I and II). The proportion of all CRC diagnoses that follow an urgent referral s rose after introduction of FIT.ConclusionsFIT allows GP's to select a more appropriate cohort for urgent investigation without a large number of missed diagnoses. FIT appears to promise a “stage migration” effect which may ultimately improve CRC outcomes

The impact of pre‐operative intravenous iron on quality of life after colorectal cancer surgery: outcomes from the intravenous iron in colorectal cancer‐associated anaemia (IVICA) trial

Anaemia is associated with a reduction in quality of life, and is common in patients with colorectal cancer . Werecently reported thefindings of the intravenous iron in colorectal cancer-associated anaemia (IVICA) trialcomparing haemoglobin levels and transfusion requirements following intravenous or oral iron replacement inanaemic colorectal cancer patients undergoing elective surgery. In this follow-up study, we compared theefficacy of intravenous and oral iron at improving quality of life in this patient group. We conducted amulticentre, open-label randomised controlled trial. Anaemic colorectal cancer patients were randomlyallocated at least two weeks pre-operatively, to receive either oral (ferrous sulphate) or intravenous (ferriccarboxymaltose) iron. We assessed haemoglobin and quality of life scores at recruitment, immediately beforesurgery and at outpatient review approximately three months postoperatively, using the Short Form 36,EuroQoL 5-dimension 5-level and Functional Assessment of Cancer Therapy–Anaemia questionnaires. Werecruited 116 anaemic patients across seven UK centres (oral iron n=61 (53%), and intravenous iron n=55(47%)). Eleven quality of life components increased by a clinically significant margin in the intravenous irongroup between recruitment and surgery compared with one component for oral iron. Median (IQR [range])visual analogue scores were significantly higher with intravenous iron at a three month outpatient review (oraliron 70, (60–85 [20–95]); intravenous iron 90 (80–90 [50–100]), p=0.001). The Functional Assessment ofCancer Therapy–Anaemia score comprises of subscales related to cancer, fatigue and non-fatigue itemsrelevant to anaemia. Median outpatient scores were higher, and hence favourable, for intravenous iron on theFunctional Assessment of Cancer Therapy–Anaemia subscale (oral iron 66 (55–72 [23–80]); intravenous iron 71(66–77 [46–80]); p=0.002), Functional Assessment of Cancer Therapy–Anaemia trial outcome index (oral iron108 (90–123 [35–135]); intravenous iron 121 (113–124 [81–135]); p=0.003) and Functional Assessment ofCancer Therapy–Anaemia total score (oral iron 151 (132–170 [69–183]); intravenous iron 168 (160–174 [125–186]); p=0.005). Thesefindings indicate that intravenous iron is more efficacious at improving quality of lifescores than oral iron in anaemic colorectal cancer patients

A scoping review of the implications of adult obesity in the delivery and acceptance of dental care.

Background Due to the increasing prevalence of obesity within the general population it is presumed that the prevalence of overweight and obese adults accessing dental services will also increase. For this reason dentists need to be aware of implications of managing such patients.Methods A scoping review was carried out. Both Medline via OVID and Scopus databases were searched along with grey literature databases and the websites of key organizations. Inclusion and exclusion criteria were established. The data were collected on a purpose-made data collection form and analysed descriptively.Results The review identified 28 relevant published articles and two relevant items of grey literature. Following review of this literature three themes relating to adult obesity in the delivery and acceptance of dental care emerged; clinical, service delivery and patient implications. The majority of the papers focused on the clinical implications.Conclusion On the topic of adult obesity and dental care, the majority of published and grey literature focuses on the clinical implications. Further research is needed on both the patients' perspectives of being overweight or obese and the delivery and acceptance of dental care and the service delivery implications

Immunogenicity and Efficacy of Single Antigen Gp63, Polytope and PolytopeHSP70 DNA Vaccines against Visceral Leishmaniasis in Experimental Mouse Model

Polytope approach of genetic immunization is a promising strategy for the prevention of infectious disease as it is capable of generating effective cell mediated immunity by delivering the T cell epitopes assembled in series. Leishmaniasis is a significant world wide health problem for which no vaccine exists. In this study we have compared immunogenicity and efficacy of three types of DNA vaccines: single antigen Gp63 (Gp63/pcDNA), polytope (Poly/pcDNA) and Polytope fused with hsp70 (Poly/hsp/pcDNA) against visceral leishmaniasis in susceptible BALB/c mice. Mice vaccinated with these plasmids generated strong Th1 immune response as seen by dominating IFN-γ over IL-10 cytokine. Interestingly, cytotoxic responses generated by polytope DNA plasmid fused with hsp70 of Leishmania donovani were significantly higher when compared to polytope and single antigen Gp63 vaccine. Challenge studies revealed that the parasite load in liver and spleen was significantly lower with Poly/hsp/pcDNA vaccination compared to other vaccines. Therefore, our study indicates that polytope DNA vaccine is a feasible, practical and effective approach for visceral leishmaniasis

Benign Ancient Schwannoma of the abdominal wall: An unwanted birthday present

<p>Abstract</p> <p>Background</p> <p>There has been a recent growth in the use of whole body Computerised Tomography (CT) scans in the private sector as a screening test for asymptomatic disease. This is despite scant evidence to show any positive effect on morbidity or mortality. There has been concern raised over the possible harms of the test in terms of radiation exposure as well as the risk and anxiety of further investigation and treatment for the large numbers of benign lesions identified.</p> <p>Case Presentation</p> <p>A healthy 64 year old lady received a privately funded whole body CT scan for her birthday which revealed an incidental mass in the right iliac fossa. This was investigated with further imaging and colonoscopy and as confident diagnosis could not be made, eventually excised. Histology demonstrated this to be a benign ancient schwannoma and we believe this to be the first reported case of an abdominal wall schwannoma in the English literature</p> <p>Conclusions</p> <p>Ancient schwannomas are rare tumours of the peripheral nerve sheaths more usually found in the head, neck and flexor surfaces of extremities. They are a subtype of classical schwannomas with a predominance of degenerative changes. Our case highlights the pitfalls of such screening tests in demonstrating benign disease and subjecting patients to what turns out to be unnecessary invasive investigation and treatment. It provides evidence as to the consequences of the large number of false positive results that are created by blind CT scanning of asymptomatic patients i.e. its tendency to detect pseudodiesease rather than affect survival rates. Should the number of scans increase there may be an unnecessary burden on NHS resources due to the large numbers of benign lesions picked up, that are then referred for further investigation.</p