ACCURACY OF FNAC IN FEMALE BREAST LESIONS

Background: Various breast lesions are common lesions in females with a wide range of variability from inflammatory lesions, benign and malignant breast lesions. FNAC is first diagnostic test, as it has high sensitivity and specificity. Lesions were categorized on FNA into inflammatory lesions, benign neoplastic lesions, malignant neoplastic lesions, and suspicious for malignancy. Methods: This was a retrospective study done in the Department of Pathology, P.D.U. Medical College, Rajkot, Gujarat State, India from Aug-2013 to July 2014. FNAC of 392 cases of breast lesions were done and reported by expert pathologist. The histopathological specimens when available were reported by other pathologist without prior knowledge of FNA diagnosis. Sensitivity, Specificity and Accuracy of FNA diagnosis were then analyzed. Results: A total of 392 cases of breast lesions were diagnosed on FNA, out of them histopathological correlation was available in 87 cases. Benign breast lesions are more common in younger patients in 21-30 yrs age group and malignant lesions are more common in old age group patients of 41-60 yrs with few exceptions. In our setup fibroadenoma is the most common benign breast lesion (26.53%) and ductal carcinoma (17.86%) is the most common malignant lesion. The sensitivity, specificity and accuracy of FNAC for malignant lesions were found to be 91.43%, 100% and 96.25% respectively. Conclusion: FNAC is an effective and valid tool as the first line diagnostic modality in the preoperative diagnosis of the malignant and benign breast lesions.KEYWORDS: FNAC; Breast lesions; Fibroadenoma; Ductal carcinoma

ACCURACY OF FNAC IN FEMALE BREAST LESIONS

Background: Various breast lesions are common lesions in females with a wide range of variability from inflammatory lesions, benign and malignant breast lesions. FNAC is first diagnostic test, as it has high sensitivity and specificity. Lesions were categorized on FNA into inflammatory lesions, benign neoplastic lesions, malignant neoplastic lesions, and suspicious for malignancy. Methods: This was a retrospective study done in the Department of Pathology, P.D.U. Medical College, Rajkot, Gujarat State, India from Aug-2013 to July 2014. FNAC of 392 cases of breast lesions were done and reported by expert pathologist. The histopathological specimens when available were reported by other pathologist without prior knowledge of FNA diagnosis. Sensitivity, Specificity and Accuracy of FNA diagnosis were then analyzed. Results: A total of 392 cases of breast lesions were diagnosed on FNA, out of them histopathological correlation was available in 87 cases. Benign breast lesions are more common in younger patients in 21-30 yrs age group and malignant lesions are more common in old age group patients of 41-60 yrs with few exceptions. In our setup fibroadenoma is the most common benign breast lesion (26.53%) and ductal carcinoma (17.86%) is the most common malignant lesion. The sensitivity, specificity and accuracy of FNAC for malignant lesions were found to be 91.43%, 100% and 96.25% respectively. Conclusion: FNAC is an effective and valid tool as the first line diagnostic modality in the preoperative diagnosis of the malignant and benign breast lesions.KEYWORDS: FNAC; Breast lesions; Fibroadenoma; Ductal carcinoma

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

Global economic burden of unmet surgical need for appendicitis

Background: There is a substantial gap in provision of adequate surgical care in many low-and middle-income countries. This study aimed to identify the economic burden of unmet surgical need for the common condition of appendicitis. Methods: Data on the incidence of appendicitis from 170 countries and two different approaches were used to estimate numbers of patients who do not receive surgery: as a fixed proportion of the total unmet surgical need per country (approach 1); and based on country income status (approach 2). Indirect costs with current levels of access and local quality, and those if quality were at the standards of high-income countries, were estimated. A human capital approach was applied, focusing on the economic burden resulting from premature death and absenteeism. Results: Excess mortality was 4185 per 100 000 cases of appendicitis using approach 1 and 3448 per 100 000 using approach 2. The economic burden of continuing current levels of access and local quality was US $92 492 million using approach 1 and$73 141 million using approach 2. The economic burden of not providing surgical care to the standards of high-income countries was $95 004 million using approach 1 and$75 666 million using approach 2. The largest share of these costs resulted from premature death (97.7 per cent) and lack of access (97.0 per cent) in contrast to lack of quality. Conclusion: For a comparatively non-complex emergency condition such as appendicitis, increasing access to care should be prioritized. Although improving quality of care should not be neglected, increasing provision of care at current standards could reduce societal costs substantially

Pooled analysis of WHO Surgical Safety Checklist use and mortality after emergency laparotomy

Background The World Health Organization (WHO) Surgical Safety Checklist has fostered safe practice for 10 years, yet its place in emergency surgery has not been assessed on a global scale. The aim of this study was to evaluate reported checklist use in emergency settings and examine the relationship with perioperative mortality in patients who had emergency laparotomy. Methods In two multinational cohort studies, adults undergoing emergency laparotomy were compared with those having elective gastrointestinal surgery. Relationships between reported checklist use and mortality were determined using multivariable logistic regression and bootstrapped simulation. Results Of 12 296 patients included from 76 countries, 4843 underwent emergency laparotomy. After adjusting for patient and disease factors, checklist use before emergency laparotomy was more common in countries with a high Human Development Index (HDI) (2455 of 2741, 89.6 per cent) compared with that in countries with a middle (753 of 1242, 60.6 per cent; odds ratio (OR) 0.17, 95 per cent c.i. 0.14 to 0.21, P <0001) or low (363 of 860, 422 per cent; OR 008, 007 to 010, P <0.001) HDI. Checklist use was less common in elective surgery than for emergency laparotomy in high-HDI countries (risk difference -94 (95 per cent c.i. -11.9 to -6.9) per cent; P <0001), but the relationship was reversed in low-HDI countries (+121 (+7.0 to +173) per cent; P <0001). In multivariable models, checklist use was associated with a lower 30-day perioperative mortality (OR 0.60, 0.50 to 073; P <0.001). The greatest absolute benefit was seen for emergency surgery in low- and middle-HDI countries. Conclusion Checklist use in emergency laparotomy was associated with a significantly lower perioperative mortality rate. Checklist use in low-HDI countries was half that in high-HDI countries.Peer reviewe

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

Global variation in anastomosis and end colostomy formation following left-sided colorectal resection

Background End colostomy rates following colorectal resection vary across institutions in high-income settings, being influenced by patient, disease, surgeon and system factors. This study aimed to assess global variation in end colostomy rates after left-sided colorectal resection. Methods This study comprised an analysis of GlobalSurg-1 and -2 international, prospective, observational cohort studies (2014, 2016), including consecutive adult patients undergoing elective or emergency left-sided colorectal resection within discrete 2-week windows. Countries were grouped into high-, middle- and low-income tertiles according to the United Nations Human Development Index (HDI). Factors associated with colostomy formation versus primary anastomosis were explored using a multilevel, multivariable logistic regression model. Results In total, 1635 patients from 242 hospitals in 57 countries undergoing left-sided colorectal resection were included: 113 (6·9 per cent) from low-HDI, 254 (15·5 per cent) from middle-HDI and 1268 (77·6 per cent) from high-HDI countries. There was a higher proportion of patients with perforated disease (57·5, 40·9 and 35·4 per cent; P < 0·001) and subsequent use of end colostomy (52·2, 24·8 and 18·9 per cent; P < 0·001) in low- compared with middle- and high-HDI settings. The association with colostomy use in low-HDI settings persisted (odds ratio (OR) 3·20, 95 per cent c.i. 1·35 to 7·57; P = 0·008) after risk adjustment for malignant disease (OR 2·34, 1·65 to 3·32; P < 0·001), emergency surgery (OR 4·08, 2·73 to 6·10; P < 0·001), time to operation at least 48 h (OR 1·99, 1·28 to 3·09; P = 0·002) and disease perforation (OR 4·00, 2·81 to 5·69; P < 0·001). Conclusion Global differences existed in the proportion of patients receiving end stomas after left-sided colorectal resection based on income, which went beyond case mix alone

Comparative performance of seven long-running telemedicine networks delivering humanitarian services

Seven long-running telemedicine networks were surveyed. The networks provided humanitarian services (clinical and educational) in developing countries, and had been in operation for periods of 5-15 years. The number of experts serving each network ranged from 15 to 513. The smallest network had a total of 10 requesters and the largest one had more than 500 requesters. The networks operated in nearly 60 countries. The seven networks managed a total of 1857 cases in 2011, i.e. an average of 265 cases per year per network. There was a significant growth in total activity, amounting to 100.3 cases per year during the 15 year study period. In 2011, network activity was 50-700 teleconsultations per network. There were clear differences in the patterns of activity, with some networks managing an increasing caseload, and others managing a slowly reducing caseload. The seven networks had published a total of 44 papers listed in Medline which summarized the evidence resulting from the delivery of services by telemedicine. There was a dearth of information about clinical and cost-effectiveness. Nevertheless, the services were widely appreciated by referring doctors, considered to be clinically useful, and there were indications that clinical outcomes for telemedicine patients were often improved. Despite a lack of formal evidence, the present study suggests that telemedicine can provide clinically useful services in developing countries

Histological analysis of the callogenesis and organogenesis from root segments of Curcuma zedoaria Roscoe

Callus was induced from root segments taken from in vitro grown plants of Curcuma zedoaria Roscoe. The explants were cultured on agar-solidified Murashige and Skoog medium supplemented with 13.4muM of alpha-naphthaleneacetic acid and 2.2muM of 6-benzylaminopurine at 25ºC in the dark. Histological analysis revealed that callus was formed from the hypertrophied cortical parenchyma cells of the explant. Some of these cells underwent division while the surrounding cells accumulated starch. Callus was capable of shoot bud regeneration after 70 days when it was transfered to liquid medium of the same composition. After 30 days in liquid medium, buds developed from nodular structures. The adventitious shoots developed extensive root systems when they were placed on agar-solidified Murashige and Skoog medium without growth regulators at 25º C in the light. The establishment of these plantlets in soil was about 95%.<br>Calo de Curcuma zedoaria Roscoe foram induzidos a partir de segmentos de raízes de plantas cultivadas in vitro. Os explantes foram inoculados em meio de Murashige & Skoog solidificado com ágar e suplementado com 13,4miM de ácido alfa-naftaleno acético e 2,2miM de 6-benzilaminopurina e mantidos no escuro a 25°C. As análises histológicas realizadas revelaram que os callus eram formados a partir de células hipertrofiadas do parênquima cortical do explante. Algumas destas células entravam em divisão, enquanto as células vizinhas a estas acumulavam amido. Após 70 dias, calos transferidos para meio de Murashige & Skoog líquido de mesma composição, eram capazes de regenerar plantas. Após 30 dias em meio líquido, gemas se desenvolveram de estruturas nodulares. Estas gemas adventíceas formaram um abundante sistema radicular quando transferidas para meio de Murashige & Skoog solidificado com ágar, sem regulador de crescimento e mantidas a 25°C na luz. A taxa de sobrevivência das plantas foi de 95%