Randomised trial to assess the efficacy of pelvic drainage in preventing pelvic collection after elective rectal resection for cancer

INTRODUCTION: Rectal cancer is the third most commonly diagnosed cancer occurring in both males and females globally. In India, the incidence of rectal cancer among males is higher than females, which is different from the rest of the world. Increasing incidence among younger males in India has been seen as a trend. Low socioeconomic status has been seen to be associated with the incidence of rectal cancer both globally and in India. Though the management of rectal cancer is multimodal, adequate surgical resection is the mainstay of treatment and is considered the primary treatment modality. Rectal resection remains a morbid operation, one of the most troublesome complications being pelvic collection. Pelvic drainage by means of closed tubular drainage has been practised routinely with the objective of reducing the post operative morbidity. This study aims to observe the role of closed tube pelvic drainage in the post operative outcome following rectal resection. Although the ineffectiveness of such an intervention in reducing postoperative morbidity has been established in patients undergoing small intestinal and colonic resections, there is no conclusive data in patients undergoing rectal resection. In fact the effectiveness of such an intervention for rectal resection has been questioned. OBJECTIVES: 1. To detect the presence of pelvic collection by ultrasonographic imaging of the pelvis on the 5th post operative day and measure its volume if present. 2. To assess the morbidity in terms of deviation in the normal post operative course 3. To record the number of days of hospital stay according to ‘fit for discharge’ criteria. 4. To document the occurrence of urinary tract infection (UTI) during the post operative period (30 days following surgery). METHODS: The study was a randomized controlled trial which included all patients undergoing elective rectal resection under General Surgery Unit 2. The intervention was absence of pelvic drainage and this was compared against the comparator which was closed pelvic drainage. The exclusion criteria were: 1. Patients operated on an emergency basis. 2. Patients with disseminated disease where surgery is a palliative procedure. 3. Patients with compromised immunity (on steroids, immunosupression, post transplant patients). 4. Patients with intraoperative complications for which drainage is inevitable (spillage). The method used for randomisation was a block randomisation with concealment in sealed envolopes. The sample size was calculated by a two proportion methos with a power of 80% and an alpha error of 5%. Statistical analysis was performed by means of chi square test and independent sample T test. RESULTS: Although the study was not carried on till the complete sample size was reached, the results were all consistent and showed trends in the same direction. However, statistically significant conclusions cannot be drawn from the analysis of the results. The duration of the study and the time constraint is one of the major limitation of this study. Apart from this, sensitivity of a pelvic ultrasonogram, observer bias and the inability to perform blinding are the other limitations. The increased incidence of rectal cancer among younger males has stood out in this study which is in contrast with studies from the western population. The use of pelvic drainage has not shown to drastically contribute towards reducing post operative morbidity in terms of decreased pelvic collections or reduced hospital stays. Infact, the absence of a pelvic drain has shown a trend towards reduced incidence of pelvic collection and reduced hospital stay. However, these results are not statistically significant. CONCLUSIONS: The aim of conducting this study was to establish a definitive association between the routine use of closed tube drainage of the pelvis in patients undergoing resection for rectal cancer. The paucity of data in this area and the equivocal results of existing studies further warranted the need for this study. Although the study was not carried on till the complete sample size was reached, the results were all consistent and showed trends in the same direction. However, statistically significant conclusions cannot be drawn from the analysis of the results. The duration of the study and the time constraint is one of the major limitation of this study. Apart from this, sensitivity of a pelvic ultrasonogram, observer bias and the inability to perform blinding are the other limitations. The increased incidence of rectal cancer among younger males has stood out in this study which is in contrast with studies from the western population. The use of pelvic drainage has not shown to drastically contribute towards reducing post operative morbidity in terms of decreased pelvic collections or reduced hospital stays. Infact, the absence of a pelvic drain has shown a trend towards reduced incidence of pelvic collection and reduced hospital stay. However, these results are not statistically significant. The other factor that contributed to the outcome of these patients was neoadjuvant therapy in the form of long course chemoradiation. The lack of unequivocal evidence in the benefit of routine pelvic drainage has shown that it is a questionable intervention

Study of water supply & sanitation practices in India using geographic information systems: some design & other considerations in a village setting

Background & objectives: Availability of clean water and adequate sanitation facilities are of prime importance for limiting diarrhoeal diseases. We examined the water and sanitation facilities of a village in southern India using geographic information system (GIS) tools. Methods: Places of residence, water storage and distribution, sewage and places where people in the village defaecated were mapped and drinking water sources were tested for microbial contamination in Nelvoy village, Vellore district, Tamil Nadu. Results: Water in the village was found to be microbiologically unfit for consumption. Analysis using direct observations supplemented by GIS maps revealed poor planning, poor engineering design and lack of policing of the water distribution system causing possible contamination of drinking water from sewage at multiple sites. Interpretation & conclusions: Until appropriate engineering designs for water supply and sewage disposal to suit individual village needs are made available, point-of-use water disinfection methods could serve as an interim solution

Massively Parallel RNA Sequencing Identifies a Complex Immune Gene Repertoire in the lophotrochozoan Mytilus edulis

The marine mussel Mytilus edulis and its closely related sister species are distributed world-wide and play an important role in coastal ecology and economy. The diversification in different species and their hybrids, broad ecological distribution, as well as the filter feeding mode of life has made this genus an attractive model to investigate physiological and molecular adaptations and responses to various biotic and abiotic environmental factors. In the present study we investigated the immune system of Mytilus, which may contribute to the ecological plasticity of this species. We generated a large Mytilus transcriptome database from different tissues of immune challenged and stress treated individuals from the Baltic Sea using 454 pyrosequencing. Phylogenetic comparison of orthologous groups of 23 species demonstrated the basal position of lophotrochozoans within protostomes. The investigation of immune related transcripts revealed a complex repertoire of innate recognition receptors and downstream pathway members including transcripts for 27 toll-like receptors and 524 C1q domain containing transcripts. NOD-like receptors on the other hand were absent. We also found evidence for sophisticated TNF, autophagy and apoptosis systems as well as for cytokines. Gill tissue and hemocytes showed highest expression of putative immune related contigs and are promising tissues for further functional studies. Our results partly contrast with findings of a less complex immune repertoire in ecdysozoan and other lophotrochozoan protostomes. We show that bivalves are interesting candidates to investigate the evolution of the immune system from basal metazoans to deuterostomes and protostomes and provide a basis for future molecular work directed to immune system functioning in Mytilus

Promoter Complexity and Tissue-Specific Expression of Stress Response Components in Mytilus galloprovincialis, a Sessile Marine Invertebrate Species

The mechanisms of stress tolerance in sessile animals, such as molluscs, can offer fundamental insights into the adaptation of organisms for a wide range of environmental challenges. One of the best studied processes at the molecular level relevant to stress tolerance is the heat shock response in the genus Mytilus. We focus on the upstream region of Mytilus galloprovincialis Hsp90 genes and their structural and functional associations, using comparative genomics and network inference. Sequence comparison of this region provides novel evidence that the transcription of Hsp90 is regulated via a dense region of transcription factor binding sites, also containing a region with similarity to the Gamera family of LINE-like repetitive sequences and a genus-specific element of unknown function. Furthermore, we infer a set of gene networks from tissue-specific expression data, and specifically extract an Hsp class-associated network, with 174 genes and 2,226 associations, exhibiting a complex pattern of expression across multiple tissue types. Our results (i) suggest that the heat shock response in the genus Mytilus is regulated by an unexpectedly complex upstream region, and (ii) provide new directions for the use of the heat shock process as a biosensor system for environmental monitoring

Water handling, sanitation and defecation practices in rural southern India: a knowledge, attitudes and practices study

Diarrhoea and water-borne diseases are leading causes of mortality in developing countries. To understand the socio-cultural factors impacting on water safety, we documented knowledge, attitudes and practices of water handling and usage, sanitation and defecation in rural Tamilnadu, India, using questionnaires and focus group discussions, in a village divided into an upper caste Main village and a lower caste Harijan colony. Our survey showed that all households stored drinking water in wide-mouthed containers. The quantity of water supplied was less in the Harijan colony, than in the Main village (P < 0.001). Residents did not associate unsafe water with diarrhoea, attributing it to 'heat', spicy food, ingesting hair, mud or mosquitoes. Among 97 households interviewed, 30 (30.9%) had toilets but only 25 (83.3%) used them. Seventy-two (74.2%) of respondents defecated in fields, and there was no stigma associated with this traditional practice. Hand washing with soap after defecation and before meals was common only in children under 15 years (86.4%). After adjusting for other factors, perception of quantity of water received (P < 0.001), stated causation of diarrhoea (P = 0.02) and low socio-economic status (P < 0.001) were significantly different between the Main village and the Harijan colony. Traditional practices may pose a significant challenge to programmes aimed at toilet usage and better sanitation

Report on the 2nd international meeting of the IUGS lower Cretaceous ammonite working group, the “Kilian Group” (Neuchâtel, Switzerland, 8 September 2005)

International audienc

Impacts of seawater acidification on mantle gene expression patterns of the Baltic Sea blue mussel: implications for shell formation and energy supply

Marine organisms have to cope with increasing CO2 partial pressures and decreasing pH in the oceans. We elucidated the impacts of an 8-week acclimation period to four seawater pCO2 treatments (39, 113, 243 and 405 Pa/385, 1,120, 2,400 and 4,000 µatm) on mantle gene expression patterns in the blue mussel Mytilus edulis from the Baltic Sea. Based on the M. edulis mantle tissue transcriptome, the expression of several genes involved in metabolism, calcification and stress responses was assessed in the outer (marginal and pallial zone) and the inner mantle tissues (central zone) using quantitative real-time PCR. The expression of genes involved in energy and protein metabolism (F-ATPase, hexokinase and elongation factor alpha) was strongly affected by acclimation to moderately elevated CO2 partial pressures. Expression of a chitinase, potentially important for the calcification process, was strongly depressed (maximum ninefold), correlating with a linear decrease in shell growth observed in the experimental animals. Interestingly, shell matrix protein candidate genes were less affected by CO2 in both tissues. A compensatory process toward enhanced shell protection is indicated by a massive increase in the expression of tyrosinase, a gene involved in periostracum formation (maximum 220-fold). Using correlation matrices and a force-directed layout network graph, we were able to uncover possible underlying regulatory networks and the connections between different pathways, thereby providing a molecular basis of observed changes in animal physiology in response to ocean acidification