Starting A Peripheral Nerve Surgery Unit in an Area of Limited Resources - Our Experience

Dedicated peripheral nerve surgery centers are few in developing countries where majority of affected patients either remain untreated or are simply palliated with just physiotherapy. In this chapter, we review our experience with surgery for peripheral nerve lesions and peripheral nerve injuries over a 5-year period. A total of 68 procedures were carried out for 58 patients with various peripheral nerve lesions and injuries. Among the 19 surgeries for adult brachial plexus injuries, 10 were for pan-brachial plexus injury, 2 procedures for lower brachial plexus injuries, and 7 procedures for upper brachial plexus injury, while 11 repair surgeries were done for pediatric brachial plexus injuries. The remaining 38 surgeries included 21 peripheral nerve sheath tumor excisions, 5 ablative procedures for chronic neuralgia, 8 procedures for non-carpal tunnel peripheral nerve entrapments, and 4 adults with upper or lower limb isolated nerve injury repairs. The patients were followed up between 6 months and 2 years post-surgery for functional outcome assessment. Overall, as many as 57.5% of the patients had significant neurologic improvement noticed at 2 years of follow-up. Despite its challenges, optimal outcomes following surgery are still possible for patients with nerve injuries, entrapments, and nerve tumors in developing countrie

An NGO-Implemented Community-Clinic Health Worker Approach to Providing Long-Term Care for Hypertension in a Remote Region of Southern India.

Poor blood pressure control results in tremendous morbidity and mortality in India where the leading cause of death among adults is from coronary heart disease. Despite having little formal education, community health workers (CHWs) are integral to successful public health interventions in India and other low- and middle-income countries that have a shortage of trained health professionals. Training CHWs to screen for and manage chronic hypertension, with support from trained clinicians, offers an excellent opportunity for effecting systemwide change in hypertension-related burden of disease. In this article, we describe the development of a program that trained CHWs between 2014 and 2015 in the tribal region of the Sittilingi Valley in southern India, to identify hypertensive patients in the community, refer them for diagnosis and initial management in a physician-staffed clinic, and provide them with sustained lifestyle interventions and medications over multiple visits. We found that after 2 years, the CHWs had screened 7,176 people over age 18 for hypertension, 1,184 (16.5%) of whom were screened as hypertensive. Of the 1,184 patients screened as hypertensive, 898 (75.8%) had achieved blood pressure control, defined as a systolic blood pressure less than 140 and a diastolic blood pressure less than 90 sustained over 3 consecutive visits. While all of the 24 trained CHWs reported confidence in checking blood pressure with a manual blood pressure cuff, 4 of the 24 CHWs reported occasional difficulty documenting blood pressure values because they were unable to write numbers properly. They compensated by asking other CHWs or members of their community to help with documentation. Our experience and findings suggest that a CHW blood pressure screening system linked to a central clinic can be a promising avenue for improving hypertension control rates in low- and middle-income countries

Science in the wilderness: the predicament of scientific research in India’s wildlife reserves

Ecology and allied scientific disciplines aim to understand patterns and processes pertaining to wild species, their ecosystems and their relationships with humans. India’s wildlife reserves are important ‘living laboratories’ for these disciplines. Today, there is a disturbing trend across India where scientists are increasingly denied access to wildlife reserves for scientific research or are seriously impeded, without scope for redress. Although official wildlife management rhetoric emphasizes the need for scientific research, in reality, it is viewed as undesirable and permitted, if at all, as a concession, subject to the discretion of individual forest officials. With no enabling legislative or policy framework to promote and apply science in our wildlife reserves, we are concerned that the future of many scientific disciplines in India is being jeopardized. Here, we provide an analysis of this issue and outline steps needed to promote scientific research in our natural areas

Shrub Invasion Decreases Diversity and Alters Community Stability in Northern Chihuahuan Desert Plant Communities

BACKGROUND:Global climate change is rapidly altering species range distributions and interactions within communities. As ranges expand, invading species change interactions in communities which may reduce stability, a mechanism known to affect biodiversity. In aridland ecosystems worldwide, the range of native shrubs is expanding as they invade and replace native grassland vegetation with significant consequences for biodiversity and ecosystem functioning. METHODOLOGY:We used two long-term data sets to determine the effects of shrub encroachment by Larrea tridentata on subdominant community composition and stability in formerly native perennial grassland dominated by Bouteloua eriopoda in New Mexico, USA. PRINCIPAL FINDINGS:Our results indicated that Larrea invasion decreased species richness during the last 100 years. We also found that over shorter temporal scales species-poor subdominant communities in areas invaded by Larrea were less stable (more variable in time) compared to species rich communities in grass-dominated vegetation. Compositional stability increased as cover of Bouteloua increased and decreased as cover of Larrea increased. SIGNIFICANCE:Changes in community stability due to altered interspecific interactions may be one mechanism by which biodiversity declines in grasslands following shrub invasion. As global warming increases, shrub encroachment into native grasslands worldwide will continue to alter species interactions and community stability both of which may lead to a decline in biodiversity

Potential of grass invasions in desert shrublands to create novel ecosystem states under variable climate

The invasion of exotic grasses into shrublands is a major disturbance to dryland ecosystems. The presence of exotic grasses enhances the occurrence of wildfire in landscapes that had not evolved in the presence of fire, leading to high rates of mortality of the native vegetation. Exotic grasses could be more prone to water stress and mortality than the shrubs they replaced and may not establish during drought, facts that are crucial in ecosystems undergoing increased climatic variability. Here, we develop a process-based modelling framework to investigate the complex dynamics resulting from the introduction of exotic grasses under variable climate. We find that the system converges towards different steady states, depending on the magnitude of climatic variability. While in the absence of climate fluctuations the shrubland state is replaced by an exotic grassland, interannual climate variability may inhibit grass invasion and stabilize the shrubland state. However, climatic variability also gives rise to a novel third, unvegetated state, with grass invasion being followed by drought, grass mortality and intense soil erosion. Most of the research on climate change effects on ecosystems has historically concentrated on the ecological impact of shifts in mean climate conditions. This study shows that changes in the variance are also important when shifts in vegetation composition (e.g. species invasions) result in different susceptibility to climatic variability. In the presence of random climate fluctuations, ecosystems can display steady states that differ from those that would exist under a constant climate or with a climate trend. Copyright © 2016 John Wiley & Sons, Ltd

HER2-enriched subtype and novel molecular subgroups drive aromatase inhibitor resistance and an increased risk of relapse in early ER+/HER2+ breast cancer

BACKGROUND: Oestrogen receptor positive/ human epidermal growth factor receptor positive (ER+/HER2+) breast cancers (BCs) are less responsive to endocrine therapy than ER+/HER2- tumours. Mechanisms underpinning the differential behaviour of ER+HER2+ tumours are poorly characterised. Our aim was to identify biomarkers of response to 2 weeks’ presurgical AI treatment in ER+/HER2+ BCs. METHODS: All available ER+/HER2+ BC baseline tumours (n=342) in the POETIC trial were gene expression profiled using BC360™ (NanoString) covering intrinsic subtypes and 46 key biological signatures. Early response to AI was assessed by changes in Ki67 expression and residual Ki67 at 2 weeks (Ki672wk). Time-To-Recurrence (TTR) was estimated using Kaplan-Meier methods and Cox models adjusted for standard clinicopathological variables. New molecular subgroups (MS) were identified using consensus clustering. FINDINGS: HER2-enriched (HER2-E) subtype BCs (44.7% of the total) showed poorer Ki67 response and higher Ki672wk (p<0.0001) than non-HER2-E BCs. High expression of ERBB2 expression, homologous recombination deficiency (HRD) and TP53 mutational score were associated with poor response and immune-related signatures with High Ki672wk. Five new MS that were associated with differential response to AI were identified. HER2-E had significantly poorer TTR compared to Luminal BCs (HR 2.55, 95% CI 1.14–5.69; p=0.0222). The new MS were independent predictors of TTR, adding significant value beyond intrinsic subtypes. INTERPRETATION: Our results show HER2-E as a standardised biomarker associated with poor response to AI and worse outcome in ER+/HER2+. HRD, TP53 mutational score and immune-tumour tolerance are predictive biomarkers for poor response to AI. Lastly, novel MS identify additional non-HER2-E tumours not responding to AI with an increased risk of relapse

The impact of immediate breast reconstruction on the time to delivery of adjuvant therapy: the iBRA-2 study

Background: Immediate breast reconstruction (IBR) is routinely offered to improve quality-of-life for women requiring mastectomy, but there are concerns that more complex surgery may delay adjuvant oncological treatments and compromise long-term outcomes. High-quality evidence is lacking. The iBRA-2 study aimed to investigate the impact of IBR on time to adjuvant therapy. Methods: Consecutive women undergoing mastectomy ± IBR for breast cancer July–December, 2016 were included. Patient demographics, operative, oncological and complication data were collected. Time from last definitive cancer surgery to first adjuvant treatment for patients undergoing mastectomy ± IBR were compared and risk factors associated with delays explored. Results: A total of 2540 patients were recruited from 76 centres; 1008 (39.7%) underwent IBR (implant-only [n = 675, 26.6%]; pedicled flaps [n = 105,4.1%] and free-flaps [n = 228, 8.9%]). Complications requiring re-admission or re-operation were significantly more common in patients undergoing IBR than those receiving mastectomy. Adjuvant chemotherapy or radiotherapy was required by 1235 (48.6%) patients. No clinically significant differences were seen in time to adjuvant therapy between patient groups but major complications irrespective of surgery received were significantly associated with treatment delays. Conclusions: IBR does not result in clinically significant delays to adjuvant therapy, but post-operative complications are associated with treatment delays. Strategies to minimise complications, including careful patient selection, are required to improve outcomes for patients

Predictors of co-activation in erb's palsy: A retrospective study

Context: Three per thousand births have Erb's palsy. Spontaneous recovery is 50%. Co-activation yields poor outcomes. There are no objective indicators of its emergence. Aims: Analyze if 1 month Axon Viability Index (AVI) of the axillary nerve and which active movement score (AMS) measures can predict co-activation. Settings and Design: Tertiary level rehabilitation center, retrospective design. Methods and Material: The electronic medical record (EMR) was reviewed for patients with Erb's palsy with Narakas grade 2 lesions, as having co-activation or not. The one-month Axillary AVI was used with monthly AMS scores. The inclusion criteria were an AVI greater than ten percent. Exclusion criteria were bi-brachial palsy, congenital anomalies, concomitant or subsequent neurological injuries, and orthopedic injuries. Statistical Analysis Used: Descriptive statistics were used to calculate the median and interquartile values for AMS scores at each respective time point. Statistical significance for each time point was determined using a student's t-test. Results: Regarding the t-test on the AVI data, a significant P value of 0.001 was found favoring the co-activation group. AVI of the Axillary nerve between 0.1 and 0.5 at 1 month is a reliable indicator of future development of co-activation. The following were strong indicators of the emergence of co-activation respectively: month three Wrist Extension in sitting, Shoulder Abduction in supine, Shoulder Abduction in sitting, Elbow Flexion in sitting, month six Elbow Flexion in sitting, month seven Elbow Flexion in sitting. Conclusions: The axillary AVI at one month is a good predictor of future development of co-activation. The mentioned AMS items are the earliest indicators of co-activation