An evidence-based review of edoxaban and its role in stroke prevention in patients with nonvalvular atrial fibrillation.

Atrial fibrillation is the most common arrhythmia in the elderly. It is responsible for significant morbidity and mortality from cardioembolic complications like stroke. As a result, atrial fibrillation patients are risk-stratified using the CHADS2 or CHA2DS2-VASc scoring systems. Those at intermediate-to-high risk have traditionally been treated with therapeutic anticoagulation with warfarin for stroke prevention. Although effective, warfarin use is fraught with multiple concerns, such as a narrow therapeutic window, drug-drug and drug-food interactions, and excessive bleeding. Novel oral anticoagulant agents have recently become available as viable alternatives for warfarin therapy. Direct thrombin inhibitor dabigatran and factor Xa inhibitors like rivaroxaban and apixaban have already been approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with nonvalvular atrial fibrillation. Edoxaban is the latest oral direct factor Xa inhibitor studied in the largest novel oral anticoagulant trial so far: ENGAGE AF-TIMI 48. Treatment with a 30 mg or 60 mg daily dose of edoxaban was found to be noninferior to dose-adjusted warfarin in reducing the rate of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a lower incidence of bleeding complications and cardiovascular deaths. Edoxaban was recently reviewed by an FDA advisory committee and recommended as a stroke-prophylaxis agent. Once approved, it promises to provide another useful alternative to warfarin therapy

Outcome following emergency surgery for refractory severe ulcerative colitis in a tertiary care centre in India

Background: Steroid-based intensive medical therapy for severe ulcerative colitis is successful in 60-70% of such patients. Patients with complications or those refractory to medical therapy require emergency colectomy for salvage. Little is known about the impact of timing of surgical intervention and surgical outcomes of such patients undergoing emergency surgery in India where the diagnosis is often delayed or missed in patients who are poor, malnourished and non-compliant to medical treatment. Methods: The clinical records of all patients undergoing emergency surgery for severe ulcerative colitis or its complication in the Department of GI surgery AIIMS, New Delhi, India, between January 1985 and December 2003 were retrieved and data pertaining to demographic features, duration of intensive medical therapy, presence of complications, time from admission to emergency surgery, surgical procedure, in-hospital morbidity and mortality and follow up status extracted. Results: A total of 72 patients underwent emergency surgery (Subtotal colectomy: 60; ileostomy alone under local anaesthesia: 12). Poor nutritional status was seen in 61% of the patients. Twenty-one patients (29%) underwent emergency surgery for complications of severe ulcerative colitis such as colonic perforation (spontaneous 6, iatrogenic 4), massive lower gastrointestinal haemorrhage (5), toxic megacolon (4) and large bowel obstruction (2). The remaining patients (n = 51) underwent emergency surgery following failed intensive therapy; 17 underwent surgery ≤ 5 days (Group I) and 34 were operated >5 days (Group II) after initiation of intensive therapy. In this group all the post-operative deaths (n = 8) occurred in those who were operated after 5 days. The difference in mortality in these two groups (i.e. surgical intervention ≤ or > 5 days) was statistically significant {0/17 (Group I) vs 8/34 (Group II); p = 0.03}. Overall, 12 patients died (in-hospital mortality: 16.7%). The mortality was higher (10/43; 23.3%) in our early experience (i.e. 1985-1995) when compared to our subsequent experience (2/29; 6.9%) (1996-2003). A total of 48 patients (including 3 awaiting a restorative procedure) are alive on follow up (66.7%; 3 patients lost to follow up). A restorative procedure could be successfully completed in 81% of the survivors of the emergency procedure. Conclusion: To optimize the outcome, a combined team of physicians and surgeons should be involved in the management of patients with severe ulcerative colitis with focus on nutritional support, correction of metabolic derangements, close clinical monitoring and timely assessment for the need for emergency surgery. This retrospective analysis shows that improved results can be achieved with experience and by following a policy of early surgical intervention within 5 days, especially in patients who have failed intensive medical therapy

Material handling and Process Imprvement using Lean Manufacturing Principles

Global competition has prompted companies to compete on the basis of Quality, Flexibility, Cost and Timely Deliveries. Lean manufacturing appears to hold considerable promise to address these competitive demands. Lean manufacturing was initiated within automotive industry, with the publication of Book “The Machine That Changed the World” (Womak, Jones, Roos,1990) lean manufacturing practices have found acceptance in many industries. In this paper we describe the case where Lean Manufacturing was started. The objective was Process improvements using Lean Manufacturing Principles. Value stream mapping was used to find the scope of improvement in Material Handling. Team also used other lean tools such as 5S, Visual System, Process improvement (Continuous improvement) and Kanban. Results obtained were cycle time, distance and manpower reduction for material handling. Some floor area was also saved. Similar cycle time for certain assembly process was reduced. Andon system helped supervisors and group leader tackle the line problem immediately as they occur. Average output  increased from 3.5 to 5 in period of 9 months

An evidence-based review of edoxaban and its role in stroke prevention in patients with nonvalvular atrial fibrillation.

Atrial fibrillation is the most common arrhythmia in the elderly. It is responsible for significant morbidity and mortality from cardioembolic complications like stroke. As a result, atrial fibrillation patients are risk-stratified using the CHADS2 or CHA2DS2-VASc scoring systems. Those at intermediate-to-high risk have traditionally been treated with therapeutic anticoagulation with warfarin for stroke prevention. Although effective, warfarin use is fraught with multiple concerns, such as a narrow therapeutic window, drug-drug and drug-food interactions, and excessive bleeding. Novel oral anticoagulant agents have recently become available as viable alternatives for warfarin therapy. Direct thrombin inhibitor dabigatran and factor Xa inhibitors like rivaroxaban and apixaban have already been approved by the US Food and Drug Administration (FDA) for stroke prevention in patients with nonvalvular atrial fibrillation. Edoxaban is the latest oral direct factor Xa inhibitor studied in the largest novel oral anticoagulant trial so far: ENGAGE AF-TIMI 48. Treatment with a 30 mg or 60 mg daily dose of edoxaban was found to be noninferior to dose-adjusted warfarin in reducing the rate of stroke and systemic embolism in patients with nonvalvular atrial fibrillation, with a lower incidence of bleeding complications and cardiovascular deaths. Edoxaban was recently reviewed by an FDA advisory committee and recommended as a stroke-prophylaxis agent. Once approved, it promises to provide another useful alternative to warfarin therapy

Multiplicity of noncommunicable diseases among the elderly in a suburban area of Delhi

Introduction: Continuing advancements in quality of health care has led to increased life expectancy over time. This in turn has resulted in increased prevalence of noncommunicable diseases (NCDs), especially among the elderly. An appropriate portrayal of its epidemiology is essential to adequately understand the health-care needs of the population. The evidence generated from the study will give us an incentive to address the rising burden of polymorbidities. We did the study to assess the prevalence and pattern of NCDs in the elderly above 60 years of age and to determine age- and sex-wise distribution of single and multiple NCDs. Materials and Methods: A community-based cross-sectional study was conducted among 350 elderly participants over 60 years of age in Mehrauli area of Delhi. Data were collected using a semi-structured questionnaire. Detailed general and systemic examination was also done. Results: A total of 87.4% of the study population were suffering from at least one NCD. The number of NCDs per person is 2.41. Overall, 80 out of the total 350 study participants (22.9%) had a single NCD, whereas 226 (64.6%) had two or more NCDs. Hypertension was the most prevalent NCD, followed by cataract, osteoarthritis, diabetes mellitus, and obesity. Conclusion: The prevalence of NCDs was quite high among the elderly. Multimorbidity was more common among the oldest-old age group and elderly women. This calls for increased focus on timely and comprehensive screening for NCDs in adults and asserts the need to approach the screening and management of NCDs in a more holistic way and not as isolated health events

Health-Seeking behavior and its determinants for different noncommunicable diseases in elderly

Steady improvement in quality of life has led to increased survival time of elderly, especially of those with noncommunicable diseases. A study about their health-seeking behavior (HSB) and its determinants is essential for provision of comprehensive care and facilitate policy development. A cross-sectional study was conducted among 350 elderly participants over 60 years of age in an urbanized village of Delhi. Data was collected using a semi-structured questionnaire, and detailed general and systemic examination was done. Tests of significance were applied to assess the HSB with various demographic, clinico-social, and economic variables. A total of 87.4% of the study population was suffering from at least one noncommunicable disease (NCD). Majority of the study subjects' NCDs (72.66%) were diagnosed while getting treatment for a symptom of the disease. Also, 52.94% of the participants had inappropriate HSB. HSB was significantly associated with gender, age, duration of illness, and importantly with modifiable variables like the level of literacy, distance of preferred health facility, and presence of multimorbidity. HSB was found to be inappropriate in over half of the participants. Policymaking should focus on modifiable variables like education, distance of health facility, and multimorbidity, especially for commonly ignored diseases like osteoarthritis and diabetes