Comparison between Supraclavicular and Infraclavicular Approach in Subclavian Vein Catheterization in a Tertiaray Center in Nepal

Introduction: Central vein catheterization can be introduced in subclavian (SCV), interjugular or femoral vein for volume resuscitation and invasive monitoring technique. Due to anatomical advantage and lesser risk of infection subclavian vein is preferred. Either supraclavicular (SC) or infraclavicualr (IC) approach could be used for subclavian vein catheterization. The aim of the study was to compare SC and IC approach in ease of catheterization of SCV and record the complications present if any. Methods and materials: This was a hospital based comparative, interventional study conducted from November 2016 to October 2017. In this study, 70 patients for elective surgical cases meeting the inclusion criteria were randomly enrolled. Then samples were equally divided by lottery into either supraclavicular or infraclavicular approach group. Access time, success rate of cannulation, number of attempts to cannulate vein, ease of guide wire and catheter insertion, length of catheter inserted and associated complications in both group were recorded. Results: The mean access time in group SC for SCV catheterization was 2.12 ± 0.81 min compared to 2.83 ± 0.99 min in group IC (p-value= 0.002). The overall success rate in catheterization of the right SCV using SC approach (34 out of 35) was better as compared with group IC (33 out of 35) using IC approach. First attempt success in the SC group was 74.28% as compared with 57.14% in the IC group. Conclusion: The SC approach of SCV catheterization can be considered alternative to IC approach in terms of landmarks accessibility, success rate and rate of complications

The development and validation of a scoring tool to predict the operative duration of elective laparoscopic cholecystectomy

Background: The ability to accurately predict operative duration has the potential to optimise theatre efficiency and utilisation, thus reducing costs and increasing staff and patient satisfaction. With laparoscopic cholecystectomy being one of the most commonly performed procedures worldwide, a tool to predict operative duration could be extremely beneficial to healthcare organisations. Methods: Data collected from the CholeS study on patients undergoing cholecystectomy in UK and Irish hospitals between 04/2014 and 05/2014 were used to study operative duration. A multivariable binary logistic regression model was produced in order to identify significant independent predictors of long (> 90 min) operations. The resulting model was converted to a risk score, which was subsequently validated on second cohort of patients using ROC curves. Results: After exclusions, data were available for 7227 patients in the derivation (CholeS) cohort. The median operative duration was 60 min (interquartile range 45–85), with 17.7% of operations lasting longer than 90 min. Ten factors were found to be significant independent predictors of operative durations > 90 min, including ASA, age, previous surgical admissions, BMI, gallbladder wall thickness and CBD diameter. A risk score was then produced from these factors, and applied to a cohort of 2405 patients from a tertiary centre for external validation. This returned an area under the ROC curve of 0.708 (SE = 0.013, p  90 min increasing more than eightfold from 5.1 to 41.8% in the extremes of the score. Conclusion: The scoring tool produced in this study was found to be significantly predictive of long operative durations on validation in an external cohort. As such, the tool may have the potential to enable organisations to better organise theatre lists and deliver greater efficiencies in care

The Cholecystectomy As A Day Case (CAAD) Score: A Validated Score of Preoperative Predictors of Successful Day-Case Cholecystectomy Using the CholeS Data Set

Background Day-case surgery is associated with significant patient and cost benefits. However, only 43% of cholecystectomy patients are discharged home the same day. One hypothesis is day-case cholecystectomy rates, defined as patients discharged the same day as their operation, may be improved by better assessment of patients using standard preoperative variables. Methods Data were extracted from a prospectively collected data set of cholecystectomy patients from 166 UK and Irish hospitals (CholeS). Cholecystectomies performed as elective procedures were divided into main (75%) and validation (25%) data sets. Preoperative predictors were identified, and a risk score of failed day case was devised using multivariate logistic regression. Receiver operating curve analysis was used to validate the score in the validation data set. Results Of the 7426 elective cholecystectomies performed, 49% of these were discharged home the same day. Same-day discharge following cholecystectomy was less likely with older patients (OR 0.18, 95% CI 0.15–0.23), higher ASA scores (OR 0.19, 95% CI 0.15–0.23), complicated cholelithiasis (OR 0.38, 95% CI 0.31 to 0.48), male gender (OR 0.66, 95% CI 0.58–0.74), previous acute gallstone-related admissions (OR 0.54, 95% CI 0.48–0.60) and preoperative endoscopic intervention (OR 0.40, 95% CI 0.34–0.47). The CAAD score was developed using these variables. When applied to the validation subgroup, a CAAD score of ≤5 was associated with 80.8% successful day-case cholecystectomy compared with 19.2% associated with a CAAD score >5 (p < 0.001). Conclusions The CAAD score which utilises data readily available from clinic letters and electronic sources can predict same-day discharges following cholecystectomy

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Privacy-Preserving Protocol for Atomic Swap Between Blockchains

Atomic swap facilitates fair exchange of cryptocurrencies without the need for a trusted authority. It is regarded as one of the prominent technologies for the cryptocurrency ecosystem, helping to realize the idea of a decentralized blockchain introduced by Bitcoin. However, due to the heterogeneity of the cryptocurrency systems, developing efficient and privacy-preserving atomic swap protocols has proven challenging. In this thesis, we propose a generic framework for atomic swap, called PolySwap, that enables fair ex-change of assets between two heterogeneous sets of blockchains. Our construction 1) does not require a trusted third party, 2) preserves the anonymity of the swap by preventing transactions from being linked or distinguished, and 3) does not require any scripting capability in blockchain. To achieve our goal, we introduce a novel secret sharing signature(SSSig) scheme to remove the necessity of common interfaces between blockchains in question. These secret sharing signatures allow an arbitrarily large number of signatures to be bound together such that the release of any single transaction on one blockchain opens the remaining transactions for the other party, allowing multi-chain atomic swaps while still being indistinguishable from a standard signature. We provide construction details of secret sharing signatures for ECDSA, Schnorr, and CryptoNote-style Ring signatures. Additionally, we provide an alternative contingency protocol, allowing parties to exchange to and from blockchains that do not support any form of time-locked escape transactions. A successful execution of PolySwap shows that it takes 8.3 seconds to complete an atomic swap between Bitcoin’s Testnet3 and Ethereum’s Rinkeby (excluding confirmation time)

A microbial perspective of Drosophila suzukii: Insights into the pest microbe interactions

The fruit fly Drosophila suzukii infests intact, ripening soft fruits using the serrated ovipositor. Originally from Asia, this fly has successfully invaded several parts of America and Europe in the last decade, resulting in direct economic losses in the horticultural sector. Microbes are important in a pest’s life history. This thesis focused on investigating the kinds of microbial associations in D. suzukii in the Netherlands. Overall, this thesis provided us with the fundamental information of D. suzukii’s microbial ecology in the Netherlands

The Benefits faced by Aphids due to their Endosymbionts

Aphids enter a symbiotic relationship with bacteria which holds influence on their ecological characteristics. Although widespread in nature, investigation on their symbiotic relationship is yet to go on full-fledged. Both the obligate and facultative endosymbionts affect the life history traits of the aphids. I discuss the beneficial effects that the endosymbionts provide to their hosts and point out the questions based on which research can proceed further with respect to aphid- bacteria interactions. I finally conclude with some questions on this aspect and by pointing out the avenues which we can work on to develop a deepened insight of the evolutionary ecological traits

A Discussion on Elliptic Curve Cryptography and its Application

Abstract- Cryptography is an important part of preventing private data from being stolen. Even if an attacker were to break into your computer or intercept your messages they still will not be able to read the data if it is protected by cryptography or encrypted. In addition to concealing the meaning of data, cryptography performs other critical security requirements for data including authentication, repudiation, confidentiality, and integrity. Cryptography comes from Greek words meaning “hidden writing”. Cryptography converts readable data or clear text into encoded data called cipher text. By definition cryptography is the science of hiding information so that unauthorized users cannot read it. It involves Encryption and decryption of messages. Encryption is the process of converting a Plain text into cipher text and decryption is the process of getting back the original Message from the encrypted text. The Crux of cryptography lies in the key involved and the secrecy of the keys used to Encrypt or decrypt. Another important factor is the key strength, i.e. the size of the Key so that it is difficult to perform a brute force on the plain and cipher text and retrieve the key. There have been various cryptographic algorithms suggested. Elliptic curve cryptography (ECC) is a kind of public key cryptosystem like RSA. But it differs from RSA in its quicker evolving capacity and by providing attractive and alternative way to researchers of cryptographic algorithm. The security level which is given by RSA can be provided even by smaller keys of ECC (for example, a 160 bit ECC has roughly the same security strength as 1024 bit RSA). In this paper, we will present some ECC algorithms and also gives mathematical explanations on the working of these algorithms

Reporting emerging resistance of <i>Streptococcus pneumoniae</i> from India

<b>Background:</b> There are reports of emergence of resistant strains of <i>S</i>. <i>pneumoniae</i> showing resistance to penicillin from all over the world, and now, resistance to multiple drugs (multidrug-resistant strains) has been added to it. However, scanty reports are available so far from India, depicting such resistance. <b> Aims:</b> The aim of the present study is to look for the prevalence of penicillin-resistant pneumococci and also the multidrug-resistant strains among <i>S</i>. <i>pneumoniae</i>, isolated from respiratory specimens, in the coastal part of South India. <b> Settings and Design:</b> A cross-sectional study was conducted from June 2008 to December 2008, in our tertiary care center. Fifty pathogenic clinical isolates were collected from patients suffering from lower respiratory tract infections. <b> Materials and Methods:</b> Penicillin resistance was screened by 1 &#181;g oxacillin disk on Muller-Hinton blood agar followed by Minimum Inhibitory Concentration (MIC) detection by the agar dilution method according to the Clinical Laboratory Standards Institute (CLSI) guidelines. Antibiotic susceptibility for other antibiotics was carried out by the Kirby Bauer disk diffusion method followed by an E-test with HiComb test strips from Hi-media. <b> Results:</b> Out of 50 isolates, 4&#x0025; (95&#x0025; Confidence Interval - 1.4, 9.4) showed total resistance to penicillin, whereas, 10&#x0025; (95&#x0025; CI; 1.6, 18.3) showed intermediate resistance. These penicillin-resistant pneumococci (4&#x0025;) were also found to be multidrug-resistant (MDR) strains. Maximum resistance was observed for cotrimoxazole and tetracycline (24&#x0025; each with 95&#x0025; CI; 12.2, 35.8) followed by erythromycin and ciprofloxacin (14&#x0025; each with 95&#x0025;CI; 4.4, 23.6). <b> Conclusions</b> : Increasing emergence of the resistant strains of <i>S</i>. <i>pneumoniae</i> in the community set up requires continuous monitoring and a restricted use of antibiotics to keep a check on its resistance pattern, for an effective treatment plan