In accelerated weathering tests, specimens are exposed to higher radiation intensity, temperature and humidity than is likely under natural weathering in order to achieve rapid degradation of the ...polymer in a convenient short time. In the current work, a correlation between the two environments is attempted so that a prediction of lifetimes in the natural environment can be achieved. During aging, surface flaws are created due to the chain scission process. This is initiated by the absorption of ultra-violet light and directly affects visual appearance and impact strength. After natural weathering, the material shows only plastic deformation in an impact test. However, after artificial weathering to 5000 h of UV exposure, there is a decrease of 85% in impact strength. Colour change occurs at a high rate in the early stages of UV exposure. Beyond 2000 h of exposure, the colour change approaches a steady state and a correlation between the changes under natural and artificial weathering becomes apparent for a potential prediction of lifetimes. From the analysis including the specular component (SCI), taking surface roughening into account, 1 year under natural weathering was found to be equivalent to 25 days under accelerated weathering.
Implementing a sustainable and effective Antimicrobial Stewardship (AMS) programme in secondary level hospitals, in Low-Middle Income Country (LMIC) contexts, has numerous challenges. It is important ...to understand these challenges so that the stewardship initiatives can be tailored according to the unique requirements thrown up by these healthcare facilities. This study explores the experiences of implementing AMS in secondary level hospitals in the state of Kerala, India.
A qualitative study was planned to map the challenges in implementing AMS in the secondary level hospitals. Toward the end of the 1 year followup period, the nodal officers at each hospital were interviewed using a semi-structured interview guide. The in-depth interviews were transcribed and later subjected to content analysis using N-Vivo 11.0, a popular software tool used for qualitative analysis.
Many physicians cite perceived patient satisfaction as one of the reasons for increased antibiotic use, as many patients consider antibiotics as standard of care. Also, the distance traveled by the patient and advancing age are factors which increase antibiotic use. The physician factors which determine use include empiric treatment needs, outbreak of diseases, absence of education programmes in antibiotic usage to fill in the knowledge gap and fear of litigation. The promotional activities by companies and antibiotics being a major source of income for small hospitals, affects use patterns. The factors which determine antibiotic selection includes conformism, experience of the physician, perceived resistance to certain antibiotics, emergence of specific diseases, and promotional activities related to antimicrobial agents. The challenges in implementing a sustainable stewardship programme is multifactorial. It includes competition between doctors, time constraints faced by physicians, absence of a champion, sub-optimal interdepartmental cooperation, absence of supporting facilities, dysfunctional regulatory systems, and unreliability of antibiograms.
AMS in resource-limited setting is going to be a challenge, especially in terms of financing, access to technologies and capacity building. Political and regulatory willpower of international partnerships should be effectively harnessed for designing solutions for LMIC contexts. Also, models for stewardship from elsewhere should undergo an adaptation process before implementation in low resource settings.
Achalasia cardia (AC) is a frequently encountered motility disorder of the esophagus resulting from an irreversible degeneration of neurons. Treatment modalities are palliative in nature, and there ...is no curative treatment available for AC as of now. Significant advancements have been made in the management of AC over last decade. The introduction of high resolution manometry and per‐oral endoscopic myotomy (POEM) has strengthened the diagnostic and therapeutic armamentarium of AC. High resolution manometry allows for the characterization of the type of achalasia, which in turn has important therapeutic implications. The endoscopic management of AC has been reinforced with the introduction of POEM that has been found to be highly effective and safe in palliating the symptoms in short‐term to mid‐term follow‐up studies. POEM is less invasive than Heller's myotomy and provides the endoscopist with the opportunity of adjusting the length and orientation of esophageal myotomy according to the type of AC. The management of achalasia needs to be tailored for each patient, and the role of pneumatic balloon dilatation, POEM, or Heller's myotomy needs to be revisited. In this review, we discuss the important aspects of diagnosis as well as management of AC. The statements presented in the manuscript reflect the cumulative efforts of an expert consensus group.
Abstract
The novel coronavirus disease 2019 (COVID-19) which originated in China has been declared a pandemic by the World Health Organization (WHO). This virus gets transmitted through air droplets ...and direct contact. Health care workers doing aerosol-generating procedures are at a higher risk of acquiring the infection. Many procedures done by the gastrointestinal endoscopists are classified as aerosol-generating procedures, which in turn underline the need for proper safety precautions during these procedures. Apart from general safety measures advised by various organizations, proper use of personal protective equipment (PPE) is a pivotal factor in safeguarding health care personnel during endoscopy. This article provides a short overview of the different PPEs available and their proper use in endoscopy.
Background and Objectives: Early diagnosis of candidemia is of vital importance in reducing mortality and morbidity. The main objective of the study was to determine the TTP (Time to Positivity) of ...different species of Candida causing blood- stream infection and to see whether TTP can help differentiate Candida glabrata which is frequently fluconazole resistant from Fluconazole sensitive Candida. Materials and Methods: TTP (Time to positivity) and AAT (Appropriate Antifungal therapy) were noted for Blood cultures becoming positive for Candida. Presence of Risk factors for candidemia like prolonged ICU stay, neutropenia, Total Paren- teral Nutrition (TPN), use of steroids , broad spectrum antibiotics, use of Central Venous Catheter, Foleys catheter were also analyzed. Results: The most frequent isolates were Candida parapsilosis, Candida tropicalis and Candida albicans. The median TTP for all Candida isolates in our study was 34 hours. The diagnostic sensitivity of TTP for detecting C. glabrata and C. tropicalis in patients with candidemia was 88% and 85% respectively. TTP showed that there was no difference in survival between TTP <24 hrs. and > 24hrs. Initiation of antifungal therapy <24 hours and > 24hrs after onset of candidemia had no association with survival. Conclusion: Longer TTP maybe predictive of C. glabrata while shorter TTP may be predictive of C. tropicalis. In our study we found that fluconazole resistant Candida causing blood stream infection is quite unlikely if the TTP of the isolate is <48hrs.
Antimicrobial resistance (AMR) is now a global public health issue and is projected to affect the longevity of people and increase health expenditure of countries. Its impact is going to be higher in ...low-middle income countries as the healthcare systems are suboptimal and ill-equipped to deal with the issue. As antibiotic misuse is the primary driver for AMR, there is an acute need to create awareness among general public regarding antibiotic misuse. This calls for a comprehensive communication strategy, which takes into account the various drivers of AMR and the solutions associated with it. In the short term, the focus of communication strategies can be on raising awareness in specific interest groups. It can help in channeling limited resources to achieve specific objectives for raising awareness among these groups, thereby improving the chances of behavior change. The general public can be targeted at a later stage or as a second phase with definite strategies and messages. But, it is erroneous to assume that a higher level of awareness will translate into a positive change in behavior. We propose that behavior change is the final fruit of a long and dynamic process. This process should rest on four pillars: adequate awareness, robust regulatory environment, emotional or material incentives, and an enabling social structure. Unless all these domains are satisfactorily addressed, the communication strategy will not be able to bring about a discernible change in behavior in terms of antibiotic use.
The cost of pharmaceuticals, as a percentage of total healthcare spending, has been rising worldwide. This has resulted in strained national budgets and a high proportion of people without access to ...essential medications. Though India has become a global hub of generic drug manufacturing, the expected benefits of cheaper drugs are not translating into savings for ordinary people. This is in part due to the rise of branded generics, which are marketed at a price point close to the innovator brands. Unbranded generic medicines are not finding their way into prescriptions due to issues of confidence and perception, though they are proven to be much cheaper and comparable in efficacy to branded medicines. The drug inventory of unbranded generic manufacturers fares reasonably when reviewed using the World Health Organization-Health Action International (WHO-HAI) tool for analysing drug availability. Also, unbranded generic medicines are much cheaper when compared to the most selling brands and they can bring down the treatment costs in primary care and family practice. We share our experience in running a community pharmacy for an urban health center in the Pathanamthitta district of Kerala State, which is run solely on generic medicines. The drug availability at the community pharmacy was 73.3% when analyzed using WHO-HAI tool and the savings for the final consumers were up to 93.1%, when compared with most-selling brand of the same formulation.
Abstract This video is of a 65 year old female patient with history of systemic hypertension, type 2 diabetes and coronary artery disease on medical management. She presented with features of acute ...pancreatitis which was managed conservatively and imaging showed features of chronic pancreatitis with dilated pancreatic duct and pancreas divisum was suggested. She had two further episodes of acute pancreatitis and was managed conservatively. Pancreatic stenting was suggested but during ERCP minor papillae couldn't be identified. Hence, EUS guided Rendez - vous pancreatic duct puncture and minor papillae stenting was done with the help of a modified cannula.
Background : : There is a paucity of literature regarding the prevalence of Mirizzi syndrome (MS) in patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) for obstructive ...jaundice. We aimed to describe the clinical presentation; laboratory, imaging, and ERCP findings; and surgical management of patients with MS at our center.
Methods : : A retrospective review was performed of the medical records of 3,852 consecutive patients who underwent ERCP between January 2010 to December 2019 at our center.
Results : : MS was diagnosed in 84 (2.2%) of the patients who underwent ERCP, with 45 male and 39 female patients. Jaundice was the most common symptom (100%) followed by abdominal pain (91.6%). Leukocytosis and altered liver function tests were noted in all our patients. Although most of our patients had one or more pre-procedure imaging studies, MS was confirmed and subclassified based on cholangiographic and intraoperative findings. There were 11 post-cholecystectomy MS patients who opted for endoscopic therapy with repeated biliary stenting. Among the remaining 73 patients, 48 with type I and 21 with type II MS underwent open cholecystectomy, 4 with type III MS received cholecystectomy and choledochoduodenostomy, and another 4 patients with type II MS underwent subtotal cholecystectomy and choledochoplasty. Associated cystic duct abnormalities were noted in 20.2% of patients. Bile duct injuries occurred in 3 patients during an attempted laparoscopic procedure; however, no mortality was reported.
Conclusion : : Although it is preferable to diagnose MS preoperatively, a preoperative diagnosis is seldom possible. ERCP is both a diagnostic and therapeutic procedure of choice before definitive surgery and helps to identify any associated cystic duct anomalies in these patients.
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