Cesarean section without urethral catheterization: a randomized control trial

BACKGROUND

Urethral catheterization is done as a routine procedure in cesarean section. It is associated with high incidence of urinary tract infections, discomfort, delayed ambulation and longer hospital stay.

OBJECTIVE

To determine the feasibility and safety of cesarean section without urethral catheterization.

METHODS

A prospective, randomized controlled trial was carried out from April 2008 to March 2009, in the Department of Obstetrics and Gynecology, B. P. Koirala Institute of Health Sciences. Among 150 patients who had undergone cesarean section 75 were catheterized and 75 were uncatheterized.

RESULTS

First void discomfort was significantly associated with the use of indwelling catheter (OR 6.95, CI 95 %, 3.74 to 12.95; P less than 0.001).Significant number of patients with indwelling catheter had signs and symptoms of urinary tract infection (OR 6,CI 95%, 2.59 to 13. 86; P less than 0.001). Positive urinalysis for urinary tract infection was high in catheterized group (P less than 0.001). Hospital stay was shorter in patients without catheter (p less than 0.05). None of the patients had bladder injury. There were no significant differences in duration of surgery and ambulation time between two groups of patients.

CONCLUSIONS

Cesarean section can be done safely without urethral catheterization with reduced morbidities.

Immunofluorescence of the outer root sheath: an aid to diagnosis in pemphigus

BACKGROUND

The direct immunofluorescence (DIF) pattern of the outer root sheath (ORS) of the hair follicle in patients with pemphigus resembles that of perilesional skin. We performed DIF on anagen and telogen hair ORS from patients with pemphigus and compared the findings with those of perilesional skin.

AIM

To assess the sensitivity of DIF in the ORS of anagen and telogen hair in patients with pemphigus with positive DIF results in perilesional skin.

METHODS

In total, 50 patients with active pemphigus and positive DIF findings in perilesional skin were selected for the study. Anagen hair was obtained from the scalp by the same method used for a trichogram, and telogen hair was selected by combing the hair and collecting the loose strands of hair from the comb. The hair type was further confirmed by microscopy. Hair samples were transported in Michel medium and prepared for DIF by mounting on a slide without sectioning. Anagen and telogen hair samples were also collected from 50 controls.

RESULTS

Immunological deposits characteristic of pemphigus were found in the ORS of anagen and telogen hairs in all 50 patients, but in none of the 50 controls. Positive DIF findings were seen in scalp hair irrespective of the presence of scalp lesions. Of the 50 patients with pemphigus, 46 were diagnosed with pemphigus vulgaris, 2 with pemphigus vegetans, and 1 each with pemphigus foliaceus and pemphigus erythematosus, based on the clinical, histopathological and DIF findings. All the pemphigus variants had positive DIF findings in the ORS.

CONCLUSIONS

Using DIF on telogen hair ORS promises to be a useful tool for diagnosis and follow-up in cases of pemphigus.

Morphometry of A1 segment of the anterior cerebral artery and its clinical importance

BACKGROUND AND AIM

Anterior cerebral artery, one of the terminal branches of the internal carotid artery is an important vessel taking part in the formation of circle of Willis. It supplies a large part of the medial surface of the cerebral hemisphere containing the areas of motor and somatosensory cortices of the lower limb. Aim of this study was the morphometry of A1 segment of the anterior cerebral artery.

MATERIALS AND METHODS

93 formalin fixed brain specimen of either sex and of Indian origin were studied. The mean length, mean external diameter and the anomalies present in A1 segment of the vessel were studied in detail and photographed.

RESULTS

The mean length of A1 segment of the vessel was 14.49+/-0.28 mm and 14.22+/-0.22 mm on right and left side respectively. The mean external diameter of the vessel on right and left side was 2.12+/-0.07 mm and 2.32+/-0.06 mm respectively. Narrowing, aneurysm formation, buttonhole formation and median anterior cerebral artery were the anomalies seen with an occurrence of 15.05%, 5.37%, 3.22% and 12.9%, respectively. The above anomalies did not have any sex or side predilection.

CONCLUSION

Knowledge of morphometry of the vessel will be of use to neurosurgeons while performing the shunt operation, in assessing the feasibility of such operations and in the choice of patients. From this study we infer that the morphometry of anterior cerebral artery varies in different population and that the neurosurgeons operating should have a thorough knowledge of the possible variations.

Anatomy of plantaris muscle: a study in adult Indians

AIM

The plantaris muscle (PM) and its tendon is subject to considerable variation in both the points of origin and of insertion. The present study was carried out to fi nd the different types of origin, insertion and possible variations of the PM in the population of southern costal region of India.

MATERIALS AND METHODS

52 embalmed (Formalin fixed) cadaver lower limbs of 26 males (age ranged 48-79 years, mean age 68 years) were dissected, to study the origin and insertion of PM. Various dimensions (length and width) of plantaris muscle belly and its tendon were also measured.

RESULTS

Three types of origin and equal number of insertion were noticed in the present study. The PM took origin from type I: Lateral Supracondylar ridge, Capsule of Knee joint and Lateral head of gastrocnemius in 73.07% cases; type II: Capsule of Knee joint and Lateral head of gastronemius in 5.76% cases; type III: Lateral Supracondylar ridge , Capsule of Knee joint , Lateral head of gastrocnemius and fibular collateral ligament in 13.46% cases. The plantaris tendon was inserted into type I: to the flexor retinaculum of foot in 28.84% cases; type II: independently to the os calcaneum in 36.53% cases; type III: to the tendocalcaneus at various levels in 26.92% cases. In four lower limbs (7.69%) the plantaris muscle was completely absent. Additionally the length and width of the plantaris muscle and its tendon were measured to know any side difference. There were no statistically significant differences between the measurements of left and right side (p>0.05).

CONCLUSION

Present study will help the surgeons while attempting various surgical procedures in and around the posterior aspect of knee involving plantaris.

The relationship between the saphenopopliteal junction and the common peroneal nerve: a cada-veric study

OBJECTIVES

The variable anatomy of the short saphenous vein (SSV) and the potential failure to identify the saphenopopliteal junction (SPJ) contribute to an increased risk of damage to the common peroneal nerve (CPN) during surgical exploration. The aim of the present study was to determine the variation of the SPJ, its relationship to the CPN, and the relationship of both SPJ and CPN to defined anatomical landmarks.

METHODS

Measurements of the distance between the SPJ and CPN, and the defined anatomical landmarks (fibula head, lateral joint space, lateral femoral epicondyle), were undertaken on 30 cadaveric limbs following careful dissection of the popliteal fossa.

RESULTS

The level of SPJ termination was classified as low (below), normal (within 100 mm above) and high (more than 100 mm above), the lateral femoral epicondyle. Of the 30 limbs dissected, 70% of SPJs were normal, 23% low and 7% high. Direct measurement from the SPJ to anatomical landmarks showed a higher interquartile range (IQR) in low compared with normal terminations; however, the vertical distance from the SPJ to the fibula head showed an increase in IQR from low to normal terminations (7.1-14.2). The mean distances between the SPJ and CPN in low and normal terminations were 23.3 and 16.7 mm, respectively. Comparison of the IQR showed values very similar to low terminations having a slightly higher IQR compared with normal terminations (7.15-6.0).

CONCLUSION

Significant anatomic variation was observed in the termination of the SSV, with 67% located within 66 mm above the lateral femoral epicondyle. The risk of damaging the CPN during saphenopopliteal ligation may be higher for SPJs located above the lateral femoral epicondyle because of the proximity of the two structures and variability of SPJ.

Treated wastewater effluent reduces sperm motility along an osmolality gradient

Many toxic effects of treated wastewater effluent on organismal and reproductive health have been documented. However, the physicochemical environment of treated wastewater effluent frequently differs considerably from that of its receiving waters and may affect organismal function independently of toxic effects. Teleost sperm, for example, may be affected by the higher osmolality of treated wastewater, as this sperm is activated for a brief period of time following ejaculation due to the sudden decrease in osmolality of its surrounding environment. In this study, we examined the effects of treated wastewater effluent on sperm motility to test the hypothesis that the higher osmolality of effluent compared to river water will adversely affect sperm activation in a concentration-dependent relationship. Treated wastewater effluent was collected on 5 days from the outflow of the Metropolitan Wastewater Treatment Plant, St. Paul, Minnesota, and from an upstream site on the Mississippi River. Milt aliquots collected from goldfish were diluted in an isotonic extender solution and subsequently activated in either deionized water, 100%, 50%, or 10% effluent, a synthetic ion mixture, or river water. Sperm motility and velocity were assessed at 15-s intervals for 1 min using a computer assisted sperm analyzer. Significant differences in performance parameters were found only at 15 s, with sperm motility and velocity declining rapidly at later sampling times. Predictably, deionized water resulted in the greatest activation of sperm motility, while motility exhibited a concentration-dependent decline in 10%, 50%, and 100% treated wastewater effluent. Interestingly, Mississippi River water and a synthetic ion mixture with an osmolality comparable to 50% effluent both resulted in the least amount of sperm activation. However, sperm activation in river water varied between collection days during the study. River water and 100% effluent both had low sperm activation characteristics despite a 10-fold difference in osmolality between these two treatments (1 and 10 mOsmol kg(-1), respectively). Results of this study indicate a concentration-dependent decrease in sperm motility in treated wastewater effluent as well as significant fluctuations of sperm activation in Mississippi River water. This study illustrates the complexity of assessing the effects of treated wastewater effluents and the difficulty of determining appropriate reference sites for such studies.

Anatomical variations of the thyroid gland: possible surgical implications

INTRODUCTION

The organogenesis of the thyroid gland in humans is often disturbed, leading to a variety of morphological variations of the gland, such as hypoplasia, ectopy, hemiagenesis and agenesis. As the morphological variations are usually diagnosed incidentally during examination for other thyroid gland diseases, the true incidence is therefore uncertain.

METHODS

This study was structured to investigate the gross anatomical features of the thyroid gland in 105 (88 male and 17 female) cadavers from the coastal belt of southern India, an endemic goitre region.

RESULTS

The pyramidal lobe was present in 61 (58 percent) male cadavers, and 52 (49.5 percent) cadavers showed the presence of the levator glandulae thyroideae. 33 percent of the specimens studied showed agenesis of the isthmus. However, the accessory thyroid tissue was found in only one cadaver.

CONCLUSION

This study highlights the various developmental anomalies of the thyroid gland, which forms a cornerstone to safe and effective surgery.

A cadaveric study of the testicular artery in the South Indian population

INTRODUCTION

The male gonadal arteries, namely the testicular arteries, may vary at their origin and arise from the renal artery, suprarenal artery or lumbar artery. They may also be doubled, tripled or even quadrupled and may arise as a common trunk. With the advent of new intra-abdominal operative and laparoscopic techniques, the anatomy of the gonadal vessels has assumed much more importance. Therefore, a study was designed to assess the percentage of normal and aberrant origin and course of the testicular artery in the Indian population.

METHODS

The posterior abdominal walls of 34 male cadavers (68 sides) were dissected and studied for the variations in the origin and course of the testicular arteries.

RESULTS

In 85.3 percent of the cases, the male gonadal artery was normal in origin, number and course. However, in the remaining 14.7 percent, various anomalies in the testicular artery were noted.

CONCLUSION

The variations in the testicular arteries are attributed to their embryological origin. A deep knowledge of these variations and their relations to the adjacent structures is very important in avoiding the complications in operative surgery.

Lithoclast(®) Master in Intracorporeal Lithotripsy during Percutaneous Nephrolithotomy : Our Experience

BACKGROUND

This study was carried out to compare the efficacy of Lithoclast(®) Master with pneumolithotriptor during percutaneous nephrolithotomy (PNL) in the treatment of renal staghorn calculi.

METHODS

In this prospective study, 60 patients suffering from partial or complete staghorn renal stones were included. Patients were divided randomly in two groups : Groups I and II and underwent PNL for removal of stones. In Group I patients, standard pneumolithotriptor and in Group II, Lithoclast(®) Master was used for stone fragmentation. The patients were evaluated for rate of fragmentation/clearance, presence of residual fragments by KUB radiograph/ultrasound. Result was analyzed by Chi-square test.

RESULT

The rate of fragmentation using Swiss Lithoclast(®) Master was more effective and quicker in comparison to standard pneumolithotriptor. The average time taken for fragmentation and clearance in Group I using pneumolithotriptor was 65 minutes, whereas it was 58 minutes using Lithoclast® Master, which was statistically significant (p< 0.01). Only 4% patients had significant residual fragments (> 4mm) in Group II and 16 (53%) patients in Group I, which was significant (p < 0.01). The complications in both the modalities were insignificant; one (1.33%) patient had bleeding and three (10%) patients had urine leak in Group I; whereas three(10%) patients had bleeding and five (16.7%) urine leak in Group II.

CONCLUSION

Lithoclast(®) Master is an effective intracorporeal lithotripter during percutaneous nephrolithotomy in the treatment of renal staghorn calculi for stone fragmentation/clearance with minimal residual fragments and complications.

Teratogenic effects of the anticonvulsant gabapentin in mice

INTRODUCTION

We aim to study and elucidate the safety profile of the antiepileptic doses of gabapentin during pregnancy, and to evaluate gabapentin-induced murine fetotoxicity at different dose levels.

METHODS

A total of 60 pregnant mice, divided into 12 groups of five mice each, were exposed to gabapentin in four different doses of 0 (control), 113, 226, or 452 mg/kg body weight per day, at three different gestational stages including early gestation (1-6 days), mid-gestation (7-12 days), and late gestation (13-17 days). The pregnant mice were euthanized on day 18 of gestation, and foetuses were examined for teratogenic manifestations. Their brains were dissected and examined for gross changes, malformations, histological changes, and quantitative protein estimation.

RESULTS

Foetal resorptions were observed in all treated groups with gabapentin administration at early gestation (1-6 days), and mid-gestation (7-12 days). On the other hand, growth retardation along with stunting in size of live foetuses were observed in all the mid-gestation (7-12 days), and late gestation (13-17 days) treated groups. Various gross malformations were observed with all the three doses (113, 226, and 452 mg/kg body weight per day) when gabapentin was administered at mid-gestation (7-12 days). The same trends were confirmed by gross and microscopic examination of brains along with quantitative protein estimation.

CONCLUSION

Gabapentin should not be prescribed during pregnancy, as no therapeutic dose of gabapentin is safe during this period as far as the foetal well-being is concerned.

Synchronous primary triple neoplasia (renal cell carcinoma and prostate cancer in combination with thyroid neoplasm). Report of an unusual case

We report a very rare case of triple primary neoplasia synchronously originating in the prostate, kidney and thyroid, in a 79-year-old male who presented with hematuria and continuous pain at the right hip. Examination revealed an enlarged nodular thyroid, while digital rectal examination showed prostatic enlargement with elevated PSA (16.7 ng/mL). Plain radiography showed an osteolytic lesion in the right ischium. Ultrasonography and CT scan of left kidney suggested renal cell carcinoma (RCC), which was subsequently confirmed on histopathology of the left radical nephrectomy specimen. Biopsies from prostate showed adenocarcinoma, along with deposits in ischial biopsy. Fine needle aspiration cytology (FNAC) of neck swellings suggested deposits from thyroid follicular carcinoma, which was subsequently confirmed by histopathology of the near-total thyroidectomy specimen. Currently, the patient is on regular follow-up since the past 24 months.

Arched left gonadal artery over the left renal vein associated with double left renal artery

Variations in the anatomical relationship of the gonadal arteries to the renal vessels are frequently reported. We present, on a male cadaver, an unusual origin and course of a left testicular artery arching over the left renal vein along with double renal arteries. The development of this anomaly is discussed in detail. Compression of the left renal vein between the abdominal aorta and the superior mesenteric artery usually induces left renal vein hypertension, resulting in varicocele. We propose that the arching of left testicular artery over the left renal vein could be an additional possible cause of the left renal vein compression. Therefore, knowledge of the possible existence of arching gonadal vessels in relation to the renal vein could be of paramount importance to vascular surgeons and urologists during surgery in the retroperitoneal region.

Lamotrigine in pregnancy: safety profile and the risk of malformations

The use of antiepileptic drugs in pregnancy always presents challenges to doctors and their patients as it may have deleterious effects on the developing embryo. Lamotrigine is most commonly-prescribed drug among the newer antiepileptic drugs; hence, it has been selected for the present review. A number of studies pertaining to the safety of lamotrigine use during pregnancy have been reported, with differing results. Contradictory results have been reported in animals regarding lamotrigine teratogenicity, and human studies have also proven inconclusive. In many countries, human pregnancy registries are maintained to establish the safety of antiepileptic drugs during pregnancy, as all the different suggestions favour some over others, with specific antiepileptic combinations still being questioned. It is our hope that the present work may integrate the available disparate relevant facts into a directed effort towards minimising the risk of foetal compromise.

Third head of biceps brachii in an Indian population

INTRODUCTION

The biceps brachii is one of the muscles of the anterior compartment of the upper arm. It is characteristically described as a two-headed muscle that originates proximally by a long head and a short head. The present study was carried out to find the occurrence of a third head of biceps brachii among a sample Indian population from the southern coastal part.

METHODS

The arms of 42 cadavers were dissected and observed for variations in the origin and insertion of biceps brachii muscle bilaterally. The cadavers were embalmed and preserved in ten percent formalin.

RESULTS

Among 42 arms studied, three had biceps brachii with three heads on the right side. The third head was of humeral origin, which inserted into the radial tuberosity by a common tendon with the long and short heads. The results of the present study compared with that of previous studies from medical literature shows that the occurrence of a third head of the biceps brachii muscle is relatively rare in Indians.

CONCLUSION

Knowledge of the existence of the third head of biceps brachii may become significant in preoperative diagnosis and during surgery of the upper limb.

Identification of Human Immunodeficiency Virus Type-1 Subtypes by Heteroduplex Mobility Assay

BACKGROUND

Human immunodeficiency virus type-1 (HIV-1) has developed marked genomic sequence differences over the course of an epidemic because of an error prone reverse transcriptase (RT), which rapidly incorporates mutations resulting in genomic diversity, altered cell tropism, immune escape and variable resistance to antiretroviral drugs. The best preventive strategy for HIV control is development of an efficacious prophylactic vaccine using the most appropriate (antigenically related) subtypes. On the basis of phylogenetic analysis, HIV strains can be separated into major group "M" consisting of genetic subtypes A-K, "N", the new group and "O", the outlier group.

METHODS

Heteroduplex mobility assay (HMA) is a rapid, economical and reliable technique of subtyping HIV-1. It is based on the principle of determining the genomic relatedness and divergence of the unknown sample with the known reference plasmid HIV-1 subtypes by studying the mobility patterns of the resulting heteroduplexes formed on the polyacrylamide gel.

RESULT

A total of 70 HIV-1 seropositive samples obtained from service personnel, their families and civilians from service hospitals were analyzed and their subtype distribution studied. 66 (94.28%) were HIV-1 subtype C and two (2.85%) subtype B. In two (2.85%) samples, the subtype distribution was homotypic recombinant, one each of subtype C1 & C2 and C2 & C4 respectively.

CONCLUSION

Service personnel and their families represent a divergent population from different regions of India. An analysis of subtypes in these HIV-1 seropositive individuals will help in understanding the geographical distribution and evolution of the virus. Determination of HIV-1 subtypes has significant implications for development of candidate vaccine for India.

A meta-analysis on the influence of inflammatory bowel disease on pregnancy

BACKGROUND

Inflammatory bowel disease (IBD) has a typical onset during the peak reproductive years. Evidence of the risk of adverse pregnancy outcomes in IBD is important for the management of pregnancy to assist in its management.

AIM

To provide a clear assessment of risk of adverse outcomes during pregnancy in women with IBD.

DESIGN

The Medline literature was searched to identify studies reporting outcomes of pregnancy in patients with IBD. Random-effect meta-analysis was used to compare outcomes between women with IBD and normal controls.

PATIENTS AND SETTING

A total of 3907 patients with IBD (Crohn's disease 1952 (63%), ulcerative colitis 1113 (36%)) and 320 531 controls were reported in 12 studies that satisfied the inclusion criteria.

RESULTS

For women with IBD, there was a 1.87-fold increase in incidence of prematurity (<37 weeks gestation; 95% CI 1.52 to 2.31; p<0.001) compared with controls. The incidence of low birth weight (<2500 g) was over twice that of normal controls (95% CI 1.38 to 3.19; p<0.001). Women with IBD were 1.5 times more likely to undergo caesarean section (95% CI 1.26 to 1.79; p<0.001), and the risk of congenital abnormalities was found to be 2.37-fold increased (95% CI 1.47 to 3.82; p<0.001).

CONCLUSION

The study has shown a higher incidence of adverse pregnancy outcomes in patients with IBD. Further studies are required to clarify which women are at higher risk, as this was not determined in the present study. This has an effect on the management of patients with IBD during pregnancy, who should be treated as a potentially high-risk group.

Cadavers as teachers in medical education: knowledge is the ultimate gift of body donors

In most of the medical colleges in India, unclaimed bodies from various mortuaries reach the dissection hall; and here, the body donors club has yet to gain the desired dimensions. In spite of all the adverse circumstances, the cadaver and the dissection both have survived the most rigorous test of pedagological fitness--the test of time. Today, many of the Western countries have long donor waiting lists where cadavers are acquired as anatomical gifts or through body donor programmes. Thailand's approach to body donors offers a role model for resolving the present situation. The spirit of volunteerism reflects the drastic shift in public perception and a global change in approach is needed in the present time.

Placental pathology of recurrent spontaneous abortion: the role of histopathological examination of products of conception in routine clinical practice: a mini review

BACKGROUND

Histopathological examination of products of conception from miscarriages is part of routine clinical practice. The extent of additional clinically relevant information provided by this investigation in the setting of recurrent spontaneous abortion remains uncertain.

METHODS

Review of the literature was performed to identify studies reporting on findings of histological examination of routinely obtained products of conception in the setting of recurrent spontaneous abortion. The initial search identified 312 potential references, but 300 were excluded on further examination due to lack of data on specific histopathological findings in routine products of conception specimens from patients with recurrent spontaneous abortion. The 12 included studies indicated that such examination may identify hydatidiform moles, villous dysmorphic features suggesting fetal aneuploidy, chronic histiocytic intervillositis (CHI) and massive perivillous fibrin deposition and impaired trophoblast invasion. However, in most cases, morphological assessment cannot reliably determine the cause of the miscarriage or distinguish recurrent from sporadic miscarriage. Studies reporting on the use of additional immunohistochemical methods do not currently provide additional clinically useful diagnostic or prognostic information.

CONCLUSION

Routine histological examination of products of conception in the setting of recurrent spontaneous abortion can provide important clinical information in a minority of cases.