Globozoospermia

Male infertility may be due to low sperm concentration, poor sperm motility, or abnormal morphology. Among the factors involved in male infertility, there is a rare morphology disorder called "Globozoospermia". This condition is primarily characterized by the presence of round-headed spermatozoa, absence of acrosomal cap and cytoskeleton defects around the nucleus. The morphological characteristics of globozoospermia are formed during spermiogenesis. We report here a case of male infertility due to morphological disorder Globozoospermia. Assessment of semen by observing macroscopic and microscopic parameters are not sufficient for sperm analysis. In present case, macroscopic and microscopic assessment was within normal range. Morphological assessment showed 80% of spermatozoa with round head and absence of acrosomal cap. The absence of acrosome makes fertilization impossible since these sperm are unable to bind to the zona pellucida. By using Intracytoplasmic Sperm Injection (ICSI), conception is possible; however, the fertilization rate remains very low.

Comparing heart risk scores to identify the most important risk factors for cardiovascular diseases

OBJECTIVE

Cardiovascular disease (CVD) is the most common non-communicable disease and the leading cause of death worldwide. To reduce the global burden of CVD and related morbidity and mortality, early prediction of CVD risk is essential. Various tools are available to access the risk of cardiovascular disorders. In the present study, we evaluated four risk score calculators associated to CVD for superiority and most reliable CVD prognosis parameters.

PATIENTS AND METHODS

In the present prospective study, we investigated the probability of CVD in 150 individuals, including both men and women, using four different cardiovascular risk assessment estimators (Framingham Risk Score [FRS] Calculator, Q-RISK calculator, Reynolds score calculator, and atherosclerotic cardiovascular disease (ASCVD) risk calculator) and evaluated how closely they were related to 16 selected parameters. The four risk estimators shared several common parameters, such as age, smoking status, and blood pressure; however, each of them also used some unique parameters. We used statistical analysis to reduce the number of parameters necessary to predict CVD.

RESULTS

Statistical analysis revealed a significant correlation between the main factors responsible for CVD risk. The analysis revealed that out of the four risk calculators tested, the FRS calculator was superior to the others because it showed more significant corroboration with statistical tools and could better predict the most important prognostic factors in CVD.

CONCLUSIONS

In all four risk estimators, the parameters that affected risk most significantly and conferred the most reliable CVD prognosis were age, weight, total cholesterol, and hemoglobin levels. With that FRS calculator was superior to the others.

Wound Infection with Multi-Drug Resistant Clostridium Perfringens: A Case Study

Wound infections are among public health problems worldwide. However, progress has been made in improving surgical techniques and antibiotic treatments. Misuse/overuse of antibiotics to prevent and treat bacterial infections eventually leads to increased bacterial resistance with rising incidences of multi-drug resistant (MDR) bacterial strains. The wider dissemination of antibiotics may ultimately result in ineffectiveness to antibiotic therapy, thereby complicating/graving the outcome of a patient. In the present study, a 60-year-old male patient having wound infection with MDR bacterium that ultimately required surgical amputation of the toe was investigated. For the confirmation of MDR bacterium, two culture media viz., MacConkeyAgar and Mueller Hinton Agar media were used. The sensitivity of the isolated strain for various antibiotics was tested using the disc diffusion method. The wound sample was found positive for Gram-positive bacterium that was identified as Clostridium Perfringens. The bacterium was screened for 40 antibiotics, and among all the antibiotics, it was found sensitive for only Piperacillin/Tazobactam antibiotic combination. C. perfringens bacterium caused the gas gangrene in the infected wound part of the patient. Amputation of the gangrene -affected foot part was performed by surgery, and with good medical care, the person recovered fast. To the best of our knowledge, this is the first-ever report of MDR C. perfringens single isolate harboring resistance against at least 40 antibiotics tested. More research is needed to develop really new and effective medicines that do not cross-react with antibiotics now in use and have robust activity against MDR organisms.

Thresholds for Spinal Anaesthesia-induced Hypotension During Caesarean Section

Background Spinal anaesthesia is the current standard for caesarean section. Hypotension, a common complication, potentially results in adverse foetal and maternal outcomes. However, hypotension-defining criteria are varied. Objective To identify the blood pressure thresholds for spinal anaesthesia-induced hypotension during caesarean section. Method This is a retrospective cohort study of spinal anaesthesia-induced hypotension that occurred till baby-delivery during caesarean section. Reports on intraoperative hypotension, collected previously from January to December 2019, were reviewed to identify the hypotension-defining thresholds. The thresholds were categorized into systolic blood pressure (SBP) of 80, 90 or 100 mmHg, mean arterial pressure (MAP) of 60, 65 or 70 mmHg, combinations, and others. Parturient and anaesthesia characteristics, and associated hypotensive symptoms were also recorded for descriptive analysis. Result Spinal anaesthesia-induced hypotension was identified in 129 (11.5%) cases among 1116 caesarean sections. Altogether, 12 hypotension-defining thresholds were employed. Thresholds of SBP 90, MAP 60, and SBP 80 mmHg were used in 53 (41%), 28 (21.7%), and 21 (16.2%) cases respectively. Mean maternal age was 28 (±4.22) years and 87 (67.4%) cases underwent emergency surgery. Median sensory blockade level was T4. Nausea-vomiting, bradycardia, and tachycardia were associated during five (3.8%), six (4.6%), and 15 (11.6%) hypotensive incidents respectively. Two cases had unrecordable blood pressure but there was no maternal mortality. Conclusion Systolic blood pressure of 90 mmHg and mean arterial pressure of 60 mmHg included the most common thresholds for spinal anaesthesia-induced hypotension during caesarean section. Identifying the safe and clinically relevant hypotension-defining criteria needs further investigation.

Study of Dexmedetomidine in Caudal Block for Children Undergoing Inguino-scrotal Surgery

Background Caudal block is the most common anaesthetic technique employed in children for managing perioperative pain of inguino-scrotal surgery. However, despite using longacting local anaesthetics, caudal analgesia lasts relatively shorter. Dexmedetomidine, an alpha-2 agonist, augments local anaesthetic action. Objective To assess the analgesic effect of caudal Dexmedetomidine. Method This is a randomized, double-blinded study conducted on otherwise healthy children (one to five years) undergoing elective inguino-scrotal surgery. General anaesthesia was administered and a laryngeal mask airway was inserted for assisting ventilation. The caudal block was applied using 0.8 milliliters/kilogram drug volume comprising either two milligrams/kilogram Bupivacaine in group A (n=42) or two milligrams/ kilogram Bupivacaine mixed with 0.75 micrograms/kilogram Dexmedetomidine in group B (n=42). Intraoperatively, inhaled Halothane, intravenous Fentanyl, fluids, and ventilation were titrated to maintain monitored hemodynamic variables within 15% from baseline values. The primary endpoint comprised the duration of analgesia, defined by a time when postoperative pain score (face, legs, activity, cry, consolability; FLACC scale) reached four out of ten. Perioperative events were studied for 24 hours. Student's t-test and Chi-square test were used for analysis, with p-value less than 0.05 considered as significant. Result Demographic, surgical, and anaesthetic characteristics were similar between the groups. Duration of analgesia was significantly prolonged in group B (group B, 413±101 minutes; group A, 204±40 minutes). The intraoperative requirement for supplement Fentanyl was significantly reduced in group B. Adverse events were comparable between the groups. Conclusion Dexmedetomidine prolongs the duration of analgesia when mixed with caudal Bupivacaine, without increasing adverse events.

'Hiding their troubles': a qualitative exploration of suicide in Bhutanese refugees in the USA

BACKGROUND

Suicide is a major global health concern. Bhutanese refugees resettled in the USA are disproportionately affected by suicide, yet little research has been conducted to identify factors contributing to this vulnerability. This study aims to investigate the issue of suicide of Bhutanese refugee communities via an in-depth qualitative, social-ecological approach.

METHODS

Focus groups were conducted with 83 Bhutanese refugees (adults and children), to explore the perceived causes, and risk and protective factors for suicide, at individual, family, community, and societal levels. Audio recordings were translated and transcribed, and inductive thematic analysis conducted.

RESULTS

Themes identified can be situated across all levels of the social-ecological model. Individual thoughts, feelings, and behaviors are only fully understood when considering past experiences, and stressors at other levels of an individual's social ecology. Shifting dynamics and conflict within the family are pervasive and challenging. Within the community, there is a high prevalence of suicide, yet major barriers to communicating with others about distress and suicidality. At the societal level, difficulties relating to acculturation, citizenship, employment and finances, language, and literacy are influential. Two themes cut across several levels of the ecosystem: loss; and isolation, exclusion, and loneliness.

CONCLUSIONS

This study extends on existing research and highlights the necessity for future intervention models of suicide to move beyond an individual focus, and consider factors at all levels of refugees' social-ecology. Simply focusing treatment at the individual level is not sufficient. Researchers and practitioners should strive for community-driven, culturally relevant, socio-ecological approaches for prevention and treatment.

Serum albumin and creatinine clearance rate among smear positive pulmonary tuberculosis patients in Bangladesh

This case control study was carried out in the Department of Biochemistry, Mymensingh Medical College in cooperation with the Outpatient Department and Medicine Units of Mymensingh Medical College Hospital, Fulbaria Upazilla Health Complex, Mymensingh and some DOTS centers of BRAC, a non-government organization during the period of July 2006 to June 2007. The aim of the study was to explore the status of serum albumin & creatinine clearance levels in smear positive Bangladeshi pulmonary tuberculosis patients as a means to monitor the possibility of management of these patients as these levels decrease significantly. Serum albumin level was investigated in TB patients for monitoring the nutritional status of TB patients and also for the adjustment of serum calcium level. Creatinine clearance rate was investigated in TB patients for monitoring the impairment of renal function and nutritional depletion in tuberculosis patients. A total of 120 people of different age groups were included in this study. Subjects were divided into two groups- Group I (Control; n=60) - apparently healthy people selected matching by age, sex and socioeconomic status with the cases and Group II (Case; n=60) - people with smear positive pulmonary tuberculosis. Serum albumin was estimated by colorimetric principle. Serum creatinine was also estimated by colorimetric principle & creatinine clearance rate was estimated from serum creatinine by Cockcroft- Gault equation. Statistical analysis was done by using SPSS windows package. Among the groups, mean±SD of serum albumin in Group II (3.74±0.44gm/dl) was significantly lower (p<0.001) than that in Group I (4.85±0.31gm/dl). Mean±SD of creatinine clearance rate in Group II (35.36±8.29ml/min) was also significantly lower than that in Group I (84.16±20.20ml/min). It is evident from the study that serum albumin & creatinine clearance rate levels significantly decrease in smear positive Bangladeshi pulmonary tuberculosis patients.

Drinking water quality assessment

BACKGROUND

Drinking water quality is the great public health concern because it is a major risk factor for high incidence of diarrheal diseases in Nepal. In the recent years, the prevalence rate of diarrhoea has been found the highest in Myagdi district. This study was carried out to assess the quality of drinking water from different natural sources, reservoirs and collection taps at Arthunge VDC of Myagdi district.

METHODS

A cross-sectional study was carried out using random sampling method in Arthunge VDC of Myagdi district from January to June,2010. 84 water samples representing natural sources, reservoirs and collection taps from the study area were collected. The physico-chemical and microbiological analysis was performed following standards technique set by APHA 1998 and statistical analysis was carried out using SPSS 11.5. The result was also compared with national and WHO guidelines.

RESULTS

Out of 84 water samples (from natural source, reservoirs and tap water) analyzed, drinking water quality parameters (except arsenic and total coliform) of all water samples was found to be within the WHO standards and national standards.15.48% of water samples showed pH (13) higher than the WHO permissible guideline values. Similarly, 85.71% of water samples showed higher Arsenic value (72) than WHO value. Further, the statistical analysis showed no significant difference (P<0.05) of physico-chemical parameters and total coliform count of drinking water for collection taps water samples of winter (January, 2010) and summer (June, 2010). The microbiological examination of water samples revealed the presence of total coliform in 86.90% of water samples.

CONCLUSIONS

The results obtained from physico-chemical analysis of water samples were within national standard and WHO standards except arsenic. The study also found the coliform contamination to be the key problem with drinking water.

SU-E-T-303: Practical Considerations for Maximizing Heat Production in Novel Thermo-Brachytherapy Seed Prototype

PURPOSE

Our recently proposed thermo-brachytherapy seed offers a convenient approach to radiation sensitization with heat in treatment of solid tumors through concurrent administration of hyperthermia and brachytherapy. The seed consists of a titanium capsule, containing radioactive I-125 and a ferromagnetic core, serving as a source of self-regulating hyperthermia when placed in an alternating electromagnetic field. We present an experimental study of the magnetic properties of ferromagnetic Ni-Cu alloy, and develop a protocol for obtaining the material capable of the maximum heat generation. Based on the practically achievable temperature interval we evaluate the effect of thermal expansion on the seed components during the hyperthermia treatment.

METHODS

Alloy samples of Ni1-xCux (0.28= × =0.3) were prepared by arc melting method in argon atmosphere. The ingots were annealed in vacuum at 1000°C for 12 hours. These samples were cut into pieces and used for magnetization measurements with SQUID magnetometer. The thermal expansion along greatest dimension of each component of the purposed seed was estimatedfor temperature increase from 37 to 60 ËšC.

RESULTS

The annealed samples show sharp Curie transition at temperature TC∼50°C, varying with the alloy concentration. However, the un-annealed sample does not show the clear transition, thus indicating a strong influence of thermal treatments on the magnetic properties of the Ni-Cu alloy. The annealing favors atomic diffusion, and leads a sample homogenization, minimizing composition fluctuations and maximizing the heat generation. The effect of the temperature rise on the thermal expansion of each component of the seed was found to be negligible.

CONCLUSIONS

We have established the thermal annealing protocol resulting in the maximum heat generation from the Ni- Cu alloy core. The negligible change in dimensions of the seed components due to heating assures the safety of the implementation of thermo-brachytherapy seed for hyperthermia treatments. This project is supported through NIH grant # 1 R41 CA153681-01A1.

Study of haemodynamic and endocrine stress responses following carbon dioxide pneumoperitonium

BACKGROUND

The aim of the study is to investigate the effect of oral gabapentin or clonidine versus placebo premedication on haemodynamic and endocrine responses in patients of American Society of Anesthesiology (ASA) physical status I and II undergoing laparoscopic cholecystectomy.

METHODS

This was a randomized prospective double-blinded comparative study of 75 ASA I and II patients with three groups: clonidine, gabapentin and placebo group having 25 patients in each. They were randomly allocated to receive 600 mg oral gabapentin or clonidine 150 mcg one hour prior to induction of anesthesia and a placebo group. Hemodynamic parameters were recorded before pneumoperitonium (PP) and every 5 minutes till 35 minutes of post PP. Blood samples for serum glucose and cortisol were collected before PP and 10 mins after PP. The investigators were blinded to what the patients received.

RESULTS

With similar demographic profiles and baseline haemodynamics in three groups (p>0.05) significant rise in haemodynamic parameters were observed in placebo group at different time points before and following PP where as those parameters remained stable in gabapentin and clonidine group (p<0.05). The serum cortisol level was high in placebo group before PP than in two other groups, p<0.05. The same marker measured at 10th minute after PP was significantly higher in placebo group than that in clonidine or gabapentin group, p<0.05.

CONCLUSIONS

Oral clonidine or gabapentin premedication offers intraoperative haemodynamic stability in laparoscopic cholecystectomy. When serum cortisol is taken as a stress marker, gabapentin group exhibited significant attenuation of stress of PP, p<0.05.

Ultrasound Versus the Landmark Technique: A Prospective Randomized Comparative Study of Internal Jugular Vein Cannulation in an Intensive Care Unit

OBJECTIVE: The aim of this study is to find out if an ultrasound technique has advantages over the conventional landmark technique. METHODS: This is a prospective randomized comparative study on 120 patients requiring central venous cannulation of the right internal jugular vein. The study comprised of two groups: ultrasound and landmark groups, each consisting of 60 patients. The outcome measures were compared between the groups. RESULTS: Cannulation of the internal jugular vein was successful in 58 patients in the ultrasound group and in 53 in the landmark group. The number of attempts was 1.5 (1 - 3) and 2 (1 - 3) in the ultrasound and landmark group respectively (p = 0.001). The time taken for the successful cannulation was 4.9 +/- 1.7 minutes in the ultrasound approach and 8.0 +/- 2.8 minutes in the landmark approach (p = 0.00). The internal jugular vein diameter in the supine position was 11.2 +/- 1.5 mm which increased to 15.04 +/- 1.5 mm with a 15 degrees head-down position in the USG group (p = 0.001). The first attempt success rate was 39/60 (63%) in the ultrasound group and 19/60 (32%) with the landmark technique. The seven (12%) failure cases in the landmark group were rescued by the ultrasound technique. Inadvertent carotid artery puncture occurred in 2/60 (3%) and 6/60 (10%) of patients in the ultrasound and land mark group respectively. CONCLUSIONS: Ultrasound improves success rate, minimizes cannulation time and complications during internal jugular vein cannulation. It can be employed as a rescue technique in cases of a failed landmark technique. Keywords:cannulation, central, landmark, technique, ultrasound.

Ultrasound versus the landmark technique: a prospective randomized comparative study of internal jugular vein cannulation in an intensive care unit

OBJECTIVE

The aim of this study is to find out if an ultrasound technique has advantages over the conventional landmark technique.

METHODS

This is a prospective randomized comparative study on 120 patients requiring central venous cannulation of the right internal jugular vein. The study comprised of two groups: ultrasound and landmark groups, each consisting of 60 patients. The outcome measures were compared between the groups.

RESULTS

Cannulation of the internal jugular vein was successful in 58 patients in the ultrasound group and in 53 in the landmark group. The number of attempts was 1.5 (1 - 3) and 2 (1 - 3) in the ultrasound and landmark group respectively (p = 0.001). The time taken for the successful cannulation was 4.9 +/- 1.7 minutes in the ultrasound approach and 8.0 +/- 2.8 minutes in the landmark approach (p = 0.00). The internal jugular vein diameter in the supine position was 11.2 +/- 1.5 mm which increased to 15.04 +/- 1.5 mm with a 15 degrees head-down position in the USG group (p = 0.001). The first attempt success rate was 39/60 (63%) in the ultrasound group and 19/60 (32%) with the landmark technique. The seven (12%) failure cases in the landmark group were rescued by the ultrasound technique. Inadvertent carotid artery puncture occurred in 2/60 (3%) and 6/60 (10%) of patients in the ultrasound and land mark group respectively.

CONCLUSIONS

Ultrasound improves success rate, minimizes cannulation time and complications during internal jugular vein cannulation. It can be employed as a rescue technique in cases of a failed landmark technique.

Substance Use among Medical Students in Kathmandu Valley

Introduction: Substance use including tobacco and alcohol is the most important cause of preventable morbidity, disability, and premature mortality. The study aims to specify the prevalence and the pattern of use of different substance. Methods: A cross sectional study was performed amongst first year and final year students in four medical colleges in Kathmandu using self administered anonymous questionnaire.Data collectedfrom 446 students were analyzed. Results: Prevalence of substance use was found to be 60.3% among the medical students. Alcohol (57.6%) was the substance most prevalently used followed by tobacco (27.58%) and cannabis (12.8%). Mean age of first exposure was 17.94 (Confidence interval: 17.91-17.97). There was significant difference in the useof tobacco and cannabis amongst final year students than first year students. Male and female differed significantly in use of every substance except for benzodiazepine. Medical college, college and school were place of first exposure in 17.26%, 15.92% and 13.23% of the cases respectively. Family history was associated with substance use in medical students and was statistically significant (P<0.0001).Experimentation was the major reason for the use of most of the substances. Conclusions: Substance use is prevalent in male medical students of both first and final year. Hence steps should be initiated early in school, college and medical college to prevent substance use. Keywords: alcohol, medical students, substance use, tobacco.

Effective control of hypertension in adults with chronic kidney disease

INTRODUCTION: Adequate control of hypertension in Chronic Kidney Disease patients is difficult to achieve. This study was designed to analyze the adequacy of Hypertension control in adults with CKD using different classes of antihypertensive drugs. METHODS: A cross-sectional observational study was done that included 85 patients with CKD admitted to our Medicine Department over a period of two years (2006-2008 A.D.). Presence of CKD was defined as glomerular filtration rate <60 ml/min per 1.73 m2 for more than three months or presence of albuminuria (albumin:creatinine ratio >30ug/mg). Adequate blood pressure control was defined as systolic blood pressure less than or equals to 130 and diastolic blood pressure less than or equals to 80 mm Hg. Data and Statistical analysis was done using SPSS Version 12 for Windows. RESULTS: Of all the CKD patients, 51.4% required three Anti-Hypertensive drugs combination for the effective control of Hypertension, while only 21% of CKD patients with hypertension was controlled on two drugs. CONCLUSION: Adequate control of blood pressure in CKD patient was shown to be most effective on combination of three antihypertensive drugs. A poor control was seen on patients taking less than three antihypertensive drugs. Keywords: antihypertensive drug; chronic kidney disease; glomerular filtration rate; hypertension.

Substance use among medical students in Kathmandu valley

INTRODUCTION

Substance use including tobacco and alcohol is the most important cause of preventable morbidity, disability, and premature mortality. The study aims to specify the prevalence and the pattern of use of different substance.

METHODS

A cross sectional study was performed amongst first year and final year students in four medical colleges in Kathmandu using self administered anonymous questionnaire.Data collectedfrom 446 students were analyzed.

RESULTS

Prevalence of substance use was found to be 60.3% among the medical students. Alcohol (57.6%) was the substance most prevalently used followed by tobacco (27.58%) and cannabis (12.8%). Mean age of first exposure was 17.94 (Confidence interval: 17.91-17.97). There was significant difference in the useof tobacco and cannabis amongst final year students than first year students. Male and female differed significantly in use of every substance except for benzodiazepine. Medical college, college and school were place of first exposure in 17.26%, 15.92% and 13.23% of the cases respectively. Family history was associated with substance use in medical students and was statistically significant (P<0.0001).Experimentation was the major reason for the use of most of the substances.

CONCLUSIONS

Substance use is prevalent in male medical students of both first and final year. Hence steps should be initiated early in school, college and medical college to prevent substance use.

Effective control of hypertension in adults with chronic kidney disease

INTRODUCTION

Adequate control of hypertension in Chronic Kidney Disease patients is difficult to achieve. This study was designed to analyze the adequacy of Hypertension control in adults with CKD using different classes of antihypertensive drugs.

METHODS

A cross-sectional observational study was done that included 85 patients with CKD admitted to our Medicine Department over a period of two years (2006-2008 A.D.). Presence of CKD was defined as glomerular filtration rate <60 ml/min per 1.73 m2 for more than three months or presence of albuminuria (albumin:creatinine ratio >30ug/mg). Adequate blood pressure control was defined as systolic blood pressure less than or equals to 130 and diastolic blood pressure less than or equals to 80 mm Hg. Data and Statistical analysis was done using SPSS Version 12 for Windows.

RESULTS

Of all the CKD patients, 51.4% required three Anti-Hypertensive drugs combination for the effective control of Hypertension, while only 21% of CKD patients with hypertension was controlled on two drugs.

CONCLUSION

Adequate control of blood pressure in CKD patient was shown to be most effective on combination of three antihypertensive drugs. A poor control was seen on patients taking less than three antihypertensive drugs.

Early Experience of Day Care Surgery in Nepal

INTRODUCTION: The day care laparoscopic cholecystectomy (DCLC) is found to be safe and effective in developed countries. However, it has not been well accepted in our part of the world probably because of lack of infrastructures,established norms and published reports. We have analyzed the safety and feasibility of the procedure in the recently established first dedicated day care surgery centre of the country. METHODS: All the patients with American society of anaesthesiologist (ASA) score I and II admitted for laparoscopic cholecystectomy are included. Operation are performed in the morning and closely observed till evening. Patients found to be medically fit to discharge; having a responsible person at home and who can make their own arrangements in case of problems were advised for discharge. Follow up was done by telephone call from next morning. RESULTS: Total 35 patients underwent laparoscopic cholecystectomy. Age range was between 16-65 years and most of them were females (88%). Only 30 patients were operated in early morning and were eligible for day care surgery. 25 (83%) Patients were advised for discharge but only 10 (33%) could make arrangement. Other 15 patients could not go home mainly due to different psychosocial reasons. Only one patient needed readmission and Complications observed were minor and relatively few. CONCLUSIONS: Day care laparoscopic cholecystectomy is safe and feasible in our set up. Acceptance of the procedure is expected to increase once it is regularly practiced and awareness in improved. Keywords: day care, laparoscopic cholecystectomy, surgery, Nepal.

Spinal anaesthesia for laparoscopic cholecystectomy: a feasibility and safety study

BACKGROUND

Regional anaesthetic techniques have benefited those patients undergoing laparoscopic surgeries that are deemed high risk to receive general anaesthesia (GA). But spinal anaesthesia (SA) has not been routinely employed as the sole technique for laparoscopic cholecystectomy (LC).

OBJECTIVE

This study was conducted to uncover feasibility and safety of SA for conducting LC.

METHODS AND MATERIALS

Twelve American Society of Anaesthesiologists' physical status I or II patients undergoing elective LC received SA using 4 ml of 0.5% hyperbaric Bupivacaine mixed with 0.15 mg Morphine. Per-operative preparations and management were all standardised, with other drugs being only administered to manage anxiety, pain, nausea/vomiting, hypotension, and any adverse event. LC was performed with CO2 pneumoperitoneum maintained at an intra-abdominal pressure of less than 10 mm Hg and with minimal operating table tilt. Per-operative events, operative difficulty, hospital stay and patient satisfaction were studied.

RESULTS

Spinal anaesthesia was adequate for surgery in all but one patient. Intraoperatively, two out of four patients who experienced right shoulder pain received Fentanyl. Two patients were given Midazolam for anxiety and one was given Ephedrine for hypotension. Operative difficulty scores were minimal and surgery in one patient was converted to open cholecystectomy. Postoperatively, pain scores were minimal and no patient demanded opioid. One patient required antiemetic for vomiting and one patient each suffered headache and urinary retention. 11 patients were discharged within 48 hours of surgery and patient satisfaction scores were very good.

CONCLUSION

Spinal anaesthesia with Morphine-mixed hyperbaric Bupivacaine is adequate and safe for elective LC in otherwise healthy patients and minimises postoperative pain and opioid use. Success and safety of this technique, however, necessitates knowledgeable patient, gentle surgical procedure, and co-operation among patient and members of the perioperative care team.

Early experience of day care surgery in Nepal

INTRODUCTION

The day care laparoscopic cholecystectomy (DCLC) is found to be safe and effective in developed countries. However, it has not been well accepted in our part of the world probably because of lack of infrastructures,established norms and published reports. We have analyzed the safety and feasibility of the procedure in the recently established first dedicated day care surgery centre of the country.

METHODS

All the patients with American society of anaesthesiologist (ASA) score I and II admitted for laparoscopic cholecystectomy are included. Operation are performed in the morning and closely observed till evening. Patients found to be medically fit to discharge; having a responsible person at home and who can make their own arrangements in case of problems were advised for discharge. Follow up was done by telephone call from next morning.

RESULTS

Total 35 patients underwent laparoscopic cholecystectomy. Age range was between 16-65 years and most of them were females (88%). Only 30 patients were operated in early morning and were eligible for day care surgery. 25 (83%) Patients were advised for discharge but only 10 (33%) could make arrangement. Other 15 patients could not go home mainly due to different psychosocial reasons. Only one patient needed readmission and Complications observed were minor and relatively few.

CONCLUSIONS

Day care laparoscopic cholecystectomy is safe and feasible in our set up. Acceptance of the procedure is expected to increase once it is regularly practiced and awareness in improved.

Changes in aqueductal CSF stroke volume in shunted patients with idiopathic normal-pressure hydrocephalus

BACKGROUND AND PURPOSE

Aqueductal CSF stroke volume (ACSV) measured by phase-contrast MR imaging is a tool for selection of surgical patients with idiopathic normal-pressure hydrocephalus (iNPH). The aim of the present study was to investigate whether there is a relationship between clinical outcome and changes in ACSV in patients with iNPH who have been shunted.

MATERIALS AND METHODS

Sixty-five shunted patients with iNPH underwent clinical evaluation and ACSV measurements 7-30 days before and 1, 3, 6, and 12 months after surgery.

RESULTS

Two patients were excluded from the study for the occurrence of a perioperative complication. In a group of 35 clinically improved patients, the mean preoperative ACSV (157.01 microL) decreased to 18% one month after ventriculoperitoneal shunt (VPS) and < or =49% at 12 months post-VPS. In a group of 15 unimproved patients, the lower mean preoperative ACSV (84.2 microL) decreased to 14.3% one month post-VPS and < or =34% at 12 months post-VPS. In the other 8 improved patients who developed a subdural fluid collection (SDFC), ACSV values decreased by 43%-75% in the 3 months post-VPS. A postoperative ACSV increase was noted in 6 patients with a shunt system malfunction. One patient experienced both SDCF and shunt malfunction.

CONCLUSIONS

ACSV decreases in all patients in whom the VPS system works properly, with the rate of ACSV decrease being higher in the patients who show clinical improvement. Postoperative ACSV increase suggests shunt malfunction. A precipitous drop of ACSV values after VPS may be the consequence of increased drainage and herald the occurrence of SDFC.

Serum zinc and copper level in children with protein energy malnutrition

This case control study was carried out in the department of Biochemistry, Mymensingh Medical College in co-operation with the Pediatric wards of Mymensingh Medical College Hospital and Ganashasthya Nagar Hospital, Dhaka during the period from July 2005 to June 2006. The aim of the study was to explore the status of serum zinc and copper level in Bangladeshi children with Protein Energy Malnutrition (PEM) as a means to monitor the possibility of management of these children as each of these mineral deficiencies produce typical deficiency syndromes. A total of 68 children aging from five months to five years were included in this study. Subjects were divided into two groups-Group I (Control; n=20)-children with normal growth, weight for age between 3rd and 97th centile curve, Centers for Disease Control (CDC) growth chart, USA, 2000 and group II-(children with PEM; n=48)-children with retarded growth, weight for age below 3rd centile of CDC growth chart, USA, 2000. Group II was again divided into three subgroups according to Wellcome classification of PEM and clinical features. These were Group IIA: Marasmus (n=19), Group IIB: Kwashiorkor (n=14) and Group IIC: Marasmic Kwashiorkor (n=15). Serum zinc and copper levels were determined by Atomic Absorption Spectrophotometric method. Statistical analysis was done by using Statistical Package for the Social Sciences (SPSS) window package. Among the different groups of children mean+/-SD (Standard Deviation) of serum zinc in PEM (59.85+/-11.18 microg/dl), Marasmus (66.73+/-8.23 microg/dl), Kwashiorkor (49.69+/-10.35 microg/dl) and Marasmic Kwashiorkor (60.63+/-8.04 microg/dl) were all significantly lower (p<0.001) than in control group (106.16+/-13.36 microg/dl). Similarly mean+/-SD of serum copper in PEM (82.73+/-16.35 microg/dl), Marasmus (93.72+/-9.77 microg/dl), Kwashiorkor (63.75+/-13.12 microg/dl) and Marasmic Kwashiorkor (86.52+/-8.68 microg/dl) were all also significantly lower (p<0.001) than in control group (135.88+/-11.88 microg/dl). It is evident from the study that serum zinc and copper level significantly decrease in children with PEM.

Comparative study between tramadol and dexamethasone as an admixture to bupivacaine in supraclavicular brachial plexus block

This is a prospective, randomized, double blind study to evaluate the postoperative analgesia following supraclavicular brachial plexus block with Tramadol or Dexamethasone as an admixture to bupivacaine in upper extremity surgery. Total 60 patients of ASA I and II undergoing upper extremity surgery under brachial plexus block with Bupivacaine were randomly divided in to two groups; one group received Tramadol (2 mg/kg) and the other group received Dexamethasone (8 mg) as an admixture to Bupivacaine. The duration of postoperative analgesia was recorded in both groups using pain VAS score which was determined by maximum VAS score of 8-10 and when patient demands for additional analgesics. The mean duration of postoperative analgesia in the Dexamethasone group was 1028.00 minutes while in the tramadol group it was 453.17 minutes We concluded that Dexamethasone with local anaesthetic prolongs postoperative analgesia significantly than Tramadol (P<0.05) when used as admixture to local anaesthetic in brachial plexus block in upper extremity surgery.

Antiemetic prophylaxis against postoperative nausea and vomiting with ondansetron-dexamethasone combination compared to ondansetron or dexamethasone alone for patients undergoing laparoscopic cholecystectomy

Background: Postoperative nausea and vomiting (PONV) is a common distressing experience in patients following laparoscopic surgeries. This study was aimed at comparing the efficacies of Ondansetron-Dexamethasone combination with each drug alone as a prophylaxis against PONV in patients after elective laparoscopic cholecystectomy done under general anaesthesia. Materials and methods: Hundred and fifty ASA I and II patients, aged 23 to 65 yrs, were enrolled in this prospective, randomized, double-blind trial to receive one of three treatment regimens: 4 mg Ondansetron (Group O), 8 mg Dexamethasone (Group D) or 4 mg Ondansetron plus 8 mg Dexamethasone (Group OD) (n=50 for each). A standardized balanced general anaesthetic technique was employed. Any episode of PONV and need for rescue antiemetic were assessed at six, 12 and 24 hrs post operation. Complete response was defined as no PONV in 24 hrs and need for rescue antiemetic was considered as failure of prophylaxis. Pain scores, time to first analgesia demand, amount of Meperidine consumption, adverse event(s) and duration of hospital stay were recorded. Results: Complete response occurred in 66.7, 66.0 and 89.4% in Groups O, D and OD respectively. Rescue antiemetics were required in 29.2, 31.9 and 8.5% of patients in Groups O, D, and OD respectively. Significantly high incidence of vomiting and failure of prophylaxis (19.1%) occurred in group D during the first six hrs (P=0.023 versus O & 0.008 versus OD). More frequent antiemetic rescue was required in group O at 6 to 24 hr interval as compared to group OD (P=0.032). Conclusion: Combination of Ondansetron and Dexamethasone is better than each drug alone in preventing PONV after laparoscopic cholecystectomy. Dexamethasone alone is significantly less effective in preventing early vomiting compared to its combination with Ondansetron; whereas Ondansetron alone is less effective against late PONV as compared with combination therapy. Key words: Antiemetic prophylaxis; Dexamethasone; laparoscopic cholecystectomy; Ondansetron; postoperative nausea and vomiting (PONV) doi: 10.3126/kumj.v6i3.1706 Kathmandu University Medical Journal (2008), Vol. 6, No. 3, Issue 23, 319-328